Interrater reliability of hemodynamic profiling of patients with heart failure in the ED.

OBJECTIVE: Hemodynamic profiling (HP) of patients with heart failure (HF) based on clinical assessment of central congestion and peripheral perfusion has been widely used by cardiologists to help guide therapy and determine prognosis but has never been tested or validated in the emergency department (ED). We hypothesized that the interrater reliability of HP in the ED would be good or greater than 0.6.

METHODS: Study design. This was a prospective, observational study. Setting. It was conducted in an academic suburban ED with emergency medicine residency. Subjects. A convenience sample of patients presenting to the ED with suspected acute decompensated HF was enrolled. Measures. Demographic and clinical information was collected using standardized data collection forms. Two emergency medicine physicians (masked to each other) evaluated all patients and classified them into 1 of 4 hemodynamic categories based on the presence or absence of central congestion (wet or dry) and peripheral hypoperfusion (cold or warm): warm and dry, warm and wet, cold and dry, and cold and wet. B-type natriuretic peptide levels, objective test of cardiac function, and final cardiologist diagnoses were obtained. Data analysis. Interrater reliabilities for overall hemodynamic profile and individual elements of congestion and perfusion were calculated using kappa coefficients.

RESULTS: Sixty-eight patients were enrolled. Their mean age was 72 +/- 14 years, 53% were female, and 78% were white. Of the patients, 79% had a final diagnosis of HF. Most patients (>60%) were considered wet and warm. Interrater agreement for HP was 64%, kappa = 0.28 (95% confidence interval, 0.01-0.51). Interrater agreement was poor to fair for all elements of congestion and perfusion except peripheral edema (kappa = 0.67) and a narrow pulse pressure (kappa = 0.66).

CONCLUSIONS: Hemodynamic profiling of patients with HF by emergency physicians in the ED is not highly reliable. One in 5 patients thought to have HF in the ED did not have a final diagnosis of HF.