Takeaways 

• Heart failure has variable symptoms without a uniform presentation, which can make diagnosis difficult.
• Symptoms include dyspnea, fatigue, exercise intolerance, weakness, peripheral edema.
• There is no single diagnostic test, and diagnosis is clinical based.
• Biomarkers, like BNP and NT-proBNP, are more helpful in gauging the severity of an already diagnosed patient as elevations can be the result of other causes.
• All patients with reduced ejection fraction (Stage B) should be placed on ACE inhibitor and beta blocker.

 

Definition/Clinical Presentation

Heart failure is defined as “a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood” (Colucci, 2019). In other words, the heart is unable to sufficiently pump blood throughout its chambers and/or out of the heart to the entire body. Any condition that weakens or injures the integrity of the cardiovascular system – the heart, the valves, or the vessels – can contribute to the heart’s lacking performance and the body’s subsequent clinical manifestations. This pump failure inadequately supplies the body with necessary oxygen and nutrients, which creates a symptom cascade characterized by fluid overload and reduction of cardiac output (Colucci, 2019). Dyspnea and fatigue are the defining symptoms of the condition but clinical presentations are often variable (Yancy et al., 2013). Other common symptoms include shortness of breath, exercise intolerance, weakness, and peripheral edema (Colucci, 2019). Predisposing factors that may complete the clinical picture include Coronary Artery Disease, Hypertension, cigarette smoking, obesity, and Diabetes Mellitus (Vasan & Wilson, 2020).

Heart failure, without a single, specific diagnostic test, remains a clinical diagnosis, ultimately decided in the exam room (Colucci, 2019). Due to the variability of the presentation, many providers struggle to diagnose and treat this condition.

 

Classification

In 2013, the American College of Cardiology and American Heart Association (ACCF/AHA) Task Force on Practice Guidelines reviewed the literature to create a set of recommendations (revised in 2016 and 2017) for the diagnosis and treatment of heart failure (Yancy et al., 2013). This task force organized heart failure into 4 progressive stages, starting from at-risk patients without symptoms and without structural injury (Stage A); to patients with structural heart disease without symptoms (Stage B); to patients with structural heart disease with symptoms or history of symptoms (Stage C); and finally to refractory heart failure (stage D) (Armstrong, 2014). Overall, the goal is to decrease risk factors before the disease and then reduce morbidity and mortality after diagnosis (Yancy et al., 2017). In 2016 the Europe Society of Cardiology also released guidelines that complemented these as well.

 

Initial vs Serial Diagnostic Testing

A detailed history and physical evaluation should be obtained, understanding the patient’s comorbidities and risk factors for heart disease (Yancy et al., 2013). A set of vital signs should be monitored at each visit (Yancy et al., 2013).

Initial laboratory orders should include complete blood count, urinalysis, fasting lipid panel, liver function testing, measurement of serum electrolytes, blood urea nitrogen, measurement of serum creatine, glucose, and TSH (Armstrong, 2014). These should be repeated as clinically indicated throughout treatment.

Biomarker testing, including B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP), should be used with limitations and are more useful during the later stages of heart failure when patients are symptomatic (Yancy et al., 2017). These biomarkers can be elevated due to other reasons other than heart failure. Ultimately the 2017 ACCF/AHA revisions found insufficient data to inform population specific screening guidelines related to NT-proBNP and BNP guided therapy (Yancy et al., 2017).

An electrocardiogram, a comprehensive 2-D echocardiogram coupled with Doppler flow studies and transthoracic echocardiogram, and a chest radiography are needed initially (Yancy et al., 2013). The echocardiogram should be repeated as needed to evaluate the ejection fraction and structural remodeling of the heart – usually when there is a change in clinical status or recovery from exacerbation, assessing effect of therapy, or evaluating candidates for new devices (Armstrong, 2014). 

 

Treatment

STAGE A: The focus should be on preventing heart failure by reducing modifiable risk factors. Clinicians should work to control chronic conditions according to their individual guidelines, especially hypertension, hyperlipidemia, diabetes mellitus, and sleep disorders (Armstrong, 2014/Borlaug, 2019). Lifestyle attributes like tobacco use, obesity, alcohol consumption, and drug use, should be addressed in detail and serially to reduce the risk of heart failure.  (Armstrong, 2014/Borlaug, 2019).

STAGE B: The focus should be continuing to reduce risk factors and maintaining the already damaged structure of the heart. All patients with reduced ejection fraction should be placed on ACE inhibitor and beta blocker to reduce their risk of cardiovascular events (Yancy et al., 2013). ARBs are appropriate substitutes (Armstrong, 2014). Strict control of hypertension according to guidelines and optimizing of lipids with statins is especially important to reduce future risk (Yancy et al, 2017).

Further evaluation by a specialist may be considered at this stage, and especially if the patient has a recent history of cardiovascular event. However, it should be noted by all clinicians that nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low left ventricular ejection fraction after an MI (Armstrong, 2014).

STAGE C: The interventions are focused on symptom management through pharmacologic and nonpharmacologic interventions. Patients will likely need to be followed by a specialist. However, diuretics should be used for fluid overload symptoms and the appropriate monitoring will need to be coordinated (Yancy et al., 2017). Other medications, like aldosterone receptor antagonist, digoxin, anticoagulants, etc. are discussed in this stage. Implantable cardiac devices become an option as well.

Most importantly, patients should understand their symptoms and how to monitor their status. It should be stressed to observe their weight fluctuations, restrict their sodium intake (<3g/day), medical adherence, and stay physically active (Yancy et al., 2013).

STAGE D:  This stage incorporates patients who experience persistently severe symptoms and often called “end stage HF” or “advanced HF”. The focus is on improving the patient’s quality of life (Yancy et al., 2013). Treatment strategies are very specialized and complex, even experimental at times. (Yancy et al., 2013). These advanced therapies include mechanical circulatory support, cardiac transplantation, etc. 

 

More Information

What is Heart Failure?

Heart Failure | cdc.gov

Heart Failure | NHLBI, NIH

Heart Failure: Understanding Heart Failure Management and Treatment

 

References

Armstrong, C. (2014, August 01). ACCF and AHA Release Guidelines on the Management of Heart Failure. Retrieved October 10, 2020, from https://www.aafp.org/afp/2014/0801/p186.html

Borlaug, B. A. (2019, March 05). Clinical manifestations and diagnosis of heart failure with preserved ejection fraction. Retrieved October 10, 2020, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-heart-failure-with-preserved-ejection-fraction?search=heart+failure+diagnosis

Colucci, W. S. (2019, July 17). Evaluation of the patient with suspected heart failure (986750469 763432333 S. S. Gottlieb, Ed.). Retrieved October 10, 2020, from https://www.uptodate.com/contents/evaluation-of-the-patient-with-suspected-heart-failure?search=heart+failure+symptoms

Vasan, R. S., & Wilson, P. W. (2020, May 05). Epidemiology and causes of heart failure. Retrieved October 10, 2020, from https://www.uptodate.com/contents/epidemiology-and-causes-of-heart-failure?search=heart+failure

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., . . . Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 62(16), 147-239. doi:10.1016/j.jacc.2013.05.019

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Colvin, M. M., . . . Westlake, C. (2017). 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of Cardiac Failure, 23(8), 628-651. doi:10.1016/j.cardfail.2017.04.014