Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations

Chronic heart failure is a common clinical syndrome that may have different causes. Its incidence and prevalence are predicted to rise substantially o ver the next 10 years. There are therefore major consequences for resource provision, especially in primary care, where most patients are managed. Chr onic heart failure is a serious condition with high morbidity and mortality . There is good evidence to show that treatment with angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunc tion improves symptoms and signs, slows progression of heart failure, reduc es hospitalisation rates, and improves survival. Despite this evidence, pri mary care studies show that patients with heart failure are incorrectly dia gnosed and inadequately treated. Most patients present in general practice, and because effective treatment relies on a correct diagnosis, this is a k ey step in the appropriate management of heart failure. The aim of this pap er is to review the evidence about the usefulness of signs, symptoms, and i nvestigations in diagnosing heart failure in primary care. To identify rele vant studies for this review, four strategies were used: a MEDLINE search f rom 1993 to January 1998 using the diagnosis search filter; a MEDLINE searc h from 1993 to January 1998 using the guideline search filter to locate pub lished heart failure guidelines; a search for review articles in the Cochra ne Library; and a check of references in the studies identified. The search terms included MeSH terms and the keywords 'heart failure' and 'diagnosis: All searches were limited to humans and English language articles. Studies were included in this review on the basis of quality and relevance to prim ary care. The review shows that symptoms and signs are important because th ey alert clinicians to the possibility of heart failure as a diagnosis. How ever, they are not sufficiently specific for confirming left ventricular sy stolic dysfunction. From the evidence available, a patient with suspected h eart failure must have objective tests to confirm the diagnosis. These shou ld include an electrocardiogram and, ideally, an echocardiogram. Further re search is also needed on the usefulness of signs and symptoms in primary ca re, as most studies of heart failure have been conducted in secondary care.