Classification of heart failure in the atherosclerosis risk in communities (ARIC) study: a comparison of diagnostic criteria

Abstract

Background: Population-based research on heart failure (HF) is hindered by lack of consensus on diagnostic criteria. Framingham (FRM), National Health and Nutrition Examination Survey (NHANES), Modified Boston (MBS), Gothenburg (GTH), and International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) code criteria, do not differentiate acute decompensated heart failure (ADHF) from chronic stable HF. We developed a new classification protocol for identifying ADHF in the Atherosclerosis Risk in Communities (ARIC) Study and compared it with these other schemes.

Methods and results: A sample of 1180 hospitalizations with a patient address in 4 study communities and eligible discharge codes were selected. After assessing whether the chart contained evidence of possible HF signs, 705 were fully abstracted. Two independent reviewers classified each case as ADHF, chronic stable HF, or no HF, using ARIC classification guidelines. Fifty-nine percent of cases met ARIC criteria for ADHF and 13.9% and 27.1% were classified as chronic stable HF or no HF, respectively. Among events classified as HF by FRM criteria, 68.4% were validated as ADHF, 9.6% as chronic stable HF, and 21.9% as no HF. However, 92.5% of hospitalizations with a primary ICD-9-CM 428 "heart failure" code were validated as ADHF. Sensitivities of comparison criteria to classify ADHF ranged from 38-95%, positive predictive values from 62-92%, and specificities from 19-96%.

Conclusions: Although comparison criteria for classifying HF were moderately sensitive in identifying ADHF, specificity varied when applied to a randomly selected set of suspected HF hospitalizations in the community.

Figure 1

Overlap between Framingham criteria, ARIC HF Classification Committee review, and ICD-9-CM 428 code as primary discharge code for the classification of a HF hospitalization.