Evaluation of the patient with suspected heart failure
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Heart failure (HF) is a common clinical syndrome caused by a variety of cardiac diseases . The initial evaluation of the patient with suspected HF with reduced or preserved ejection fraction will be reviewed here. Evaluation of the etiology and management of HF and evaluation and treatment of acute decompensated HF are discussed separately. (See "Determining the etiology and severity of heart failure or cardiomyopathy" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Evaluation of acute decompensated heart failure" and "Treatment of acute decompensated heart failure: General considerations".)
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).
The approach to the patient with suspected heart failure (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 2013 American College of Cardiology guidelines , the 2010 Heart Failure Society of America guidelines , the 2012 European Society of Cardiology guidelines , and the 2012 Canadian Cardiovascular Society consensus conference .
The discussion below focuses on diagnosis of HF. The history and physical examination of the patient with suspected HF should also include assessment of risk factors and potential etiologies of HF as discussed separately. (See "Determining the etiology and severity of 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 sodium-retaining renin-angiotensin-aldosterone and sympathetic nervous systems. (See "Pathophysiology of heart failure: Neurohumoral adaptations".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 1993; 22:6A.
- WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:e240.
- Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
- McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
- McKelvie RS, Moe GW, Ezekowitz JA, et al. The 2012 Canadian Cardiovascular Society heart failure management guidelines update: focus on acute and chronic heart failure. Can J Cardiol 2013; 29:168.
- Mant J, Doust J, Roalfe A, et al. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. Health Technol Assess 2009; 13:1.
- Kelder JC, Cramer MJ, van Wijngaarden J, et al. The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation 2011; 124:2865.
- Davie AP, Francis CM, Caruana L, et al. Assessing diagnosis in heart failure: which features are any use? QJM 1997; 90:335.
- O'Reilly RA. Splenomegaly in 2,505 patients at a large university medical center from 1913 to 1995. 1963 to 1995: 449 patients. West J Med 1998; 169:88.
- GLEASON WL, BRAUNWALD E. Studies on Starling's law of the heart. VI. Relationships between left ventricular enddiatolic volume and stroke volume in man with observations on the mechanism of pulsus alternans. Circulation 1962; 25:841.
- Ishmail AA, Wing S, Ferguson J, et al. Interobserver agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure. Chest 1987; 91:870.
- Lok CE, Morgan CD, Ranganathan N. The accuracy and interobserver agreement in detecting the 'gallop sounds' by cardiac auscultation. Chest 1998; 114:1283.
- Marcus GM, Gerber IL, McKeown BH, et al. Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. JAMA 2005; 293:2238.
- From AM, Lam CS, Pitta SR, et al. Bedside assessment of cardiac hemodynamics: the impact of noninvasive testing and examiner experience. Am J Med 2011; 124:1051.
- Wong CM, Hawkins NM, Jhund PS, et al. Clinical characteristics and outcomes of young and very young adults with heart failure: The CHARM programme (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity). J Am Coll Cardiol 2013; 62:1845.
- Heart Failure Society Of America . Evaluation of patients for ventricular dysfunction and heart failure. J Card Fail 2006; 12:e16.
- Le Jemtel TH, Padeletti M, Jelic S. Diagnostic and therapeutic challenges in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure. J Am Coll Cardiol 2007; 49:171.
- Davie AP, Francis CM, Love MP, et al. Value of the electrocardiogram in identifying heart failure due to left ventricular systolic dysfunction. BMJ 1996; 312:222.
- Maisel A. B-type natriuretic peptide levels: diagnostic and prognostic in congestive heart failure: what's next? Circulation 2002; 105:2328.
- Mehra MR, Uber PA, Park MH, et al. Obesity and suppressed B-type natriuretic peptide levels in heart failure. J Am Coll Cardiol 2004; 43:1590.
- Redfield MM, Rodeheffer RJ, Jacobsen SJ, et al. Plasma brain natriuretic peptide concentration: impact of age and gender. J Am Coll Cardiol 2002; 40:976.
- Hunt PJ, Richards AM, Nicholls MG, et al. Immunoreactive amino-terminal pro-brain natriuretic peptide (NT-PROBNP): a new marker of cardiac impairment. Clin Endocrinol (Oxf) 1997; 47:287.
- Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J 2006; 27:330.
- de Lemos JA, McGuire DK, Drazner MH. B-type natriuretic peptide in cardiovascular disease. Lancet 2003; 362:316.
- Gillespie ND, McNeill G, Pringle T, et al. Cross sectional study of contribution of clinical assessment and simple cardiac investigations to diagnosis of left ventricular systolic dysfunction in patients admitted with acute dyspnoea. BMJ 1997; 314:936.
- Badgett RG, Mulrow CD, Otto PM, Ramírez G. How well can the chest radiograph diagnose left ventricular dysfunction? J Gen Intern Med 1996; 11:625.
- Knudsen CW, Omland T, Clopton P, et al. Diagnostic value of B-Type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. Am J Med 2004; 116:363.
- Gola A, Pozzoli M, Capomolla S, et al. Comparison of Doppler echocardiography with thermodilution for assessing cardiac output in advanced congestive heart failure. Am J Cardiol 1996; 78:708.
- CLINICAL PRESENTATION
- Physical examination
- - Vital signs and appearance
- - Volume assessment
- - Pulsus alternans
- - Precordial palpation
- - Heart sounds
- - Pulmonary hypertension
- Diagnostic accuracy of clinical features
- Impact of age
- DIFFERENTIAL DIAGNOSIS
- INITIAL TESTING
- Initial blood tests
- - Initial panels
- - BNP and NT-proBNP
- Limitations of BNP and NT-proBNP
- Chest radiograph
- Diagnostic accuracy of initial testing
- EXERCISE TESTING
- DIAGNOSTIC RULES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS