Congestive heart failure clinical assessment
 |
Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Edzel Lorraine Co, D.M.D., M.D. [2]
Overview
Clinical assessment of a patient based on a thorough history taking and physical examination is still the cornerstone in diagnosing heart failure. Based on the gathered data, patients can be assessed if he has an underlying heart condition which necessitates a disease-specific therapy such as amyloid heart disease, a cardiomyopathy, or a developing decompensated heart failure. It is important to investigate for presence of heart congestion so as to treat it the at the earliest stage to avoid deterioration in the quality of life and prognosis.
Diagnostic algorithm for heart failure
Suspected heart failure
| |||||||||||||||||||||||||||||||||||||||
| 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 |
|---|
Criteria for definition of advanced heart failure
1. Severe and persistent symptoms of heart failure NYHA class III-IV
2. Severe cardiac dysfunction is defined by at least one of the following:
- LVEF <_30%
- Isolated RV failure (ARVC)
- Non-operable severe valve abnormalities
- Non-operable severe congenital abnormalities
- Persistently high (or increasing) BNP or NT-proBNP values and severe LV diastolic dysfunction or structural abnormalities
3. Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalization in the last 12 months
4. Severe impairment of exercise capacity with inability to exercise or low 6MWT distance (<300 m) or pVO2 <12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin[1]
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.
2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]
| Class I |
| "1. In patients with HF, vital signs and evidence of clinical congestion should be assessed at each encounter to guide overall management, including adjustment of diuretics and other medications.[3][4][5][6][7][8] (Level of Evidence: B-NR) " |
| "2. In patients with symptomatic HF, clinical factors indicating the presence of advanced HF should be sought via the history and physical examination. [9][10][11][12][13][14] (Level of Evidence: B-NR) " |
| "3. In patients with cardiomyopathy, a 3-generation family history should be obtained or updated when assessing the cause of the cardiomyopathy to identify possible inherited disease. [15][16] (Level of Evidence: B-NR) " |
| "4. In patients presenting with HF, a thorough history and physical examination should direct diagnostic strategies to uncover specific causes that may warrant disease-specific management. [17][18] (Level of Evidence: B-NR) " |
| "4. In patients presenting with HF, a thorough history and physical examination should be obtained and performed to identify cardiac and noncardiac disorders, lifestyle and behavioral factors, and social determinants of health that might cause or accelerate the development or progression of HF. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]) " |
References
- ↑ 1.0 1.1 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
|pmid=value (help). Vancouver style error: initials (help) - ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check
|pmid=value (help). - ↑ Ambrosy AP, Pang PS, Khan S, Konstam MA, Fonarow GC, Traver B; et al. (2013). "Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial". Eur Heart J. 34 (11): 835–43. doi:10.1093/eurheartj/ehs444. PMID 23293303.
- ↑ Selvaraj S, Claggett B, Pozzi A, McMurray JJV, Jhund PS, Packer M; et al. (2019). "Prognostic Implications of Congestion on Physical Examination Among Contemporary Patients With Heart Failure and Reduced Ejection Fraction: PARADIGM-HF". Circulation. 140 (17): 1369–1379. doi:10.1161/CIRCULATIONAHA.119.039920. PMID 31510768.
- ↑ Selvaraj S, Claggett B, Shah SJ, Anand IS, Rouleau JL, Desai AS; et al. (2019). "Utility of the Cardiovascular Physical Examination and Impact of Spironolactone in Heart Failure With Preserved Ejection Fraction". Circ Heart Fail. 12 (7): e006125. doi:10.1161/CIRCHEARTFAILURE.119.006125. PMC 6686863 Check
|pmc=value (help). PMID 31220936. - ↑ Caldentey G, Khairy P, Roy D, Leduc H, Talajic M, Racine N; et al. (2014). "Prognostic value of the physical examination in patients with heart failure and atrial fibrillation: insights from the AF-CHF trial (atrial fibrillation and chronic heart failure)". JACC Heart Fail. 2 (1): 15–23. doi:10.1016/j.jchf.2013.10.004. PMID 24622114.
- ↑ Simonavičius J, Sanders van-Wijk S, Rickenbacher P, Maeder MT, Pfister O, Kaufmann BA; et al. (2019). "Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial". Am J Med. 132 (9): e679–e692. doi:10.1016/j.amjmed.2019.04.010. PMID 31051151.
- ↑ Fudim M, Parikh KS, Dunning A, DeVore AD, Mentz RJ, Schulte PJ; et al. (2018). "Relation of Volume Overload to Clinical Outcomes in Acute Heart Failure (From ASCEND-HF)". Am J Cardiol. 122 (9): 1506–1512. doi:10.1016/j.amjcard.2018.07.023. PMC 6924269 Check
|pmc=value (help). PMID 30172362. - ↑ Anker SD, Negassa A, Coats AJ, Afzal R, Poole-Wilson PA, Cohn JN; et al. (2003). "Prognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensin-converting-enzyme inhibitors: an observational study". Lancet. 361 (9363): 1077–83. doi:10.1016/S0140-6736(03)12892-9. PMID 12672310.
- ↑ Eshaghian S, Horwich TB, Fonarow GC (2006). "Relation of loop diuretic dose to mortality in advanced heart failure". Am J Cardiol. 97 (12): 1759–64. doi:10.1016/j.amjcard.2005.12.072. PMID 16765130.
- ↑ Gorodeski EZ, Chu EC, Reese JR, Shishehbor MH, Hsich E, Starling RC (2009). "Prognosis on chronic dobutamine or milrinone infusions for stage D heart failure". Circ Heart Fail. 2 (4): 320–4. doi:10.1161/CIRCHEARTFAILURE.108.839076. PMID 19808355.
- ↑ Kittleson M, Hurwitz S, Shah MR, Nohria A, Lewis E, Givertz M; et al. (2003). "Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality". J Am Coll Cardiol. 41 (11): 2029–35. doi:10.1016/s0735-1097(03)00417-0. PMID 12798577.
- ↑ Poole JE, Johnson GW, Hellkamp AS, Anderson J, Callans DJ, Raitt MH; et al. (2008). "Prognostic importance of defibrillator shocks in patients with heart failure". N Engl J Med. 359 (10): 1009–17. doi:10.1056/NEJMoa071098. PMC 2922510. PMID 18768944.
- ↑ Setoguchi S, Stevenson LW, Schneeweiss S (2007). "Repeated hospitalizations predict mortality in the community population with heart failure". Am Heart J. 154 (2): 260–6. doi:10.1016/j.ahj.2007.01.041. PMID 17643574.
- ↑ Marume K, Noguchi T, Tateishi E, Morita Y, Miura H, Nishimura K; et al. (2020). "Prognosis and Clinical Characteristics of Dilated Cardiomyopathy With Family History via Pedigree Analysis". Circ J. 84 (8): 1284–1293. doi:10.1253/circj.CJ-19-1176. PMID 32624524 Check
|pmid=value (help). - ↑ Waddell-Smith KE, Donoghue T, Oates S, Graham A, Crawford J, Stiles MK; et al. (2016). "Inpatient detection of cardiac-inherited disease: the impact of improving family history taking". Open Heart. 3 (1): e000329. doi:10.1136/openhrt-2015-000329. PMC 4762189. PMID 26925241.
- ↑ González-López E, Gagliardi C, Dominguez F, Quarta CC, de Haro-Del Moral FJ, Milandri A; et al. (2017). "Clinical characteristics of wild-type transthyretin cardiac amyloidosis: disproving myths". Eur Heart J. 38 (24): 1895–1904. doi:10.1093/eurheartj/ehx043. PMID 28329248.
- ↑ Lousada I, Comenzo RL, Landau H, Guthrie S, Merlini G (2015). "Light Chain Amyloidosis: Patient Experience Survey from the Amyloidosis Research Consortium". Adv Ther. 32 (10): 920–8. doi:10.1007/s12325-015-0250-0. PMC 4635176. PMID 26498944.