Heart Failure Reviews

, Volume 11, Issue 2, pp 95–107 | Cite as

Diagnosis of heart failure in primary care

  • Cândida FonsecaEmail author


Heart failure is becoming an increasing concern to healthcare worldwide. It is the only cardiovascular disorder that continues to increase in both prevalence and incidence, and as the population continues to age, it is expected that the prevalence of this disease will continue to rise. Guidelines on diagnosis and treatment of heart failure are to be met.

Most patients with heart failure will present themselves in general practice. Therefore, the community management of heart failure has become increasingly important and the role of General Practitioners even more crucial. Improving the reliability of diagnosis in primary care is essential since determining the aetiology and stage of heart failure leads to different management choices to improve symptoms, quality of life and disease prognosis. Furthermore, early diagnosis is needed, when there may be no symptoms, since treatment can delay or reverse disease progression. Diagnostic methods may therefore need to encompass screening strategies, as well as symptomatic case identification, in the future. General Practitioners must make correct decisions regarding appropriate further investigation, treatment and referral. A correct diagnosis is the cornerstone leading to effective management.

The aim of this paper is to review the role of symptoms and signs and diagnostic tests, such as, chest X-ray, ECG, natriuretic peptides and echocardiography, for diagnosing heart failure in the primary care setting.

Improving diagnostic skills remains a continuous challenge for clinicians. Simple and reliable diagnostic procedures are crucial to comply with Guidelines and reduce healthcare utilisation and costs.


Heart failure Diagnosis Primary care 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Davies MK, Hobbs FDR, Davis RC, et al. Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England screening study: a population based study. Lancet 2001;358:439–44.PubMedCrossRefGoogle Scholar
  2. 2.
    McDonagh TA, Morrison CE, Lawrence A, et al. Symptomatic and asymptomatic left ventricular systolic dysfunction in an urban population. Lancet 1997;350:829–33.PubMedCrossRefGoogle Scholar
  3. 3.
    Ceia F, Fonseca C, Mota T, et al. Prevalence of chronic heart failure in southwestern Europe: the EPICA study. Eur J Heart Fail 2002;4:531–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Cleland JGF, Khand A, Clarck AL. The heart failure epidemic: exactly how big is it? Eur Heart J 2001;22:623–6.PubMedCrossRefGoogle Scholar
  5. 5.
    McKee PA, Castelli WP, McNamara PM, Kannell WB. The natural history of heart failure: the Framingham study. N Engl J Med 1971;285:1441–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Ho KKL, Pinsky JL, Kannell WB. The epidemiology of heart failure: the Framingham study. J Am Coll Cardiol 1993;22:6A–13A.PubMedGoogle Scholar
  7. 7.
    Davis RC, Hobbs FDR, Kenkre J, Roalfe AK, McLeod S, Hare R, et al. Quality of life in heart failure and other conditions. Eur Heart J 2002;23:1867–76.PubMedCrossRefGoogle Scholar
  8. 8.
    McMurray J. Hart W, Rhodes G. An evaluation of the economic cost of heart failure to the National Health Service in the United Kingdom. Br J Med Econ 1993;6:99–110.Google Scholar
  9. 9.
    O'Connell JB, Bristow MR. Economic impact of heart failure in the United States: time for a different approach. J Heart Lung Transplant 1994;13(suppl 4):S107–12.PubMedGoogle Scholar
  10. 10.
    Wheeldom NM, MacDonald TM, Flucker CJ, Mckendrick AD, Mcdevitt DG, Struthers AD. Echocardiography in chronic heart failure in the community. Q J Med 1993;86:17–23.Google Scholar
  11. 11.
    Hobbs FDR, Jones MI, Allan TF, et al. European survey of primary care physician perceptions, on heart failure diagnosis and management (Euro-HF). Eur Heart J 2000;21:1877–87.PubMedCrossRefGoogle Scholar
  12. 12.
    Hobbs FDR, Korewicki J, Cleland JGF, Eastaugh J, Freemantle N on behalf of the IMPROVEMENT Investigators. The diagnosis of heart failure in European primary care: the IMPROVEMENT programme survey of perception and practice. Eur J Heart Fail 2005;7:768–79.PubMedCrossRefGoogle Scholar
  13. 13.
    Fuat A, Hungin AP, Murphy JJ. Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study. BMJ 2003;326:196.PubMedCrossRefGoogle Scholar
  14. 14.
    Remes J, Miettinen H, Reunanen A, Pyoralaa K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 1991;12:315–21.PubMedGoogle Scholar
  15. 15.
    Francis CM, Caruana L, Kearney P, et al. Open access echocardiography in management of heart failure in the community. Br Med J 1995;310:634–6.Google Scholar
  16. 16.
    Davie AP, Francis CM, Caruana L, Sutherland GR, McMurray JJV. Assessing diagnosis in heart failure: which features are any use? Q J Med 1997;90:335–9.Google Scholar
  17. 17.
    Cowie MR, Wood DA, Coats AJS, et al. Incidence and aetiology of heart failure. A population based study. Eur Heart J 1999;20:421–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Fonseca C, Morais H, Mota T, et al. The diagnosis of heart failure in primary care: value of symptoms and signs. Eur J Heart Fail 2004;6:795–800.PubMedCrossRefGoogle Scholar
  19. 19.
    Cowie MR, Struthers AD, Wood DA, et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. Lancet 1997;350:1349–53.PubMedCrossRefGoogle Scholar
  20. 20.
    Mosterd A, Hoes AW, de Bruijne MC, et al. Prevalence of heart failure and left ventricular dysfunction in the general population. The Rotterdam Study. Eur Heart J 1999;20:447–55.PubMedCrossRefGoogle Scholar
  21. 21.
    Remes J, Reunanen A, Aromaa A, Pyorala K. Incidence of heart failure in eastern Finland: a population-based surveillance study. Eur Heart J 1992;13:588–93.PubMedGoogle Scholar
  22. 22.
    Fox KF, Cowie MR, and Wood DA, et al. Coronary artery disease as the cause of incident heart failure in the population. Eur Heart J 2001;22:228–36.PubMedCrossRefGoogle Scholar
  23. 23.
    ACC/AHA Guidelines for the evaluation and management of chronic heart failure in adult: executive summary: report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). Circulation 2001;104:2996–3007.Google Scholar
  24. 24.
    Giuli F, Khaw KT, Cowie MR, Sutton GC, Ferrari R. Poole-Wilson FA. Incidence and outcome of persons with a clinical diagnosis of heart failure in general practice population of 696,884 in the United Kingdom. Eur J Heart Fail 2005;7:295–302.PubMedCrossRefGoogle Scholar
  25. 25.
    Guidelines for the diagnosis and treatment of heart failure: executive summary (update 2005). The Task Force for the Diagnosis and treatment of heart failure of the European Society of Cardiology. Eur Heart J 2005;26:1115–40.Google Scholar
  26. 26.
    Ceia F, Fonseca C, Mota T, et al. On behalf of the EPICA investigators. Epidemiology of heart failure in mainland Portugal: new data from the EPICA study. Rev Port Cardiol 2004;23(suppl. III):15–22.Google Scholar
  27. 27.
    Dahlström U. Frequent non-cardiac comorbidities in patients with chronic heart failure. Eur J Heart Fail 2005;7:309–16.PubMedCrossRefGoogle Scholar
  28. 28.
    Harlan WR, Oberman A, Grim R, Rosati RA. Chronic congestive heart failure in coronary artery disease: clinical criteria. Ann Intern Med 1977;86:133–8.PubMedGoogle Scholar
  29. 29.
    Chakko S, Woska D, Martinez H, et al. Clinical, radiographic, and haemodynamic correlations in chronic congestive heart failure: conflicting results may lead to inappropriate care. Am J Med 1991;90:353–9.PubMedGoogle Scholar
  30. 30.
    Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 1989;261:884–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM. Congestive heart failure: ecochardiographic insights. Am J Med 1983;75:750–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Butman SM, Ewy GA, Standen JR, Kern KB Hahn E. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. J Am Coll Cardiol 1993;22:968–74.PubMedCrossRefGoogle Scholar
  33. 33.
    Marantz PR, Tobin JM, Wassertheil-Smoller S, et al. The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation 1988;77:607–12.PubMedGoogle Scholar
  34. 34.
    Sparrow N, Adlam D, Cowley A, Hampton JR. The diagnosis of heart failure in general practice: implications for the UK National Service Framework. Eur J Heart Fail 2003;5:349–54.PubMedCrossRefGoogle Scholar
  35. 35.
    Cleland JGF, Swedberg K, Follath F, Komajda M, Cohen Solal A, Aguilar JC, Dietz R, Gavazzi A, Hobbs R, Korewicki J, Madeira HC, Moiseyev VS, Preda I, van Gilst WH, Widimsky J, Freemantle N, Eastaugh J, Mason J, Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The EuroHeart Failure survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 1: Patient characteristics and diagnosis. Eur Heart J 2003;24:442–63.PubMedCrossRefGoogle Scholar
  36. 36.
    Banerjee P, Banerjee T, Khand A, et al. Diastolic heart failure-neglected or misdiagnosed? J Am Coll Cardiol 2002;39:138–41.PubMedCrossRefGoogle Scholar
  37. 37.
    Thomas JT, Kelly RF, Thomas SJ, Stamos TD, Albasha K, Parrillo JE, Calvin JE. Utility of history, physical examination, electrocardiogram, and chest radiograph for differentiating normal from decreased systolic function in patients with heart failure. Am J Med 2002;112:437–45.PubMedCrossRefGoogle Scholar
  38. 38.
    Knudson CW, Riis JS, Finsen AV, et al. Diagnostic value of rapid test for B-type natriuretic peptide in patients presenting with acute dyspnoea: effect of age and gender. Eur J Heart Fail 2004;6:55–62.CrossRefGoogle Scholar
  39. 39.
    Ceia F, Fonseca C, Mota T, et al. Aetiology co-morbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy. Eur J Heart Fail 2004;6:801–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality, in a population-based cohort. J Am Coll Cardiol 1999;33:1948–55.PubMedCrossRefGoogle Scholar
  41. 41.
    Devereux RB, Roman MJ, Liu JE, et al. Congestive heart failure despite normal left ventricular systolic function in a population-based sample: the Strong Heart study. Am J Cardiol 2000;86:1090–96.PubMedCrossRefGoogle Scholar
  42. 42.
    O'Neill TW, Barry M, Smith M, Graham IM. Diagnostic value of the apex beat. Lancet 1989;1:410–1.PubMedCrossRefGoogle Scholar
  43. 43.
    McKee PA, Castelli WP, McNamara PM, et al. The natural history of congestive heart failure: the Framingham study. N Engl J Med 1971;26:1441–6.CrossRefGoogle Scholar
  44. 44.
    Eriksson H, Caidahl K, Larsson B, et al. Cardiac and pulmonary causes of dyspnoea. A validation of a scoring test for clinical-epidemiological use. The Study of Men Born in 1913. Eur Heart J 1987;8:1007–14.PubMedGoogle Scholar
  45. 45.
    Eriksson H, Svardsudd K, Caidhal K, et al. Early heart failure in the population. The Study of Men Born in 1913. Acta Med Scand 1988;223:197–209.PubMedCrossRefGoogle Scholar
  46. 46.
    Schocken DD, Arrieta MI, Leaverton PE, Ross EA. Prevalence and mortality of congestive heart failure in the United States. J Am Coll Cardiol 1992;20:301–6.PubMedGoogle Scholar
  47. 47.
    Carlson KJ, Lee DC-S, Goroll AH, Leahy M, Johnson RA. An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients. J Chron Dis 1985;38:733–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Harlan W, Oberman A, Grimm R, Rosati RA. Chronic congestive heart failure in coronary artery disease: clinical criteria. Ann Intern Med 1977;86:133–8.PubMedGoogle Scholar
  49. 49.
    Walma EP, Hoes AW, Prins A, Boukes FS, van der Does E. Withdrawing long-term diuretic therapy in the elderly: a study in general practice in the Netherlands. Fam Med 1993;25:661–4.PubMedGoogle Scholar
  50. 50.
    Gheorghiade M, Beller GA. Effects of discontinuing maintenance digoxin therapy in patients with ischemic heart disease and congestive heart failure in sinus rhythm. Am J Cardiol 1983;51:1243–50.PubMedCrossRefGoogle Scholar
  51. 51.
    Marantz PR, Tobin JN, Wassertheil-Smoller S, et al. The relationship between left ventricular and congestive heart failure diagnosed by clinical criteria. Circulation 1988;77:607–12.PubMedGoogle Scholar
  52. 52.
    Mosterd A, Deckers JW, Hoes AW, et al. Classification of heart failure in population based research systolic function: An assessment of six heart failure scores. Eur Heart J 1997;13:491–502.Google Scholar
  53. 53.
    Fonseca C, Oliveira AG, Mota T, et al. Evaluation of the performance and concordance of clinical questionnaires for the diagnosis of heart failure in primary care. Eur J Heart Fail 2004;6:813–20.PubMedCrossRefGoogle Scholar
  54. 54.
    Elkman I, Cleland JG, Andersson B, Swedberg K. Exploring symptoms in chronic heart failure. Eur J Heart Fail 2005;7:699–703.CrossRefGoogle Scholar
  55. 55.
    Ekman I, Cleland JCF, Swedberg K, Charlesworth A, Metra M, Poole-Wilson PA. Symptoms in patients with heart failure are prognostic predictors. Insights from COMET. J Card Fail 2005;11:288–92.PubMedCrossRefGoogle Scholar
  56. 56.
    Rihal CS, Davies KB, Kennedy JW, et al. The utility of clinical electrocardiographic, and roentgenographic variables in the prediction of left ventricular function. Am J Cardiol 1995;75:220–3.PubMedCrossRefGoogle Scholar
  57. 57.
    Davie AP, Francis CM, Love MP, et al. Value of the electrocardiogram in identifying heart failure due to left ventricular systolic dysfunction. Br Med J 1996;312:22.Google Scholar
  58. 58.
    Khunti K, Squire I, Abrams KR, Sutton AJ. Accuracy of a 12 lead electrocardiogram in screening patients with suspected heart failure for open access echocardiography: a systematic review and meta-analysis. Eur J Heart Fail 2004;6:571–6.PubMedCrossRefGoogle Scholar
  59. 59.
    Khandekar S, Murphy JJ, Bossingham CM. Value of ECGs in identifying heart failure due to left ventricular systolic dysfunction. Echocardiography is still necessary. Br Med J 1996;312:1160.Google Scholar
  60. 60.
    Murphy JJ, Frain JP, Ramesh P, Siddiqui RN, Bossingham CM. Open-access echocardiography to general practitioners for suspected heart failure. Br Med J 1996;46:475–6.Google Scholar
  61. 61.
    Sandler DA, Steeds RP, Hadfield JW. Opening access to echocardiography to general practitioners in North Derbyshire. Br J Cardiol 2000;7:94–100.Google Scholar
  62. 62.
    Lindsay MM, Goodfield NE, Hogg KJ, Dunn FG. Optimising direct access ECHO referral in suspected heart failure. Scott Med J 2000;45:43–4.PubMedGoogle Scholar
  63. 63.
    Fonseca C, Mota T, Morais H, et al. The value of the electrocardiogram and the chest X-ray for confirming or refuting a suspected diagnosis of heart failure in the community. Eur J Heart Fail 2004;6:807–12.PubMedCrossRefGoogle Scholar
  64. 64.
    Sparrow N, Adlam D, Cowley A, Hampton JR. Difficulties in introducing the National Service Framework for heart failure into general practice in the UK. Eur J Heart Fail 2003;5:355–61.PubMedCrossRefGoogle Scholar
  65. 65.
    Clark AL, Coats AJ. Unreliability of cardiothoracic ratio as a marker of left ventricular impairment: comparison with radionuclide ventriculography and echocardiography. Postgrad Med J 2000;76:289–91.PubMedCrossRefGoogle Scholar
  66. 66.
    Petrie MC, McMurray JJV. It cannot be cardiac failure because the heart is not enlarged on the chest X-ray. Eur J Heart Fail 2003;5:117–9.PubMedCrossRefGoogle Scholar
  67. 67.
    The Digitalis Investigation Group: The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997;336:525–33.CrossRefGoogle Scholar
  68. 68.
    Dahlström U. Frequent non-cardiac comorbidities in patients with chronic heart failure. Eur J Heart Fail 2005;7:309–16.PubMedCrossRefGoogle Scholar
  69. 69.
    Levin ER, Gardner DG, Samson WK. Natriuretic peptides. N Eng J Med 1998;339:321–8.CrossRefGoogle Scholar
  70. 70.
    McDonagh TA, Robb SD, Murdoch DR, et al. Biochemical detection of left-ventricular systolic dysfunction. Lancet 1998;351:9–13.PubMedCrossRefGoogle Scholar
  71. 71.
    Bettencourt P. Ferreira A, Pardal-Oliveira N, et al. Clinical significance of brain natriuretic peptide in patients with post-myocardial infarction. Clin Cardiol 2000;23:921–7.PubMedGoogle Scholar
  72. 72.
    Choy AM, Darbar D, Lang CC, et al. Detection of left ventricular dysfunction after acute myocardial infarction: comparison of clinical, echocardiographic, and neurohormonal methods. Br Heart J 1994;72:16–22.PubMedGoogle Scholar
  73. 73.
    Valli N, Georges A, Corcuff JB, Barat JL, Bordenave L. Assessment of brain natriuretic peptide in patients with suspected heart failure: comparison with radionuclide ventriculography data. Clin Chim Acta 2001;306:19–26.PubMedCrossRefGoogle Scholar
  74. 74.
    Vasan RS, Benjamin EJ, Larson MG, et al. Plasma natriuretic peptides for community screening for left ventricular hypertrophy and systolic dysfunction: The Framingham Heart Study. JAMA 2002;288:1252–9.PubMedCrossRefGoogle Scholar
  75. 75.
    Hutcheon SD, Gillespie ND, Struthers AD, McMurdo ME. B-type natriuretic peptide in the diagnosis of cardiac disease in elderly day hospital patients. Age Ageing 2002;31:295–301.PubMedCrossRefGoogle Scholar
  76. 76.
    Landray MJ, Lehman R, Arnold I. Measuring brain natriuretic peptide in suspected left ventricular systolic dysfunction in general practice: cross-sectional study. Br Med J 2000;320:985–6.CrossRefGoogle Scholar
  77. 77.
    Smith H, Pickering RM, Struthers A, Simpson I, Mant D. Biochemical diagnosis of ventricular dysfunction in elderly patients in general practice: Observational study. Br Med J 2000;320:906–8.CrossRefGoogle Scholar
  78. 78.
    Davis M, Espiner E, Richards G, et al. Plasma brain natriuretic peptide in assessment of acute dyspnoea. Lancet 1994;343:440–4.PubMedCrossRefGoogle Scholar
  79. 79.
    Hobbs F, Davis R, Roalfe A, Hare R, Davies M, Kenkre J. Reliability of N-terminal pro-brain natriuretic peptide assay in diagnosis of heart failure: cohort study in representative and high risk community populations. Br Med J 2002;324:1498–500.CrossRefGoogle Scholar
  80. 80.
    Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161–7.PubMedCrossRefGoogle Scholar
  81. 81.
    Krishnaswamy P, Lubien E, Clopton P, et al. Utility of B- natriuretic peptide levels in identifying patients with left ventricular systolic or diastolic dysfunction. Am J Med 2001;111:274–9.PubMedCrossRefGoogle Scholar
  82. 82.
    Pfister R, Scholz M, Wielckens K, Erdmann E, Schneider CA. Use of NT-proBNP in routine testing and comparison to BNP. Eur J Heart Fail 2004;6:289–93.PubMedCrossRefGoogle Scholar
  83. 83.
    Doust JA, Glasziou PP, Pietrzak E, Dobson AJ. A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure. Arch Intern Med 2004;164:1978–84.PubMedCrossRefGoogle Scholar
  84. 84.
    Fonseca C, Sarmento PM, Minez A, et al. Comparative value of BNP and NT-proBNP in diagnosis of heart failure. Rev Port Cardiol 2004;23:979–91.PubMedGoogle Scholar
  85. 85.
    Dahlström U. Can natriuretic peptides be used for the diagnosis of diastolic heart failure? Eur J Heart Fail 2004;6:281–7.PubMedCrossRefGoogle Scholar
  86. 86.
    Fonseca C, Ceia F, Mota T, et al. The diagnostic challenge of heart failure with preserved systolic function in primary care setting. Eur Heart J 2003;24(suppl 1):259.CrossRefGoogle Scholar
  87. 87.
    Talwar S, Siebenhofer A, Williams B, Ng LL. Influence of hypertension, left ventricular hypertrophy, and left ventricular systolic dysfunction on plasma N-terminal pro-BNP. Heart 2000;83:278–82.PubMedCrossRefGoogle Scholar
  88. 88.
    Bayés-Genís A, Santaló-Bel M, Zapico-Muniz E, et al. N-terminal probrain natriuretic peptide (NT-proBNP) in the emergency diagnosis and in-hospital monitoring of patients with dyspnoea and ventricular dysfunction. Eur J Heart Fail 2004;301–8.Google Scholar
  89. 89.
    Seino Y, Ogawa A, Yamashita T, et al. Application of NT-proBNP and BNP measurements in cardiac care: a more discerning marker for the detection and evaluation of heart failure. Eur J Heart Fail 2004;6:295–300.PubMedCrossRefGoogle Scholar
  90. 90.
    Clerico A, Del Ry S, Maffei S, Prontera C, Endin M, Giannesi D. The circulating levels of cardiac natriuretic hormones in healthy adults: effects of age and sex. Clin Chem Lab Med 2002;40:31–7.Google Scholar
  91. 91.
    Raymond I, Groenning BA, Hildebrant PR, et al. The influence of age, sex and other variables on the plasma levels of N-terminal pro-brain natriuretic peptide in a large sample of the general population. Heart 2003;89:745–51.PubMedCrossRefGoogle Scholar
  92. 92.
    Vesely L. Natriuretic peptides and acute renal failure. Am J Renal Physiol 2003;285:F167–77.Google Scholar
  93. 93.
    McCullough PA, Sandberg KR. B-type natriuretic peptide and renal disease. Heart Fail Rev 2003;8:355–8.PubMedCrossRefGoogle Scholar
  94. 94.
    McCullough PA, Omland T, Maisel AS. B-type natriuretic peptides: a diagnostic breakthrough for clinicians. Rev Cardiol Vasc Med 2003;4:72–80.Google Scholar
  95. 95.
    Nielsen OW, Kirk V, Bay M, Boesgaard S, Nielson H. Value of N-terminal pro brain natriuretic peptide in the elderly: data from the prospective Copenhagen Hospital Heart Failure study (CHHF). Eur J Heart Fail 2004;6:275–79.PubMedCrossRefGoogle Scholar
  96. 96.
    McDonagh TA, Holmer S, Raymond I, Luchner A, Hildebrant P, Dargie HJ. NT-proBNP and the diagnosis of heart failure: a pooled analysis of three European epidemiological studies. Eur J Heart Fail 2004;6:269–73.PubMedCrossRefGoogle Scholar
  97. 97.
    Luchner A, Hengstenberg C, Lowel H, et al. N-terminal pro-brain natriuretic peptide after myocardial infarction: a marker of cardio-renal function. Hypertension 2002;39:99–104.PubMedCrossRefGoogle Scholar
  98. 98.
    Raymond I, Petersen R, Steensgaard-Hansen F, et al. Prevalence of impaired left ventricular systolic function and heart failure in middle aged and elderly urban population segment of Copenhagen. Heart 2003;89:1422–9.PubMedCrossRefGoogle Scholar
  99. 99.
    McCullough PA, Nowak RM, McCord J, et al. B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure: analysis from breathing Not Properly (BNP) Multinational Study. Circulation 2002;106:416–22.PubMedCrossRefGoogle Scholar
  100. 100.
    Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by Echocardiography Committee on standards, Subcommittee on quantitation of two-dimensional echocardiograms. J Am Soc Echocardiogr 1989;2:358–67.PubMedGoogle Scholar
  101. 101.
    Teichholz LE, Kreulen T, Herman MV, Gorlin R. Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence or absence of asynergy. Am J Cardiol 1976;37:7–11.PubMedCrossRefGoogle Scholar
  102. 102.
    Berning J, Rokkedal NJ, Launbjerg J, et al. Rapid estimation of left ventricular ejection fraction in acute myocardial infarction by echocardiographic wall motion analysis. Cardiology 1992;80:257–66.PubMedCrossRefGoogle Scholar
  103. 103.
    Bonow RO, Carabello BA, de Leon AC, et al. Guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines. Circulation 1998;98:1949–84.PubMedGoogle Scholar
  104. 104.
    European Study Group on Diastolic Heart Failure. How to diagnose diastolic heart failure. Eur Heart J 1998;19:990–1003.CrossRefGoogle Scholar
  105. 105.
    Vasan RS, Levy D. Defining diastolic heart failure. A call for more standardized diagnostic criteria. Circulation 2000;101:2118–21.PubMedGoogle Scholar
  106. 106.
    Benjamin EJ, Levy D, Anderson KM, et al. Determinants of Doppler indexes of left ventricular diastolic dysfunction in normal subjects (the Framingham Heart Study). Am J Cardiol 1992;70:508–15.PubMedCrossRefGoogle Scholar
  107. 107.
    Iwase M, Nagata K, Izawa H, et al. Age-related changes in left and right ventricular filling velocity profiles and their relationship in normal subjects. Am Heart J 1993;126:419–26.PubMedCrossRefGoogle Scholar
  108. 108.
    Cahill JM, Horan M, Quigley P, Maurer BJ, McDonald K. Doppler-echocardiographic indices of diastolic function in heart failure admissions with preserved left ventricular systolic function. Eur J Heart Failure 2002;4:473–8.CrossRefGoogle Scholar
  109. 109.
    Jarnert C, Mejhert M, Ring M, Persson H, Edner M. Doppler tissue imaging in congestive heart failure patients due to diastolic or systolic dysfunction: a comparison with Doppler echocardiography and the atrio-ventricular plane displacement technique. Eur J Heart Failure 2000;2:151–60.CrossRefGoogle Scholar
  110. 110.
    Vinereanu D, Nicolaides E, Tweddel AC, Fraser AG. “Pure” diastolic dysfunction is associated with long-axis systolic dysfunction. Implications for the diagnosis and classification of heart failure. Eur J Heart Fail 2005;7:820–28.PubMedCrossRefGoogle Scholar
  111. 111.
    The SOLVD investigators. Effects of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Eng J Med 1991;325:293–302.CrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2006

Authors and Affiliations

  1. 1.São Francisco Xavier Hospital, Medical Sciences SchoolNew University of LisbonPortugal

Personalised recommendations