Congestive heart failure clinical assessment

Congestive Heart Failure Microchapters
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Natural History, Complications and Prognosis
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Electrocardiogram
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Medical Therapy:
Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF Diuretics ACE Inhibitors Angiotensin receptor blockers Aldosterone Antagonists Beta Blockers Ca Channel Blockers Nitrates Hydralazine Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes Associated conditions
Exercise Training
Surgical Therapy: Biventricular Pacing or Cardiac Resynchronization Therapy (CRT) Implantation of Intracardiac Defibrillator Ultrafiltration Cardiac Surgery Left Ventricular Assist Devices (LVADs) Cardiac Transplantation
ACC/AHA Guideline Recommendations Initial and Serial Evaluation of the HF Patient Hospitalized Patient Patients With a Prior MI Sudden Cardiac Death Prevention Surgical/Percutaneous/Transcather Interventional Treatments of HF Patients at high risk for developing heart failure (Stage A) Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B) Patients with current or prior symptoms of heart failure (Stage C) Patients with refractory end-stage heart failure (Stage D) Coordinating Care for Patients With Chronic HF Quality Metrics/Performance Measures
Implementation of Practice Guidelines
Congestive heart failure end-of-life considerations
Specific Groups: Special Populations Patients who have concomitant disorders Obstructive Sleep Apnea in the Patient with CHF NSTEMI with Heart Failure and Cardiogenic Shock
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

There are several diagnostic criteria / algorithms that are used to diagnose heart failure including an algorithm from the ESC, Framingham study, and Boston.

ESC algorithm

The ESC algorithm weights the following parameters in establishing the diagnosis of heart failure:

Influence Parameter	Supports if present	Opposes if normal or absent
	+ - to some degree ++ - to intermediate degree +++ - to high degree
Compatible symptoms	++	++
Compatible signs	++	+
Cardiac dysfunction on echocardiography	+++	+++
Response of symptoms or signs to therapy	+++	++
ECG
Normal		++
Abnormal	++	+
Dysrhythmia	+++	+
Laboratory
BNP > 400 pg/mL and/or NT-proBNP > 2000 pg/mL	+++	+
BNP < 100 pg/mL and NT-proBNP < 400 pg/mL	+	+++
Hyponatraemia	+	+
Renal dysfunction	+	+
Mild elevations of troponin	+	+
Chest X-ray
Pulmonary congestion	+++	+
Reduced exercise capacity	+++	++
Abnormal pulmonary function tests	+	+
Abnormal haemodynamics at rest	+++	++

Framingham Criteria

Major Criteria

• Paroxysmal nocturnal dyspnea
• Jugular vein distention
• Rales
• Radiographic cardiomegaly
• Acute pulmonary edema
• S3
• Central venous pressure > 16 cmH2O
• Circulation time ≥ 25 sec
• Hepatojugular reflux
• Pulmonary edema
• Visceral congestion
• Cardiomegaly at autopsy
• Weight loss ≥ 4.5 kg in 5 days in response to treatment of heart failure

Minor Criteria

• Bilateral ankle edema
• Nocturnal cough
• Dyspnea on ordinary exertion
• Hepatomegaly
• Pleural effusion
• 30% decrease in baseline vital capacity
• Tachycardia

Boston Criteria of Congestive Heart Failure

Category I: History

• Rest dyspnea 4 points
• Orthopnea 4 points
• Paroxysmal nocturnal dyspnea 3 points
• Dyspnea on walking on level ground 2 points
• Dyspnea on climbing 1 point

Category II: Physical Examination

• Heart rate abnormality (1 point if 91 to 110 bpm; if >110 bpm, 2 points)
• Jugular venous pressure elevation (2 points if >6 cm H₂O; 3 points if >6 cm H₂O and hepatomegaly or edema))
• Lung crackles (1 point if basilar; 2 points if more than basilar)
• Wheezing 3 points
• Third heart sound 3 points

Category III: Chest Radiography

• Alveolar pulmonary edema 4 points
• Interstitial pulmonary edema 3 points
• Bilateral pleural effusion 3 points
• Cardiothoracic ratio >0.50 (posteroanterior projection) 3 points
• Upper zone flow redistribution 2 points

No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points.

The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.

ACC/AHA Guidelines- Initial Clinical Assessment

Class I

"1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (Level of Evidence: C) "

"2. A careful history of current and past use of alcohol, illicit drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patients presenting with HF. (Level of Evidence: C) "

"3. In patients presenting with HF, initial assessment should be made of the patient’s ability to perform routine and desired activities of daily living. (Level of Evidence: C) "

"4. Initial examination of patients presenting with HF should include assessment of the patient’s volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index. (Level of Evidence: C) "

"5. Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C) "

"6. Twelve-lead electrocardiogram and chest radiograph (PA and lateral) should be performed initially in all patients presenting with HF. (Level of Evidence: C) "

"7. Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess LVEF, LV size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes. (Level of Evidence: C) "

"8. Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B) "

Class III (No Benefit)

"1. Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF. (Level of Evidence: C) "

"2. Routine use of signal-averaged electrocardiography is not recommended for the evaluation of patients presenting with HF. (Level of Evidence: C) "

"3. Routine measurement of circulating levels of neurohormones (e.g., norepinephrine or endothelin) is not recommended for patients presenting with HF. (Level of Evidence: C) "

Class IIa

"1. Coronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularization. (Level of Evidence: C) "

"2. Coronary arteriography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: C) "

"3. Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B) "

"4. Maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation is reasonable in patients presenting with HF to help determine whether HF is the cause of exercise limitation when the contribution of HF is uncertain. (Level of Evidence: C) "

"5. Maximal exercise testing with measurement of respiratory gas exchange is reasonable to identify high-risk patients presenting with HF who are candidates for cardiac transplantation or other advanced treatments. (Level of Evidence: B) "

"6. Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF. (Level of Evidence: C)"

"7. Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level of Evidence: C)"

"8. Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy. (Level of Evidence: C)"

"9. Measurement of B-type natriuretic peptide (BNP) can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Measurement of natriuretic peptides (BNPand NT-proBNP) can be useful in risk stratification(Level of Evidence: A)"

Class IIb

"1. Noninvasive imaging may be considered to define the likelihood of coronary artery disease in patients with HF and LV dysfunction. (Level of Evidence: C)"

"2. Holter monitoring might be considered in patients presenting with HF who have a history of MI and are being considered for electrophysiologic study to document VT inducibility. (Level of Evidence: C) "

ACC/AHA Guidelines- Serial Clinical Assessment

Class I

1. Assessment should be made at each visit of the ability of a patient with HF to perform routine and desired activities of daily living. (Level of Evidence: C)

2. Assessment should be made at each visit of the volume status and weight of a patient with HF. (Level of Evidence: C)

3. Careful history of current use of alcohol, tobacco, illicit drugs, “alternative therapies,” and chemotherapy drugs, as well as diet and sodium intake, should be obtained at each visit of a patient with HF. (Level of Evidence: C)

Class IIa

"1. Repeat measurement of ejection fraction and the severity of structural remodeling can provide useful information in patients with heart failur who have had a change in clinical status or who have experienced or recovered from a clinical event or received treatment that might have had a significant effect on cardiac function. (Level of Evidence: C) "

Class IIb

"1. The value of serial measurements of BNP to guide therapy for patients with HF is not well established. (Level of Evidence: C) "

Vote on and Suggest Revisions to the Current Guidelines

• The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation

References

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