Diagnostic Tests for Heart Failure That Are Oldies but Goodies

November 1, 2007

In his article, "Heart Failure: Part 1, Diagnosis and Staging" (CONSULTANT, July 2007), why did Dr W. H. Wilson Tang omit central venous pressure and circulation time as means of diagnosing congestive heart failure? Is it possible that the simplicity and accuracy of these 2 tests, which can establish the diagnosis in 5 or 10 minutes in any hospital room-or physician's examining room-have been forgotten since the advent of testing of natriuretic peptide levels (which, as Dr Tang notes, "also increase in response to other noncardiac processes")?

In his article, "Heart Failure: Part 1, Diagnosis and Staging" (CONSULTANT, July 2007), why did Dr W. H. Wilson Tang omit central venous pressure and circulation time as means of diagnosing congestive heart failure? Is it possible that the simplicity and accuracy of these 2 tests, which can establish the diagnosis in 5 or 10 minutes in any hospital room-or physician's examining room-have been forgotten since the advent of testing of natriuretic peptide levels (which, as Dr Tang notes, "also increase in response to other noncardiac processes")?

---- William Meyers, MD Syracuse, Ind

My article was intended to serve as an update on recent developments in the diagnosis and staging of heart failure. It should not be inferred from this emphasis that I ignore or judge as inferior many of the well-established clinical examination signs and symptoms commonly used by physicians. In fact, in several areas of the article (eg, my discussion of early detection) I highlighted the importance of the physical examination in the diagnosis of heart failure; this includes observations of jugular venous distention as a surrogate bedside measure of central venous pressure.

However, the point has been made in many prospective studies that physical examination may have some limitations, particularly in patients with minimal congestion. As a consequence, many people evaluated primarily with physical examination have remained undiagnosed and under-treated (at least half of the patients with underlying abnormalities of cardiac structure and function are asymptomatic in epidemiological studies). Therefore, many of the new advances are valuable tools that have been included in recent guidelines and broadly adopted clinically.

Moreover, my article noted many potential limitations of "modern technology" (eg, natriuretic peptide testing) and underscored the need for clinical evidence to validate the relative clinical utility of new technologies in usual care. In my opinion, there is no single measurement that defines heart failure; this clinical diagnosis requires integration of experience, judgment, and interpretation of objective findings.

---- W. H. Wilson Tang, MD
Research Director, Section of Heart Failure and Cardiac Transplantation Medicine
Department of Cardiovascular Medicine
The Cleveland Clinic