European Journal of Heart Failure 2005 7(3):303-308; doi:10.1016/j.ejheart.2005.01.003
© 2005 European Society of Cardiology
Diagnosis and assessment of the heart failure patient: the cornerstone of effective management
Kenneth Dickstein
Univ. of Bergen, Cardiology Division, Stavanger University Hospital Stavanger, Norway E-mail address: trout{at}online.no
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Abstract
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Heart Failure is a syndrome describing a pathophysiological
state with diverse etiologies. Providing an adequate mechanistic
definition is difficult. The current guidelines from the European
Society of Cardiology define the diagnosis of heart failure
based on three criteria [Remme WJ, Swedberg K. Guidelines for
the diagnosis and treatment of chronic heart failure. Eur Heart
J 2001;22:1527–60]. Patients should have symptoms compatible
with heart failure at rest or on exercise. There should be objective
evidence of cardiac dysfunction at rest. In doubtful cases,
there should be a favourable response following therapy for
heart failure.
The term diagnosis derives from the Greek words "dia" and "nosi" meaning "through knowledge". It implies that a conclusion is drawn describing the patient's current status based on the available information. This information is commonly based on the symptoms, history, findings at physical examination, results from laboratory tests, and the results from various non-invasive and invasive special examinations [Knotterus JA, van Weel C, Muris JWM. Evaluation of diagnostic procedures. BMJ 2002;324:477–80]. Diagnostic precision is crucial in deciding treatment strategy and this task presents a continuous academic and clinical challenge.
Ultimately, the clinical diagnosis of heart failure is based on all the information available to the physicians. No single investigation is specific for this clinical syndrome and management strategies attempt to modify the underlying mechanisms in order to alleviate symptoms and improve survival.
Key Words: Heart failure • Diagnosis • Effective management
Received May 18, 2004; Revised October 26, 2004; Accepted January 1, 2005
A correct and updated heart failure diagnosis is the cornerstone
that leads to appropriate and efficacious management. An individual
patient's diagnosis should include three central pieces of information
essential to the creation of an effective management plan.
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1. The three components of a complete diagnosis
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Firstly, the etiology should be clearly established with a focus
on the pathology. For example, is heart failure due to dilated
cardiomyopathy following an acute myocarditis? Is heart failure
due to coronary artery disease with myocardial infarction and
persistent ischemia? Secondly, the hemodynamic mechanisms should
be adequately investigated and understood. For example, is the
heart failure due to volume overload secondary to aortic insufficiency
with hypertension? Is the heart failure due to systolic dysfunction
with a reduced ejection fraction and a dilated left ventricle?
Thirdly, the degree of current limitation must be correctly
staged. For example, is the patient in stable NYHA class II
on no therapy? Are there signs or symptoms of recent decompensation
with worsening function capacity and fluid retention on triple
therapy?
It is conventional to classify heart failure as either acute or chronic as well as to estimate severity as mild, moderate or severe. Further, it is often relevant to specify whether heart failure is predominantly left of right sided failure. Recently, increased focus is placed on patients with heart failure and preserved left ventricular function. These patients often have evidence of diastolic dysfunction. The New York Heart Association classification has proved to be a most useful tool for describing patients' symptoms and functional status.
All current, relevant information from the symptoms, history, physical examination, laboratory testing along with the results from appropriate non-invasive and invasive studies should be considered when making or updating the current working diagnosis. A complete diagnosis must include other cardiovascular conditions such as hypertension, ischemia, valvular dysfunction and rhythm disturbance (panel) as well as non-cardiovascular co-morbidities (see Dahlstrøm in this issue). Special attention should be made to ensure that rectifiable causes are identified. Early diagnosis permits strategies for secondary prevention and measures to prevent progression. The essential principle is that the treatment strategy assumes that the diagnosis is correct and complete.
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2. History
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A thorough history is the first essential step leading to a
complete diagnosis and optimal management. The patient's symptoms
must be identified. NYHA functional class should be determined
at the first interview in stable patients and updated subsequently.
Cardiovascular and other relevant medical history, risk profile,
the extent of comorbidity and potential precipitating factors
should be noted with care. The interview should also elicit
signs of depression or a history of poor compliance. It is particularly
important to accurately record the response to previous medical
therapy as this information may be essential in confirming the
diagnosis and designing therapeutic strategy (panel).
Symptoms should be recorded carefully. Patients frequently have difficulty in distinguishing between dyspnea and fatigue. The extent of exercise intolerance should be assessed, preferably with an example of a daily task that results in dyspnea. It is especially important to elicit a history of angina in that this may have therapeutic consequences.
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3. Physical examination
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Physical examination should be thorough initially with special
attention to systolic murmurs, signs of congestion and evidence
of comorbidity. Examinations may then be abbreviated on subsequent
visits and are increasingly being performed by nurses trained
in managing patients with heart failure. Blood pressure, heart
rate and rhythm, signs of pulmonary and peripheral congestion
and fluid retention must be monitored periodically.
Extracardiac causes of peripheral edema are common (panel).
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4. ECG
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The ECG interpretation directly impacts on the components of
an adequate diagnosis (panel)
[3]. A normal ECG suggests that
the diagnosis of heart failure should be re-evaluated. Signs
of previous infarction, ongoing ischemia or the presence of
atrial fibrillation provide essential information. The rate
and rhythm along with QRS prolongation, ventricular dysrhythmia
or bradycardia may also identify patients that would profit
from device intervention. Ambulant monitoring with a Holter
device should be employed if the work-up suggests that episodes
of tachycardia, bradycardia or silent ischemia may be clinically
relevant (panel).
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5. Chest X-ray
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The routine standing chest X-ray in two planes is mandatory
(panel). Evaluation of the degree of acute and chronic pulmonary
congestion is central to an accurate assessment and provides
documentation. Additional findings, such as cardiomegaly, pleural
effusion, infiltrates or pneumonia, are often demonstrated.
Findings consistent with the most common comorbidity in the
differential diagnosis of patients with dyspnea, obstructive
airways disease, may be detected. Pulmonary function tests (spirometry)
may be required.
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6. Laboratory testing
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A substantial number of routine blood tests are usually required
in the initial diagnostic work-up and should include thyroid
status and liver function tests (panel). Urinalysis should also
be performed. Each of these results may provide clues to comorbidity
and the extent of disease and may necessitate further investigation.
Anemia, hyponatremia, renal dysfunction, diabetes, infection
and neoplasm are frequently observed. Serum creatinine and potassium
should be routinely evaluated during the initiation and titration
of angiotensin converting enzyme inhibition or angiotensin receptor
blockade. Mild elevations in troponins are commonly seen, most
often secondary to ischemia and/or the cytokine toxicity of
decompensated heart failure. These complications have consequences
for the design of effective management strategy and may require
further investigation.
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7. BNP
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The assay of B-type natriuretic peptide levels has been shown
to have a potentially major impact on diagnosis and patient
management (panel)
[4]. All current diagnosis guidelines in
heart failure discuss the role of BNP in evaluating individual
patients
[5]. Blood sampling for other hormones and cytokines
is common only in clinical research and has no current role
in the routine diagnostic work-up. BNP is secreted primarily
from ventricular myocytes in response to cardiac overload. Both
the N-terminal and C-terminal BNP fragments are now commonly
assayed using commercially available techniques. Although ANP
has been shown to of diagnostic value, most studies demonstrate
consistent superiority for BNP which has now emerged as the
natriuretic peptide most commonly assayed for diagnostic purposes.
In addition, a considerable literature supports the use of BNP
testing in the screening, staging, triage and assessment of
prognosis in the patient with heart failure. Ongoing research
is evaluating the potential role of BNP in titrating and determining
optimal dose levels of pharmacologic therapy
[6].
The most convincing data confirms the power of BNP testing to rule out the presence of heart failure and relatively low cut-off points have high negative predictive values. For example, a BNP<80 pg/ml has a negative predictive value of >90% for the presence of heart failure in an unselected population [7]. This would make BNP testing especially valuable as a screening tool in primary practice [8]. However, the performance of a diagnostic test depends on the prevalence of the condition in a particular population and the prevalence of heart failure in a population referred for treatment would be high. In contrast, a high BNP level does not confirm the diagnosis of heart failure, nor does it provide information regarding etiology. Further evaluation is necessary.
BNP also reliably reflects the severity of symptoms and closely follows functional status [9]. It has been shown to be a useful prognostic index in the evaluation of patients with both acute and chronic heart failure [10]. This suggests a role in decision making regarding both admission and time for discharge from hospital [11]. Elevated BNP levels in the presence of heart failure symptoms and preserved left ventricular function supports the diagnosis of diastolic dysfunction [12]. Several studies indicate that BNP levels improve following efficacious therapy suggesting a potential role in monitoring and adjusting treatment [13].
These findings are encouraging and BNP testing is emerging as a useful tool with broad application in the management of patients with heart failure. Clinical research has addressed the peptide's potential value both in acute and chronic heart failure with diverse etiologies in both inpatients and in the ambulant setting. However, the result should not be viewed in isolation but rather as a useful addition to the clinical picture. There is no strong evidence suggesting superiority for either the C-terminal or the N-terminal BNP fragment and both assays appear to be of equal accuracy. The choice is usually determined by local laboratory facilities and the importance of a rapid result. Modest increases in BNP levels are seen with increasing age and values are slightly higher in women [14].
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8. Echocardiography
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The results of an ECHO/Doppler study are mandatory to an accurate
appraisal of all three components of an adequate diagnosis.
Ideally, all patients with a diagnosis of heart failure should
undergo echocardiographic examination. Chamber dimensions and
geometry, diffuse or focal systolic dysfunction, evidence of
diastolic dysfunction, valvular dysfunction (particularly mitral
insufficiency, aortic stenosis or insufficiency) and estimation
of pulmonary pressures provide us with the ability to appropriately
tailor our therapeutic strategy in the individual patient (panel).
Although intuitively attractive and routinely measured ejection fraction does not correlate well to patients symptoms and exercise capacity. Left ventricular volumes and the degree of mitral insufficiency may impact importantly on the assessment of ejection fraction. It is especially important to evaluate the severity and hemodynamic significance of valvular dysfunction. The degree of mitral insufficiency or aortic stenosis tends to progress over time. A relatively low threshold for repeat examination with progression of symptoms will often reveal evidence of an anatomic or hemodynamic explanation for clinical decompensation.
Heart failure with preserved systolic function often termed diastolic dysfunction remains a challenge. This diagnosis implies the presence of typical signs and symptoms of acute or chronic heart failure in the presence of a "normal" ejection fraction (>40%). The condition is most common in the elderly and patients with hypertension or coronary artery disease. The echocardiographer evaluates measurements of diastolic relaxation and obtains important left ventricular filling information from the mitral flow pattern in diastole. A multitude of diastolic performance indices are commonly employed. However, the diagnosis is ultimately based on the exclusion of systolic dysfunction. Frequently, these two mechanisms co-exist in the individual patient. Although it is useful to make these diagnoses when possible, the practical consequences with regard to treatment are limited in that therapies are similar for both conditions. The converse situation, i.e. asymptomatic left ventricular dysfunction (EF<40%), is most commonly detected during pre-operative evaluations or during epidemiological screening studies with echo.
Stress echocardiography is a useful tool for detecting potentially reversible ischemic left ventricular dysfunction. Tissue Doppler imaging is increasingly employed to assess the degree of ventricular dyssynchrony in patients with QRS prolongation being evaluated for possible cardiac resynchronisation therapy.
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9. Coronary angiography and ventriculography
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The most important three pieces of diagnostic information required
in managing patients with heart failure and ischemic heart disease
are; knowledge of the extent of coronary artery disease, the
degree of myocardial dysfunction and the potential for reversibility
following revascularisation. Selective angiography and ventriculography
will reliably satisfy the first two requirements (panel). The
indications for invasive studies are now far broader in that
patients not eligible for surgery may still be candidates for
culprit percutaneous procedures. The presence of mild or moderate
heart failure, even in the elderly is no longer considered a
contraindication and indeed patients with evidence suggesting
the presence of coronary artery disease should be actively investigated
(panel)
[15]. Such diagnostic information may translate into
an effective therapeutic procedure. However, the demonstration
of potentially reversible ischemia (hibernating myocardium)
requires additional imaging studies.
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10. Imaging techniques
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The techniques most commonly employed are pharmacologic stress
testing (dobutamine), nuclide imaging studies (thallium, technetium),
PET scanning for mismatch and, more recently, magnetic resonance
imaging with contrast (gadolinium) (panel). The information
from these studies is complementary and directly relates coronary
anatomy to myocardial perfusion. All these techniques attempt
to identify focal ischemic areas that may improve following
successful revascularisation (PCI/CABG). The diagnosis of hibernating
myocardium has become increasingly important in the post-stenting
era and is often considered imperative in the decision making
process.
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11. Hemodynamic evaluation
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Routine hemodynamic studies are routinely performed during diagnostic
cardiac catheterisation and in connection with clinical research.
The information provided (cardiac output, filling pressures,
vascular resistance) does permit a more complete and accurate
demonstration of the impact of the underlying pathophysiology
(panel). However, much of this information is available through
the non-invasive echo study. The results of right heart catheterisation
in patients not otherwise undergoing coronary angiography will
rarely provide important information that impacts on an individual
patient's management.
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12. Exercise testing
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Although exercise testing will not usually yield information
regarding etiology, it does provide clinically relevant diagnostic
information. The results describe the clinical impact of the
disease and permit an accurate assessment of the degree of exercise
intolerance, limiting symptoms and work performed. There are
a number of techniques and protocols employed (panel). Bikes,
treadmills and the simple floor all have their advantages. Gas
exchange data (peak VO2, respiratory exchange ratio) quantify
evaluation of maximal, submaximal and endurance exercise performance.
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13. Conclusions
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A correct diagnosis is the cornerstone leading to efficacious
management. A patient's diagnosis should ideally include an
understanding of the primary etiology, potential mechanisms
and the degree of limitation due to heart failure symptoms.
All relevant information from the symptoms, history, physical
examination, laboratory testing along with the results from
appropriate non-invasive and invasive studies should be considered.
Special attention should be made to ensure that rectifiable
causes are identified. The essential principle is that the treatment
strategy assumes that the diagnosis is correct and complete.
Improving diagnostic skills remains a continuous challenge for
the clinician. Accuracy translates into successful management.
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References
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- Remme W.J., Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur. Heart J. (2001) 22:1527–1560.[Free Full Text]
- Knotterus J.A., van Weel C., Muris J.W.M. Evaluation of diagnostic procedures. BMJ (2002) 324:477–480.[Free Full Text]
- Davie A.P., Francis C.M., Love M.P., et al. Value of the electrocardiogram in identifying heart failure due to left ventricular systolic dysfunction. Br. Med. J. (1996) 312:222.[Free Full Text]
- Cowie M.R., Jourdain P., Maisel A., Dahlstrom U., Follath F., Isnard R., et al. Clinical applications of B-type natriuretic peptide (BNP) testing. Eur. Heart J. (2003) 24:1710–1718.[Abstract/Free Full Text]
- Hunt S.A., Baker D.W., Chin M.H., Cinquegrani M.P., Feldman A.M., Francis G.S., et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). Circulation (2001) 104:2996–3007.[Free Full Text]
- Murdoch D.R., McDonagh T.A., Byrne J., et al. Titration of vasodilator therapy in chronic heart failure according to plasma brain natriuretic peptide concentration: randomised comparison of the hemodynamic and neuroendocrine effects of tailored versus empirical therapy. Am. Heart J. (1999) 138:1126–1132.[CrossRef][Web of Science][Medline]
- McDonagh T.A., Cunningham A.D., Morrison C.E., et al. Left ventricular dysfunction, natriuretic peptides, and mortality in an urban population. Heart (2001) 86:21–26.[Abstract/Free Full Text]
- Wright S.P., Doughty R.N., Pearl A., Gamble G.D., Whalley G.A., Walsh H.J., et al. Plasma amino-terminal pro-brain natriuretic peptide and accuracy of heart-failure diagnosis in primary care. JACC (2003) 42(10):1793–1800.[Abstract/Free Full Text]
- Kruger S., Graf J., Kunz D., et al. Brain natriuretic peptide levels predict functional capacity in patients with chronic heart failure. JACC (2002) 40:718–722.[Abstract/Free Full Text]
- Kroglin J., Pehlivanli S., Schwaiblmair M., et al. Role of brain natriuretic peptide in risk stratification of patients with congestive heart failure. JACC (2001) 38:1934–1941.[Abstract/Free Full Text]
- Caldwell M.A., Howie J.N., Dracup K. BNP as discharge criteria for heart failure. J. Card. Fail. (2003) 9(5):416–422.[CrossRef][Web of Science][Medline]
- Lubien E., DeMaria A., Krishnaswamy P., et al. Utility of B-natriuretic peptide in detecting diastolic dysfunction: comparison with Doppler velocity recordings. Circulation (2002) 105:595–601.[Abstract/Free Full Text]
- Troughton R.W., Frampton C.M., Yandle T.G., et al. Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations. Lancet (2000) 355:1126–1130.[CrossRef][Web of Science][Medline]
- Loke I., Squire I.B., Davies J.E., Ng L.L. Reference ranges for natriuretic peptide for diagnostic use are dependent on age, gender and heart rate. Eur. J. Heart Fail. (2003) 599–606.
- Fox K.F., Cowie M.R., Wood D.A., et al. The aetiological importance of coronary artery disease in new cases of heart failure. Eur. Heart J. (2001) 22:228–236.[Abstract/Free Full Text]
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Abstract
1. The three components...