Evaluation of Patients w ith H ear t Failure Maria Patarroyo-Aponte, MDa, Monica Colvin-Adams, MD, MS, FAHAb,* KEYWORDS Heart failure Evaluation Risk factors Cardiovascular disease
KEY POINTS Identification of risk factors for heart failure and its aggressive treatment are as important as early identification of heart failure. A complete patient history and a comprehensive physical examination can provide clues regarding the cause of heart failure and its severity. Echocardiogram is the most useful test during diagnosis of heart failure. A comprehensive echocardiogram gives the clinician information regarding ventricular function as well as causes of heart failure and its complications. Additional tests during evaluation of patients with heart failure must include routine laboratory tests and, in certain cases, specific laboratory tests and new imaging technologies, including cardiac magnetic resonance and computed tomography angiography. Noninvasive impedance cardiography could be helpful for evaluation of volume status in patients with heart failure and prevention of frequent hospitalizations caused by decompensated heart failure.
Heart failure is one of the most prevalent cardiovascular diseases in the United States, and its incidence has been steadily increasing over the years. In 2010, the prevalence of heart failure in US adults was near 6.6 million. It is estimated that by 2030 the prevalence of heart failure will increase by 25%.1 Data from the Framingham Health Study show that heart failure incidence is approximately 10 per 1000 in those older than 65 years of age.2 Furthermore, despite the improvement in survival after diagnosis, the death rate associated with heart failure remains as high as 50% within 5 years of diagnosis.3,4 Thus, the early identification of patients at risk of heart failure and prompt diagnosis
of those with heart failure symptoms is important to decrease mortality, hospital stay, and treatment costs.5,6 This article reviews the appropriate evaluation of patients with heart failure, including clinical examination and diagnostic tools.
DEFINITION OF HEART FAILURE Heart failure is characterized by abnormal cardiac structure or function that results in a failure of the heart to deliver oxygen to the organs at a rate that can fulfill their metabolic requirements.7 Heart failure has been defined as a progressive syndrome caused by cardiac dysfunction (either systolic, diastolic, or mixed) that leads to neurohormonal and circulatory abnormalities resulting
The authors have nothing to disclose. a Division of Cardiovascular Medicine, University of Minnesota Medical Center, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA; b Section on Advanced Heart Failure, Transplant and Mechanical Circulatory Support, Cardiovascular Division, University of Minnesota Medical Center, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA * Corresponding author. E-mail address: [email protected] Cardiol Clin 32 (2014) 47–62 http://dx.doi.org/10.1016/j.ccl.2013.09.014 0733-8651/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
cardiology.theclinics.com
INTRODUCTION
48
Patarroyo-Aponte & Colvin-Adams in symptoms such fluid retention, shortness of breath, and fatigue.7 The physiology that underlies this syndrome includes neuroendocrine activation with increased production of norepinephrine, angiotensin II, and arginine vasopressin, which results in vasoconstriction, increase in left ventricular impedance, cardiac myocyte hypertrophy, and increase in myocardial collagen synthesis. In addition, there is increase in atrial natriuretic peptide, which counter-regulates vasoconstriction and remodeling of the heart.8,9 Heart failure is a progressive disease that has a preclinical phase characterized by the absence of symptoms compared with later phases, and by the presence of myocardial injury that triggers neuroendocrine activation and cardiac remodeling (stages A and B). This preclinical phase progresses to a clinical phase during which symptoms appear. In this symptomatic phase, the patient’s symptoms can be controlled with medical treatment (stage C) or can be severe enough to require advanced therapies including mechanical circulatory support or heart transplant (stage D) (Table 1).10 Patients with heart failure can present
Table 1 American College of Cardiology/American Heart Association Heart failure stages Stage
Characteristics
Stage A
At risk for heart failure No structural heart disease or heart failure symptoms Examples: hypertension, diabetes, metabolic syndrome, family history of cardiomyopathy, cardiotoxin exposure Structural heart disease No signs or symptoms or heart failure Examples: patients with acute myocardial infarction, valvular heart disease, left ventricular hypertrophy Structural heart disease Prior or current heart failure symptoms Refractory heart failure requiring specialized interventions Example: marked symptoms at rest despite maximal medical therapy
Stage B
Stage C
Stage D
Adapted from Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACC/AHA Guidelines 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(16):e240–319.
with a varied spectrum of symptoms and signs, with variations between patients and during the course of the disease. Although the disease is progressive, the symptoms can be stabilized with therapy.11 The heart failure syndrome may manifest clinically as: A syndrome of fluid retention. Patients present with peripheral edema or increase in abdominal girth.10 Other signs of congestion include jugular venous distention, orthopnea, rales, and hepatojugular reflux.12 A syndrome of decreased exercise tolerance. This syndrome is typically characterized by progressive fatigue or dyspnea with exertion.10 Although these symptoms are common in patients with heart failure, they are also the most challenging for the clinician, given that they are not exclusive to patients with heart failure and can be present in other conditions, including pulmonary and muscular diseases.13 Other cardiovascular symptoms/end-organ hypoperfusion. Patients with heart failure may present with signs and symptoms that may be related directly to cardiac dysfunction or compromise of other organs. Some of these symptoms include arrhythmias, acute myocardial infarction, or renal and hepatic failure.
EVALUATION OF PATIENTS WITH HEART FAILURE A thorough evaluation of heart failure seeks to determine cause, severity, and prognosis, and combine a thorough history and physical examination with appropriate diagnostic tests (Box 1). The evaluation of patients with heart failure is based on a complete and comprehensive history, physical examination, and diagnostic studies. The importance of the history and physical examination is supported by a meta-analysis of 22 studies of patients who presented with dyspnea to the emergency department. Wang and colleagues,14 showed that the overall clinical impression of the emergency room physician, based on several signs and symptoms as well as laboratory and imaging tests, significantly increased the probability of having heart failure (positive likelihood ratio [LR], 4.4; 95% confidence interval [CI], 1.8–10). The most useful features were prior history of heart failure (positive LR, 5.8; 95% CI, 4.1–8.0), presence of paroxysmal nocturnal dyspnea (positive LR, 2.6; 95% CI, 1.5–4.5), S3 gallop on examination (positive LR, 11; 95% CI, 4.9–25.0), chest radiograph showing
Evaluation of Patients with Heart Failure
Box 1 Evaluation of patients with heart failure Initial diagnosis of heart failure History and physical examination Echocardiogram Routine laboratory testing including serum electrolytes, renal function, thyroid and liver function test, lipid profile, glucose, and complete blood count Biomarkers: N-terminal pro–brain natriuretic peptide or brain natriuretic peptide, troponin Additional laboratory tests might include ferritin, human immunodeficiency virus, plasma metanephrins, protein electrophoresis, antinuclear antibodies (ANA), extractable nuclear antigens (ENA), uric acid Other imaging techniques: magnetic resonance imaging, nuclear medicine stress test, cardiac computed tomography Endomyocardial biopsy if giant cell myocarditis and necrotizing eosinophilic myocarditis are suspected Chronic heart failure follow-up History: focus on duration and severity of symptoms Physical examination: weight, vital signs, and evaluation of signs of congestion and/or hypoperfusion Echocardiogram Routine laboratory testing: serum electrolytes, renal function, thyroid and liver function tests, lipid profile, glucose, and complete blood count Noninvasive impedance cardiography Acute decompensated heart failure History and physical Hemodynamic evaluation with pulmonary artery catheter Routine laboratory tests: serum electrolytes, renal function test, liver function test Prognostication Vital signs Laboratory test Cardiopulmonary stress test Six-minute walk test
pulmonary venous congestion (positive LR, 12.0; 95% CI, 6.8–21.0), and atrial fibrillation on electrocardiogram (positive LR, 3.8; 95% CI, 1.7–8.8).14
History and Physical Examination History A comprehensive history is the first step in the evaluation of patients with suspected or established heart failure. The personal history can provide important clues regarding risk factors for heart failure and aid interpretation of signs and symptoms that can lead to diagnosis of heart failure and determination of functional impairment and prognosis in patients with established heart failure.10,15 Thus, the American Heart Association (AHA)/American College of Cardiology (ACC) heart failure guidelines
recommend a thorough history be obtained/performed in patients presenting with heart failure to identify disorders or behaviors that can cause or accelerate the development or progression of heart failure (class I indication; level of evidence, C).10 Some asymptomatic patients can be at risk for heart failure. These patients might have one or more risk factors for heart failure including hypertension, prior history of myocardial infarction, diabetes mellitus, valvular heart disease, family history of cardiomyopathy, congenital heart disease, sleep disorders, and exposure to cardiac toxins including chemotherapy agents and alcohol.15 Once these risk factors are identified, they must be aggressively treated in order to prevent or delay development of heart failure symptoms. Identification of risk factors is recommended by the
49
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AHA/ACC guidelines as a class I indication with level of evidence C.10 For patients with known or suspected heart failure, it is important to identify characteristic symptoms such as dyspnea, decreased exercise tolerance, edema, or ascites. Once identified, these symptoms must be well described, including duration and severity. Patients with chronic heart failure can adapt to their condition and may not recognize, or may minimize, the symptoms.16 Documentation and grading of functional capacity, including the ability to perform routine daily activities and the New York Heart Association (NYHA) functional classification, is required (level of evidence, A) (Table 2).15 Other symptoms that must be considered during evaluation of patients with heart failure include angina, syncope, lightheadedness, or symptoms of sleep disorders, specifically sleep apnea (Box 2).15 In addition, in patients with suspected familial cardiomyopathy, defined as 2 or more relatives with idiopathic dilated cardiomyopathy, a 3-generation family history should be obtained to aid in establishing the diagnosis of familial cardiomyopathy (class I indication; level of evidence, C).10 Physical examination The AHA/ACC guidelines recommend that the evaluation of patients with heart failure include assessment of volume status, evidence of orthostatic blood pressure changes, and weight and height, with calculation of body mass index (class I; level of evidence, C).10
Box 2 Information that should be gathered during history Presence of heart failure symptoms (including duration and severity) Decreased exercise tolerance and NYHA class Dyspnea of exertion Orthopnea Paroxysmal nocturnal dyspnea Edema Ascites Other symptoms Angina Syncope Palpitations Symptoms of sleep disorder including daytime sleepiness, snoring, restless sleeping Presence of risk factors for heart failure Prior history of myocardial infarction Hypertension Diabetes mellitus Dyslipidemia Thyroid disease Smoking Valvular heart disease Family history of cardiomyopathy, sudden cardiac death, coronary artery disease Congenital heart disease
Table 2 NYHA functional class NYHA Class I
II
III
IV
Sleep disorders Exposure to cardiac toxins including chemotherapy agents and alcohol
Criteria No limitation of physical activity. The patient can perform the daily activities without symptoms of fatigue or dyspnea Mild limitation. Usually the patient is asymptomatic at rest but gets fatigue or dyspnea with regular daily activities IIIa: fatigue or dyspnea with less than regular daily activities; comfortable at rest IIIb: fatigue or dyspnea with minimal activity; comfortable at rest Patient symptomatic at rest, with worsening of the symptoms with minimal activity
The physical examination can provide clues regarding heart failure etiology and its severity based on volume status and perfusion state. This evaluation provides the clinician with a snapshot of the patient’s hemodynamic profile, which may be useful in guiding treatment (Table 3). Physical examination should include: Vital signs. Vital signs provide important information including presence of orthostasis, low cardiac output states characterized by narrow pulse pressure and tachycardia, or hypotension that has been related to poor prognosis in patients with heart failure.12,16,17 The presence of hypertension may provide information regarding cause.
Evaluation of Patients with Heart Failure
Table 3 Hemodynamic profiles in patients with heart failure Hemodynamic Profile Based on Clinical Evidence of Congestion and/or Hypoperfusion
Hemodynamic Profile (Forrester Classification) 2
Cardiac index >2.2 L/m/m , PCWP 2.2 L/m/m2, PCWP >18 mm Hg
A: warm and dry
Cardiac index
KEY POINTS Identification of risk factors for heart failure and its aggressive treatment are as important as early identification of heart failure. A complete patient history and a comprehensive physical examination can provide clues regarding the cause of heart failure and its severity. Echocardiogram is the most useful test during diagnosis of heart failure. A comprehensive echocardiogram gives the clinician information regarding ventricular function as well as causes of heart failure and its complications. Additional tests during evaluation of patients with heart failure must include routine laboratory tests and, in certain cases, specific laboratory tests and new imaging technologies, including cardiac magnetic resonance and computed tomography angiography. Noninvasive impedance cardiography could be helpful for evaluation of volume status in patients with heart failure and prevention of frequent hospitalizations caused by decompensated heart failure.
Heart failure is one of the most prevalent cardiovascular diseases in the United States, and its incidence has been steadily increasing over the years. In 2010, the prevalence of heart failure in US adults was near 6.6 million. It is estimated that by 2030 the prevalence of heart failure will increase by 25%.1 Data from the Framingham Health Study show that heart failure incidence is approximately 10 per 1000 in those older than 65 years of age.2 Furthermore, despite the improvement in survival after diagnosis, the death rate associated with heart failure remains as high as 50% within 5 years of diagnosis.3,4 Thus, the early identification of patients at risk of heart failure and prompt diagnosis
of those with heart failure symptoms is important to decrease mortality, hospital stay, and treatment costs.5,6 This article reviews the appropriate evaluation of patients with heart failure, including clinical examination and diagnostic tools.
DEFINITION OF HEART FAILURE Heart failure is characterized by abnormal cardiac structure or function that results in a failure of the heart to deliver oxygen to the organs at a rate that can fulfill their metabolic requirements.7 Heart failure has been defined as a progressive syndrome caused by cardiac dysfunction (either systolic, diastolic, or mixed) that leads to neurohormonal and circulatory abnormalities resulting
The authors have nothing to disclose. a Division of Cardiovascular Medicine, University of Minnesota Medical Center, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA; b Section on Advanced Heart Failure, Transplant and Mechanical Circulatory Support, Cardiovascular Division, University of Minnesota Medical Center, Lillehei Heart Institute, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA * Corresponding author. E-mail address: [email protected] Cardiol Clin 32 (2014) 47–62 http://dx.doi.org/10.1016/j.ccl.2013.09.014 0733-8651/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
cardiology.theclinics.com
INTRODUCTION
48
Patarroyo-Aponte & Colvin-Adams in symptoms such fluid retention, shortness of breath, and fatigue.7 The physiology that underlies this syndrome includes neuroendocrine activation with increased production of norepinephrine, angiotensin II, and arginine vasopressin, which results in vasoconstriction, increase in left ventricular impedance, cardiac myocyte hypertrophy, and increase in myocardial collagen synthesis. In addition, there is increase in atrial natriuretic peptide, which counter-regulates vasoconstriction and remodeling of the heart.8,9 Heart failure is a progressive disease that has a preclinical phase characterized by the absence of symptoms compared with later phases, and by the presence of myocardial injury that triggers neuroendocrine activation and cardiac remodeling (stages A and B). This preclinical phase progresses to a clinical phase during which symptoms appear. In this symptomatic phase, the patient’s symptoms can be controlled with medical treatment (stage C) or can be severe enough to require advanced therapies including mechanical circulatory support or heart transplant (stage D) (Table 1).10 Patients with heart failure can present
Table 1 American College of Cardiology/American Heart Association Heart failure stages Stage
Characteristics
Stage A
At risk for heart failure No structural heart disease or heart failure symptoms Examples: hypertension, diabetes, metabolic syndrome, family history of cardiomyopathy, cardiotoxin exposure Structural heart disease No signs or symptoms or heart failure Examples: patients with acute myocardial infarction, valvular heart disease, left ventricular hypertrophy Structural heart disease Prior or current heart failure symptoms Refractory heart failure requiring specialized interventions Example: marked symptoms at rest despite maximal medical therapy
Stage B
Stage C
Stage D
Adapted from Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACC/AHA Guidelines 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(16):e240–319.
with a varied spectrum of symptoms and signs, with variations between patients and during the course of the disease. Although the disease is progressive, the symptoms can be stabilized with therapy.11 The heart failure syndrome may manifest clinically as: A syndrome of fluid retention. Patients present with peripheral edema or increase in abdominal girth.10 Other signs of congestion include jugular venous distention, orthopnea, rales, and hepatojugular reflux.12 A syndrome of decreased exercise tolerance. This syndrome is typically characterized by progressive fatigue or dyspnea with exertion.10 Although these symptoms are common in patients with heart failure, they are also the most challenging for the clinician, given that they are not exclusive to patients with heart failure and can be present in other conditions, including pulmonary and muscular diseases.13 Other cardiovascular symptoms/end-organ hypoperfusion. Patients with heart failure may present with signs and symptoms that may be related directly to cardiac dysfunction or compromise of other organs. Some of these symptoms include arrhythmias, acute myocardial infarction, or renal and hepatic failure.
EVALUATION OF PATIENTS WITH HEART FAILURE A thorough evaluation of heart failure seeks to determine cause, severity, and prognosis, and combine a thorough history and physical examination with appropriate diagnostic tests (Box 1). The evaluation of patients with heart failure is based on a complete and comprehensive history, physical examination, and diagnostic studies. The importance of the history and physical examination is supported by a meta-analysis of 22 studies of patients who presented with dyspnea to the emergency department. Wang and colleagues,14 showed that the overall clinical impression of the emergency room physician, based on several signs and symptoms as well as laboratory and imaging tests, significantly increased the probability of having heart failure (positive likelihood ratio [LR], 4.4; 95% confidence interval [CI], 1.8–10). The most useful features were prior history of heart failure (positive LR, 5.8; 95% CI, 4.1–8.0), presence of paroxysmal nocturnal dyspnea (positive LR, 2.6; 95% CI, 1.5–4.5), S3 gallop on examination (positive LR, 11; 95% CI, 4.9–25.0), chest radiograph showing
Evaluation of Patients with Heart Failure
Box 1 Evaluation of patients with heart failure Initial diagnosis of heart failure History and physical examination Echocardiogram Routine laboratory testing including serum electrolytes, renal function, thyroid and liver function test, lipid profile, glucose, and complete blood count Biomarkers: N-terminal pro–brain natriuretic peptide or brain natriuretic peptide, troponin Additional laboratory tests might include ferritin, human immunodeficiency virus, plasma metanephrins, protein electrophoresis, antinuclear antibodies (ANA), extractable nuclear antigens (ENA), uric acid Other imaging techniques: magnetic resonance imaging, nuclear medicine stress test, cardiac computed tomography Endomyocardial biopsy if giant cell myocarditis and necrotizing eosinophilic myocarditis are suspected Chronic heart failure follow-up History: focus on duration and severity of symptoms Physical examination: weight, vital signs, and evaluation of signs of congestion and/or hypoperfusion Echocardiogram Routine laboratory testing: serum electrolytes, renal function, thyroid and liver function tests, lipid profile, glucose, and complete blood count Noninvasive impedance cardiography Acute decompensated heart failure History and physical Hemodynamic evaluation with pulmonary artery catheter Routine laboratory tests: serum electrolytes, renal function test, liver function test Prognostication Vital signs Laboratory test Cardiopulmonary stress test Six-minute walk test
pulmonary venous congestion (positive LR, 12.0; 95% CI, 6.8–21.0), and atrial fibrillation on electrocardiogram (positive LR, 3.8; 95% CI, 1.7–8.8).14
History and Physical Examination History A comprehensive history is the first step in the evaluation of patients with suspected or established heart failure. The personal history can provide important clues regarding risk factors for heart failure and aid interpretation of signs and symptoms that can lead to diagnosis of heart failure and determination of functional impairment and prognosis in patients with established heart failure.10,15 Thus, the American Heart Association (AHA)/American College of Cardiology (ACC) heart failure guidelines
recommend a thorough history be obtained/performed in patients presenting with heart failure to identify disorders or behaviors that can cause or accelerate the development or progression of heart failure (class I indication; level of evidence, C).10 Some asymptomatic patients can be at risk for heart failure. These patients might have one or more risk factors for heart failure including hypertension, prior history of myocardial infarction, diabetes mellitus, valvular heart disease, family history of cardiomyopathy, congenital heart disease, sleep disorders, and exposure to cardiac toxins including chemotherapy agents and alcohol.15 Once these risk factors are identified, they must be aggressively treated in order to prevent or delay development of heart failure symptoms. Identification of risk factors is recommended by the
49
Patarroyo-Aponte & Colvin-Adams
50
AHA/ACC guidelines as a class I indication with level of evidence C.10 For patients with known or suspected heart failure, it is important to identify characteristic symptoms such as dyspnea, decreased exercise tolerance, edema, or ascites. Once identified, these symptoms must be well described, including duration and severity. Patients with chronic heart failure can adapt to their condition and may not recognize, or may minimize, the symptoms.16 Documentation and grading of functional capacity, including the ability to perform routine daily activities and the New York Heart Association (NYHA) functional classification, is required (level of evidence, A) (Table 2).15 Other symptoms that must be considered during evaluation of patients with heart failure include angina, syncope, lightheadedness, or symptoms of sleep disorders, specifically sleep apnea (Box 2).15 In addition, in patients with suspected familial cardiomyopathy, defined as 2 or more relatives with idiopathic dilated cardiomyopathy, a 3-generation family history should be obtained to aid in establishing the diagnosis of familial cardiomyopathy (class I indication; level of evidence, C).10 Physical examination The AHA/ACC guidelines recommend that the evaluation of patients with heart failure include assessment of volume status, evidence of orthostatic blood pressure changes, and weight and height, with calculation of body mass index (class I; level of evidence, C).10
Box 2 Information that should be gathered during history Presence of heart failure symptoms (including duration and severity) Decreased exercise tolerance and NYHA class Dyspnea of exertion Orthopnea Paroxysmal nocturnal dyspnea Edema Ascites Other symptoms Angina Syncope Palpitations Symptoms of sleep disorder including daytime sleepiness, snoring, restless sleeping Presence of risk factors for heart failure Prior history of myocardial infarction Hypertension Diabetes mellitus Dyslipidemia Thyroid disease Smoking Valvular heart disease Family history of cardiomyopathy, sudden cardiac death, coronary artery disease Congenital heart disease
Table 2 NYHA functional class NYHA Class I
II
III
IV
Sleep disorders Exposure to cardiac toxins including chemotherapy agents and alcohol
Criteria No limitation of physical activity. The patient can perform the daily activities without symptoms of fatigue or dyspnea Mild limitation. Usually the patient is asymptomatic at rest but gets fatigue or dyspnea with regular daily activities IIIa: fatigue or dyspnea with less than regular daily activities; comfortable at rest IIIb: fatigue or dyspnea with minimal activity; comfortable at rest Patient symptomatic at rest, with worsening of the symptoms with minimal activity
The physical examination can provide clues regarding heart failure etiology and its severity based on volume status and perfusion state. This evaluation provides the clinician with a snapshot of the patient’s hemodynamic profile, which may be useful in guiding treatment (Table 3). Physical examination should include: Vital signs. Vital signs provide important information including presence of orthostasis, low cardiac output states characterized by narrow pulse pressure and tachycardia, or hypotension that has been related to poor prognosis in patients with heart failure.12,16,17 The presence of hypertension may provide information regarding cause.
Evaluation of Patients with Heart Failure
Table 3 Hemodynamic profiles in patients with heart failure Hemodynamic Profile Based on Clinical Evidence of Congestion and/or Hypoperfusion
Hemodynamic Profile (Forrester Classification) 2
Cardiac index >2.2 L/m/m , PCWP 2.2 L/m/m2, PCWP >18 mm Hg
A: warm and dry
Cardiac index
