Family Practice Advance Access originally published online on September 7, 2007
Family Practice 2007 24(6):628-635; doi:10.1093/fampra/cmm055
Diagnosis of left ventricular systolic dysfunction (LVSD): development and validation of a clinical prediction rule in primary care
a Division of Community Health Sciences, University of Dundee, Mackenzie Building, Dundee DD2 4BF
b Department of General Practice, Royal College of Surgeons in Ireland, 120 St Stephens Green, Stephen Street Lower, Dublin 2
c Division of Medicine and Therapeutics, University of Dundee, Ninewells Hospital, Dundee DD1 9SY, UK
Correspondence to Tom Fahey, Division of Community Health Sciences, University of Dundee, Mackenzie Building, Dundee DD2 4BF, UK; Email: tomfahey{at}rcsi.ie
Received 2 February 2007; Revised 27 July 2007; Accepted 30 July 2007.
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Abstract |
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Background: Diagnosing suspected left ventricular systolic dysfunction (LVSD) in the community is a challenge for GPs. We developed and validated a clinical prediction rule (CPR) for LVSD based on history, examination and electrocardiogram (ECG).
Methods: Prospective cohort studies of 458 symptomatic patients (derivation cohort) and 535 patients (validation cohort) in 26 general practices in Tayside and Fife, Scotland. All patients underwent a structured clinical examination and ECG and the ‘reference standard’ investigation of echocardiography to establish the presence of LVSD.
Results: Four elements from the clinical history and examination were all independently associated with LVSD—male sex [adjusted odds ratio (OR) 2.5; 95% CI 1.1, 5.0], presence of orthopnoea (OR 5.4; 1.9, 13.8) history of myocardial infarction (OR 5.6; 2.3, 13.6) and elevated jugular venous pulsations (OR 15.1; 4.6, 49.3). Addition of ECG (OR 20.6; 2.7, 158.6) provides important diagnostic information in terms of probability of LVSD. A CPR based on the presence or absence of these five elements will generate probabilities ranging from 1% to 97% for LVSD when applied to an individual patient. In the validation cohort, the model under-predicted the probability of LVSD, particularly at lower levels of expected risk, reflecting differences in the risk-factor profiles of the derivation and validation cohorts.
Conclusions: The derived CPR provides quantitative estimates of post-test probability for LVSD. This rule requires further validation in other populations and settings because of the difficulties encountered in the validation cohort.
Fahey T, Jeyaseelan S, McCowan C, Carr E, Goudie BM, Pringle SD, Donnan PT, Sullivan FM and Struthers AD. Diagnosis of left ventricular systolic dysfunction (LVSD): development and validation of a clinical prediction rule in primary care. Family Practice 2007; 24: 628–635.