Background: The value of symptoms and signs in the diagnosis of CHF has rarely been tested in large numbers of patients in the community. The aim of this study was to evaluate the importance of symptoms, signs, and past medical history in the diagnosis of CHF in primary care. Methods: Data on a sample of Portuguese men and women attending 365 primary care centres for any condition other than the treatment of acute infection, metabolic conditions or pregnancy were collected. All subjects who scored three or more points in the sum of categories one and two of the Boston questionnaire (history and physical examination) and those being treated for heart failure with loop or thiazide diuretics were considered to have possible heart failure and referred for further assessment including a resting echocardiogram. The sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio (LR) for the diagnosis of heart failure were calculated. Results: A total of 5434 subjects were identified, of whom 1058 fulfilled the criteria for further assessment; 551 subjects had cardiac dysfunction at rest, of which 35.5% were in NYHA class I and 4.9% in class IV. Prior use of digoxin (LR 24.9) and/or diuretics (LR 10.6), a history of coronary artery disease (LR 7.1) or of pulmonary oedema (LR 54.2), were associated with a greater likelihood of having heart failure. Amongst current symptoms, a history of paroxysmal nocturnal dyspnoea (LR 35.5), orthopnea (LR 39.1) and breathlessness when walking on the flat (LR 25.8) were associated with a diagnosis of heart failure. However, these symptoms were not frequent amongst patients with heart failure within this population (sensitivity b36%). Jugular pressure N6 cm with hepatic enlargement, and oedema of the lower limbs (LR 130.3), a ventricular gallop (LR 30.0), a heart rate above 110 bpm (LR 26.7), and rales at pulmonary auscultation (LR 23.3) were all associated with a diagnosis of heart failure, but were infrequent findings in patients with heart failure (sensitivity b10%). Conclusions: Symptoms and signs, and clinical history had limited value in diagnosing heart failure when used alone. The signs and symptoms that best predicted a diagnosis of heart failure were those associated with more severe disease. If investigation is limited to patients with more definite symptoms and signs of heart failure, fewer than 50% of cases will be identified and a large number of patients with mild symptoms will be missed.

Aim: To validate and estimate the performance statistics and concordance of seven clinical questionnaires for the diagnosis of chronic heart failure (HF). Methods: Community-based epidemiological survey of patients aged N25 years attending a random sample of primary health care centers in Portugal. Heart failure was identified according to the Guidelines of the European Society of Cardiology (ESC). Results: A total of 5434 subjects evaluated by 365 investigators were eligible for analysis, 551 of which had criteria for heart failure. Overall, the questionnaires had high specificity, usually above 90%, but low sensitivity, providing an increase in the likelihood of heart failure from 4.3% pre-test to 25-35% post-test in most cases. The Gfteborg questionnaire was the most balanced regarding sensitivity (84%) and specificity (81%) but this may reflect its use of prescription of digoxin or diuretics as diagnostic criteria for diagnosis. The Walma, Framingham and NHANES-I questionnaires performed similarly (Sensitivity: 63%, Specificity: 93%), while the Boston and the Gheorghiade questionnaires had a somewhat lower sensitivity (55%). Concordance was good between the Boston, Framingham, Gheorghiade, NHANES-I and Walma questionnaires. Conclusions: This study evaluated seven clinical questionnaires for the diagnosis of heart failure in the community. Their low sensitivity impairs their usefulness as diagnostic instruments, but their high specificity makes them useful for the identification of patients with fluid retention and/or exercise intolerance from non-cardiac causes.

Background: There is a common assumption that a normal ECG or a normal heart size on chest X-ray virtually rules out a diagnosis of heart failure. Aims: To assess the value of the electrocardiogram and chest X-ray in identifying patients with chronic heart failure in the community. Methods and results: This study was a secondary analysis of data prospectively collected at the time of patient's enrolment in the EPICA study, an epidemiological study of the prevalence of heart failure in Portugal. A total of 6300 subjects were clinically evaluated. Patients who presented with symptoms or signs of heart failure, and/or were receiving diuretics for chronic heart failure (CHF) had a chest X-ray, ECG, and echocardiogram. The diagnosis of heart failure was confirmed in 551 cases. Patients with right atrial enlargement, atrial flutter, atrial fibrillation, 2nd degree-Mobitz I atrioventricular block, 1st degree atrioventricular block, left bundle branch block, lung interstitial oedema, and bilateral pleural effusion were more likely to be diagnosed with heart failure. For the diagnosis of heart failure, in the Portuguese population aged over 25 years, an abnormal electrocardiogram had an estimated sensitivity of 81%, and negative predictive value of 75%; an abnormal chest X-ray had an estimated sensitivity of 57%, and negative predictive value of 83%. Twenty five percent of patients with CHF had a normal ECG or chest X-ray. Conclusion: Our results show that electrocardiographic and roentgenographic features are not sufficient to allow heart failure to be reliably predicted in the community and support the recommendation that all patients with suspected heart failure should undergo echocardiography.

Background: Chronic heart failure (CHF) is common and is frequently managed by primary care physicians (PCPs). Despite the European Society of Cardiology (ESC) Guidelines, standard treatments for CHF are frequently underutilised, particularly in primary care. Aim: To evaluate current drug therapy for CHF in adults with HF diagnosed according to ESC guidelines in the context of the EPICA study. Aetiological features and therapy relevant comorbidities were also analysed. Methods: EPICA was a community-based epidemiological study conducted in mainland Portugal. The study involved 365 primary care physicians, who evaluated 6300 primary care attendees aged over 25 years. CHF was diagnosed by clinical and echocardiography criteria according to ESC guidelines. Results: Total of 551 cases of CHF were identified, with a mean age of 65F9 years. The estimated overall prevalence of CHF in the Portuguese population was 4.4%; 1.3% with and 1.7% without left ventricular systolic dysfunction (LVSD). There are 6,280,792 people aged N25 years in Portugal, which extrapolates to 261,400 cases of heart failure. About 80% of patients had a history of hypertension, 39% had a history of coronary artery disease and 15% had atrial fibrillation. Only 58% of patients were on angiotensin-converting enzyme (ACE) inhibitors and 7% on beta-blockers. The type of ventricular dysfunction, age and presence of renal failure had little effect on prescription rates. Diuretics were prescribed in 78%. Thiazides were used more frequently in those with preserved systolic function and frusemide in those with left ventricular systolic dysfunction. Digoxin was prescribed more often to patients with than without left ventricular systolic dysfunction (34% vs. 17%; p=0.02). Long-acting nitrates were prescribed to 20% and amiodarone to 8% of patients. Conclusion: The EPICA study, as in other studies in primary care in Europe, particularly the IMPROVEMENT study, suggests that greater efforts are required to improve training of primary care teams in the management of CHF.

Calciphylaxis is a rare condition characterized by the emergence of non-healing skin ulcers secondary to arterial calcification and thrombosis, typically diagnosed in patients with end-stage kidney disease (ESKD). When it develops in patients without ESKD, it is called non-uremic calciphylaxis (NUC). The latter is an even rarer diagnosis with an uncertain pathophysiology and a high mortality rate (52%), mainly due to sepsis (50%). Cutaneous biopsy is diagnostic. Therapeutic measures recommended for NUC are limited to wound debridement, analgesia, and control of infection and risk factors. Other therapeutic options exist but with a low level of evidence. We present the case of a 78-year-old woman with NUC in her lower limbs who died of sepsis. NUC is a therapeutic challenge lacking efficient strategies.LEARNING POINTSCalciphylaxis in the absence of end-stage kidney disease is called non-uremic calciphylaxis (NUC).This disease is a diagnostic and therapeutic challenge.As therapeutic strategies for NUC mainly derive from those for uremic calciphylaxis, more efficient therapeutic measures and evidence-based recommendations are needed.

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