History

Fact Explanation
Dyspnea, fatigue, exercise intolerance In heart failure, there is impaired ejection of blood from the ventricles or impaired ventricular filling leading to fluid retention and volume overload. This will in turn give rise to the characteristic dyspnea, fatigue and exercise intolerance in heart failure.[1,2,3]
Orthopnea Pulmonary congestion in lying down position will cause orthopnea.[1,2]
Paroxysmal nocturnal dyspnea At night, as the patients are sleeping in supine position for a long time, increased pulmonary congestion will cause episodes of breathlessness during sleep.[1,3]
Ankle swelling Impaired ejection of blood from the ventricles, particularly in right ventricular failure will lead to peripheral fluid retention, causing ankle edema.[1,2]
Abdominal distention Volume overload will cause accumulation of fluid in the peritoneal cavity giving rise to ascites.[1,3]
History of predisposing disease condition There are several, well recognized disease conditions which cause heart failure. They are ischemic heart disease, hypertension, valvular heart disease, thyroid disorders, acromegaly and other hormonal disorders, rheumatological disorders etc.[1,3]
History of cardiovascular risk factors Presence of cardiovascular risk factors such as hypertension, diabetes mellitus, metabolic syndrome, atherosclerosis, excessive alcohol use, coccaine abuse favours the diagnosis of heart failure.[1,2,3]
Family history of certain predisposing disease conditions Family history should be taken properly to identify familial cardiomyopathy.[1]
Age of the patient Incidence of heart failure increases with age.[1]
Race of the patient Studies have shown that black people have a higher risk of developing heart failure than white people.[1]
Chest pain Retrosternal, constricting type chest pain occur when there is myocardial ischemia.[1]
Anorexia, early satiety and weight loss Most patients with heart failure are suffering from loss of appetite leading to cardiac cachexia which is known as a bad prognostic factor.[1]
Weight gain Because of volume overload, patients may develop weight gain.[1]
Palpitations Patients with heart failure are more prone to develop arrhythmias such as paroxysmal atrial fibrillation and ventricular tachycardia which can give rise to palpitations.[1]
Transient, sudden loss of vision, paralysis of a limb These symptoms suggest that patient is suffering from a transient ischemic attack or a stroke. Most of the time this can be due to thromboembolic phenomena, as there is high chance of clot formation in the left ventricle due to stasis of blood.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776
  2. FIGUEROA MS, PETERS JI. Congestive heart failure: Diagnosis, pathophysiology, therapy, and implications for respiratory care. Respir Care [online] 2006 Apr, 51(4):403-12 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16563194
  3. GILLESPIE N. D. The diagnosis and management of chronic heart failure in the older patient. British Medical Bulletin [online] 2006 February, 75-76(1):49-62 [viewed 20 June 2014] Available from: doi:10.1093/bmb/ldh060

Examination

Fact Explanation
Elevated jugular venous pressure Right ventricular failure/congestive cardiac failure will cause pooling of blood in the right heart and in the venous circulation causing increased back pressure which in turn results in elevation of the jugular venous pressure.[1]
Tender hepatomegaly Volume overload will give rise to enlargement of liver due to hepatic venous congestion. Liver enlargement will cause stretching of liver capsule which causes tenderness.[1]
Peripheral edema Impaired ejection of blood from the ventricles, particularly in right ventricular failure will lead to peripheral fluid retention, causing ankle edema.[1]
Ascites Volume overload will cause accumulation of fluid in the peritoneal cavity giving rise to ascites.[1]
Irregular pulse Patients with heart failure are more prone to develop arrhythmias causing pulse irregularity.[1]
Shifted apex beat Ventricular enlargement due to stasis of blood, shifts the cardiac apex to the left from its normal position.[1]
Parasternal haeve When there is severe right ventricular failure and/or pulmonary hypertension, parasternal heave can be elicited.[1]
Gallop rythm, third heart sound (S3) Typically found in heart failure, when listening to the heart sounds using stethoscope.[1]
Low/high body mass index (BMI), evidence of weight loss If there is cardiac cachexia, it is a poor prognostic factor.[1]
Hypertension/hypotension It is essential to measure blood pressure in supine and upright positions to recognize hypertension or hypotension. Adequacy of cardiac output may be reflected by the width of pulse pressure. Valsalva maneuver also can be carried out as it indicates the left ventricular filling pressures,[1]
Pulmonary status: increased respiratory rate, basal crepitations, areas with stony dullness In congestive, advanced heart failure, there is severe pulmonary congestion causing increased respiratory rate, bilateral basal crepitations and pleural effusions giving rise to these signs.[1]
Temperature of lower extremities Decreased cardiac out put will eventually cause poor peripheral circulation causing cold lower extremities.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776

Differential Diagnoses

Fact Explanation
Renal failure Suspect in patients having hematuria, proteinuria, periorbital edema.[1,2]
Chronic obstructive pulmonary disease Patient will have long term history of respiratory disease with habit of cigarette smoking.[1,2]
Cirrhosis Presence of peripheral stigmata of chronic liver disease favours the diagnosis of cirrhosis.[1,2]
Nephrotic syndrome Significant proteinuria will aid the diagnosis of nephrotic syndrome.[1,2]
Pneumothorax Clinical examination findings and chest X-ray will help diagnosing pneumothorax.[1,2]
References
  1. FIGUEROA MS, PETERS JI. Congestive heart failure: Diagnosis, pathophysiology, therapy, and implications for respiratory care. Respir Care [online] 2006 Apr, 51(4):403-12 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16563194
  2. GILLESPIE N. D. The diagnosis and management of chronic heart failure in the older patient. British Medical Bulletin [online] 2006 February, 75-76(1):49-62 [viewed 20 June 2014] Available from: doi:10.1093/bmb/ldh060

Investigations - for Diagnosis

Fact Explanation
Electrocardiogram (ECG) As an initial investigation, a 12-lead ECG should be performed in all patients presenting with heart failure.[1]
Brain natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) When there is an uncertainty of diagnosing heart failure, measurement of BNP levels is the investigation of choice as in heart failure there is elevation of BNP levels in serum.[1]
Cardiac troponin Cardiac troponin levels in blood may be high in patients with heart failure, due to ongoing myocyte necrosis without evidence of myocardial ischemia or underlying coronary artery disease. Useful to determine the prognosis and the degree of severity in acutely decompensated heart failure.[1]
Chest x-ray Patients should undergo a chest x-ray as a baseline investigation to assess cardiac chamber enlargement, interstitial or alveolar edema, valvular or pericardial calcification and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms.[1]
Echocardiogram A 2-dimensional echocardiogram with Doppler flow studies is the most useful diagnostic investigation and should be done to assess the ventricular function (ejection fraction measurements), size (ventricular dimensions, volumes), wall thickness, wall motion, atrial size, atrial dimensions and valve function (anatomical and flow abnormalities). The transthoracic echocardiography can identify abnormalities of myocardium, heart valves, and pericardium.[1]
Radionuclide ventriculography Useful to assess left ventricular ejection fraction and volume when echocardiography is inadequate. However, it cannot be used to assess the valvular structure, function, or ventricular wall thickness directly.[1]
Specific diagnostic tests to diagnose underlying diseases Should be performed when there is a clinical suspicion of a underlying disease process such as rheumatologic diseases, amyloidosis, or pheochromocytoma etc.[1]
Magnetic resonance imaging (MRI) Magnetic resonance imaging assesses left ventricular volume, ejection fraction, myocardial perfusion, viability, and fibrosis. This information help identify heart failure etiology and assess prognosis. It also provides high anatomical resolution of all aspects of the heart and surrounding structure, leading to its recommended use in known or suspected congenital heart diseases.[1]
Cardiac computed tomography Choice of investigation to get an accurate assessment of cardiac structure and function, including the coronary arteries. It also has the ability to characterize the myocardium, which cannot be done using echocardiography.[1]
Coronary angiography When there is high suspicion of coronary artery disease as a causative factor for the heart failure, those patients should undergo coronary angiography.[1]
Invasive hemodynamic monitoring - pulmonary artery catheterisation Should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment.[1]
Endomyocardial biopsy Useful in patients with heart failure when a specific diagnosis is suspected that would influence therapy.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776

Investigations - Fitness for Management

Fact Explanation
Full blood count Should be done to assess the hemoglobin level, white blood cell count in case to identify ongoing infection, platelet count if on anticoagulation therapy.[1]
Serum electrolytes (including calcium and magnesium) Should be done as most of the drugs given for the heart failure patients known to cause electrolyte abnormalities, which should diagnose and manage as soon as possible.[1]
Blood urea nitrogen, serum creatinine To assess the renal function of the patient.[1]
Plasma glucose To identify co-morbid diabetes mellitus.[1]
Fasting lipid profile To detect associated dyslipidemia.[1]
Liver function tests Liver functions should be assessed to determine the dosage of certain drugs.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776

Investigations - Followup

Fact Explanation
Serum electrolytes Should be done as most of the drugs given for the heart failure patients known to cause electrolyte abnormalities, which should diagnose and manage as soon as possible.[1]
Renal function tests - serum creatinine Dosage of some drugs should be changed according to the level of renal function. Therefore at follow up visits renal functions should be assessed.[1]
Brain natriuretic peptide (BNP) Useful to assess disease severity in chronic heart failure.[1]
Echocardiogram - assessment of left ventricular ejection fraction Should not be done routinely, unless there is a change in clinical status of the patient.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776

Investigations - Screening/Staging

Fact Explanation
Serial echocardiographic screening First-degree relatives of a patient with familial dilated cardiomyopathy, not known to be affected should undergo periodic, serial echocardiographic screening with assessment of left ventricular function and size.[1]
Genetic testing Should be done to detect familial cardiomyopathies.[1]
Hemochromatosis screening test Reasonable to do in selected heart failure patients who present with other clinical features suggestive of hemochromatosis.[1]
Human immunodeficiency virus (HIV) screening test If clinical picture and other investigation findings suggest HIV infection as the underlying cause of heart failure, HIV screening test should be done with the consent of the patient.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776

Management - General Measures

Fact Explanation
Patient and family education It is important that patients should aware about their disease condition, risk factors, medications, follow up strategies, importance of drug compliance. Also they should be educated regarding monitoring their symptoms by themselves, dietary modifications such as salt restriction.[1]
Social support Social support will promote treatment adherence and a healthy lifestyle.[1]
Activity, exercise prescription Regular physical activity is recommended as safe and effective for patients with heart failure who are able to participate to improve functional status.[1]
Cardiac rehabilitation Useful in clinically stable patients with medications to improve functional capacity, exercise duration, quality of life, and mortality. Also known to reduce frequency of hospital admissions. Some other additional benefits are improved endothelial function, blunted catecholamine spillover and increased peripheral oxygen extraction.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776

Management - Specific Treatments

Fact Explanation
Identification of patient's stage of heart failure and planing the management Therapeutic interventions differ according to the patient's stage of heart failure. Stage A - aimed at modifying risk factors, Stage B - treating structural heart disease, Stage C and D - aim is to reduce morbidity and mortality [1]
Recognition and treatment of elevated blood pressure, dyslipidemia, obesity, diabetes mellitus and substance abuse It is important to treat these co-morbid diseases. Blood pressure should be controlled to prevent symptomatic heart failure. Use of tobacco and other known cardiotoxic agents should be recognized and avoided.[1]
Angiotensin converting enzyme (ACE) inhibitors/ Angiotensin receptor blockers (ARBs) ACE inhibitors should be used in all patients with a reduced ejection fraction to prevent symptomatic heart failure, even if they do not have a history of myocardial infarction. Highly recommended if there is a recent or remote history of myocardial infarction or acute coronary syndrome to reduce mortality. In patients intolerant of ACE inhibitors, ARBs are appropriate unless contraindicated.[1]
Beta blockers Should be prescribed to all patients with a reduced ejection fraction to prevent symptomatic heart failure, even if they do not have a history of myocardial infarction. [1]
Statins All patients with a recent or remote history of myocardial infarction or acute coronary syndrome should be given statins to prevent symptomatic heart failure and cardiovascular events.[1]
Diuretics Recommended in patients with heart failure with reduced ejection fraction who have evidence of fluid retention, unless contraindicated, to improve symptoms. Note that loop diuretics are preferred agents in most cases, although Thiazides may be considered in hypertensive patients with heart failure.[1]
Spironolactone Recommended in patients with NYHA class II–IV heart failure and who have left ventricular ejection fraction of 35% or less, unless contraindicated, to reduce morbidity and mortality.[1]
Hydralazine and isosorbide dinitrate The combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients with NYHA class III–IV heart failure with reduced ejection fraction, receiving optimal ACE inhibitor and beta blocker therapy, unless contraindicated.[1]
Digoxine Digoxin can be beneficial in patients with heart failure with reduced ejection fraction, unless contraindicated, to decrease hospitalizations for heart failure.[1]
Nondihydropyridine calcium channel blockers Should not be given as it may be harmful.[1]
Anticoagulation Patients with chronic heart failure are at an increased risk of thromboembolic events due to stasis of blood in dilated hypokinetic cardiac chambers and in peripheral blood vessels. Therefore anticoagulation therapy is indicated for some patients. Those indications include, patients with chronic heart failure with permanent/persistent/paroxysmal atrial fibrillation and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, previous stroke or transient ischemic attack, or ≥75 years of age). Selection of the anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) should be individualized considering several aspects.[1]
Omega-3 polyunsaturated fatty acid (PUFA) supplementation Can be used as an adjunctive therapy in patients with NYHA class II–IV symptoms, unless contraindicated, to reduce mortality and cardiovascular hospitalizations.[1]
Positive inotropic drugs Use to manage acute decompensated heart failure. Long-term use of infused positive inotropic drugs is potentially harmful for patients with reduced ejection fraction, except as palliation for patients who with end-stage disease and cannot be stabilized with standard medical treatment.[1]
Insertion of an Implantable Cardioverter-Defibrillator (ICD) Patients with severe heart failure are at increased risk of ventricular tachyarrhythmias leading to sudden cardiac death. ICDs are highly effective in preventing sudden death from ventricular arrhythmias. Indicated only in patients with a reasonable expectation of survival with good functional status beyond a year, such as patients with asymptomatic ischemic cardiomyopathy who are at least 40 days post-myocardial infarction, have an left ventricular ejection fraction of 30% or less.[1]
Cardiac resynchronization therapy Multisite ventricular pacing (CRT or biventricular pacing) known to improve ventricular contractile function, diminish secondary mitral regurgitation, reverse ventricular remodeling, and sustain improvement in left ventricular ejection fraction.[1]
Mechanical circulatory support Beneficial in carefully selected patients with stage D, in whom definitive management (eg, cardiac transplantation) or cardiac recovery is anticipated or planned.[1]
Venous thromboembolism prophylaxis in hospitalized patients Hospitalized patients with heart failure has a greater risk compared to ambulatory heart failure patient for venous thromboembolic disease. Therefore they should receive venous thromboembolism prophylaxis with an anticoagulant medication after considering the risk–benefit ratio.[1]
Anemia management Anemia is a common finding in patients with chronic heart failure. In patients without identifiable causes of anemia, erythropoiesis-stimulating agents have gained significant interest as potential adjunctive therapy.[1]
Surgical treatment modalities Surgical therapies and percutaneous interventions that are commonly integrated, or at least considered, in heart failure management include coronary revascularization (eg, CABG, angioplasty, stenting), aortic valve replacement, mitral valve replacement or repair, septal myectomy or alcohol septal ablation for hypertrophic cardiomyopathy, surgical ablation of ventricular arrhythmia and cardiac transplantation. Cardiac transplantation considered as the gold standard for the treatment of refractory end-stage heart failure. [1]
Management of sleep disorders Continuous positive airway pressure can be beneficial to increase left ventricular ejection fraction and improve functional status in patients with heart failure and sleep apnea.[1]
References
  1. YANCY C. W., JESSUP M., BOZKURT B., BUTLER J., CASEY D. E., DRAZNER M. H., FONAROW G. C., GERACI S. A., HORWICH T., JANUZZI J. L., JOHNSON M. R., KASPER E. K., LEVY W. C., MASOUDI F. A., MCBRIDE P. E., MCMURRAY J. J. V., MITCHELL J. E., PETERSON P. N., RIEGEL B., SAM F., STEVENSON L. W., TANG W. H. W., TSAI E. J., WILKOFF B. L.. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation [online] December, 128(16):e240-e327 [viewed 20 June 2014] Available from: doi:10.1161/​CIR.0b013e31829e8776