Utility of History, Physical Examination, Electrocardiogram, and ...

ecorded, and it is possible that the temporal evolution of
symptoms may differ in the two groups of patients. We
also excluded patients in whom left ventricular function
was not measured, which may have introduced bias.
However, only 15% of admitted patients were excluded
for this reason. In addition, ejection fraction was determined
by visual estimation of ECGs. Interobserver and
intraobserver variability of estimates of ejection fractions
were not calculated, but this method correlates well with
radionuclide angiography (r 0.88), with low interobserver
variability (r 0.88) in patients with adequate images
(31). Although the data were collected prospectively,
some physicians may have known the ejection fractions
of their patients when they recorded their admission
notes. In addition, this study was performed in an innercity
hospital that had patients with a high prevalence of
hypertension, and these results may not apply to other
groups of patients. Nevertheless, the prevalence of diastolic
dysfunction was similar to that reported in other
studies (11,32).
The etiology and prognosis of heart failure may be different
in patients with normal or decreased systolic function
(1,5). The treatment of diastolic dysfunction is not
well defined; if future trials find that standard therapies
for systolic dysfunction are equally effective in patients
with diastolic dysfunction, recommendations to determine
left ventricular function in patients with heart failure
may need to be reassessed. However, our results indicate
that differences in clinical parameters are not of sufficient
magnitude to allow systolic function to be
predicted reliably in a patient with heart failure, and support
the recommendations of the American College of
Cardiology/American Heart Association (5) and the
Agency for Health Care Policy and Research (33) that all
patients with heart failure should undergo echocardiography
or radionuclide ventriculography to measure left
ventricular function.
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