Congestive heart failure clinical assessment

Resident Survival Guide

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

Diagnostic algorithm for heart failure

Suspected heart failure Risk factors Symptoms and/or signs Abnormal ECG

NT-proBNP ≥ 125 pg/mL or BNP ≥ 35 pg/mL or if HF strongly suspected or if NT-proBNP/BNP unavailable

Echocardiography

Abnormal findings

Hear failure unlikely, other dignosis shoulb be considered

NO

Yes

Heart failure confirmed based on LVEF

LVEF≤ 40%

LVEF=41-49%

LVEF≥50%

The above table adopted from 2021 ESC Guideline

Criteria for definition of advanced heart failure

1. Severe and persistent symptoms of heart failure [NYHA class III (advanced) or IV].
2. Severe cardiac dysfunction is defined by at least one of the following:

• LVEF <_30%
• Isolated RV failure (ARVC)
• Non-operable severe valve abnormalities
• Non-operable severe congenital abnormalities
• Persistently high (or increasing) BNP or NT-proBNP values and severe LV diastolic dysfunction or structural abnormalities
  

3. Episodes of pulmonary or systemic congestion requiring high-dose i.v. diuretics (or diuretic combinations) or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned visit or hospitalization in the last 12 months
4. Severe impairment of exercise capacity with inability to exercise or low 6MWT distance (<300 m) or pVO2 <12 mL/kg/min or <50% predicted value, estimated to be of cardiac origin

Initial studies for evaluation of HFrEF

• BNP, NT Pro BNP
• CBC, basic metabolic panel, liver function, Iron studies, thyroid studies, Hb A1C
• ECG
• CXR
• Echocardiography
• Coronary angiogram, cardiac MRI, biopsy, other appropriate studies

=

Clinical Assessment

Framingham Criteria

Major Criteria

• Paroxysmal nocturnal dyspnea
• Jugular vein distention
• Rales
• Radiographic cardiomegaly
• Acute pulmonary edema
• Third heart sound (S3)
• Central venous pressure > 16 cm H₂O
• Circulation time ≥ 25 sec
• Hepatojugular reflux
• Pulmonary edema
• Visceral congestion
• Cardiomegaly at autopsy
• Weight loss ≥ 4.5 kg in 5 days in response to treatment of heart failure

Minor Criteria

• Bilateral ankle edema
• Nocturnal cough
• Dyspnea on ordinary exertion
• Hepatomegaly
• Pleural effusion
• 30% decrease in baseline vital capacity
• Tachycardia

Boston Criteria of Congestive Heart Failure

Category I: History

• Rest dyspnea 4 points
• Orthopnea 4 points
• Paroxysmal nocturnal dyspnea 3 points
• Dyspnea on walking on level ground 2 points
• Dyspnea on climbing 1 point

Category II: Physical Examination

• Heart rate abnormality (1 point if 91 to 110 bpm; if >110 bpm, 2 points)
• Jugular venous pressure elevation (2 points if >6 cm H₂O; 3 points if >6 cm H₂O and hepatomegaly or edema)
• Lung crackles (1 point if basilar; 2 points if more than basilar)
• Wheezing 3 points
• Third heart sound 3 points

Category III: Chest Radiography

• Alveolar pulmonary edema 4 points
• Interstitial pulmonary edema 3 points
• Bilateral pleural effusion 3 points
• Cardiothoracic ratio >0.50 (posteroanterior projection) 3 points
• Upper zone flow redistribution 2 points

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

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