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MICHAEL KING, MD; JOE KINGERY, DO; and BARETTA CASEY, MD, MPH
University of Kentucky College of Medicine, Lexington, Kentucky
Heart failure is a common clinical syndrome characterized by dyspnea, fatigue, and signs of volume overload, which
may include peripheral edema and pulmonary rales. Heart failure has high morbidity and mortality rates, especially
in older persons. Many conditions, such as coronary artery disease, hypertension, valvular heart disease, and diabetes
mellitus, can cause or lead to decompensation of chronic heart failure. Up to 40 to 50 percent of patients with heart
failure have diastolic heart failure with preserved left ventricular function, and the overall mortality is similar to
that of systolic heart failure. The initial evaluation includes a history and physical examination, chest radiography,
electrocardiography, and laboratory assessment to identify causes or precipitating factors. A displaced cardiac apex, a
third heart sound, and chest radiography findings of venous congestion or interstitial edema are useful in identifying
heart failure. Systolic heart failure is unlikely when the Framingham criteria are not met or when B-type natriuretic
peptide level is normal. Echocardiography is the diagnostic standard to confirm systolic or diastolic heart failure
through assessment of left ventricular ejection fraction. Evaluation for ischemic heart disease is warranted in patients
with heart failure, especially if angina is present, given that coronary artery disease is the most common cause of heart
failure. (Am Fam Physician. 2012;85(12):1161-1168. Copyright 2012 American Academy of Family Physicians.)
Patient information: eart failure is a common clini- blood.3 As cardiac output decreases because
A handout on this topic is cal syndrome characterized by of stresses placed on the myocardium, activa-
available at http://
familydoctor.org /
dyspnea, fatigue, and signs of tion of the sympathetic nervous and renin-
familydoctor/en /diseases- volume overload, which may angiotensin-aldosterone systems increases
conditions/heart-failure. include peripheral edema and pulmonary blood pressure (for tissue perfusion) and
html. rales. There is no single diagnostic test for blood volume (enhancing preload, stroke
heart failure; therefore, it remains a clinical volume, and cardiac output by the Frank-
diagnosis requiring a history, physical exam- Starling mechanism). These compensatory
ination, and laboratory testing. Symptoms mechanisms can also lead to further myocar-
of heart failure can be caused by systolic or dial deterioration and worsening myocardial
diastolic dysfunction. Appropriate diagno- contractility. In systolic heart failure, cardiac
sis and therapy for heart failure are impor- output is decreased directly through reduced
tant given the poor prognosis. Survival is left ventricular function. In diastolic heart
89.6 percent at one month from diagnosis, failure, cardiac output is compromised by
78 percent at one year, and only 57.7 percent poor ventricular compliance, impaired relax-
at five years.1 ation, and worsened end-diastolic pressure.3,4
Heart failure has an estimated overall CAD is the underlying etiology in up to
prevalence of 2.6 percent.2 It is becoming 60 to 70 percent of patients with systolic heart
more common in adults older than 65 years failure,5,6 and a predictor for progression
because of increased survival after acute from asymptomatic to symptomatic left ven-
myocardial infarction and improved treat- tricular systolic dysfunction. Hypertension
ment of coronary artery disease (CAD), val- and valvular heart disease are significant risk
vular disease, and hypertension. factors for heart failure, with relative risks of
1.4 and 1.46, respectively.6 Diabetes mellitus
Causes increases the risk of heart failure twofold by
Heart failure is defined by the American directly leading to cardiomyopathy and sig-
Heart Association and American College nificantly contributing to CAD. Diabetes is
of Cardiology as a complex clinical syn- one of the strongest risk factors for heart fail-
drome that can result from any structural ure in women with CAD.7 Smoking, physical
or functional cardiac disorder that impairs inactivity, obesity, and lower socioeconomic
the ability of the ventricle to fill with or eject status are often overlooked risk factors.6
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June 15, 2012 Volume 85, Number 12 www.aafp.org/afp American Family Physician 1161
Heart Failure
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
The initial evaluation of patients with suspected heart failure should include a history and C 3
physical examination, laboratory assessment, chest radiography, and electrocardiography.
Echocardiography can confirm the diagnosis.
A displaced cardiac apex, a third heart sound, and chest radiography findings of pulmonary C 21, 23
venous congestion or interstitial edema are good predictors to rule in the diagnosis of
heart failure.
Systolic heart failure can be effectively ruled out with a normal B-type natriuretic peptide C 21-23, 25, 27, 28
or N-terminal proB-type natriuretic peptide level.
Systolic heart failure can be effectively ruled out when the Framingham criteria are not met. C 17, 29
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
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tor of mortality and can be used at diagnosis and to monitor
treatment response.
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Table 2. New York Heart Association
Functional Classification of Heart
Failure
Table 3. History and Physical Examination Findings for Heart Failure and Selected Alternative Causes
Heart failure Alternative causes
Symptoms Symptoms
Abdominal swelling Abdominal swelling (liver failure)
Dyspnea on exertion Anorexia, weight loss (sarcoidosis)
Edema Chest pain (coronary artery disease)
Exercise intolerance Claudication (atherosclerotic disease)
Fatigue Cough (pulmonary disease)
Orthopnea Diarrhea or skin lesions (amyloidosis)
Paroxysmal nocturnal dyspnea Dyspnea on exertion (pulmonary disease, valvular disease)
Recent weight gain Edema (liver or kidney failure)
Physical examination findings Neurologic problems (sarcoidosis)
Abdomen: hepatojugular reflux, ascites Palpitations (tachyarrhythmia)
Extremities: cool, dependent edema Recent fevers, viral infection (endocarditis, myocarditis, infection)
Heart: bradycardia /tachycardia, laterally Syncope (bradycardia, heart block)
displaced point of maximal impulse, Physical examination findings
third heart sound (gallop or murmur)
Abdomen: distended, hepatosplenomegaly, tender, ascites (liver disease)
Lungs: labored breathing, rales
Extremities: joint inflammation /warmth (rheumatologic disease)
Neck: elevated jugular venous pressure
Heart: irregular rate or rhythm (arrhythmia)
Skin: cyanosis, pallor
Lungs: wheezing (pulmonary disease)
Neck: thyromegaly/nodule (thyroid disease)
Skin: cyanosis (anemia), jaundice (liver failure)
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Information from references 3, 8, and 20.
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Table 4. Laboratory Evaluation for Heart Failure and
Selected Alternative Causes
Initial tests
B-type natriuretic peptide level moderate effect (LR+ = 5.1 and 6.4), whereas
Calcium and magnesium levels (diuretics, cause of arrhythmia) the others, along with cardiac murmurs,
Complete blood count (anemia) have only a small effect on the diagnostic
Liver function (hepatic congestion, volume overload) probability (LR+ = 2.3 to 2.8). The absence
Renal function (renal causes) of any of these findings is of little help in rul-
Serum electrolyte level (electrolyte imbalance) ing out heart failure.21
Thyroid-stimulating hormone level (thyroid disorders)
Urinalysis (renal causes) Laboratory Tests
Other tests for alternative causes Laboratory testing can help identify alter-
Arterial blood gases (hypoxia, pulmonary disease) native and potentially reversible causes of
Blood cultures (endocarditis, systemic infection) heart failure. Table 4 lists laboratory tests
Human immunodeficiency virus (cardiomyopathy) appropriate for the initial evaluation of heart
Lyme serology (bradycardia /heart block) failure and other potential causes.3,8,20 Other
Serum ferritin level, transferrin saturation (macrocytic anemia, laboratory tests should be performed based
hemochromatosis) on physician discretion to evaluate further
Thiamine level (deficiency, beriberi, alcoholism) causes or identify comorbid conditions that
Troponin and creatine kinase-MB levels (myocardial infarction, myocardial require enhanced control.
injury) BNP and N-terminal pro-BNP (the
Tests for comorbid conditions, risk management cleaved inactive N-terminal fragment of the
A1C level (diabetes mellitus) BNP precursor) levels can be used to evalu-
Lipid profile (hyperlipidemia) ate patients with dyspnea for heart failure.
BNP is secreted by the atria and ventricles
Information from references 3, 8, and 20.
in response to stretching or increased wall
tension.25 BNP levels increase with age, are
higher in women and blacks, and can be
patients with heart failure have dyspnea on elevated in patients with renal failure.21,26
exertion. However, heart failure accounts BNP appears to have better reliability than
for only 30 percent of the causes of dyspnea N-terminal pro-BNP, especially in older
in the primary care setting.24 The absence of populations.25,26 Multiple systematic reviews
dyspnea on exertion only slightly decreases have concluded that BNP and N-terminal
the probability of systolic heart failure, pro-BNP levels can effectively rule out a
and the presence of orthopnea or paroxys- diagnosis of heart failure22,25,27,28 because
mal nocturnal dyspnea has a small effect of their negative predictive value (negative
in increasing the probability of heart fail- likelihood ratio [LR] = 0.1 and 0.14).22 The
ure (positive likelihood ratio [LR+] = 2.2 average cutoff levels for heart failure were a
and 2.6). 21,23 BNP level of 95 pg per mL (95 ng per L) or a
The presence of a third heart sound (ven- N-terminal pro-BNP level of 642 pg per mL
tricular filling gallop) is an indication of (642 ng per L).22
increased left ventricular end-diastolic pres- As BNP levels increase, the specificity
sure and a decreased LVEF. Despite being increases and thus the likelihood of a heart
relatively uncommon findings, a third heart failure diagnosis. 25 BNP levels are strong
sound and displaced cardiac apex are good predictors of mortality at two to three
predictors of left ventricular dysfunction months and cardiovascular events in acute
and effectively rule in the diagnosis of sys- heart failure, specifically when BNP level is
tolic heart failure (LR+ = 11 and 16).21,23 greater than 200 pg per mL (200 ng per L)
The presence of jugular venous distention, or N-terminal pro-BNP level is greater than
hepatojugular reflux, pulmonary rales, and 5,180 pg per mL (5,180 ng per L).22,25 Limited
pitting peripheral edema is indicative of vol- evidence supports monitoring reduction
ume overload and enhances the probability of BNP levels in the acute and outpatient
of a heart failure diagnosis. Jugular venous settings. A 30 to 50 percent reduction in
distention and hepatojugular reflex have a BNP level at hospital discharge showed
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Table 5. Accuracy of Initial Evaluation Findings in Diagnosing Heart Failure
Positive Negative
likelihood Finding has likelihood
Finding has conclusive effect ratio > 10 Specificity conclusive effect ratio < 0.1 Sensitivity
Positive Negative
likelihood ratio Finding has likelihood ratio
Finding has moderate effect of 5 to 10 Specificity moderate effect of 0.1 to 0.2 Sensitivity
History of heart failure 5.8 0.90 Framingham criteria for 0.1 0.92
Hepatojugular reflex 6.4 0.96 heart failure
Jugular venous distension 5.1 0.92 Framingham criteria for 0.13 0.89
diastolic heart failure
Reduced BNP level 0.1 0.94
Reduced N-terminal 0.14 0.92
pro-BNP level
Positive Negative
likelihood likelihood ratio
Finding has small effect ratio of 2 to 5 Specificity Finding has small effect of 0.2 to 0.5 Sensitivity
Framingham criteria for systolic 4.57 0.79 Dyspnea on exertion 0.48 0.84
heart failure Chest radiography: 0.33 0.97
Framingham criteria for heart 4.35 0.79 cardiomegaly
failure Chest radiography: 0.48 0.96
Framingham criteria for diastolic 4.21 0.79 venous congestion
heart failure ECG: normal* 0.27 0.84
Initial clinical judgment 4.4 0.86
History of myocardial infarction 3.1 0.87
Rales (crackles) 2.8 0.78
Murmur 2.6 0.90
Paroxysmal nocturnal dyspnea 2.6 0.84
Peripheral edema 2.3 0.78
Orthopnea 2.2 0.77
Elevated BNP level 2.92 0.66
Elevated N-terminal pro-BNP level 2.67 0.65
Chest radiography: cardiomegaly 3.3 0.78
Chest radiography: pleural effusion 3.2 0.92
ECG: atrial fibrillation 3.8 0.93
ECG: new T-wave change 3.0 0.92
ECG: any abnormality 2.2 0.78
NOTE: Items are listed by the following groups: clinical criteria, history, physical examination, laboratory tests, chest radiography, and electrocardiography.
BNP = B-type natriuretic peptide; ECG = electrocardiography.
* Findings from research evaluating only systolic heart failure.
Information from references 17, and 21 through 23.
improved survival and reduced rehospi- N-terminal pro-BNP level less than 1,700 pg
talization rates. Optimizing management per mL (1,700 ng per L) showed improve-
for outpatient targets of a BNP level less ment in decompensations, hospitalizations,
than 100 pg per mL (100 ng per L) and an and mortality events.22,25
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Table 6. Framingham Diagnostic Criteria for Heart Failure*
Major criteria Minor criteria
Acute pulmonary edema Ankle edema
Cardiomegaly Dyspnea on exertion diagnosis. Several groups have published
Hepatojugular reflex Hepatomegaly diagnostic criteria, but the Framingham
Neck vein distension Nocturnal cough criteria are widely accepted and include the
Paroxysmal nocturnal dyspnea Pleural effusion components of the initial evaluation, which
or orthopnea Tachycardia (> 120 enhances their accuracy (Table 6).17 A pre-
Rales beats per minute) vious study validated the Framingham cri-
Third heart sound gallop teria for diagnosing systolic heart failure,29
and a more recent study analyzed them for
*Heart failure is diagnosed when two major criteria or one major and two minor systolic and diastolic heart failure.17 Both
criteria are met.
studies reported high sensitivity for systolic
Adapted with permission from Maestre A, Gil V, Gallego J, Aznar J, Mora A, Martin-
Hidalgo A. Diagnostic accuracy of clinical criteria for identifying systolic and diastolic heart failure (97 percent compared with
heart failure: cross-sectional study. J Eval Clin Pract. 2009;15(1):60. 89 percent for diastolic heart failure),
which effectively rules out heart failure
when the Framingham criteria are not met
Chest Radiography (LR = 0.04).17,29 The Framingham crite-
Chest radiography should be performed ini- ria only have a small effect on confirming
tially to evaluate for heart failure because it a diagnosis of heart failure (LR+ = 4.21 to
can identify pulmonary causes of dyspnea 4.57), but have a moderate effect on ruling
(e.g., pneumonia, pneumothorax, mass). out heart failure in general and diastolic
Pulmonary venous congestion and intersti- heart failure (LR = 0.1 and 0.13).17
tial edema on chest radiography in a patient Echocardiography is the most widely
with dyspnea make the diagnosis of heart accepted and available method for identi-
failure more likely (LR+ = 12). Other find- fying systolic dysfunction and should be
ings, such as pleural effusion or cardiomeg- performed after the initial evaluation to
aly, may slightly increase the likelihood of confirm the presence of heart failure.3 Two-
heart failure (LR+ = 3.2 and 3.3), but their dimensional echocardiography with Doppler
absence is only slightly useful in decreasing flow studies can assess LVEF, left ventricular
the probability of heart failure (LR = 0.33 size, wall thickness, valve function, and the
to 0.48).21 pericardium. Echocardiography can assist in
diagnosing diastolic heart failure if elevated
Electrocardiography left atrial pressure, impaired left ventricular
Electrocardiography (ECG) is useful for relaxation, and decreased compliance are
identifying other causes in patients with present.2,3 Often, the diagnosis of diastolic
suspected heart failure. Changes such as heart failure is clinical without conclusive
left bundle branch block, left ventricular echocardiographic evidence. If echocardiog-
hypertrophy, acute or previous myocardial raphy results are equivocal or inadequate,
infarction, or atrial fibrillation can be iden- transesophageal echocardiography, radionu-
tified and may warrant further investiga- clide angiography, or cineangiography with
tion by echocardiography, stress testing, or contrast media (at catheterization) can be
cardiology consultation. Normal findings used to assess cardiac function.30
(or minor abnormalities) on ECG make If angina or chest pain is present with
systolic heart failure only slightly less likely heart failure, the American Heart Associa-
(LR = 0.27).23 The presence of other find- tion and the American College of Cardiol-
ings such as atrial fibrillation, new T-wave ogy recommend that the patient undergo
changes, or any abnormality has a small coronary angiography, unless there is a con-
effect on the diagnostic probability of heart traindication to potential revascularization.3
failure (LR+ = 2.2 to 3.8).21 Coronary angiography has been shown to
improve symptoms and survival in patients
Clinical Decision Making with angina and reduced ejection fraction.3 It
The definition of heart failure contin- is important to evaluate for CAD because it
ues to be debated, but it remains a clinical is the cause of heart failure and low ejection
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Evaluation and Diagnosis of Heart Failure
Signs and symptoms of heart failure (e.g., dyspnea,
fatigue, peripheral edema, pulmonary rales)
alternative or reversible causes of heart fail- One major and two minor criteria met
Agency for Healthcare Research and Quality Evidence Diastolic heart failure Systolic heart failure
Reports, Bandolier, the Cochrane Database of Systematic
Reviews, the Database of Abstracts of Reviews of Effects,
the Institute for Clinical Systems Improvement, and the Treat diastolic Treat systolic
National Guideline Clearinghouse database. Search dates: heart failure heart failure
April 5 through 16, 2010; May 24 through 28, 2010;
selected newer articles January 1 and April 20, 2011.
The Authors BARETTA CASEY, MD, MPH, FAAFP, is a professor and the vice chair in the Department
of Family and Community Medicine at the University of Kentucky College of Medi- cine,
MICHAEL KING, MD, FAAFP, is an assistant professor and and the campus director of the East Kentucky cam- pus at the University of Kentucky
the residency program director in the Department of Fam- Center for Rural Health, Hazard.
ily and Community Medicine at the University of Kentucky
College of Medicine, Lexington.
JOE KINGERY, DO, is an assistant professor at the Univer-
sity of Kentucky College of Medicine, and an associate
residency director of the East Kentucky Family Medicine
Residency Program, Hazard.
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giography recommended
C
o
n
s Figure 1. Algorithm for the evaluation and diagnosis of heart failure.
i (BNP = B-type natriuretic peptide.)
d
e
r Address correspondence to Michael King, MD, FAAFP,
e University of Kentucky College of Medicine, K302 Ken-
v tucky Clinic, Lexington, KY 40536 (e-mail: mrking02@
a uky.edu). Reprints are not available from the authors.
l
u Author disclosure: No relevant financial affiliations to
a disclose.
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