How to diagnose heart failure
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Diagnosing Heart Failure: Key Methods and Approaches
Heart failure (HF) is a complex clinical syndrome with significant morbidity and mortality. Accurate and timely diagnosis is crucial for effective management and improved patient outcomes. This article synthesizes current research on the diagnostic approaches for heart failure, focusing on acute heart failure (AHF), heart failure with preserved ejection fraction (HFpEF), and diastolic heart failure (DHF).
Diagnosing Acute Heart Failure in the Emergency Department
Clinical Assessment and Physical Examination
Diagnosing acute heart failure (AHF) in the emergency department (ED) can be challenging due to overlapping symptoms with other conditions. Key clinical features include dyspnea, orthopnea, and systemic edema. Physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema, although these findings are not always sensitive or specific .
Diagnostic Tests
Several diagnostic tests are utilized to confirm AHF:
- Electrocardiogram (ECG): Often used but not definitive.
- Chest Radiograph (CXR): Can show pulmonary edema but is not always conclusive.
- Natriuretic Peptides (BNP and NT-proBNP): Useful for excluding AHF when levels are low. BNP < 100 pg/mL and NT-proBNP < 300 pg/mL have low negative likelihood ratios, making them valuable for ruling out AHF .
- Point-of-Care Ultrasound (POCUS): Effective in identifying B-lines, assessing cardiac function, and measuring inferior vena cava size, making it a reliable tool for diagnosing AHF .
Meta-Analysis Findings
A systematic review and meta-analysis highlighted that lung ultrasound and bedside echocardiography are the most useful tests for affirming AHF, with high positive likelihood ratios for pulmonary edema and reduced ejection fraction.
Diagnosing Heart Failure with Preserved Ejection Fraction (HFpEF)
HFA-PEFF Diagnostic Algorithm
The Heart Failure Association (HFA) of the European Society of Cardiology (ESC) recommends a stepwise diagnostic process known as the HFA-PEFF algorithm for diagnosing HFpEF :
- Pre-test Assessment (P): Includes evaluating HF symptoms, clinical demographics (e.g., obesity, hypertension, diabetes), and initial diagnostic tests (e.g., ECG, echocardiography).
- Echocardiography and Natriuretic Peptide Score (E): Comprehensive echocardiography measures and natriuretic peptide levels are used to calculate a score. A score ≥ 5 points indicates definite HFpEF, while a score ≤ 1 point makes HFpEF unlikely.
- Functional Testing (F1): For intermediate scores (2-4 points), further testing with echocardiographic or invasive hemodynamic exercise stress tests is recommended.
- Final Aetiology (F2): Establishes the specific cause of HFpEF or alternative explanations .
Validation and Clinical Impact
The HFA-PEFF score has been validated and shown to be effective in diagnosing HFpEF, emphasizing the importance of a structured approach in clinical practice.
Diagnosing Diastolic Heart Failure (DHF)
Diagnostic Criteria
Diastolic heart failure (DHF), also known as heart failure with normal left ventricular ejection fraction (HFNEF), requires the following conditions for diagnosis:
- Signs or Symptoms of Heart Failure: Clinical evidence of HF.
- Normal or Mildly Abnormal Systolic LV Function: LVEF > 50% and LV end-diastolic volume index < 97 mL/m².
- Evidence of Diastolic LV Dysfunction: Can be obtained invasively or non-invasively using tissue Doppler imaging (E/E' > 15) .
Echocardiography
Comprehensive two-dimensional and Doppler echocardiography are essential for diagnosing DHF. These methods can demonstrate abnormal myocardial relaxation, decreased compliance, and increased filling pressure, confirming the diagnosis in patients with normal LVEF .
Conclusion
Diagnosing heart failure requires a combination of clinical assessment, physical examination, and various diagnostic tests. For acute heart failure, point-of-care ultrasound and natriuretic peptides are valuable tools. The HFA-PEFF algorithm provides a structured approach for diagnosing HFpEF, while comprehensive echocardiography is crucial for identifying diastolic heart failure. Accurate and timely diagnosis is essential for effective management and improved patient outcomes.
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