Diagnostic Accuracy of Modalities For Acute Heart Failure In Emergency Settings. A Systematic Review and Diagnostic Accuracy Meta-Analysis

Abstract

Background: Acute heart failure diagnosis in emergency departments remains challenging despite multiple available diagnostic modalities. Current emergency evaluations rely variably on clinical assessment, biomarkers, and ultrasound techniques; however, their comparative diagnostic accuracy remains inadequately compared in previous studies. This systematic review and meta-analysis aim to evaluate the diagnostic accuracy of four categories of diagnostic approaches: Clinical Assessment, Biomarker Assessment, Basic Ultrasound Assessment, and Advanced Ultrasound Assessment for diagnosing acute heart failure in emergency settings. Methods: We conducted a literature review across PubMed/MEDLINE, Scopus, Google Scholar, Cochrane Library, Google Scholar, and Web of Science up to December 2024. Studies investigating the diagnostic modalities for acute heart failure in emergency settings with sufficient data to construct 2×2 contingency tables were included. Two independent reviewers performed screening, data extraction, and quality assessment using QUADAS-2. Diagnostic accuracy was synthesized using a bivariate random-effects model. Summary receiver operating characteristic (SROC) curves, pooled sensitivity, specificity, and area under the curve (AUC) were calculated with 95% confidence intervals (CI). Heterogeneity was assessed using I² statistics and publication bias with Deeks' funnel plot. Results: Thirty-three studies including a total of 17 participants to 1,586 participants met the inclusion criteria. Clinical Assessment demonstrated moderate diagnostic performance (AUC=0.591) with limited sensitivity (0.500, 95% CI: 0.484-0.515) but high specificity (0.858, 95% CI: 0.830-0.886). Biomarker Assessment showed excellent performance (AUC=0.906) with high sensitivity (0.874, 95% CI: 0.872-0.875) and good specificity (0.781, 95% CI: 0.778-0.783). Basic Ultrasound Assessment had moderate performance (AUC=0.750) with low sensitivity (0.349, 95% CI: 0.303-0.395) but high specificity (0.889, 95% CI: 0.874-0.904). Advanced Ultrasound Assessment demonstrated excellent performance (AUC=0.892) with good sensitivity (0.713, 95% CI: 0.705-0.720) and very high specificity (0.903, 95% CI: 0.900-0.905). All modalities showed remarkably consistent performance across studies (I²=0%). Conclusion: Biomarker Assessment provides the highest overall diagnostic accuracy for acute heart failure in emergency settings, while Advanced Ultrasound Assessment offers the optimal balance between sensitivity and specificity when equipment and expertise are available. Clinical Assessment alone has limitations for detecting acute heart failure but remains useful for exclusion. Our findings highly recommend adapting a multimodal diagnostic approach integrating biomarkers and advanced ultrasound techniques whenever possible for optimal diagnostic accuracy in emergency settings.