Investigating heart failure in elderly people: does everyone need an echocardiogram?

Age and Ageing 998; 27: 29-295 Investigating heart failure in elderly people: does everyone need an echocardiogram? NIALL L J. Cox, PAUL SAINSBURY, JAMES M. MCLENACHAN 2, OLIVER J. CORRADO 3 Department of Medicine for the Elderly, St James's University Hospital, Leeds LS9 7TF, UK 'Department of General Medicine, Bradford Royal Infirmary, Bradford, UK Departments of 2 Cardiology and 3 Medicine for the Elderly, Leeds General Infirmary, Leeds, UK Address correspondence to: N. L T Cox. Fax: (+44) I 3 242995 Abstract Objective: to establish whether an echocardiogram is always necessary when investigating heart failure (HF) in elderly patients. Method: a clinical assessment was compared with echocardiography in 5 elderly patients aged S75 years complaining of breathlessness of more than month's duration. Results: the greater the number of clinical features of HF present, the more likely was echocardiography to reveal a potential cause. It revealed a potential cause of HF in all 6 patients with strong clinical evidence (four or more features present). Of the 20 patients in whom clinical evidence of HF was equivocal (two or three features present), the echocardiogram revealed a potential cause of HF in nine and so was valuable in directing the diagnosis towards or away from HF. In only two of the 5 patients with minimal clinical evidence of HF (one feature or less) did the echocardiogram reveal a potential cause of HF. Severe valvular lesions were common, occurring in 20 (39%) patients. These were difficult to identify clinically as clinical features were non-specific and murmurs were not always present. Conclusions: echocardiography is most useful in those elderly patients in whom the clinical diagnosis of HF is uncertain or for whom valvular surgery might be considered. Keywords: echocardiography, heart failure, investigation Introduction Heart failure (HF) is traditionally diagnosed clinically from history and physical examination, supported by radiography and electrocardiography. However, recent studies have cast doubt on the accuracy of the clinical diagnosis of HF [-3]. The use of echocardiography in the investigation of HF in elderly people is increasing, since multiple pathology and atypical presentation often make clinical diagnosis difficult [4, 5]. However, since HF is very common in elderly people the prevalence may be as high as 0% in octogenarians [6] routine echocardiography for all elderly patients thought to have HF has resource implications. Echocardiography resources in the UK are limited, particularly in district general hospitals [7]. The question of whether it is necessary for all patients with suspected HF to have an echocardiogram is therefore an important one. Some patients have such strong clinical evidence of HF that the clinical diagnosis is fairly easy and echocardiography (other than to identify surgically treatable valvular lesions) might be unnecessary. In contrast, there are some patients in whom the clinical evidence for HF is inconclusive and here echocardiography might be useful. Previous studies [-3] which demonstrated the advantages of echocardiography were not designed to evaluate for whom an echocardiogram was most valuable. In this study, we set out to determine whether a clinical assessment could be used to predict in which patients an echocardiogram was most useful. In a prospective study of a group of breathless elderly patients, we have documented the number of clinical features of HF in each patient and then compared these with echocardiographic evidence of a potential cause of HF. We believe this is the first time such a comparison has been made. 29

N. L. T. Cox et al. Methods The study population was of patients aged S:75 years admitted acutely to the department of medicine for the elderly at Leeds General Infirmary on Mondays, Tuesdays and Fridays. Approval was obtained from the local ethics committee. In order to avoid bias in patient selection, we recruited people with symptomatic breathlessness rather than those whose case notes recorded 'possible HF' based on no clear diagnostic criteria. Patients were seen 3 days after admission and asked if they suffered from breathlessness. If so, and if this was of longer than month's duration (to exclude acute coronary ischaemia), the patient was recruited and consent obtained. Patients were excluded if they were severely ill, had haemoglobin levels <8g/00ml, had cognitive impairment (Hodkinson abbreviated mental test score [8] <7 out of 0) or were normally immobile. Cardiac or respiratory medication were not exclusion criteria. All patients had a history and physical examination undertaken by one of us (N.L.T.C.) as well as the following investigations: full blood count; urea and electrolytes; thyroid function tests; forced expiratory volume in s (FEVO and forced viral capacity (FVQ using a hand-held spirometer (Micro Plus Spirometer); electrocardiogram and posterio- anterior chest X-ray. Further investigations, such as ventilation-perfusion scan, were performed only if indicated. The investigator was blind to patients' treatment whilst making this assessment. For each patient the number of clinical features of HF was documented (Table ). Valvular lesions were diagnosed clinically using standard physical signs. Chronic obstructive pulmonary disease (COPD) was diagnosed if two or more of the following were present in addition to breathlessness: (i) chronic cough and Table I. Clinical features used to assess for evidence of heart failure. Peripheral oedema 2. Elevated jugular venous pressure 3. Third heart sound 4. Bilateral basal fine pulmonary crackles Postero-anterior chest X-ray 5. Cardiothoracic ratio" >0.55 6. Upper lobe blood diversion 7. Kerley B lines or bilateral pleural effusions 8. Pulmonary oedema 9. ECG evidence of previous myocardial infarction, left ventricular hypertrophy or left bundle branch block "Cardiac diameter divided by thoracic diameter measured from the inner border of the ribs on a postero-anterior chest X-ray. ECG, electrocardiographic. sputum production, (ii) wheeze on auscultation, (iii) hyperinflated lungs on postero-anterior chest X-ray and (iv) an obstructive picture on spirometry with the FEV/FVC ratio <60%. All patients had an echocardiogram performed by one of four experienced full-time echocardiography technicians. A Toshiba Sonolayer SSH-60A echocardiography machine was used. The echocardiography technician was informed that patients had 'possible HF' but did not have access to case notes or X-rays. All valves and chambers were examined. Left ventricular (LV) systolic function was assessed using LV enddiastolic diameter (LVEDd; abnormal if >55 cm). The LVEDd is simpler to measure but as effective as the ejection fraction [9]. If measurement of LVEDd was not technically possible, a subjective assessment of LV systolic function was used since such subjective assessment correlates well with ejection fraction as measured by radionuclide scan [0]. Valvular lesions were recorded: aortic stenosis was considered important if the aortic valve gradient was >50 mm mercury; mitral regurgitation was considered important when moderate or severe mitral regurgitation was associated with left atrial dilation (left atrial width >4 cm); mitral stenosis was considered important if the mitral valve pressure half-time was > 00 ms (equivalent to a mitral valve area of <2.2 cm 2 ); aortic regurgitation was considered important when the colour flow jet was broad and extended into the LV cavity. Results Two hundred and sixty patients were admitted on Mondays, Wednesdays and Fridays during the 3-month study period. Eight patients died within 3 days of admission, so 252 were interviewed. A total of 37 were excluded due to severe illness, anaemia, chronic immobility, confusion or consent refused. Of the remaining 5 patients, 57 experienced breathlessness of more than month's duration. Six of these were excluded because information was incomplete at the time of discharge and 5 (3 women) studied. Their ages ranged from 75 to 94 years (mean 84.8 years). LVEDd measurements were obtained in 4 patients; in the other 0 a subjective assessment of LV systolic function was made. In 27 patients, the echocardiogram revealed a potential cause of HF: mostly LV systolic dysfunction, mitral regurgitation or a combination of these (see Table 2). A comparison of the clinical assessment with the echocardiographic results is shown in Figure. The likelihood of the echocardiogram revealing a potential cause of HF increased with the number of clinical features present. Sixteen patients had four or more clinical features and the echocardiogram revealed a potential cause in all. Clinical evidence was equivocal (two or three features present) in 20 patients and the 292

Investigating heart failure in elderly people Table 2. Echocardiographic evidence of a potential cause of heart failure Abnormality No. of patients Left ventricular systolic dysfunction Alone with mitral regurgitation with mixed mitral valve disease with aortic stenosis Mitral regurgitation Aortic stenosis and mitral regurgitation 7 8 8 2 Number of clinical features of HF per patient echocardiogram revealed a potential cause of HF in nine of these. Fifteen patients had one or no clinical features of HF and in only two of these patients did the echocardiogram provide evidence of a potential cause ofhf. Twenty patients (39%) had a clinically significant valvular lesion according to our criteria. In only one of these (a patient with aortic stenosis) were there specific clinical features (other than a murmur) suggesting a valvular lesion. In nine of the patients with valvular lesions, no murmur was heard on clinical examination. All three patients with aortic stenosis had an audible murmur but two had no other signs of aortic stenosis (normal character pulse and pulse pressure). No patient was referred for valvular surgery. The consultants responsible for the patients with aortic stenosis found on echocardiogram considered that angiotensin-converting enzyme (ACE) inhibitors were contraindicated. Other abnormalities were detected on echocardiography: six patients had LV hypertrophy and six had right heart dilatation. This was due to multiple pulmonary emboli in two, and to COPD, coal miners' pneumoconiosis and mitral regurgitation in one case each. There was no clear reason in the final one. Details of the 24 patients with non-cardiac diagnoses are shown in Table 3. Twenty-two had evidence of respiratory disease (mostly COPD) and two had multiple pulmonary emboli. Figure I. Clinical evidence of heart failure versus echocardiographic evidence for a cause of heart failure:, potential cause seen;, no potential cause seen. Discussion Echocardiography is of use in evaluating cardiac disease in elderly people. However, it is not costeffective to routinely investigate all patients. We have found that the greater the clinical evidence of HF, the more likely it is that an echocardiogram will provide evidence of a cause of HF. Furthermore, valvular lesions, particularly mitral regurgitation, are common but may be difficult to diagnose clinically. Echocardiography cannot diagnose HF but can provide evidence of a potential cause. The information provided may be used to direct treatment (such as valvular surgery) or to support a diagnosis of HF where there is diagnostic uncertainty. In this study, we found that echocardiography always revealed a potential cause of HF in patients with strong clinical evidence of HF (four or more features present), and therefore confers no additional diagnostic benefit over clinical assessment in these patients. However, where clinical evidence of HF is inconclusive (two or three features present), the echocardiogram is useful in directing the diagnosis towards or away from HF. Echocardiography is invaluable in clarifying valvular problems. These are common, occurring in 39% of Table 3. Non-cardiac diagnoses in 5 elderly breathless patients Diagnosis Chronic obstructive pulmonary disease Bronchiectasis Bronchial carcinoma with persistent chest infection Cryptogenic pulmonary fibrosis Coal miner's pneumoconiosis Pulmonary disease, cause uncertain Pulmonary emboli No. of patients 6 2 I I 2 293

N. L. T. Cox et al. patients. Most were due to mitral regurgitation, which may be difficult to diagnose clinically as signs may be non-specific. The incidence of mitral regurgitation in this study may seem high but in some patients with LV systolic dysfunction, it is likely to be functional; this cannot be differentiated with certainty by echocardiography. However, diagnosing mitral regurgitation probably does not influence management. Surgical treatment of mitral regurgitation carries a high mortality (approximately 20%) [, 2] and HF due to mitral regurgitation responds to diuretics and ACE inhibitors. The clinical diagnosis of aortic stenosis may also be difficult because murmurs, although invariably audible, may be soft and other features (pulse character and narrow pulse pressure) are often absent [3]. However, establishing a diagnosis of aortic stenosis may be very important. Referral of elderly patients with severe aortic stenosis remains uncommon, although such surgery is safe, with a mortality of about 5% [, 2, 4]. Many regard echocardiographic exclusion of aortic stenosis as a necessary prerequisite for the commencement of ACE inhibitor therapy and this was the case with our three patients. However, this practice is controversial: whilst there is a strong theoretical argument to suggest that ACE inhibitors are dangerous in patients with aortic stenosis, some studies have suggested that these patients may benefit from such therapy [5, 6]. We had intended to use established clinical criteria such as the Framingham or Boston criteria [7, 8] to separate patients with and without clinical evidence of HE However, -whilst in the pilot stages, it became clear that these criteria were inappropriate for some of our patients who were diagnosed as having definite HF despite having very limited clinical evidence of HF. hi our assessment, we utilised clinical features (Table ) which we believe reflect those normally used by clinicians to diagnose HF. We did not include severity of breathlessness or associated symptoms such as orthopnoea and wheeze as we felt these did not differentiate HF from COPD. All our clinical examinations were undertaken by an experienced middle-grade doctor. It is possible that a more junior admitting doctor would not have made the same assessment and it would be interesting to explore this issue in the future. Although HF may occur in patients with normal LV systolic function and valves [9, 20] our results show that in patients with strong evidence of HF, the echocardiogram always revealed a potential cause. It is possible that the phenomenon of HF in the presence of a normal echocardiogram may result from using clinical diagnostic criteria which are oversensitive in elderly people: this is an area which we are studying further. In conclusion, we believe that echocardiography is most valuable in elderly patients in whom the clinical diagnosis of HF is uncertain and in those in whom valvular surgery might be considered. We suggest that if echocardiogram resources are limited, such patients should take priority. Key points In patients with strong clinical evidence of heart failure, echocardiography invariably reveals a potential cause. hi patients with equivocal clinical evidence of heart failure, echocardiography reveals a potential cause in around 50% of all cases. Echocardiography is most useful in those elderly patients in whom the clinical diagnosis of heart failure is uncertain and in those in whom valvular surgery might be considered. Acknowledgements We thank J. Catchpole and the echocardiography department at Leeds General Infirmary for their help with this study. References. Wheeldon NM, Macdonald TM, Flucker CJ, McKendrick AD, McDevitt DG, Struthers AD. Echocardiography in chronic heart failure in the community. Q J Med 993; 86: 7-23. 2. Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM. Congestive heart failure: echocardiographic insights. Am J Med 983; 75: 750-5. 3. Aguirre FV, Pearson AC, Lewen MK, McCluskey M, Labovitz AJ. Usefulness of Doppler echocardiography in the diagnosis of congestive heart failure. Am J Cardiol 989; 63: 098-02. 4. Lawson-Matthew PJ, Charmer KS. Reporting on reports cardiological intervention in elderly patients. J R Coll Phys Lond 995; 29: -4. 5. Pycock CJ, King A, Marshall AJ. Management of heart disease in the elderly in the Plymouth Health District. J R Coll Physicians Lond 995; 29: 5-9. 6. Kannel WB, Belanger AJ. Epidemiology of heart failure. Am Heart J 99; 2: 95-7. 7. Struthers AD. Health care delivery for chronic congestive heart failure in the United Kingdom. Curr Opin Cardiol 994; 9(suppl. ):S2-5. 8. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 972; : 233-7. 9- Dargie HJ, McMurray JJ. Diagnosis and management of heart failure. Br Med J 994; 308: 32-8. 0. Amico AF, Lichtenberg GS, Reisner SA, Stone CK, Schwartz RG, Meltzer RS. Superiority of visual versus computerised echocardiographic estimation of radionuclide left ventricular ejection fraction. Am Heart J 989; 8: 259-65. 294

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In the greenhouse. Joe Partridge/Help the Aged.