Chronic heart failure in the community: missed diagnosis and missed opportunities

BACKGROUND: The aim of this study was to determine the incidence of congestive heart failure (CHF) in patients discharged from a hospital without a diagnosis of CHF who were admitted with shortness of breath and had a low left ventricular ejection fraction (LVEF). CHF is a devastating disease in terms of financial cost, prevalence, and effect on morbidity and mortality. The true incidence rate is not known because of reliance on discharge records and death certificates, and because diagnosis remains a clinical judgment. METHODS AND RESULTS: CHF was diagnosed by the Framingham criteria. We retrospectively reviewed the records of 225 randomly selected patients admitted with a complaint of shortness of breath and discharged without a diagnosis of CHF (group 1). We compared group 1 with patients admitted at the same time with a diagnosis of CHF and of similar age and LVEF (group 2). In group 1, 100 patients had a low LVEF (< or =40%) and 51% met criteria for CHF that had been missed. Readmission rate was high (42%). Mortality at 12 months was 18%. Rate of cardiomegaly on x-ray films was similar in groups 1 and 2 (64.6% v 64.4%, respectively). Third heart sound (39% v 10%; P <.001) and heart rate > 120 beats/min (41.7% v 12.5%; P <.001) were significantly more frequent in group 1. By contrast, signs and symptoms suggestive of fluid overload were more frequent in group 2. CONCLUSIONS: Many patients admitted with shortness of breath and low LVEF have CHF but are not diagnosed. Physicians are more likely to miss CHF in patients presenting without signs of fluid overload even when third heart sound is present with resting tachycardia. A missed diagnosis of CHF is associated with a high readmission rate, multiple admissions, and a mortality rate comparable to that of patients with newly diagnosed CHF.