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Evaluationofthepatientwithsuspectedheartfailure Author WilsonSColucci,MD Disclosures Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete. Literaturereviewcurrentthrough:Apr2013.|Thistopiclastupdated:Jan21,2012. INTRODUCTIONHeartfailure(HF)isacommonclinicalsyndromecausedbyavarietyofcardiacdiseases[1].TheinitialevaluationofthepatientwithsuspectedHFdueto systolicordiastolicdysfunctionwillbereviewedhere.EvaluationoftheetiologyandmanagementofHFandevaluationandtreatmentofacutedecompensatedHFarediscussed separately.(See"Evaluationofthepatientwithheartfailureorcardiomyopathy"and"Overviewofthetherapyofheartfailureduetosystolicdysfunction"and"Clinical manifestationsanddiagnosisofdiastolicheartfailure"and"Evaluationofacutedecompensatedheartfailure"and"Treatmentofacutedecompensatedheartfailure:General considerations".) DEFINITIONHeartfailure(HF)isacomplexclinicalsyndromethatcanresultfromanystructuralorfunctionalcardiacdisorderthatimpairstheabilityoftheventricletofillwith orejectblood.Itischaracterizedbyspecificsymptoms,suchasdyspneaandfatigue,andsigns,suchasthoserelatedtofluidretention.Therearemanywaystoassess cardiacfunction.However,thereisnodiagnostictestforHF,sinceitislargelyaclinicaldiagnosisthatisbaseduponacarefulhistoryandphysicalexamination(table1). CLINICALPRESENTATIONTheapproachtothepatientwithsuspectedHFincludesthehistoryandphysicalexamination,anddiagnosticteststohelpestablishthe diagnosis,assessacuityandseverityandinitiateassessmentofetiology.RecommendationsfortheevaluationofpatientswithHFwereincludedinthe2005AmericanCollege ofCardiology(ACC/AHA)guidelineswith2009focusedupdate(table2andalgorithm1)[2],the2010HeartFailureSocietyofAmerica(HFSA)guidelines[3],the2008European SocietyofCardiology(ESC)guidelines[4],andthe2006CanadianCardiovascularSociety(CCS)consensusconference[5]. Thediscussionbelowfocusesondiagnosisofheartfailure.Thehistoryandphysicalexaminationofthepatientwithsuspectedheartfailureshouldalsoincludeassessmentof riskfactorsandpotentialetiologiesofheartfailureasdiscussedseparately.(See"Evaluationofthepatientwithheartfailureorcardiomyopathy"and"Evaluationofacute decompensatedheartfailure".) HistorySymptomsofHFincludethoseduetoexcessfluidaccumulation(dyspnea,orthopnea,edema,painfromhepaticcongestion,andabdominaldistentionfromascites) andthoseduetoareductionincardiacoutput(fatigue,weakness)thatismostpronouncedwithexertion.FluidretentioninHFisinitiatedbythefallincardiacoutput,leadingto alterationsinrenalfunction,dueinparttoactivationofthesodiumretainingreninangiotensinaldosteroneandsympatheticnervoussystems.(See"Pathophysiologyofheart failure:Neurohumoraladaptations".) ImportantinformationconcerningtheacuityofHFissuggestedbythepresentingsymptoms: Acuteandsubacutepresentations(daystoweeks)arecharacterizedprimarilybyshortnessofbreath,atrestand/orwithexertion.Alsocommonareorthopnea, paroxysmalnocturnaldyspnea,and,withrightHF,rightupperquadrantdiscomfortduetoacutehepaticcongestion,whichcanbeconfusedwithacutecholecystitis. Patientswithatrialand/orventriculartachyarrhythmiasmaycomplainofpalpitationswithorwithoutlightheadedness. Patientswithacutedecompensatedheartfailurerequirepromptdiagnosisandmanagement.(See"Evaluationofacutedecompensatedheartfailure"and"Treatmentofacute decompensatedheartfailure:Generalconsiderations".) Chronicpresentations(months)differinthatfatigue,anorexia,abdominaldistension,andperipheraledemamaybemorepronouncedthandyspnea.Theanorexiais secondarytoseveralfactorsincludingpoorperfusionofthesplanchniccirculation,boweledema,andnauseainducedbyhepaticcongestion.Overtime,pulmonary venouscapacitanceaccommodatestothechronicstateofvolumeoverload,leadingtolessornofluidaccumulationinthealveoli,despitetheincreaseintotallungwater. Thesepatientspresentwithexcessivefatigueandlowoutputsymptoms. Otherclinicalfeaturessuchasolderage,historyofcoronaryarterydiseaseormyocardialinfarction,anduseofaloopdiureticareassociatedwithincreasedlikelihoodofheart failure[6,7].Asdiscussedbelow,thehistoryaloneisinsufficienttomakethediagnosisofHF.(See'Diagnosticaccuracyofclinicalfeatures'below.) Nevertheless,adetailedhistoryremainsthesinglebestdiscriminatortodeterminetheacuity,etiology,andrateofprogressionofHFandthehistoryoftenprovidesimportant cluestothecauseofHF.(See"Evaluationofthepatientwithheartfailureorcardiomyopathy".) PhysicalexaminationThephysicalexaminationcanprovideevidenceofthepresenceandextentofcardiacfillingpressureelevation,volumeoverload,ventricular enlargement,pulmonaryhypertension,andreductionincardiacoutput. Inthestudyofprimarycarepatientscitedabove,thephysicalfindingofadisplacedapicalimpulsehadthebestcombinationofsensitivity,specificity,andpositiveandnegative predictivevalueofanyphysicalsignofsystolicHF[8].OtherstrongpredictorsofHFincludedagalloprhythmandelevatedjugularvenouspressure. VitalsignsandappearancePatientswithadvancedHFmayshowevidenceofamajordeclineincardiacoutputandthereforeadecreaseintissueperfusion.Fourmajor findingssuggestseverityofthecardiacdysfunction:restingsinustachycardia,narrowpulsepressure,diaphoresis,andperipheralvasoconstriction.Thelastabnormalityis manifestedascool,pale,andsometimescyanoticextremities(duetothecombinationofdecreasedperfusionandincreasedoxygenextraction).Adecreaseincardiacoutput shouldbesuspectedwhenthepulsepressureisreducedbelow25mmHg. Boththecardiacdiseaseitselfandthesecondaryneurohumoraladaptationcontributetothelowoutputstate.Patientscompensateforafallincardiacoutputbyincreasing sympatheticoutflowwithresultantshuntingofthecardiacoutputtovitalorgans. AnirregularlyirregularpulseissuggestiveofatrialfibrillationwhichfrequentlyaccompaniesHF.(See"Atrialfibrillationinpatientswithheartfailure".) VolumeassessmentTherearethreemajormanifestationsofvolumeoverloadinpatientswithHF:pulmonarycongestion,peripheraledema,andelevatedjugularvenous pressure. Pulmonarycongestionthatmaymanifestasralesismoreprominentinacuteorsubacutedisease.Asnotedabove,chronicHFisassociatedwithincreasesinvenous capacitanceandlymphaticdrainageofthelungsasaresult,ralesareoftenabsenteventhoughthepulmonarycapillarypressureiselevated.Continuedsodiumretentioninthis settingpreferentiallyaccumulatesintheperipheryalthoughachronicelevationinpulmonaryvenouspressurecanleadtopleuraleffusions. Peripheraledemaismanifestedbyswellingofthelegs(whichismoreprominentwhenthepatientisupright),andmayalsocauseascites,scrotaledema,hepatomegaly,and splenomegaly[9].(See"Approachtotheadultpatientwithsplenomegalyandothersplenicdisorders".)Inthissetting,manualcompressionoftherightupperquadranttoincrease venousreturnmayelevatejugularvenouspressureabovethetransient1to3cmelevationsseeninnormalindividuals.Thissignisknownasthehepatojugularreflux.(See "Examinationofthejugularvenouspulse",sectionon'Hepatojugularreflux'.) ElevatedjugularvenouspressureisusuallypresentifperipheraledemaisduetoHF,sinceitisthehighintracapillarypressurethatisresponsibleforfluidmovementintothe interstitium.Withthepatientsittingat45jugularvenouspressurecanbeestimatedfromtheheightabovetheleftatriumofvenouspulsationsintheinternaljugularvein.The heightofexternaljugularveinpulsationsmayalsobehelpfulbutcaremustbetakentoavoidspuriousinterpretation.(See"Examinationofthejugularvenouspulse".) Theaccuracyofclinicalvolumeassessmentisdiscussedbelow.(See'Diagnosticaccuracyofclinicalfeatures'below.) SectionEditor StephenSGottlieb,MD DeputyEditor SusanBYeon,MD,JD,FACC

PulsusalternansPulsusalternans,ifpresent,isvirtuallypathognomonicofsevereleftventricularfailure.Thisphenomenonischaracterizedbyevenlyspacedalternating strongandweakperipheralpulses.Itisbestappreciatedbyapplyinglightpressureontheperipheralarterialpulse,andcanbeconfirmedbymeasuringthebloodpressure.When thecuffpressureisslowlyreleased,phaseIKorotkoffsoundsareinitiallyheardonlyduringthealternatestrongbeatswithfurtherreleaseofcuffpressure,thesoftersoundsof theweakbeatalsoappear.Thedegreeofpulsusalternanscanbequantitatedbymeasuringthedifferenceinsystolicpressurebetweenthestrongandtheweakbeat.(See "Examinationofthearterialpulse",sectionon'Pulsusalternans'.) Thepathophysiologyofpulsusalternansisnotwellunderstood.Thesevereventriculardysfunctionmaybeassociatedwithvariationsincontractilitysecondarytoshiftsin afterload,preload,andelectricalexcitability[10]. PrecordialpalpationVentricularchambersizecanbeestimatedbyprecordialpalpation.Anapicalimpulsethatislaterallydisplacedpastthemidclavicularlineisusually indicativeofleftventricularenlargement.Leftventriculardysfunctioncanalsoleadtosustainedapicalimpulse,whichmaybeaccompaniedbyaparasternalliftinthesettingof rightventricularhypertrophyorenlargement.TheS3maybepalpableinsevereventricularfailure.(See"Examinationoftheprecordialpulsation".) HeartsoundsAnS3gallopisassociatedwithleftatrialpressuresexceeding20mmHg,increasedleftventricularenddiastolicpressures(>15mmHg),andelevatedserum brainnatriureticpeptideconcentrations.However,thereisappreciableinterobservervariabilityintheabilitytodetectanS3thatcannotbesolelyexplainedbytheexperienceof theobserver[11,12].Inaddition,inaphonocardiographicstudyofpatientswhowereundergoingcardiaccatheterization,anS3wasnotverysensitive(40to50percent)forthe detectionofanelevatedleftventricularenddiastolicpressureorareducedleftventricularejectionfractionhowever,theS3washighlyspecific(90percent)fortheseparameters andforanelevatedserumbrainnatriureticpeptideconcentration[13].Similarly,anS3(orextraheartsound)hasalowsensitivity(eg,4to11percent)buthighspecificity(eg, 99percent)forclinicaldiagnosisofHF[6,7].(See"Auscultationofheartsounds",sectionon'Leftventriculargallops'.) PulmonaryhypertensionPatientswithchronicHFoftendevelopsecondarypulmonaryhypertension,whichcancontributetodyspneaaspulmonarypressuresrisewith exertion.Thesepatientsmayalsocomplainofsubsternalchestpressure,typicalofangina.Inthissetting,elevatedrightventricularenddiastolicpressureleadstosecondary rightventricularsubendocardialischemia.PhysicalsignsofpulmonaryhypertensioncanincludeincreasedintensityofP2,amurmurofpulmonaryinsufficiency,aparasternallift, andapalpablepulmonictap(feltintheleftsecondintercostalspace).(See"Auscultationofcardiacmurmurs"and"Auscultationofheartsounds"and"Examinationofthe precordialpulsation".) DiagnosticaccuracyofclinicalfeaturesTheaccuracyofsymptomsandsignsfortheclinicaldiagnosisofheartfailurewasevaluatedbyasystematicreviewthatincluded datafrom15studiesofpatientswithsuspectedheartfailure[6]: Dyspneawastheonlysymptomorsignwithhighsensitivity(87percent)butitsspecificitywaslow(51percent). Otherclinicalfeatureshadrelativelyhighspecificitybutlowsensitivity: SymptomsOrthopnea(specificityandsensitivityof89and44percent)andhistoryofmyocardialinfarction(89and26percent). SignsExtraheartsoundswerehighlyspecific(99percent)buthadlowsensitivity(11percent).Inthispopulation,hepatomegalywasalsohighlyspecific(97percent) buthadlowsensitivity(17percent).Greaterspecificitythansensitivitywasalsoseenforcardiomegaly(85and27percent),lungcrepitation(81and51percent), edema(72and53percent),andelevatedjugularvenouspressure(70and52percent). Theaccuracyofclinicalevaluationofcardiacfillingpressuresvariesamongobserversasillustratedbyastudyof116patientsundergoingcardiaccatheterization[14].Signsof elevatedrightheartfillingpressureincludedincreasedjugularvenouspressure,peripheraledema,andascites.Signsofelevatedleftheartfillingpressureincludedfindingsof elevatedrightheartfillingpressureaswellasgallopsorrales. Rightandleftheartfillingpressureswereaccuratelyestimatedbyphysicalexaminationin71and60percentof215observations.Examinationbystaffcardiologistswas moreaccuratethanbytraineesforrightheartpressures(82versus67percent)andleftheartpressures(71versus55percent). ExposuretoechocardiographicandNTproBNPresultsdidnotimprovetheaccuracyofclinicalevaluations.Theaccuracyofestimationofrightfillingpressureby echocardiographicexaminationoftheIVC(75percent)wassimilartotheaccuracyofphysicalexamination.Theaccuracyofestimatesofleftheartfillingpressuresby NTproBNP(67percent)andbyechocardiographyE/eratio(60percent)wasalsosimilartophysicalexamination.(See'NTproBNP'belowand"Natriureticpeptide measurementinheartfailure"and"Echocardiographicevaluationofleftventriculardiastolicfunction",sectionon'AlgorithmsforestimatingLVfillingpressure'.) ThediagnosisofHFisbaseduponaconstellationofsymptoms,signs,andtestresults.Diagnosticrulesbaseduponcombinationsofclinicalfeaturesarediscussedbelow(See 'Diagnosticrules'below.). DIFFERENTIALDIAGNOSISManyofthesymptomsandsignsofHFarenonspecificsootherpotentialcausesshouldbeconsidered.PatientswithHFmaypresentwitha syndromeofdecreasedexercisetolerance,fluidretention,orboth[2].Variousothercausesforsuchsymptomsandsignsshouldalsobeconsidered. Patientswithdecreasedexercisetolerancehavesymptomsofdyspneaorfatiguewithexertionandmayalsohavesymptomsatrest.Heartfailureshouldbedistinguished fromothercausesofdyspneaincludingmyocardialischemia,pulmonarydisease,andotherdisorders[15].Causesoffatigueincludedeconditioning,sleepapneaand depression.(See"Approachtothepatientwithdyspnea"and"Approachtotheadultpatientwithfatigue".) Forexample,chronicobstructivepulmonarydisease(COPD)andHFmaybedifficulttodistinguishinsomepatients.Becauseofthehighprevalenceofthesedisorders, theirsimilarpresentations,andtheirfrequentcoexistence,itisreasonabletoconsiderbothdiagnoses,notonlyinpatientspresentingwithdyspneaforthefirsttime,but alsoinanypatientwithoneofthesediagnoseswhopresentswithadeteriorationinrespiratorystatus[16].Thisissueisdiscussedindetailseparately.(See"Chronic obstructivepulmonarydisease:Definition,clinicalmanifestations,diagnosis,andstaging",sectionon'Diagnosis'and"Chronicobstructivepulmonarydisease:Definition, clinicalmanifestations,diagnosis,andstaging".) Patientspresentingwithfluidretentionmaycomplainoflegorabdominalswelling.Heartfailureshouldbedistinguishedfromothercausesofedemaincludingvenous thrombosisorinsufficiency,renalsodiumretention,drugsideeffect(eg,calciumchannelblocker)andcirrhosis.(See"Clinicalmanifestationsanddiagnosisofedemain adults"and"Pathophysiologyandetiologyofedemainadults".) INITIALTESTING Electrocardiogram MostpatientswithHFduetosystolicdysfunctionhaveasignificantabnormalityonanelectrocardiogram(ECG).AnormalECGmakessystolic dysfunctionunlikely(98percentnegativepredictivevalue)[17]. AlthoughtheECGmaybelesspredictiveofHFthantheBNP(orNTproBNP)level[6],theECGmayshowfindingsthatfavorthepresenceofaspecificcauseofHFandcan alsodetectarrhythmias(eg,atrialfibrillation)thatsuggestheartdiseaseandmaycauseorexacerbateHF.(See"Tachycardiamediatedcardiomyopathy"and"Evaluationofthe patientwithheartfailureorcardiomyopathy".) TheECGisparticularlyimportantforidentifyingevidenceofacuteorpriormyocardialinfarctionoracuteischemia.IschemiamaycausesymptomsofdyspneasimilartoHFand mayalsocauseorexacerbateHF.(See"Electrocardiograminthediagnosisofmyocardialischemiaandinfarction".) InitialbloodtestsRecommendedinitialbloodtestsforpatientswithsymptomsandsignsofHFinclude: Acompletebloodcountwhichmaysuggestconcurrentoralternateconditions.AnemiaorinfectioncanexacerbatepreexistingHF.(See"Impactofanemiainpatients withheartfailure".) Serumelectrolytes,bloodureanitrogen,andcreatininemayindicateassociatedconditions.HyponatremiagenerallyindicatessevereHF,thoughitmayoccasionallyresult fromexcessivediuresis[2].Renalimpairmentmaybecausedbyand/orcontributetoHFexacerbation.Baselineevaluationofelectrolytesandcreatineisalsonecessary wheninitiatingtherapywithdiureticsand/orangiotensinconvertingenzymeinhibitors.

Liverfunctiontests,whichmaybeaffectedbyhepaticcongestion.Inonestudy,gammaglutamyltransferaselevel(GGT)>2timestheupperlimitofnormalwastheonly standardinitialbloodtestthataddeddiagnosticvaluetothehistoryandphysicalexamination[7].However,NTproBNPwasthemostpowerfulsupplementarytest. Fastingbloodglucosetodetectunderlyingdiabetesmellitus.(See"Heartfailureindiabetesmellitus".) BNPandNTproBNPBrainnatriureticpeptide(BNP)isanatriuretichormonereleasedprimarilyfromtheheart,particularlytheventricles.TheactiveBNPhormoneiscleaved fromtheCterminalendofitsprohormone,proBNP.TheNterminalfragment(NTproBNP)isalsoreleasedintothecirculation.TheplasmaconcentrationsofBNPandNT proBNPareincreasedinpatientswithleftventriculardysfunction,particularlythosewithheartfailure. BNPorNTproBNPlevelsareusefulindistinguishingHFduetosystolicand/ordiastolicdysfunctionfromothercausesofdyspnea.Asnotedbelow,studiesdevelopingand validatingdiagnosticrulesforHFhavefoundthattheBNPorNTproBNPlevelsaddgreaterdiagnosticvaluetothehistoryandphysicalexaminationthanotherinitialtests(ECG, chestxray,andinitialbloodtests)[6,7].EvidenceofefficacyandlimitationsofBNPandNTproBNPlevelsinthediagnosisofHFisdiscussedindetailseparately.(See "Natriureticpeptidemeasurementinheartfailure".) MeasurementofplasmaBNPorNTproBNPissuggestedintheevaluationofpatientswithsuspectedHFwhenthediagnosisisuncertain,asrecommendedinthe2005 ACC/AHAguidelineswith2009updateaswellasthe2006HFSA,2008ESC,and2006CCSguidelines[2,4,5,15].Elevatednatriureticpeptidelevelsshouldbeinterpretedinthe contextofotherclinicalinformationtheymaylendweighttothediagnosisofHFortriggerconsiderationofHFbutshouldNOTbeusedinisolationtodiagnoseHF[2]. BNPMostdyspneicpatientswithHFhavevaluesabove400pg/mL,whilevaluesbelow100pg/mLhaveaveryhighnegativepredictivevalueforHFasacauseof dyspnea[18].Intherangebetween100and400pg/mL,plasmaBNPconcentrationsarenotverysensitiveorspecificfordetectingorexcludingHF.Otherdiagnoses,suchas pulmonaryembolism,LVdysfunctionwithoutexacerbation,andcorpulmonaleshouldalsobeconsideredinpatientswithplasmaBNPconcentrationsinthisrange. Atrialfibrillation(AF)isassociatedwithhigherlevelsofBNPintheabsenceofHF.Inoneanalysis,aBNPcutoffof100pg/mLwasassociatedwithaspecificityofonly40 percentcomparedto79percentinpatientswithoutAF[19].Usingacutoffof200pg/mLinpatientswithAFincreasedspecificityfrom40to73percentwithasmallerreduction insensitivityfrom95to85percent. NormalplasmaBNPvaluesincreasewithageandarehigherinwomenthanmen[20].Thus,somewhathighercutoffvaluesmaybeneededinthesesettings,althoughthe optimaldiscriminatoryvaluesthatshouldbeusedhavenotbeendetermined. NTproBNPInnormalsubjects,theplasmaconcentrationsofBNPandNTproBNParesimilar(approximately10pmol/L).However,inpatientswithLVdysfunction, plasmaNTproBNPconcentrationsareapproximatelyfourfoldhigherthanBNPconcentrations[21].(See"Natriureticpeptidemeasurementinheartfailure",sectionon'PlasmaN terminalproBNP'.) TheoptimalvaluesfordistinguishingHFfromothercausesofdyspneavarywithpatientage.Inalargemulticenterstudy,forpatients<50,50to75,and>75yearsofage,the optimalplasmaNTproBNPcutoffsfordiagnosingHFwere450pg/mL,900pg/mL,and1800pg/mLrespectively[22].Overall,thesecutoffsyieldedasensitivityandspecificityof 90and84percent,respectively.Acrosstheentirepopulation,NTproBNPlevelsbelow300pg/mLwereoptimalforexcludingadiagnosisofHF,withanegativepredictivevalue of98percent. LimitationsofBNPandNTproBNPThereareseveralimportantlimitationstotheuseofplasmaBNPandNTproBNPfordiagnosisofHF[23]: Patientsmaypresentwithmorethanonecauseofdyspnea(suchaspneumoniaandanexacerbationofHF).Thus,ahighplasmaBNPorNTproBNPconcentrationdoes notexcludethepresenceofotherdiseases. InsomepatientswithacutedecompensatedHF,plasmaBNPorNTproBNPlevelsarenotdiagnostic. SomepatientswithseverechronicHFmayhavepersistentlyelevatedplasmaBNPorNTproBNPconcentrationsregardlessoftreatment,andsuchlevelsmaynotbe usefulinguidingmanagement. RightheartfailureandpulmonaryhypertensionareassociatedwithelevationsinplasmaBNPandNTproBNP.However,whenrightheartfailureisduesolelytolung diseaseandnotduetosecondarypulmonaryhypertensionfromleftsidedheartdiseaseoraspartofaglobalcardiomyopathy,elevatedplasmaBNPmaybe misinterpretedsincedyspneainthesepatientsisduetolungdiseasenotleftheartfailure. PlasmaBNPandNTproBNPlevelstendtobelowerinobesepatientsandareelevatedinpatientswithrenalfailure,andsomeacutenoncardiacillnessessuchassepsis. GreaterincreasesinNTproBNPthanBNPlevelsareobservedinrenalfailure. MeasurementandinterpretationofBNPandNTproBNPlevelsisdiscussedindetailseparately.(See"Natriureticpeptidemeasurementinheartfailure".) ChestxrayThechestxrayisausefulfirstdiagnostictest,particularlyintheevaluationofpatientswhopresentwithdyspnea,todifferentiateHFfromprimarypulmonary disease[2426].FindingssuggestiveofHFincludecardiomegaly(cardiactothoracicwidthratioabove50percent),cephalizationofthepulmonaryvessels,KerleyBlines,and pleuraleffusions(image1AE).Thecardiacsizeandsilhouettemayalsorevealsignsofcongenitalanomalies(ventricularoratrialseptaldefect)orvalvulardisease(mitral stenosisoraorticstenosis). AsystematicreviewoftheutilityofthechestxraytodiagnoseLVdysfunctionconcludedthatredistributionandcardiomegalywerethebestpredictorsofincreasedpreloadand reducedejectionfraction,respectively[25].Neitherfinding,however,wassufficienttomakeadefinitivediagnosisofHF.Inamulticenterstudyof880patients,alveolaredema, interstitialedema,andcephalizationallhadaspecificityof>90percentforHF,butonlycardiomegalyhadasensitivity>50percent[26]. DiagnosticaccuracyofinitialtestingTheaccuracyofinitialtestingfortheclinicaldiagnosisofheartfailurewasevaluatedbyasystematicreviewthatincludeddatafrom15 studiesofpatientswithsuspectedheartfailure[6]: BNPorNTproBNPlevelshaverelativelyhighsensitivity(both93percent)andmorelimitedspecificityforclinicaldiagnosisofHF(74and65percent).(See"Natriuretic peptidemeasurementinheartfailure".) Asnotedabove,anECGhasrelativelyhighsensitivity(89percent)butmorelimitedspecificity(56percent).(See'Electrocardiogram'above.) ChestxrayevidenceofHFishelpfulinconfirmingthediagnosissinceithasrelativelyhighspecificity(83percent)thoughmorelimitedsensitivity(68percent). DiagnosticrulesforHFthatincludeinitialtestingarediscussedbelow.(See'Diagnosticrules'below.) ECHOCARDIOGRAPHYInpatientswithsymptomsandsignsofHF,echocardiographyishelpfulfordeterminingwhetherventricularfunctionandhemodynamicsare consistentwithHFandinidentifyingacause.The2007ACCF/ASE/ACEP/ANC/SCAI/SCCT/SCMRappropriatenesscriteriarateechocardiographyasappropriateinpatientswith symptoms(includingdyspnea,shortnessofbreathandothers)duetoasuspectedcardiacetiology[27].Theyalsorateechocardiographyappropriatewhenotherstudies(such aschestxrayorelevationofserumBNP)areconcerningforcardiacdisease. Importantechocardiographicfindingsincludethefollowing: Atrialandventricularsizes,whichmaybehelpfulinidentifyingthecauseandchronicityofdisease.Forexample,patientswithidiopathicdilatedcardiomyopathytypically havebothleftandrightatrialandventricularenlargement(fourchamberdilatation)withdecreasedleftsystolicventricularfunction(image2andfigure1andmovie1and movie2andmovie3).(See"Echocardiographicrecognitionofcardiomyopathies".) Globalleftandrightventricularsystolicfunction(leftandrightventricularejectionfraction,LVEFandRVEF).(See"Noninvasivemethodsformeasurementofleft ventricularsystolicfunction",sectionon'Echocardiography'.) Diastolicleftventricularfunction.(See"Echocardiographicevaluationofleftventriculardiastolicfunction".)

Regionalwallmotionabnormalitiesinacoronarydistributionaresuggestiveofcoronaryheartdiseasebutsegmentalabnormalitiesalsooccurcommonlyinpatientswith dilatedcardiomyopathy Pericardialdiseaseincludesthickeningsuggestiveofconstrictivepericarditisoreffusionwhichmayormaynotbeassociatedwithtamponade.(See"Constrictive pericarditis"and"Cardiactamponade".) Valvularheartdisease Echocardiographyalsoprovidesanoninvasiveassessmentofhemodynamicstatus: Thepulmonarycapillarywedgepressure(PCWP)canbeestimatedviatheratio(E/EaorE/E')oftissueDopplerofearlymitralinflowvelocity(E)toearlydiastolicvelocity ofthemitralannulus(Eaore').AnE/e'ratio>15suggestsaPCWP>15mmHgwhene'isthemeanofmedialandlateralmitralannulusearlydiastolicvelocities.Useand limitationsofthismethodarediscussedseparately.(See"Echocardiographicevaluationofleftventriculardiastolicfunction",sectionon'TissueDopplerimaging'.) RightventricularandpulmonaryarterypressurescanbeestimatedbythepeakvelocityoftricuspidregurgitationonDopplerechocardiography.Rightatrialpressuremay beestimatedfromevaluatingthesizeoftheinferiorvenacavaanditsrespiratoryvariation. ThecardiacoutputcanbeestimatedbypulsedwaveDopplerfromtheleftventricularoutflowtract[28]. DIAGNOSTICRULESDiagnosticruleshavebeendevelopedinanattempttoincreasetheaccuracyandefficiencyofHFdiagnosisasillustratedbythefollowingtwo examples. Anindividualpatientdataanalysistestedvariousdiagnosticmodelsinonedataset[6].Themodelwiththebestfitwassimplifiedintothefollowingclinicalpredictionrule: EchocardiographyisrecommendedforapatientwithsuspectedHFpresentingwithsymptomssuchasbreathlessnessifanyoneofthefollowingispresent:historyof myocardialinfarction,orbasalcrepitations(rales),ormalewithankleedema. ApatientwithsuspectedHFwithoutoneoftheabovefeaturesisreferredforBNPorNTproBNPleveltesting.Echocardiographyisrecommendedinthefollowingsettings : FemalewithoutankleedemaifBNP>210to360pg/mL(orNTproBNP>620to1060pg/mL)dependinguponlocalavailabilityofechocardiography. MalewithoutankleedemaifBNP>130to220pg/mL(orNTproBNP>390to660pg/mL). FemalewithankleedemaifBNP>100to180pg/mL(orNTproBNP>190to520pg/mL). TheabovemodelwasappliedtootherdatasetswithanareaundertheROCcurve(AUC)of0.84to0.96.(See"Evaluatingdiagnostictests",sectionon'Receiveroperating characteristiccurves'.) Amulticenterprospectivestudyof721patientswithsuspectedHFevaluatedvariousmodelsincludingelementsfromhistory,physicalexamination,andinitialtesting[7].A diagnosticrulewasdevelopedwiththefollowingelements: Age<60years(nopoints),60to70(4points),70to80(7points),>80(10points) Historyofmyocardialinfarction,coronaryarterybypassgraftsurgery,orpercutaneouscoronaryintervention(15pointsifpresent) Loopdiuretic(10pointsifpresent) Displacedapicalimpulse(20pointsifpresent) Rales(14pointsifpresent) Irregularlyirregularpulse(11pointsifpresent) Heartmurmur(10pointsifpresent) Pulserate[(bpm60)/3points} Elevatedjugularvenouspressure(12pointsifpresent) NTproBNP(pg/mL)<100(nopoints),100to200(8points),200to400(16points),400to800(24points),800to1600(32points),1600to3200(40points),>3200(48 points) Withasummedscore<13points,theestimatedprobabilityofHFis<10percent.Withasummedscore>54points,theestimatedprobabilityofHFis>70percent.Therulewas appliedtotwoexternalvalidationdatasetswithAUCof0.88to0.95.(See"Evaluatingdiagnostictests",sectionon'Receiveroperatingcharacteristiccurves'.) Althoughbothoftheaboverulesperformedwellwhenappliedtovalidationdatasets,theirgeneralizabilitytovariousclinicalsettingsisuncertain. INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsandBeyondtheBasics.TheBasicspatienteducationpiecesare writteninplainlanguage,atthe5thto6thgradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesarebest forpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore detailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon. Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopicstoyourpatients.(Youcanalsolocatepatienteducation articlesonavarietyofsubjectsbysearchingonpatientinfoandthekeyword(s)ofinterest.) Basicstopic(see"Patientinformation:Heartfailure(TheBasics)") BeyondtheBasicstopic(see"Patientinformation:Heartfailure(BeyondtheBasics)") SUMMARYANDRECOMMENDATIONS Initialevaluationofpatientswithsymptomsorsignssuggestiveofheartfailure(HF)includesclinicalassessment(historyandphysicalexam),electrocardiogram,blood tests,andchestxray. EarlymeasurementofplasmaBNPorNTproBNPlevelsissuggestedinpatientswithsuspectedHFinwhomthediagnosisisuncertain. InpatientswithsymptomsandsignsofHF,echocardiographyisusefulforevaluatinghemodynamicsandidentifyingpotentialcausesofHF. Furtherevaluationandmanagementofpatientsdiagnosedwithheartfailureisdiscussedseparately.(See"Evaluationofthepatientwithheartfailureorcardiomyopathy"and "Overviewofthetherapyofheartfailureduetosystolicdysfunction".) UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

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GRAPHICS
ModifiedFraminghamclinicalcriteriaforthediagnosisofheartfailure
Major
Paroxysmalnocturnaldyspnea Orthopnea Elevatedjugularvenouspressure Pulmonaryrales Thirdheartsound Cardiomegalyonchestxray Pulmonaryedemaonchestxray Weightloss4.5kginfivedaysinresponsetotreatmentofpresumedheartfailure

Minor
Bilaterallegedema Nocturnalcough Dyspneaonordinaryexertion Hepatomegaly Pleuraleffusion Tachycardia(heartrate120beats/min) Weightloss4.5kginfivedays

Diagnosis
Thediagnosisofheartfailurerequiresthat2majoror1majorand2minorcriteriacannotbeattributedtoanothermedicalcondition. FromSenni,M,Tribouilloy,CM,Rodeheffer,RJ,etal,Circulation199898:2282adaptedfromMcKee,PA,Castelli,WP,McNamara,PM,Kannel,WB.NEnglJMed 197185:1441.

ACC/AHAguidelinesummary:Initialevaluationofpatientswithheartfailure(HF)
ClassIThereisevidenceand/orgeneralagreementthattheinitialevaluationofpatientspresentingwithHFshould includethefollowing:
Acompletehistoryandphysicalexaminationtoidentifycardiacandnoncardiacdisordersorbehaviorsthatmightcauseoracceleratethedevelopmentor progressionofHF. Acarefulhistoryofcurrentandpastuseofalcohol,illicitdrugs,standardor"alternative"therapies,andchemotherapydrugs. Anassessmentoftheabilitytoperformroutineanddesiredactivitiesofdailyliving. Anassessmentofthevolumestatus,orthostaticbloodpressurechanges,heightandweight,andcalculationofbodymassindex. Laboratorystudiesincludingcompletebloodcount,urinalysis,serumelectrolytes(includingcalciumandmagnesium),bloodureanitrogen,serumcreatinine, fastingbloodglucose(glycohemoglobin),lipidprofile,liverfunctiontests,andserumthyroidstimulatinghormone. Atwelveleadelectrocardiogramandchestradiograph(posteroanteriorandlateral). TwodimensionalechocardiographywithDopplertoassessleftventricularejectionfraction(LVEF),leftventricularsize,wallthickness,andvalvefunction. RadionuclideventriculographycanbeperformedtoassessLVEFandvolumes. Coronaryarteriographyifthereisahistoryoranginaorsignificantischemiaunlessthepatientisnoteligibleforrevascularizationofanykind.

ClassIIaTheweightofevidenceoropinionisinfavorofbenefitfromperformingthefollowingstudiesaspartofthe initialevaluationofpatientspresentingwithHF:
Coronaryarteriographyinpatientswhohavechestpainthatmayormaynotbeofcardiacoriginwhohavenothadapriorevaluationoftheircoronary anatomyandareeligibleforcoronaryrevascularization. Coronaryarteriographyinpatientswithknownorsuspectedcoronaryarterydiseasewhodonothaveanginaandareeligibleforrevascularization. Noninvasiveimagingtodetectmyocardialischemiaandviabilityinpatientswithknownorsuspectedcoronaryarterywhodonothaveanginaandareeligible forrevascularization. WhenthecontributionofHFtoexerciselimitationisuncertain,maximalexercisetestingwithorwithoutmeasurementofrespiratorygasexchangeand/or bloodoxygensaturation. Toidentifycandidatesforcardiactransplantationorotheradvancedtreatments,maximalexercisetestingwithmeasurementofrespiratorygasexchange. Inselectedpatients,screeningforhemochromatosis,sleepdisturbedbreathing,orhumanimmunodeficiencyvirus(HIV)infection. Whensuspectedclinically,diagnostictestsforrheumatologicdisease,amyloidosis,orpheochromocytoma. Endomyocardialbiopsywhenaspecificdiagnosisissuspectedthatwouldinfluencetherapy. MeasurementofserumBtypenatriureticpeptide(BNP)intheurgentcaresettingiftheclinicaldiagnosisofHFisuncertain.Measurementofnatriuretic peptides(BNPandNTproBNP)canbeusefulinriskstratification.

ClassIIbTheweightofevidenceoropinionislesswellestablishedforthefollowingtestingintheinitialevaluation ofpatientswithHF
Noninvasiveimagingtodefinethelikelihoodofcoronaryarterydiseaseinpatientswithleftventriculardysfunction. Holtermonitoringinpatientswhohaveahistoryofmyocardialinfarctionandarebeingconsideredforelectrophysiologicstudytodocumenttheinducibilityof ventriculartachycardia.

ClassIIIThereisevidenceand/orgeneralagreementthatthefollowingtestsarenotusefulormaybeharmfulinthe initialevaluationofpatientswithHF
Routineendomyocardialbiopsyintheabsenceofsuspicionofaspecificdiagnosisthatwouldinfluencetherapysuspected. Routinesignalaveragedelectrocardiography. RoutinemeasurementofserumneurohormonesotherthanBNP(eg,norepinephrineorendothelin). DatafromHuntSA,AbrahamWT,ChinMH,etal.2009focusedupdateincorporatedintotheACC/AHA2005GuidelinesfortheDiagnosisandManagementofHeart FailureinAdults:areportoftheAmericanCollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuidelines:developedincollaboration withtheInternationalSocietyforHeartandLungTransplantation.Circulation2009119:e391.

Flowdiagramfortheworkupofpatientswithdilated cardiomyopathy

ECG:electrocardiographyecho:echocardiography. *Thetimingofendomyocardialbiopsyinpatientswhofailtoimproveon medicaltherapyiscontroversial.Ifthepatient'sleftventricularfunctionand symptomsarenotstableafteroneweekoftreatment,additionaltimebefore endomyocardialbiopsycouldbeconsidered,ifappropriateinthetreating physician'sclinicaljudgment,toallowfordelayedrecoverytooccur. Reproducedwithpermissionfrom:Wu,LA,Lapeyre,AC3rd,Cooper,LT.Mayo ClinProc200176:1030.Copyright2001MayoClinicProceedings.

Dilatedcardiomyopathychestradiograph

Thisplainfrontalradiographofthechestina51yearoldmale demonstratesmarkedenlargementofthecardiacsilhouette compatiblewithadilatedcardiomyopathy.Cardiomegalyis nonspecificandcanbeseenwithanyetiologyofcardiomyopathy.


CourtesyofJonathanKruskal,MD,PhD.

Normalchestradiograph

Posteroanteriorviewofanormalchestradiograph.
CourtesyofCarolMBlack,MD.

Heartfailure

Thischestradiographofa65yearoldmalewithdyspneaand orthopneademonstratesmildpulmonaryvascularcongestion, septallymphaticdistention(whitearrow),interstitialveiling,and enlargedhilarshadows(blackarrow),indicativeofleftventricular decompensation.


CourtesyofJonathanKruskal,MD.

Normalchestradiograph

Posteroanteriorviewofanormalchestradiograph.
CourtesyofCarolMBlack,MD.

Pulmonaryedema

Thisplainfrontalchestradiographofa55yearoldmalewith knowncoronaryarterydiseasedemonstratescharacteristic radiographicfeaturesofheartfailurewithinterstitialpulmonary edema,bilateralperihilaralveolaredemaproducinga characteristicbutterflypatternandbilateralpleuraleffusions.


PhotocourtesyofJonathanKruskal,MD.

Normalchestradiograph

Posteroanteriorviewofanormalchestradiograph.
CourtesyofCarolMBlack,MD.

Severeheartfailure

Thischestradiographyshowssevereheartfailurewith cardiomegaly,pulmonaryvascularcongestionwithinfiltratesin themidlungfields(whitearrow),andasmallpleuraleffusion (blackarrow).


CourtesyofJonathanKruskal,MD.

Normalchestradiograph

Posteroanteriorviewofanormalchestradiograph.
CourtesyofCarolMBlack,MD.

Cardiogenicpulmonaryedema

Pulmonaryedemaina"butterflydistribution"duetoleft ventricularfailure.Chestradiographshowslargeperihilar opacitiesinpatientwithenlargedcardiacsilhouette.


CourtesyofPaulStark,MD.

Normalchestradiograph

Posteroanteriorviewofanormalchestradiograph.
CourtesyofCarolMBlack,MD.

Dilatedcardiomyopathy

Mmodescanoftheheartisobtainedbymovingthetransducer fromacephaladtocaudaldirection,recordingtheaorticroot, mitalvalveandmitralvalveannulus,andtheleftventricular chamber.Inthispatientwithaseveredilatedcardiomyopathy, thereissignificantenlargementoftheleftatriumandleft ventricle.Inaddition,theseptumandposteriorleftventricular wallarethinnedandhypokinetic.

Mitralvalvemotionindilatedcardiomyopathy

Mmodeechocardiogram,recordedatthelevelofthemitralvalve leaflets,showsadilatedleftventricle.Theinterventricular septumandposteriorleftventricularwallarethinnedand hypokinetic.Themovementofboththeanteriorandposterior mitralvalveleafletsiswellseenandthereareprominentechoes fromthechordaetendinaeduetotheenlargedleftventricular chamber.

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