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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.
History
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.
Physical Examination
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)