Congestive heart failure clinical assessment

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Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary
Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure clinical assessment On the Web

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FDA on Congestive heart failure clinical assessment

CDC on Congestive heart failure clinical assessment

Congestive heart failure clinical assessment in the news

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Directions to Hospitals Treating Congestive heart failure clinical assessment

Risk calculators and risk factors for Congestive heart failure clinical assessment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

There are several diagnostic criteria / algorithms that are used to diagnose heart failure including an algorithm from the ESC, Framingham study, and Boston.

Initial studies for evaluation of HFrEF

Serial evaluation , Titration of Medications, Evaluation about history, symptoms, physical exam, lab result

Intensification 2-4 months, (1-4 weeks cycles)

  • In the presence of volume overload, adjusting diuretic dose and reevaluation in 1-2 weeks
  • In the setting of stable euvolumic status, medications initiation, increase, switch dose and follow-up in 1-2 weeks and checking basic metabolites panel, repeating cycles until no change in clinical status and reached appropriate titration

Assessment of response to medications and cardiac remodeling

Lack of response , instability

Assessment of response to medications





Clinical Assessment

ESC Algorithm

The ESC algorithm weights the following parameters in establishing the diagnosis of heart failure:[1]

Influence

Parameter
Supports if present Opposes if
normal or absent
+ - to some degree
++ - to intermediate degree
+++ - to high degree
Compatible symptoms ++ ++
Compatible signs ++ +
Cardiac dysfunction
on echocardiography
+++ +++
Response of symptoms
or signs to therapy
+++ ++
ECG
Normal ++
Abnormal ++ +
Dysrhythmia +++ +
Laboratory
BNP > 400 pg/mL and/or
NT-proBNP > 2000 pg/mL
+++ +
BNP < 100 pg/mL and
NT-proBNP < 400 pg/mL
+ +++
Hyponatraemia + +
Renal dysfunction + +
Mild elevations of troponin + +
Chest X-ray
Pulmonary congestion +++ +
Reduced exercise capacity +++ ++
Abnormal pulmonary function tests + +
Abnormal haemodynamics at rest +++ ++

Framingham Criteria

Major Criteria

Minor Criteria

Boston Criteria of Congestive Heart Failure

Category I: History

Category II: Physical Examination

Category III: Chest Radiography

No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points.

The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.

2009 ACC/AHA Focused Update and 2005 Guidelines for the Diagnosis and Management of Chronic Heart Failure in the Adult (DO NOT EDIT) [2][3]

Initial Clinical Assessment of Patients Presenting With Heart Failure (DO NOT EDIT) [2][3]

Class I
"1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (Level of Evidence: C) "
"2. A careful history of current and past use of alcohol, illicit drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patients presenting with HF. (Level of Evidence: C) "
"3. In patients presenting with HF, initial assessment should be made of the patient’s ability to perform routine and desired activities of daily living. (Level of Evidence: C) "
"4. Initial examination of patients presenting with HF should include assessment of the patient’s volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index. (Level of Evidence: C) "
"5. Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C) "
"6. Twelve-lead electrocardiogram and chest radiograph (PA and lateral) should be performed initially in all patients presenting with HF. (Level of Evidence: C) "
"7. Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess LVEF, LV size, wall thickness, and valve function. Radionuclideventriculography can be performed to assess LVEF and volumes. (Level of Evidence: C) "
"8. Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B) "
Class III (No Benefit)
"1. Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF.[4] (Level of Evidence: C) "
"2. Routine use of signal-averaged electrocardiography is not recommended for the evaluation of patients presenting with HF. (Level of Evidence: C) "
"3. Routine measurement of circulating levels of neurohormones (e.g., norepinephrine or endothelin) is not recommended for patients presenting with HF. (Level of Evidence: C) "
Class IIa
"1. Coronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularization. (Level of Evidence: C) "
"2. Coronary arteriography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: C) "
"3. Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B) "
"4. Maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation is reasonable in patients presenting with HF to help determine whether HF is the cause of exercise limitation when the contribution of HF is uncertain. (Level of Evidence: C) "
"5. Maximal exercise testing with measurement of respiratory gas exchange is reasonable to identify high-risk patients presenting with HF who are candidates for cardiac transplantation or other advanced treatments. (Level of Evidence: B) "
"6. Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF. (Level of Evidence: C)"
"7. Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level of Evidence: C)"
"8. Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy. (Level of Evidence: C)"
"9. Measurement of natriuretic peptides (BNP and NT-proBNP) can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Measurement of natriuretic peptides (BNP and NT-proBNP) can be useful in risk stratification. (Level of Evidence: A)"
Class IIb
"1. Noninvasive imaging may be considered to define the likelihood of coronary artery disease in patients with HF and LV dysfunction. (Level of Evidence: C)"
"2. Holter monitoring might be considered in patients presenting with HF who have a history of MI and are being considered for electrophysiologic study to document VT inducibility. (Level of Evidence: C) "

Serial Clinical Assessment of Patients Presenting With Heart Failure (DO NOT EDIT)[2][3]

Class I
"1. Assessment should be made at each visit of the ability of a patient with HF to perform routine and desired activities of daily living. (Level of Evidence: C) "
"2. Assessment should be made at each visit of the volume status and weight of a patient with HF. (Level of Evidence: C) "
"3. Careful history of current use of alcohol, tobacco, illicit drugs, “alternative therapies,” and chemotherapy drugs, as well as diet and sodium intake, should be obtained at each visit of a patient with HF. (Level of Evidence: C) "
Class IIa
"1. Repeat measurement of ejection fraction and the severity of structural remodeling can provide useful information in patients with heart failur who have had a change in clinical status or who have experienced or recovered from a clinical event or received treatment that might have had a significant effect on cardiac function. (Level of Evidence: C) "
Class IIb
"1. The value of serial measurements of BNP to guide therapy for patients with HF is not well established. (Level of Evidence: C) "

References

  1. [ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-HF-FT.pdf] European Heart Journal (2008) 29, 2388–2442, doi:10.1016/j.ejheart.2008.08.005
  2. 2.0 2.1 2.2 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  3. 3.0 3.1 3.2 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA 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. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  4. Cooper LT, Baughman KL, Feldman AM, Frustaci A, Jessup M, Kuhl U et al. (2007) The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Circulation 116 (19):2216-33. DOI:10.1161/CIRCULATIONAHA.107.186093 PMID: 17959655

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