title: Independent evaluation of a simple clinical prediction rule to identify right ventricular dysfunction in patients with shortness of breath.
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%).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN. Electronic address: framruss@iupui.edu.
authors.forename: Frances M
authors.initials: FM
authors.lastname: Russell
authors.affiliation: Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT. Electronic address: chris.moore@yale.edu.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Moore
authors.affiliation: Department of Emergency Medicine, Northwestern University, Evanston, IL. Electronic address: mcourtney@nmff.org.
authors.forename: D Mark
authors.initials: DM
authors.lastname: Courtney
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA. Electronic address: ckabrhel@partners.org.
authors.forename: Christopher
authors.initials: C
authors.lastname: Kabrhel
authors.affiliation: Department of Emergency Medicine, Baystate Medical Center, Springfield, MA. Electronic address: howard.smithline@bhs.org.
authors.forename: Howard A
authors.initials: HA
authors.lastname: Smithline
authors.affiliation: Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO. Electronic address: Kristen.Nordenholz@ucdenver.edu.
authors.forename: Kristen E
authors.initials: KE
authors.lastname: Nordenholz
authors.affiliation: Department of Emergency Medicine, Texas A&M Health Science Center, Corpus Christi, TX. Electronic address: prichmanmdmba@gmail.com.
authors.forename: Peter B
authors.initials: PB
authors.lastname: Richman
authors.affiliation: Department of Emergency Medicine, Wayne State University, Detroit, MI. Electronic address: boneil@med.wayne.edu.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: O'Neil
authors.affiliation: Department of Emergency Medicine, Mercy St Vincent Mercy Medical Center, Toledo, OH. Electronic address: Michael_Plewa@mhsnr.org.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Plewa
authors.affiliation: Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN. Electronic address: dmbeam@iu.edu.
authors.forename: Daren M
authors.initials: DM
authors.lastname: Beam
authors.affiliation: Department of Internal Medicine, Division of Cardiology, Indiana University School of Medicine, Indianapolis, IN. Electronic address: ramastou@iu.edu.
authors.forename: Ronald
authors.initials: R
authors.lastname: Mastouri
authors.affiliation: Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN. Electronic address: jefkline@iupui.edu.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kline
mesh_terms: D000792:Angiography; D003661:Decision Support Techniques; D003937:Diagnosis, Differential; D004417:Dyspnea / Q000175:diagnosis*; D004452:Echocardiography; D005260:Female; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed; D018497:Ventricular Dysfunction, Right / Q000175:diagnosis*