Nurses’ performance in classifying heart failure patients based on physical exam: comparison with cardiologist’s physical exam and levels of N‐terminal pro‐B‐type natriuretic peptide
Authors: Sauer Jaquelini , Rabelo Eneida R , Castro Raquel A , Goldraich Livia , Rohde Luis E , Clausell Nadine , Beck‐da‐Silva Luis 
Published: October 2010

Aim.  The purpose of this study is to compare clinical assessment of congestion performed by a nurse to that performed by cardiologist and correlate them with NT‐ProBNP levels.

Background.  The nurses’ role in heart failure has been strongly focused in therapeutic, educational and self‐care interventions. The diagnostic performance of nurses in heart failure outpatients is not well explored. N‐terminal pro‐B‐type natriuretic peptide is a cardiac marker that reflects elevated filling pressures.

Design.  Cross‐sectional contemporaneous study.

Methods.  Heart failure outpatients underwent a systematic clinical assessment of clinical congestion score performed by cardiologist and nurse during the same visit. Assessments were performed independently and N‐terminal pro‐B‐type natriuretic peptide levels obtained. The nurses’ ability to classify patients in hemodynamic profile was compared to the cardiologist’s.

Results.  Eighty‐nine assessments were performed in 63 patients with heart failure. The correlation of clinical congestion scores obtained by nurse with those obtained by cardiologist was rs = 0·86; p < 0·001. The correlation of clinical congestion scores from nurse and cardiologist with levels of N‐terminal pro‐B‐type natriuretic peptide were as follows: rs = 0·45; p < 0·0001 and rs = 0·51, respectively, p < 0·0001. Patients with clinical congestion score ≥3 had levels of NT‐ProBNP significantly higher than those with clinical congestion score <3, in the assessment performed by the cardiologist (1866 SD 1151 vs. 757 SD 988 pg/ml; p < 0·0001) and by the nurse (1720 SD 1228 vs. 821 SD 914 pg/ml; p < 0·0001). The nurse and cardiologist had similar capacity in classifying patients in congested quadrants (p = 0·027) or in dry quadrants (p = 0·03), according to the levels of N‐terminal pro‐B‐type natriuretic peptide. Area under the receiver‐operating characteristic curve of the nurse and cardiologist to detect congestion was, respectively, 0·77 and 0·72.

Conclusions.  Our data suggests that nurses trained in heart failure may have a similar performance to that of the cardiologist for the clinical detection of congestion and assessment of the hemodynamic profile in patients with chronic heart failure.

Relevance to clinical practice.  Considering that consistent clinical assessment can identify congested or hypovolemic patients with reasonable reliability, as well as patients with low or normal cardiac output, our results may help confirm nurses’ capability in performing reliable clinical assessment in heart failure patients. While nurses’ led heart failure programmes are usually focused on the management of patients, nurses’ ability to perform accurate assessment would expand nurses’ role in these programmes. As many institutions now focus on home visits by heart failure nurses, accurate assessment would benefit patients and improve their clinical outcomes.