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".)
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- 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