Congestive heart failure clinical assessment
 |
Resident Survival Guide |
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.
Initial studies for evaluation of HFrEF
- BNP, NT Pro BNP
- CBC, basic metabolic panel, liver function, Iron studies, thyroid studies, Hb A1C
- ECG
- CXR
- Echocardiography
- Coronary angiogram, cardiac MRI, biopsy, other appropriate studies
Serial evaluation , Titration of Medications, Evaluation about history, symptoms, physical exam, lab result
Intensification 2-4 months, (1-4 weeks cycles)
- In the presence of volume overload, adjusting diuretic dose and reevaluation in 1-2 weeks
- In the setting of stable euvolumic status, medications initiation, increase, switch dose and follow-up in 1-2 weeks and checking basic metabolites panel, repeating cycles until no change in clinical status and reached appropriate titration
Assessment of response to medications and cardiac remodeling
- Repeating BNP, pro BNP and basic metabolic panel
- Pepeating ECG, Echocardiography
- Refferal eligible patients to electrophysiology specialist for CRT or ICD implantation
Lack of response , instability
- Referral to advanced heart failure specialist in the presence of:
- Use of IV inotropes
- NYHA 3B, 4, or persistently high level of natrioretic peptide
- End organ dysfunction
- LVEF ≤ 35%
- Defibrillator shocks
- Hospitalization > 1 day
- Edema despite increase dose of diuretics
- Low blood pressure, high heart rate
- Intolerance to medications
Assessment of response to medications
- Repeating laboratory tests such as NT pro BNP, BNP, electrolytes
- Repeating ECG
- Repeating echocardiography for evaluation of structure, function
- Referral to electrophysiologic for implantation of ICD, CRT in eligible patients
Clinical Assessment
Framingham Criteria
Major Criteria
- Paroxysmal nocturnal dyspnea
- Jugular vein distention
- Rales
- Radiographic cardiomegaly
- Acute pulmonary edema
- Third heart sound (S3)
- Central venous pressure > 16 cm H2O
- 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.