Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath

Frances Russell, Christopher L. Moore, D. Mark Courtney, Christopher Kabrhel, Howard A. Smithline, Kristen E. Nordenholz, Peter B. Richman, Brian J. O'Neil, Michael C. Plewa, Daren Beam, Ronald Mastouri, Jeffrey Kline

Research output: Contribution to journalArticle

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Abstract

Background Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53% of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. Methods A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. Results A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19% (95% confidence interval [CI], 14%-25%) and 33% (95% CI, 25%-42%) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39% vs 18%; 95% CI of the difference, 4%-38%). Conclusion This simple clinical prediction rule predicted a 33% prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes.

Original languageEnglish
Pages (from-to)542-547
Number of pages6
JournalThe American journal of emergency medicine
Volume33
Issue number4
DOIs
StatePublished - Apr 1 2015

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Right Ventricular Dysfunction
Decision Support Techniques
Dyspnea
Angiography
Lung
Confidence Intervals
Hospital Emergency Service
Tricuspid Valve Insufficiency
Multicenter Studies
Observational Studies
Echocardiography
Dilatation

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath. / Russell, Frances; Moore, Christopher L.; Courtney, D. Mark; Kabrhel, Christopher; Smithline, Howard A.; Nordenholz, Kristen E.; Richman, Peter B.; O'Neil, Brian J.; Plewa, Michael C.; Beam, Daren; Mastouri, Ronald; Kline, Jeffrey.

In: The American journal of emergency medicine, Vol. 33, No. 4, 01.04.2015, p. 542-547.

Research output: Contribution to journalArticle

Russell, Frances ; Moore, Christopher L. ; Courtney, D. Mark ; Kabrhel, Christopher ; Smithline, Howard A. ; Nordenholz, Kristen E. ; Richman, Peter B. ; O'Neil, Brian J. ; Plewa, Michael C. ; Beam, Daren ; Mastouri, Ronald ; Kline, Jeffrey. / Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath. In: The American journal of emergency medicine. 2015 ; Vol. 33, No. 4. pp. 542-547.
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abstract = "Background Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53{\%} of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. Methods A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. Results A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19{\%} (95{\%} confidence interval [CI], 14{\%}-25{\%}) and 33{\%} (95{\%} CI, 25{\%}-42{\%}) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39{\%} vs 18{\%}; 95{\%} CI of the difference, 4{\%}-38{\%}). Conclusion This simple clinical prediction rule predicted a 33{\%} prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes.",
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T1 - Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath

AU - Russell, Frances

AU - Moore, Christopher L.

AU - Courtney, D. Mark

AU - Kabrhel, Christopher

AU - Smithline, Howard A.

AU - Nordenholz, Kristen E.

AU - Richman, Peter B.

AU - O'Neil, Brian J.

AU - Plewa, Michael C.

AU - Beam, Daren

AU - Mastouri, Ronald

AU - Kline, Jeffrey

PY - 2015/4/1

Y1 - 2015/4/1

N2 - Background Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53% of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. Methods A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. Results A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19% (95% confidence interval [CI], 14%-25%) and 33% (95% CI, 25%-42%) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39% vs 18%; 95% CI of the difference, 4%-38%). Conclusion This simple clinical prediction rule predicted a 33% prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes.

AB - Background Many patients have unexplained persistent dyspnea after negative computed tomographic pulmonary angiography (CTPA). We hypothesized that many of these patients have isolated right ventricular (RV) dysfunction from treatable causes. We previously derived a clinical decision rule (CDR) for predicting RV dysfunction consisting of persistent dyspnea and normal CTPA, finding that 53% of CDR-positive patients had isolated RV dysfunction. Our goal is to validate this previously derived CDR by measuring the prevalence of RV dysfunction and outcomes in dyspneic emergency department patients. Methods A secondary analysis of a prospective observational multicenter study that enrolled patients presenting with suspected PE was performed. We included patients with persistent dyspnea, a nonsignificant CTPA, and formal echo performed. Right ventricular dysfunction was defined as RV hypokinesis and/or dilation with or without moderate to severe tricuspid regurgitation. Results A total of 7940 patients were enrolled. Two thousand six hundred sixteen patients were analyzed after excluding patients without persistent dyspnea and those with a significant finding on CTPA. One hundred ninety eight patients had echocardiography performed as standard care. Of those, 19% (95% confidence interval [CI], 14%-25%) and 33% (95% CI, 25%-42%) exhibited RV dysfunction and isolated RV dysfunction, respectively. Patients with isolated RV dysfunction or overload were more likely than those without RV dysfunction to have a return visit to the emergency department within 45 days for the same complaint (39% vs 18%; 95% CI of the difference, 4%-38%). Conclusion This simple clinical prediction rule predicted a 33% prevalence of isolated RV dysfunction or overload. Patients with isolated RV dysfunction had higher recidivism rates and a trend toward worse outcomes.

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