Congestive heart failure clinical assessment
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Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Diagnostic algorithm for heart failure
Suspected heart failure
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| NT-proBNP ≥ 125 pg/mL or BNP ≥ 35 pg/mL
or if HF strongly suspected or if NT-proBNP/BNP unavailable | |||||||||||||||||||||||||||||||||||||||
| Echocardiography | |||||||||||||||||||||||||||||||||||||||
| Abnormal findings | |||||||||||||||||||||||||||||||||||||||
| Hear failure unlikely, other dignosis shoulb be considered | NO | Yes | |||||||||||||||||||||||||||||||||||||
| Heart failure confirmed based on LVEF | |||||||||||||||||||||||||||||||||||||||
| LVEF≤ 40% | LVEF=41-49% | LVEF≥50% | |||||||||||||||||||||||||||||||||||||
| The above table adopted from 2021 ESC Guideline |
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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.
References
- ↑ McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland J, Coats A, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam C, Lyon AR, McMurray J, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano G, Ruschitzka F, Kathrine Skibelund A (September 2021). "2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure". Eur Heart J. 42 (36): 3599–3726. doi:10.1093/eurheartj/ehab368. PMID 34447992 Check
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