cardiovascular disorders
Heart Failure (HF)
Diagnosis of Heart Failure
Sometimes only clinical evaluation Chest x-ray Echocardiography, cardiac radionuclide scan, and/or MRI BNP or N-terminal-pro-BNP (NT-pro-BNP) levels ECG and other tests for etiology as needed Clinical findings (eg, exertional dyspnea or fatigue, orthopnea, edema, tachycardia, pulmonary crackles, S3, jugular venous distention) suggest heart failure but are usually not apparent early. Some similar symptoms may result from Chronic Obstructive Pulmonary Disease (COPD) (chronic obstructive pulmonary disease) or recurrent ). Blood tests, except for BNP levels, are not used for diagnosis but are useful for identifying cause and systemic effects ( Diagnosis references , Data fromMcDonagh TA, Metra M, Adamo M, et al: 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J42(36):3599-3726, 2021. doi: 10.1093/eurheartj/ehab368. Chest x-ray findings suggesting heart failure include an enlarged cardiac silhouette, pleural effusion, fluid in the major fissure, and horizontal lines in the periphery of lower posterior lung fields (Kerley B lines). These findings reflect chronic elevation of left atrial pressure and chronic thickening of the intralobular septa due to edema. Upper lobe pulmonary venous congestion and interstitial or alveolar edema may also be present. Careful examination of the cardiac silhouette on a lateral projection can identify specific ventricular and atrial chamber enlargement. The x-ray may also suggest alternative diagnoses (eg, COPD, pneumonia, Idiopathic Pulmonary Fibrosis , This patient has bilateral pleural effusions (arrows). The normally sharp costophrenic angles are obscured by fluid in this patient. © 2017 Elliot K. Fishman, MD. Kerley B lines (arrows) are horizontal lines in the lung periphery that extend to the pleural surface. They denote thickened, edematous interlobular septa often due to pulmonary edema. © 2017 Elliot K. Fishman, MD. This patient has cardiomegaly (width of cardiac silhouette is > 50% of thoracic cage on a posterior-anterior chest x-ray). The patient also has cephalization (black arrows) whereby upper lobe pulmonary vessels become more prominent. These findings are often seen in patients with heart failure. © 2017 Elliot K. Fishman, MD. Lateral chest x-ray in a patient with fluid in major (1) and minor (2) fissures as well as a loculated effusion (3) seen along right posterior chest wall. © 2017 Elliot K. Fishman, MD. ECG findings are not diagnostic, but an abnormal ECG, especially showing previous myocardial infarction, left ventricular hypertrophy, left bundle branch block, or tachyarrhythmia (eg, rapid Atrial Fibrillation ), increases suspicion for HF and may help identify the cause. An entirely normal ECG is uncommon in chronic HF. Echocardiography None Radionuclide Imaging of the Heart None Magnetic Resonance Imaging (MRI) in Cardiac Diagnosis None Serum BNP levelsare often high in heart failure; this finding may help when clinical findings are unclear or other diagnoses (eg, COPD) need to be excluded. It may be particularly useful for patients with a history of both pulmonary and cardiac disorders. NT-pro-BNP, an inactive moiety created when pro-BNP is cleaved, can be used similarly to BNP. However,a normal BNP level does not exclude the diagnosis of heart failure,particularly in patients with HFpEF and/or obesity. In HFpEF, BNP levels tend to be about 50% of those associated with HFrEF (at similar degree of symptoms), and up to 30% of patients with acute HFpEF have a BNP level below the commonly used threshold of 100 pg/mL (100 ng/L). Obesity, which is becoming an increasingly common comorbidity in HF, is associated with reduced BNP production and increased BNP clearance, resulting in lower levels. Besides BNP, recommended blood tests include complete blood count, creatinine, BUN (bloodureanitrogen), electrolytes (including magnesium and calcium), glucose,albumin, ferritin, and liver tests. Thyroid function tests are recommended for patients with atrial fibrillation and for selected, especially older, patients. Thoracic ultrasonographyis a noninvasive method of detecting pulmonary congestion in patients with heart failure. Sonographic "comet tail artifact" on thoracic ultrasonography corresponds to the x-ray finding of Kerley B lines. is indicated when Overview of Coronary Artery Disease is suspected or the etiology of HF is uncertain. Cardiac catheterization with intracardiac pressure measurements (invasive hemodynamics) may be helpful in the diagnosis of restrictive cardiomyopathies and constrictive pericarditis. Invasive hemodynamic measurements are also very helpful when the diagnosis of HF is equivocal, particularly in patients with HFpEF. In addition, perturbing the cardiovascular system (eg, exercise testing, volume challenge, drug challenges [eg,nitroglycerin,nitroprusside]) can be very helpful during invasive hemodynamic testing to help diagnose HF. Endocardial biopsy is sometimes done when an infiltrative cardiomyopathy, or acute giant cell myocarditis is strongly suspected but cannot be confirmed with noninvasive imaging (eg, cardiac MRI). 1.McDonagh TA, Metra M, Adamo M, et al: 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J42(36):3599-3726, 2021. doi: 10.1093/eurheartj/ehab368 2.Heidenreich PA, Bozkurt B, Aguilar D, et al: 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation145:e876–e894, 2022, doi: 10.1161/CIR.0000000000001062 