Diagnosis and management of chronic heart failure in adults

American Family Physician,  March 1, 2007  by Liz Smith

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Guideline source: American College of Cardiology, American Heart Association

Literature search described? Yes

Evidence rating system used? Yes

Published source: Circulation, September 20, 2005

Available at: http://circ.ahajournals.org/cgi/content/full/112/12/e154

As the number of treatments for heart failure has increased, uncertainty about the timing and sequence of initiating new medications and the appropriateness of combining them has made clinical decision making more complex. In addition, recognition of clinical heart failure in patients with a normal ejection fraction (EF) has highlighted the limitations of evidence-based therapy for these patients. These changes are reflected in the updated American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for the diagnosis and management of chronic heart failure in adults.

Heart failure is a clinical syndrome characterized by specific symptoms (e.g., dyspnea, fatigue) and signs (e.g., edema, rales). The development of heart failure has been divided into four stages (Figure 1): A--high risk of heart failure but no structural disease or symptoms; B--structural heart disease but no signs or symptoms; C--structural heart disease with current or past symptoms; and D--refractory heart failure requiring specialized interventions. Possible structural or functional reasons for the development of heart failure include cardiomyopathy and left ventricular (LV) dysfunction. Patients with LV dysfunction or heart failure typically present with decreased exercise tolerance caused by dyspnea or fatigue, fluid retention in the legs or abdomen, or evidence of cardiac enlargement or dysfunction found during evaluation for another disorder. Diagnosis is largely clinical, based on a careful history and physical examination.

Clinical Assessment

In the initial evaluation of patients with heart failure, physicians should locate structural and functional cardiac abnormalities and identify disorders and behaviors that could cause the disease or accelerate its progression. Physicians then should focus on clinical assessment to identify symptoms and determine their effects on function. An ongoing review of symptoms and function is critical to treatment selection.

IDENTIFICATION OF ABNORMALITIES

The history and physical examination may provide clues as to the nature of the underlying abnormality, but a specific diagnosis generally requires cardiac imaging. The most useful diagnostic tool for evaluating patients with heart failure is two-dimensional echocardiography with Doppler to assess left ventricular ejection fraction (LVEF), LV size, ventricular compliance, wall thickness, and valve function. This should be performed during the initial evaluation. Comprehensive evaluation is important because there often is more than one contributing cardiac abnormality, and the test also can be useful as a baseline for comparison.

Radionuclide ventriculography can be used to assess LVEF and volumes, and magnetic resonance imaging or computed tomography also may provide information in selected patients. Twelve-lead electrocardiography and chest radiography (posteroanterior and lateral) should be performed in all patients presenting with heart failure, but they should not be used as the primary basis for determining responsible abnormalities.

EVALUATION OF THE CAUSE

To evaluate the cause of heart failure, physicians should obtain a thorough history (Table 1), including current and past use of alcohol, illicit drugs, standard or alternative therapies, and chemotherapy drugs. A careful physical examination should be performed, including assessment of volume status, orthostatic blood pressure changes, weight and height, body mass index, and ability to perform routine and desired activities of daily living. Maximal exercise testing may be used to determine whether heart failure is the cause of exercise limitation; or, with measurement of respiratory gas exchange, to identify high-risk patients who may need advanced treatments such as cardiac transplantation.

Laboratory tests should include complete blood count; urinalysis; lipid profile; liver function tests; and measurement of serum electrolyte levels (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose levels, and thyroid-stimulating hormone levels. Elevated brain natriuretic peptide (BNP) levels may support a suspected diagnosis of heart failure or trigger its consideration, but this finding should not be used alone to confirm or exclude the diagnosis. BNP measurement may be useful in the emergency setting if heart failure is uncertain. Routine measurement of circulating neurohormone levels is not recommended.

Because patients with hemochromatosis may show improved LV function after treatment, screening for hemochromatosis is reasonable in selected patients. Screening for sleep-disturbed breathing also may be reasonable. Human immunodeficiency virus testing should be considered in those at high risk of infection, and diagnostic testing for rheumatologic disease, amyloidosis, or pheochromocytoma is reasonable if these conditions are suspected.