Authors: Dr. Munirah Fahaid Alhemaidani , Ahmed Y. Azzam , Dr Saga Khalid Alwabel , Dr. Yara Ali Alqazlan , Dr Lamya Fahad alsheheil , Dr Reem Fuad Alayash , Dr Dhiyaa Abdullah Almusaylim , Dr Rilan Asad Alimani , Dr Hussain Hussam Almusa , Dr Sadeem Khalid Alquraini , Dr Asayil Abdulmuttalib

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.

Keywords: Acute Heart Failure; Emergency; Ultrasound; Imaging; Clinical Assessment