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Evaluation of the patient with suspected heart failure Author Wilson S Colucci, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Apr 2013. | This topic last updated: Jan 21, 2012. INTRODUCTION — Heart failure (HF) is a common clinical syndrome caused by a variety of cardiac diseases . The initial evaluation of the patient with suspected HF due to systolic or diastolic dysfunction will be reviewed here. Evaluation of the etiology and management of HF and evaluation and treatment of acute decompensated HF are discussed separately. (See "Evaluation of the patient with heart failure or cardiomyopathy" and "Overview of the therapy of heart failure due to systolic dysfunction" and "Clinical manifestations and diagnosis of diastolic heart failure" and "Evaluation of acute decompensated heart failure" and "Treatment of acute decompensated heart failure: General considerations".) DEFINITION — Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. It is characterized by specific symptoms, such as dyspnea and fatigue, and signs, such as those related to fluid retention. There are many ways to assess cardiac function. However, there is no diagnostic test for HF, since it is largely a clinical diagnosis that is based upon a careful history and physical examination (table 1). CLINICAL PRESENTATION — The approach to the patient with suspected HF includes the history and physical examination, and diagnostic tests to help establish the diagnosis, assess acuity and severity and initiate assessment of etiology. Recommendations for the evaluation of patients with HF were included in the 2005 American College of Cardiology (ACC/AHA) guidelines with 2009 focused update (table 2 and algorithm 1) , the 2010 Heart Failure Society of America (HFSA) guidelines , the 2008 European Society of Cardiology (ESC) guidelines , and the 2006 Canadian Cardiovascular Society (CCS) consensus conference . The discussion below focuses on diagnosis of heart failure. The history and physical examination of the patient with suspected heart failure should also include assessment of risk factors and potential etiologies of heart failure as discussed separately. (See "Evaluation of the patient with heart failure or cardiomyopathy" and "Evaluation of acute decompensated heart failure".) History — Symptoms of HF include those due to excess fluid accumulation (dyspnea, orthopnea, edema, pain from hepatic congestion, and abdominal distention from ascites) and those due to a reduction in cardiac output (fatigue, weakness) that is most pronounced with exertion. Fluid retention in HF is initiated by the fall in cardiac output, leading to alterations in renal function, due in part to activation of the sodiumretaining reninangiotensinaldosterone and sympathetic nervous systems. (See "Pathophysiology of heart failure: Neurohumoral adaptations".) Important information concerning the acuity of HF is suggested by the presenting symptoms: Acute and subacute presentations (days to weeks) are characterized primarily by shortness of breath, at rest and/or with exertion. Also common are orthopnea, paroxysmal nocturnal dyspnea, and, with right HF, right upper quadrant discomfort due to acute hepatic congestion, which can be confused with acute cholecystitis. Patients with atrial and/or ventricular tachyarrhythmias may complain of palpitations with or without lightheadedness. Patients with acute decompensated heart failure require prompt diagnosis and management. (See "Evaluation of acute decompensated heart failure" and "Treatment of acute decompensated heart failure: General considerations".) Chronic presentations (months) differ in that fatigue, anorexia, abdominal distension, and peripheral edema may be more pronounced than dyspnea. The anorexia is secondary to several factors including poor perfusion of the splanchnic circulation, bowel edema, and nausea induced by hepatic congestion. Over time, pulmonary venous capacitance accommodates to the chronic state of volume overload, leading to less or no fluid accumulation in the alveoli, despite the increase in total lung water. These patients present with excessive fatigue and lowoutput symptoms. Other clinical features such as older age, history of coronary artery disease or myocardial infarction, and use of a loop diuretic are associated with increased likelihood of heart failure [6,7]. As discussed below, the history alone is insufficient to make the diagnosis of HF. (See 'Diagnostic accuracy of clinical features' below.) Nevertheless, a detailed history remains the single best discriminator to determine the acuity, etiology, and rate of progression of HF and the history often provides important clues to the cause of HF. (See "Evaluation of the patient with heart failure or cardiomyopathy".) Physical examination — The physical examination can provide evidence of the presence and extent of cardiac filling pressure elevation, volume overload, ventricular enlargement, pulmonary hypertension, and reduction in cardiac output. In the study of primary care patients cited above, the physical finding of a displaced apical impulse had the best combination of sensitivity, specificity, and positive and negative predictive value of any physical sign of systolic HF . Other strong predictors of HF included a gallop rhythm and elevated jugular venous pressure. Vital signs and appearance — Patients with advanced HF may show evidence of a major decline in cardiac output and therefore a decrease in tissue perfusion. Four major findings suggest severity of the cardiac dysfunction: resting sinus tachycardia, narrow pulse pressure, diaphoresis, and peripheral vasoconstriction. The last abnormality is manifested as cool, pale, and sometimes cyanotic extremities (due to the combination of decreased perfusion and increased oxygen extraction). A decrease in cardiac output should be suspected when the pulse pressure is reduced below 25 mmHg. Both the cardiac disease itself and the secondary neurohumoral adaptation contribute to the low output state. Patients compensate for a fall in cardiac output by increasing sympathetic outflow with resultant shunting of the cardiac output to vital organs. An irregularly irregular pulse is suggestive of atrial fibrillation which frequently accompanies HF. (See "Atrial fibrillation in patients with heart failure".) Volume assessment — There are three major manifestations of volume overload in patients with HF: pulmonary congestion, peripheral edema, and elevated jugular venous pressure. Pulmonary congestion that may manifest as rales is more prominent in acute or subacute disease. As noted above, chronic HF is associated with increases in venous capacitance and lymphatic drainage of the lungs; as a result, rales are often absent even though the pulmonary capillary pressure is elevated. Continued sodium retention in this setting preferentially accumulates in the periphery although a chronic elevation in pulmonary venous pressure can lead to pleural effusions. Peripheral edema is manifested by swelling of the legs (which is more prominent when the patient is upright), and may also cause ascites, scrotal edema, hepatomegaly, and splenomegaly . (See "Approach to the adult patient with splenomegaly and other splenic disorders".) In this setting, manual compression of the right upper quadrant to increase venous return may elevate jugular venous pressure above the transient 1 to 3 cm elevations seen in normal individuals. This sign is known as the hepatojugular reflux. (See "Examination of the jugular venous pulse", section on 'Hepatojugular reflux'.) Elevated jugular venous pressure is usually present if peripheral edema is due to HF, since it is the high intracapillary pressure that is responsible for fluid movement into the interstitium. With the patient sitting at 45º jugular venous pressure can be estimated from the height above the left atrium of venous pulsations in the internal jugular vein. The height of external jugular vein pulsations may also be helpful but care must be taken to avoid spurious interpretation. (See "Examination of the jugular venous pulse".) The accuracy of clinical volume assessment is discussed below. (See 'Diagnostic accuracy of clinical features' below.) Section Editor Stephen S Gottlieb, MD Deputy Editor Susan B Yeon, MD, JD, FACC
Because of the high prevalence of these disorders.). edema (72 and 53 percent). (See 'NTproBNP' below and "Natriuretic peptide measurement in heart failure" and "Echocardiographic evaluation of left ventricular diastolic function". Exposure to echocardiographic and NTproBNP results did not improve the accuracy of clinical evaluations.12]. section on 'Diagnosis' and "Chronic obstructive pulmonary disease: Definition. When the cuff pressure is slowly released. lung crepitation (81 and 51 percent).) INITIAL TESTING Electrocardiogram — Most patients with HF due to systolic dysfunction have a significant abnormality on an electrocardiogram (ECG). increased left ventricular enddiastolic pressures (>15 mmHg). Signs of elevated right heart filling pressure included increased jugular venous pressure. there is appreciable interobserver variability in the ability to detect an S3 that cannot be solely explained by the experience of the observer [11. Anemia or infection can exacerbate preexisting HF. and ascites. However. Patients with decreased exercise tolerance have symptoms of dyspnea or fatigue with exertion and may also have symptoms at rest. hepatomegaly was also highly specific (97 percent) but had low sensitivity (17 percent). section on 'Algorithms for estimating LV filling pressure'. These patients may also complain of substernal chest pressure. but also in any patient with one of these diagnoses who presents with a deterioration in respiratory status .) The ECG is particularly important for identifying evidence of acute or prior myocardial infarction or acute ischemia. Signs Extra heart sounds were highly specific (99 percent) but had low sensitivity (11 percent). and elevated serum brain natriuretic peptide concentrations. Physical signs of pulmonary hypertension can include increased intensity of P2. and creatinine may indicate associated conditions. and test results. Various other causes for such symptoms and signs should also be considered. Other clinical features had relatively high specificity but low sensitivity: Symptoms Orthopnea (specificity and sensitivity of 89 and 44 percent) and history of myocardial infarction (89 and 26 percent). and their frequent coexistence.) The pathophysiology of pulsus alternans is not well understood. This issue is discussed in detail separately. or both . the ECG may show findings that favor the presence of a specific cause of HF and can also detect arrhythmias (eg. in a phonocardiographic study of patients who were undergoing cardiac catheterization. phase I Korotkoff sounds are initially heard only during the alternate strong beats; with further release of cuff pressure. Causes of fatigue include deconditioning. This phenomenon is characterized by evenly spaced alternating strong and weak peripheral pulses. signs. It is best appreciated by applying light pressure on the peripheral arterial pulse. The accuracy of estimation of right filling pressure by echocardiographic examination of the IVC (75 percent) was similar to the accuracy of physical examination. a parasternal lift. and can be confirmed by measuring the blood pressure. and a palpable pulmonic tap (felt in the left second intercostal space).) The diagnosis of HF is based upon a constellation of symptoms.) Serum electrolytes. fluid retention. the S3 was highly specific (90 percent) for these parameters and for an elevated serum brain natriuretic peptide concentration . (See "Electrocardiogram in the diagnosis of myocardial ischemia and infarction". Greater specificity than sensitivity was also seen for cardiomegaly (85 and 27 percent). In this setting. diagnosis. if present. Left ventricular dysfunction can also lead to sustained apical impulse. Hyponatremia generally indicates severe HF. sleep apnea and depression. it is reasonable to consider both diagnoses. DIFFERENTIAL DIAGNOSIS — Many of the symptoms and signs of HF are nonspecific so other potential causes should be considered. renal sodium retention. is virtually pathognomonic of severe left ventricular failure. and staging". (See "Auscultation of heart sounds". (See "Auscultation of cardiac murmurs" and "Auscultation of heart sounds" and "Examination of the precordial pulsation".) Initial blood tests — Recommended initial blood tests for patients with symptoms and signs of HF include: A complete blood count which may suggest concurrent or alternate conditions. . an S3 (or “extra heart sound”) has a low sensitivity (eg. In this population.) Patients presenting with fluid retention may complain of leg or abdominal swelling. A normal ECG makes systolic dysfunction unlikely (98 percent negative predictive value) . typical of angina. The accuracy of estimates of left heart filling pressures by NTproBNP (67 percent) and by echocardiography E/e’ ratio (60 percent) was also similar to physical examination. a murmur of pulmonary insufficiency. Patients with HF may present with a syndrome of decreased exercise tolerance. (See "Approach to the patient with dyspnea" and "Approach to the adult patient with fatigue". (See "Examination of the precordial pulsation". Renal impairment may be caused by and/or contribute to HF exacerbation. The severe ventricular dysfunction may be associated with variations in contractility secondary to shifts in afterload. In addition. The accuracy of clinical evaluation of cardiac filling pressures varies among observers as illustrated by a study of 116 patients undergoing cardiac catheterization . section on 'Pulsus alternans'. (See "Examination of the arterial pulse". Examination by staff cardiologists was more accurate than by trainees for right heart pressures (82 versus 67 percent) and left heart pressures (71 versus 55 percent). their similar presentations. (See "Impact of anemia in patients with heart failure". Although the ECG may be less predictive of HF than the BNP (or NTproBNP) level . and elevated jugular venous pressure (70 and 52 percent).) Heart sounds — An S3 gallop is associated with left atrial pressures exceeding 20 mmHg. calcium channel blocker) and cirrhosis. The S3 may be palpable in severe ventricular failure. peripheral edema. An apical impulse that is laterally displaced past the midclavicular line is usually indicative of left ventricular enlargement. which can contribute to dyspnea as pulmonary pressures rise with exertion.) Pulmonary hypertension — Patients with chronic HF often develop secondary pulmonary hypertension. clinical manifestations. (See "Chronic obstructive pulmonary disease: Definition.) For example. and other disorders . section on 'Left ventricular gallops'.Pulsus alternans — Pulsus alternans. The degree of pulsus alternans can be quantitated by measuring the difference in systolic pressure between the strong and the weak beat. the softer sounds of the weak beat also appear. and staging". which may be accompanied by a parasternal lift in the setting of right ventricular hypertrophy or enlargement. Right and left heart filling pressures were accurately estimated by physical examination in 71 and 60 percent of 215 observations. Signs of elevated left heart filling pressure included findings of elevated right heart filling pressure as well as gallops or rales. (See "Tachycardiamediated cardiomyopathy" and "Evaluation of the patient with heart failure or cardiomyopathy". preload. Baseline evaluation of electrolytes and creatine is also necessary when initiating therapy with diuretics and/or angiotensin converting enzyme inhibitors.7]. 99 percent) for clinical diagnosis of HF [6. diagnosis. blood urea nitrogen. Precordial palpation — Ventricular chamber size can be estimated by precordial palpation. drug side effect (eg. not only in patients presenting with dyspnea for the first time. elevated right ventricular enddiastolic pressure leads to secondary right ventricular subendocardial ischemia. chronic obstructive pulmonary disease (COPD) and HF may be difficult to distinguish in some patients. Ischemia may cause symptoms of dyspnea similar to HF and may also cause or exacerbate HF. Similarly. Heart failure should be distinguished from other causes of dyspnea including myocardial ischemia. Diagnostic rules based upon combinations of clinical features are discussed below (See 'Diagnostic rules' below. pulmonary disease. 4 to 11 percent) but high specificity (eg. (See "Clinical manifestations and diagnosis of edema in adults" and "Pathophysiology and etiology of edema in adults". though it may occasionally result from excessive diuresis . an S3 was not very sensitive (40 to 50 percent) for the detection of an elevated left ventricular enddiastolic pressure or a reduced left ventricular ejection fraction; however.) Diagnostic accuracy of clinical features — The accuracy of symptoms and signs for the clinical diagnosis of heart failure was evaluated by a systematic review that included data from 15 studies of patients with suspected heart failure : Dyspnea was the only symptom or sign with high sensitivity (87 percent) but its specificity was low (51 percent). atrial fibrillation) that suggest heart disease and may cause or exacerbate HF. Heart failure should be distinguished from other causes of edema including venous thrombosis or insufficiency. and electrical excitability . clinical manifestations.
(See "Natriuretic peptide measurement in heart failure". but only cardiomegaly had a sensitivity >50 percent . proBNP. The Nterminal fragment (NTproBNP) is also released into the circulation. 900 pg/mL. interstitial edema.) As noted above. such as pulmonary embolism. In one analysis. They also rate echocardiography appropriate when other studies (such as chest xray or elevation of serum BNP) are concerning for cardiac disease. and pleural effusions (image 1AE). As noted below. (See "Noninvasive methods for measurement of left ventricular systolic function". BNP — Most dyspneic patients with HF have values above 400 pg/mL. The active BNP hormone is cleaved from the Cterminal end of its prohormone. In the range between 100 and 400 pg/mL. section on 'Echocardiography'. section on 'Plasma N terminal proBNP'. Fasting blood glucose to detect underlying diabetes mellitus. A systematic review of the utility of the chest xray to diagnose LV dysfunction concluded that redistribution and cardiomegaly were the best predictors of increased preload and reduced ejection fraction. 2008 ESC. plasma BNP or NTproBNP levels are not diagnostic. shortness of breath and others) due to a suspected cardiac etiology . a BNP cutoff of ≥100 pg/mL was associated with a specificity of only 40 percent compared to 79 percent in patients without AF . Greater increases in NTproBNP than BNP levels are observed in renal failure. Kerley Blines. when right heart failure is due solely to lung disease and not due to secondary pulmonary hypertension from left sided heart disease or as part of a global cardiomyopathy. elevated plasma BNP may be misinterpreted since dyspnea in these patients is due to lung disease not left heart failure. Neither finding. Important echocardiographic findings include the following: Atrial and ventricular sizes. (See "Natriuretic peptide measurement in heart failure". alveolar edema. (See "Echocardiographic evaluation of left ventricular diastolic function". respectively. Plasma BNP and NTproBNP levels tend to be lower in obese patients and are elevated in patients with renal failure. LV dysfunction without exacerbation. with a negative predictive value of 98 percent. plasma NTproBNP concentrations are approximately fourfold higher than BNP concentrations . In some patients with acute decompensated HF.7]. for patients <50. somewhat higher cutoff values may be needed in these settings. However. an ECG has relatively high sensitivity (89 percent) but more limited specificity (56 percent). In a multicenter study of 880 patients.) Diastolic left ventricular function.) ECHOCARDIOGRAPHY — In patients with symptoms and signs of HF. and >75 years of age. the plasma concentrations of BNP and NTproBNP are similar (approximately 10 pmol/L). although the optimal discriminatory values that should be used have not been determined. which may be helpful in identifying the cause and chronicity of disease. The plasma concentrations of BNP and NT proBNP are increased in patients with left ventricular dysfunction. while values below 100 pg/mL have a very high negative predictive value for HF as a cause of dyspnea . and such levels may not be useful in guiding management.) BNP and NTproBNP — Brain natriuretic peptide (BNP) is a natriuretic hormone released primarily from the heart. patients with idiopathic dilated cardiomyopathy typically have both left and right atrial and ventricular enlargement (four chamber dilatation) with decreased left systolic ventricular function (image 2 and figure 1 and movie 1 and movie 2 and movie 3). and some acute noncardiac illnesses such as sepsis. echocardiography is helpful for determining whether ventricular function and hemodynamics are consistent with HF and in identifying a cause.15]. (See 'Diagnostic rules' below. 50 to 75. BNP or NTproBNP levels are useful in distinguishing HF due to systolic and/or diastolic dysfunction from other causes of dyspnea. LVEF and RVEF). respectively . however. and initial blood tests) [6. and 1800 pg/mL respectively . Diagnostic accuracy of initial testing — The accuracy of initial testing for the clinical diagnosis of heart failure was evaluated by a systematic review that included data from 15 studies of patients with suspected heart failure : BNP or NTproBNP levels have relatively high sensitivity (both 93 percent) and more limited specificity for clinical diagnosis of HF (74 and 65 percent). (See "Natriuretic peptide measurement in heart failure". and 2006 CCS guidelines [2. studies developing and validating diagnostic rules for HF have found that the BNP or NTproBNP levels add greater diagnostic value to the history and physical examination than other initial tests (ECG. as recommended in the 2005 ACC/AHA guidelines with 2009 update as well as the 2006 HFSA. (See "Echocardiographic recognition of cardiomyopathies". particularly in the evaluation of patients who present with dyspnea.Liver function tests. Evidence of efficacy and limitations of BNP and NTproBNP levels in the diagnosis of HF is discussed in detail separately. and cephalization all had a specificity of >90 percent for HF. Some patients with severe chronic HF may have persistently elevated plasma BNP or NTproBNP concentrations regardless of treatment.) The optimal values for distinguishing HF from other causes of dyspnea vary with patient age. Limitations of BNP and NTproBNP — There are several important limitations to the use of plasma BNP and NTproBNP for diagnosis of HF : Patients may present with more than one cause of dyspnea (such as pneumonia and an exacerbation of HF). the optimal plasma NTproBNP cutoffs for diagnosing HF were 450 pg/mL. Normal plasma BNP values increase with age and are higher in women than men . In a large multicenter study. Atrial fibrillation (AF) is associated with higher levels of BNP in the absence of HF. in patients with LV dysfunction. Using a cutoff of ≥200 pg/mL in patients with AF increased specificity from 40 to 73 percent with a smaller reduction in sensitivity from 95 to 85 percent. Diagnostic rules for HF that include initial testing are discussed below. NTproBNP was the most powerful supplementary test. Other diagnoses. plasma BNP concentrations are not very sensitive or specific for detecting or excluding HF. The 2007 ACCF/ASE/ACEP/ANC/SCAI/SCCT/SCMR appropriateness criteria rate echocardiography as appropriate in patients with symptoms (including dyspnea. Thus. gammaglutamyltransferase level (GGT) >2 times the upper limit of normal was the only standard initial blood test that added diagnostic value to the history and physical examination .) Chest xray evidence of HF is helpful in confirming the diagnosis since it has relatively high specificity (83 percent) though more limited sensitivity (68 percent).) Chest xray — The chest xray is a useful first diagnostic test.4. particularly the ventricles. For example.) . However. which may be affected by hepatic congestion. these cutoffs yielded a sensitivity and specificity of 90 and 84 percent. chest xray. NTproBNP — In normal subjects. However. to differentiate HF from primary pulmonary disease . Thus. Elevated natriuretic peptide levels should be interpreted in the context of other clinical information; they may lend weight to the diagnosis of HF or trigger consideration of HF but should NOT be used in isolation to diagnose HF . In one study.5. particularly those with heart failure. Measurement and interpretation of BNP and NTproBNP levels is discussed in detail separately. Across the entire population. cephalization of the pulmonary vessels. Findings suggestive of HF include cardiomegaly (cardiactothoracic width ratio above 50 percent). a high plasma BNP or NTproBNP concentration does not exclude the presence of other diseases. (See "Heart failure in diabetes mellitus".) Measurement of plasma BNP or NTproBNP is suggested in the evaluation of patients with suspected HF when the diagnosis is uncertain. The cardiac size and silhouette may also reveal signs of congenital anomalies (ventricular or atrial septal defect) or valvular disease (mitral stenosis or aortic stenosis). (See "Natriuretic peptide measurement in heart failure". and cor pulmonale should also be considered in patients with plasma BNP concentrations in this range. was sufficient to make a definitive diagnosis of HF.) Global left and right ventricular systolic function (left and right ventricular ejection fraction. (See 'Electrocardiogram' above. Right heart failure and pulmonary hypertension are associated with elevations in plasma BNP and NTproBNP. NTproBNP levels below 300 pg/mL were optimal for excluding a diagnosis of HF. Overall.
(See "Evaluation of the patient with heart failure or cardiomyopathy" and "Overview of the therapy of heart failure due to systolic dysfunction".96. 100 to 200 (8 points). (See "Constrictive pericarditis" and "Cardiac tamponade". (See "Evaluating diagnostic tests". “The Basics” and “Beyond the Basics. 200 to 400 (16 points). Female with ankle edema if BNP >100 to 180 pg/mL (or NTproBNP >190 to 520 pg/mL). A patient with suspected HF without one of the above features is referred for BNP or NTproBNP level testing. The model with the best fit was simplified into the following clinical prediction rule: Echocardiography is recommended for a patient with suspected HF presenting with symptoms such as breathlessness if any one of the following is present: history of myocardial infarction. >3200 (48 points) With a summed score <13 points.” The Basics patient education pieces are written in plain language. or male with ankle edema. coronary artery bypass graft surgery. physical examination. (See "Echocardiographic evaluation of left ventricular diastolic function". electrocardiogram. The rule was applied to two external validation datasets with AUC of 0. 1600 to 3200 (40 points). These articles are written at the 10th to 12th grade reading level and are best for patients who want indepth information and are comfortable with some medical jargon. echocardiography is useful for evaluating hemodynamics and identifying potential causes of HF. Early measurement of plasma BNP or NT proBNP levels is suggested in patients with suspected HF in whom the diagnosis is uncertain. . and they answer the four or five key questions a patient might have about a given condition.95.) Valvular heart disease Echocardiography also provides a noninvasive assessment of hemodynamic status: The pulmonary capillary wedge pressure (PCWP) can be estimated via the ratio (E/Ea or E/E') of tissue Doppler of early mitral inflow velocity (E) to early diastolic velocity of the mitral annulus (Ea or e'). (See "Evaluating diagnostic tests". 60 to 70 (4 points). >80 (10 points) History of myocardial infarction. A diagnostic rule was developed with the following elements: Age <60 years (no points). Use and limitations of this method are discussed separately. Beyond the Basics patient education pieces are longer. Further evaluation and management of patients diagnosed with heart failure is discussed separately. section on 'Tissue Doppler imaging'.) Right ventricular and pulmonary artery pressures can be estimated by the peak velocity of tricuspid regurgitation on Doppler echocardiography. section on 'Receiver operating characteristic curves'.Regional wall motion abnormalities in a coronary distribution are suggestive of coronary heart disease but segmental abnormalities also occur commonly in patients with dilated cardiomyopathy Pericardial disease includes thickening suggestive of constrictive pericarditis or effusion which may or may not be associated with tamponade.88 to 0.) Basics topic (see "Patient information: Heart failure (The Basics)") Beyond the Basics topic (see "Patient information: Heart failure (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Initial evaluation of patients with symptoms or signs suggestive of heart failure (HF) includes clinical assessment (history and physical exam). Right atrial pressure may be estimated from evaluating the size of the inferior vena cava and its respiratory variation. These articles are best for patients who want a general overview and who prefer short. An E/e' ratio >15 suggests a PCWP >15 mm Hg when e' is the mean of medial and lateral mitral annulus early diastolic velocities.) A multicenter prospective study of 721 patients with suspected HF evaluated various models including elements from history. The cardiac output can be estimated by pulsedwave Doppler from the left ventricular outflow tract . their generalizability to various clinical settings is uncertain. In patients with symptoms and signs of HF. Here are the patient education articles that are relevant to this topic. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.) Although both of the above rules performed well when applied to validation datasets. the estimated probability of HF is >70 percent. With a summed score >54 points. The above model was applied to other datasets with an area under the ROC curve (AUC) of 0. An individual patient data analysis tested various diagnostic models in one dataset . 70 to 80 (7 points). or basal crepitations (rales). blood tests. or percutaneous coronary intervention (15 points if present) Loop diuretic (10 points if present) Displaced apical impulse (20 points if present) Rales (14 points if present) Irregularly irregular pulse (11 points if present) Heart murmur (10 points if present) Pulse rate [(bpm60)/3 points} Elevated jugular venous pressure (12 points if present) NTproBNP (pg/mL) <100 (no points).) Use of UpToDate is subject to the Subscription and License Agreement.84 to 0. DIAGNOSTIC RULES — Diagnostic rules have been developed in an attempt to increase the accuracy and efficiency of HF diagnosis as illustrated by the following two examples. at the 5th to 6th grade reading level. section on 'Receiver operating characteristic curves'. We encourage you to print or email these topics to your patients. 400 to 800 (24 points). Echocardiography is recommended in the following settings : Female without ankle edema if BNP >210 to 360 pg/mL (or NTproBNP >620 to 1060 pg/mL) depending upon local availability of echocardiography. Male without ankle edema if BNP >130 to 220 pg/mL (or NTproBNP >390 to 660 pg/mL). and initial testing . and more detailed. and chest xray. the estimated probability of HF is <10 percent. INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials. 800 to 1600 (32 points). easytoread materials. more sophisticated.
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Castelli. CM. et al. N Engl J Med 1971; 85:1441. PA. .5 kg in five days Diagnosis The diagnosis of heart failure requires that 2 major or 1 major and 2 minor criteria cannot be attributed to another medical condition. Circulation 1998; 98:2282; adapted from McKee. WB. McNamara.5 kg in five days in response to treatment of presumed heart failure Minor Bilateral leg edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion Tachycardia (heart rate ≥120 beats/min) Weight loss ≥4. RJ. Kannel. PM. M. Rodeheffer. Tribouilloy. WP. From Senni.GRAPHICS Modified Framingham clinical criteria for the diagnosis of heart failure Major Paroxysmal nocturnal dyspnea Orthopnea Elevated jugular venous pressure Pulmonary rales Third heart sound Cardiomegaly on chest xray Pulmonary edema on chest xray Weight loss ≥4.
• Routine measurement of serum neurohormones other than BNP (eg. serum electrolytes (including calcium and magnesium). maximal exercise testing with measurement of respiratory gas exchange. • In selected patients. Class III There is evidence and/or general agreement that the following tests are not useful or may be harmful in the initial evaluation of patients with HF • Routine endomyocardial biopsy in the absence of suspicion of a specific diagnosis that would influence therapy suspected. screening for hemochromatosis. lipid profile. standard or "alternative" therapies. liver function tests. • An assessment of the ability to perform routine and desired activities of daily living. • An assessment of the volume status. serum creatinine. • Coronary arteriography in patients with known or suspected coronary artery disease who do not have angina and are eligible for revascularization. left ventricular size. height and weight. • Endomyocardial biopsy when a specific diagnosis is suspected that would influence therapy. Abraham WT. Class IIa The weight of evidence or opinion is in favor of benefit from performing the following studies as part of the initial evaluation of patients presenting with HF: • Coronary arteriography in patients who have chest pain that may or may not be of cardiac origin who have not had a prior evaluation of their coronary anatomy and are eligible for coronary revascularization. and serum thyroidstimulating hormone. Class IIb The weight of evidence or opinion is less well established for the following testing in the initial evaluation of patients with HF • Noninvasive imaging to define the likelihood of coronary artery disease in patients with left ventricular dysfunction. • Measurement of serum Btype natriuretic peptide (BNP) in the urgent care setting if the clinical diagnosis of HF is uncertain. . 2009 focused update incorporated into the ACC/AHA 2005 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. • Laboratory studies including complete blood count. and calculation of body mass index. norepinephrine or endothelin). et al. • A careful history of current and past use of alcohol. • Holter monitoring in patients who have a history of myocardial infarction and are being considered for electrophysiologic study to document the inducibility of ventricular tachycardia. amyloidosis. • Twodimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF). orthostatic blood pressure changes. • When the contribution of HF to exercise limitation is uncertain. sleep disturbed breathing. diagnostic tests for rheumatologic disease. fasting blood glucose (glycohemoglobin). • Routine signalaveraged electrocardiography. Circulation 2009; 119:e391. Data from Hunt SA. • A twelvelead electrocardiogram and chest radiograph (posteroanterior and lateral). Chin MH. • Coronary arteriography if there is a history or angina or significant ischemia unless the patient is not eligible for revascularization of any kind. Radionuclide ventriculography can be performed to assess LVEF and volumes. wall thickness. and valve function. urinalysis. • To identify candidates for cardiac transplantation or other advanced treatments. • When suspected clinically. • Noninvasive imaging to detect myocardial ischemia and viability in patients with known or suspected coronary artery who do not have angina and are eligible for revascularization. and chemotherapy drugs.ACC/AHA guideline summary: Initial evaluation of patients with heart failure (HF) Class I There is evidence and/or general agreement that the initial evaluation of patients presenting with HF should include the following: • A complete history and physical examination to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. blood urea nitrogen. or pheochromocytoma. maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation. or human immunodeficiency virus (HIV) infection. illicit drugs. Measurement of natriuretic peptides (BNP and NTproBNP) can be useful in risk stratification.
Reproduced with permission from: Wu. if appropriate in the treating physician's clinical judgment. LT. LA. Lapeyre. to allow for delayed recovery to occur. additional time before endomyocardial biopsy could be considered. * The timing of endomyocardial biopsy in patients who fail to improve on medical therapy is controversial. . If the patient's left ventricular function and symptoms are not stable after one week of treatment. Mayo Clin Proc 2001; 76:1030. AC 3rd.Flow diagram for the workup of patients with dilated cardiomyopathy ECG: electrocardiography; echo: echocardiography. Cooper. Copyright © 2001 Mayo Clinic Proceedings.
Courtesy of Jonathan Kruskal. MD. . Normal chest radiograph Posteroanterior view of a normal chest radiograph. MD. Cardiomegaly is nonspecific and can be seen with any etiology of cardiomyopathy.Dilated cardiomyopathy chest radiograph This plain frontal radiograph of the chest in a 51yearold male demonstrates marked enlargement of the cardiac silhouette compatible with a dilated cardiomyopathy. PhD. Courtesy of Carol M Black.
and enlarged hilar shadows (black arrow). septal lymphatic distention (white arrow). MD. interstitial veiling.Heart failure This chest radiograph of a 65yearold male with dyspnea and orthopnea demonstrates mild pulmonary vascular congestion. Courtesy of Carol M Black. Courtesy of Jonathan Kruskal. MD. indicative of left ventricular decompensation. . Normal chest radiograph Posteroanterior view of a normal chest radiograph.
Courtesy of Carol M Black. bilateral perihilar alveolar edema producing a characteristic butterfly pattern and bilateral pleural effusions. Normal chest radiograph Posteroanterior view of a normal chest radiograph. . MD. MD. Photo courtesy of Jonathan Kruskal.Pulmonary edema This plain frontal chest radiograph of a 55yearold male with known coronary artery disease demonstrates characteristic radiographic features of heart failure with interstitial pulmonary edema.
Courtesy of Jonathan Kruskal. Normal chest radiograph Posteroanterior view of a normal chest radiograph. Courtesy of Carol M Black.Severe heart failure This chest radiography shows severe heart failure with cardiomegaly. MD. pulmonary vascular congestion with infiltrates in the mid lung fields (white arrow). . and a small pleural effusion (black arrow). MD.
Courtesy of Paul Stark. Normal chest radiograph Posteroanterior view of a normal chest radiograph. Chest radiograph shows large perihilar opacities in patient with enlarged cardiac silhouette. . Courtesy of Carol M Black. MD.Cardiogenic pulmonary edema Pulmonary edema in a "butterfly distribution" due to left ventricular failure. MD.
. In addition. In this patient with a severe dilated cardiomyopathy. there is significant enlargement of the left atrium and left ventricle. mital valve and mitral valve annulus. and the left ventricular chamber. the septum and posterior left ventricular wall are thinned and hypokinetic.Dilated cardiomyopathy Mmode scan of the heart is obtained by moving the transducer from a cephalad to caudal direction. recording the aortic root.
The movement of both the anterior and posterior mitral valve leaflets is well seen and there are prominent echoes from the chordae tendinae due to the enlarged left ventricular chamber. shows a dilated left ventricle. . recorded at the level of the mitral valve leaflets. The interventricular septum and posterior left ventricular wall are thinned and hypokinetic.Mitral valve motion in dilated cardiomyopathy Mmode echocardiogram.
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