European Journal of Epidemiology

, Volume 13, Issue 5, pp 491–502 | Cite as

Classification of heart failure in population based research: An assessment of six heart failure scores

  • Arend Mosaterd
  • Jaap W. Deckers
  • Arno W. Hoes
  • Angelique Nederpel
  • Albert Smeets
  • David T. Linker
  • Diederick E. Grobbee


Several scores based on symptoms and signs have been developed to assess the presence of heart failure. The goal of this study was to compare six heart failure scores in non-hospitalised subjects and to determine their usefulness in population based research. The scores were applied to 54 participants of a population based study. All underwent a complete medical examination, including chest X-ray, electrocardiography and Doppler echocardiography. Using all information available, a cardiologist, unaware of the results of the scores, clinically classified participants as having no, possible or definite heart failure. Sensitivity, specificity, predictive values and receiver operating characteristics were calculated, using the cardiologist's assessment as a gold standard. The cardiologist judged definite or possible heart failure to be present in 17 persons. All scores had a high sensitivity for the detection of definite heart failure, whereas the study of men born in 1913 and Walma's score had the highest sensitivity for the combination of possible and definite heart failure. Gheorgiade's and the Boston score had the highest positive predictive values. In conclusion, five of the six scores we studied are broadly similar in the detection of heart failure. The men born in 1913 score relies heavily on the assessment of dyspnea, resulting in a relatively large number of false positives. Although the scores are useful in detecting manifest heart failure, objective measurements of cardiac function appear necessary to reduce the false positive rate and accurately detect early stages of heart failure.

Classification Epidemiology Heart failure Predictive value Sensitivity Specificity 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: The Framingham Study. J Am Coll Cardiol 1993; 22: 6A-13A.Google Scholar
  2. 2.
    Bonneux L, Barendregt JJ, Meeter K, Bonsel GJ, van der Maas PJ. Estimating clinical morbidity due to ischemic heart disease and congestive heart failure: The future rise of heart failure. Am J Public Health 1994; 84: 20–28.Google Scholar
  3. 3.
    Lenfant C. Report of the task force on research in heart failure. Circulation 1994; 90: 1118–1123.Google Scholar
  4. 4.
    Ho KK, Anderson KM, Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation 1993; 88: 107–115.Google Scholar
  5. 5.
    Rodeheffer RJ, Jacobsen SJ, Gersh BJ, et al. The incidence and prevalence of congestive heart failure in Rochester, Minnesota. Mayo Clin Proc 1993; 68: 1143–1150.Google Scholar
  6. 6.
    Packer M. Pathophysiology of chronic heart failure. Lancet 1992; 340: 88–92.Google Scholar
  7. 7.
    Denolin H, Kuhn H, Krayenbuehl H, Loogen F, Reale A. The definition of heart failure. Eur Heart J 1983; 4: 445–448.Google Scholar
  8. 8.
    Hlatky MA, Fleg JL, Hinton PC, et al. Physician practice in the management of congestive heart failure. J Am Coll Cardiol 1986; 8: 966–970.Google Scholar
  9. 9.
    Marantz PR, Alderman MH, Tobin JN. Diagnostic heterogeneity in clinical trials for congestive heart failure. Ann Intern Med 1988; 109: 55–61.Google Scholar
  10. 10.
    Guyatt GH. Methodologic problems in clinical trials in heart failure. J Chronic Dis 1985; 38: 353–363.Google Scholar
  11. 11.
    Chakko S, Gheorghiade M. Estimating severity of chronic heart failure: A clinical challenge for the 1990s. Am Heart J 1992; 124: 260–264.Google Scholar
  12. 12.
    McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: The Framingham Study. N Engl J Med 1971; 285: 1441–1446.Google Scholar
  13. 13.
    Wilhelmsen L, Eriksson H, Svardsudd K, Caidahl K. Improving the detection and diagnosis of congestive heart failure. Eur Heart J 1989; 10(suppl C): 13–18.Google Scholar
  14. 14.
    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: 1243–1250.Google Scholar
  15. 15.
    Carlson KJ, Lee DC, Goroll AH, Leahy M, Johnson RA. An analysis of physicians' reasons for prescribing long-term digitalis therapy in outpatients. J Chronic Dis 1985; 38: 733–739.Google Scholar
  16. 16.
    Schocken DD, Arrieta MI, Leaverton PE, Ross EA. Prevalence and mortality rate of congestive heart failure in the United States. J Am Coll Cardiol 1992; 20: 301–306.Google Scholar
  17. 17.
    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: 661–664.Google Scholar
  18. 18.
    Lee DC, Johnson RA, Bingham JB, et al. Heart failure in outpatients: a randomized trial of digoxin versus placebo. N Engl J Med 1982; 306: 699–705.Google Scholar
  19. 19.
    Hofman A, Grobbee DE, de Jong PT, van den Ouweland FA. Determinants of disease and disability in the elderly: The Rotterdam Elderly Study. Eur J Epidemiol 1991; 7: 403–422.Google Scholar
  20. 20.
    Remes J, Miettinen H, Reunanen A, Pyorala K. Validity of clinical diagnosis of heart failure in primary health care. Eur Heart J 1991; 12: 315–321.Google Scholar
  21. 21.
    Rose GA, Blackburn H. Cardiovascular survey methods. Geneva: WHO, 1968.Google Scholar
  22. 22.
    Willems JL, Abreu-Lima C, Arnaud P, et al. The diagnostic performance of computer programs for the interpretation of electrocardiograms. N Engl J Med 1991; 325: 1767–1773.Google Scholar
  23. 23.
    Sahn DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantication in M-mode echocardiography: Results of a survey of echocardiographic measurements. Circulation 1978; 58: 1072–1083.Google Scholar
  24. 24.
    The Criteria Committee of the New York Heart Association. Diseases of the heart and blood vessels, 6th ed. Boston: Little, Brown & Co. 1995.Google Scholar
  25. 25.
    Altman DG. Practical statistics for medical research. London: Chapman & Hall, 1993.Google Scholar
  26. 26.
    Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982; 143: 29–36.Google Scholar
  27. 27.
    Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 1983; 148: 839–843.Google Scholar
  28. 28.
    The Task Force on Heart Failure of the European Society of Cardiology. Guidelines for the diagnosis of heart failure. Eur Heart J 1995; 16: 741–751.Google Scholar
  29. 29.
    The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure: Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987; 316: 1429–35.Google Scholar
  30. 30.
    Anonymous. Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet 1993; 342: 821–828.Google Scholar
  31. 31.
    The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293–302.Google Scholar
  32. 32.
    Goldman L, Hashimoto B, Cook EF, Loscalzo A. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: Advantages of a new specific activity scale. Circulation 1981; 64: 1227–1234.Google Scholar
  33. 33.
    Gaasch WH. Diagnosis and treatment of heart failure based on left ventricular systolic or diastolic dysfunction. JAMA 1994; 271: 1276–1280.Google Scholar
  34. 34.
    Bonow RO, Udelson JE. Left ventricular diastolic dysfunction as a cause of congestive heart failure. Mechanisms and management. Ann Intern Med 1992; 117: 502–510.Google Scholar
  35. 35.
    Vasan RS, Benjamin EJ, Levy D. Prevalence, clinical features and prognosis of diastolic heart failure: An epidemiologic perspective. J Am Coll Cardiol 1995; 26: 1565–1574.Google Scholar
  36. 36.
    McCall D. Recognition and management of asymptomatic patients with left ventricular dysfunction. Am J Cardiol 1992; 69: 130G-139G.Google Scholar
  37. 37.
    The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992; 327: 685–691.Google Scholar
  38. 38.
    Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. N Engl J Med 1992; 327: 669–677.Google Scholar
  39. 39.
    Marantz PR, Tobin JN, Wassertheil-Smoller S, et al. The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation 1988; 77: 607–612.Google Scholar
  40. 40.
    Eriksson H, Svardsudd K, Caidahl K, et al. Early heart failure in the population. The study of men born in 1913. Acta Med Scand 1988; 223: 197–209.Google Scholar
  41. 41.
    Eriksson H, Caidahl K, Larsson B, et al. Cardiac and pulmonary causes of dyspnoea — validation of a scoring test for clinical-epidemiological use: The Study of Men Born in 1913. Eur Heart J 1987; 8: 1007–1014.Google Scholar
  42. 42.
    Mosterd A. Epidemiology of heart failure. Thesis. Rotterdam, 1997.Google Scholar
  43. 43.
    Dargie HJ, McMurray JJ. Diagnosis and management of heart failure. Br Med J 1994; 308: 321–328.Google Scholar
  44. 44.
    Goldsmith SR, Dick C. Differentiating systolic from diastolic heart failure: Pathophysiologic and therapeutic considerations. Am J Med 1993; 95: 645–655.Google Scholar
  45. 45.
    Wheeldon NM, Clarkson P, MacDonald TM. Diastolic heart failure. Eur Heart J 1994; 15: 1689–1697.Google Scholar
  46. 46.
    Lerman A, Gibbons RJ, Rodeheffer RJ, et al. Circulating N-terminal atrial natriuretic peptide as a marker for symptomless left-ventricular dysfunction. Lancet 1993; 341: 1105–1109.Google Scholar
  47. 47.
    Benedict CR. Neurohumoral aspects of heart failure. Cardiol Clin 1994; 12: 9–23.Google Scholar
  48. 48.
    Armstrong PW, Moe GW. Medical advances in the treatment of congestive heart failure. Circulation 1993; 88: 2941–2952.Google Scholar
  49. 49.
    Garg R, Yusuf S. Overview of randomized trials of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure. JAMA 1995; 273: 1450–1406.Google Scholar

Copyright information

© Kluwer Academic Publishers 1997

Authors and Affiliations

  • Arend Mosaterd
    • 1
    • 2
  • Jaap W. Deckers
    • 2
  • Arno W. Hoes
    • 1
    • 3
    • 4
  • Angelique Nederpel
    • 1
    • 2
  • Albert Smeets
    • 5
  • David T. Linker
    • 6
  • Diederick E. Grobbee
    • 1
    • 4
  1. 1.Department of Epidemiology and BiostatisticsThe Netherlands
  2. 2.Thoraxcenter, Department of CardiologyUniversity Hospital Rotterdam ‘Dijkzigt’RotterdamThe Netherlands
  3. 3.Department of General PracticeErasmus University Medical SchoolRotterdamThe Netherlands
  4. 4.Department of Epidemiology and Public HealthUtrecht UniversityUtrechtThe Netherlands
  5. 5.Department of RadiologyCarolus HospitalDen BoschThe Netherlands
  6. 6.Division of CardiologyUniversity of WashingtonSeattleUSA

Personalised recommendations