Heart Failure - Chronic Đánh giá ban đầu

Clinical Presentation

Patients with heart failure may present with signs and symptoms depicting decreased exercise tolerance and fluid retention. Decreased exercise tolerance may present as dyspnea and/or fatigue occurring at rest or during exercise and symptoms may not be noticed by the patient as it occurs gradually. Fluid retention may be apparent if the patient complains of leg or abdominal swelling as their primary symptom.  

Other patients do not present with symptoms, or the symptoms may be explained by another cardiac or other diseases. Cardiac enlargement or dysfunction may be noted during their evaluation for a disease other than heart failure.  

The diagnosis of heart failure requires a thorough history and physical examination, identification of the etiology and risk factors, and diagnostic examination of the cardiac structure and function. In doing so, identifies diseases that will require specific management.  

Tiền sử bệnh

Many symptoms of heart failure are nonspecific and do not distinguish between heart failure and other diseases.  

More specific symptoms of heart failure include dyspnea at rest or on exertion or breathlessness, paroxysmal nocturnal dyspnea, orthopnea, reduced exercise capacity, fatigue, or longer time to recover post-exercise, and edema or ankle swelling.  

Less specific symptoms of heart failure include nocturnal cough, wheezing, palpitations, dizziness, bendopnea, bloated feeling, anorexia, confusion (especially in the elderly), depression, and syncope.  

During history-taking it is important to determine the predisposition to risk factors, especially in lifestyle (eg smoking, diet, alcohol consumption, substance abuse, and inactivity). It is also essential to review the patient’s past medical history to identify the possible cause of heart failure and the presence of comorbid illnesses (eg history of CAD or arterial hypertension, previous cardiac surgery, chronic lung, liver, or kidney disease, coronavirus disease 2019 [COVID-19] infection). Screening heart failure patients for cardiovascular and non-cardiovascular comorbidities helps alleviate symptoms and improves prognosis. Current or past standard or alternative therapies and chemotherapy (eg diuretic use, exposure to radiation or cardiotoxic drug) should be taken note of.  

Family history to determine familial predisposition to atherosclerotic disease, cardiomyopathy (obtain a 3-generation family history), conduction system disease or tachyarrhythmias is likewise important. 

Khám thực thể

More specific signs of heart failure include S3 gallop, laterally displaced or prominent apical impulse, elevated jugular venous pressure (JVP), and hepatojugular reflux.  

Less specific signs of heart failure include irregular pulse, tachycardia with pulsus alternans, narrow pulse pressure, murmurs or S4 gallop, pulmonary rales or crepitations, reduced air entry or dullness at lung bases, tachypnea or orthopnea, weight gain (>2 kg/week), weight loss (in advanced heart failure), or oliguria. Other findings such as hepatomegaly, ascites, peripheral edema or bilateral ankle edema, cold extremities, or cachexia may also be seen.  

Assessment of Volume Status  

The assessment of the patient’s volume status helps determine the need for diuretic treatment. In doing so, it is essential to detect any sodium excess or deficiency that may affect the efficacy and reduce the tolerability of drugs used to treat heart failure. At each visit, record the patient’s weight, vital signs especially blood pressure (BP) (sitting and standing), and other abnormal physical findings including the presence of clinical congestion.  

Diagnosis or Diagnostic Criteria

The diagnosis of heart failure requires a thorough history and physical examination, identification of the etiology and risk factors, and diagnostic examination of the cardiac structure and function. In doing so, identifies diseases that will require specific management.    

Framingham Diagnostic Criteria for Heart Failure  

Heart failure is diagnosed with ≥2 major criteria or 1 major criterion with 2 minor criteria.  

The major criteria include jugular venous distension, orthopnea, rales, acute pulmonary edema, cardiomegaly, S3 gallop rhythm, and hepatojugular reflux.  

The minor criteria include nocturnal cough, dyspnea on exertion, pleural effusion, heart rate of >120 beats per minute (bpm), hepatomegaly, and ankle edema.

H₂FPEF Score  

Due to the lack of testing to definitively diagnose HFpEF, a diagnostic scoring system may be utilized to help in the evaluation of patients with suspected HFpEF. A score of ≥6 points is highly diagnostic of HFpEF and each component is graded as follows: 

• Heavy (body mass index [BMI] of >30 kg/m²) (2 points)
• Hypertension (on ≥2 antihypertensive medications) (1 point)
• atrial Fibrillation (3 points)
• Pulmonary hypertension (pulmonary artery systolic pressure of >35 mmHg on Doppler echocardiography) (1 point)
• Elder (>60 years old) (1 point)
• Filling pressures (E/e’ >9 on Doppler echocardiography) (1 point)