Investigation and Diagnosis of Heart Failure: Present

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• Investigation and Diagnosis of Heart Failure
  Present Future

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• HF is a complex clinical syndrome that can result
  from any structural or functional cardiac
  disorder that impairs the ability of the
  ventricles to fill with or eject blood.

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• The cardinal manifestations of HF are dyspnoea
  and fatigue, which may limit exercise tolerance,
• and fluid retention, which may lead to pulmonary
  and peripheral oedema.
• Both abnormalities can impair the functional
  capacity and quality of life of affected
  individuals, but they may not necessarily
  dominate the clinical picture at the same time

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• Some pts have exercise intolerance but little
  fluid retention
• NYHA classification
• Others report little dyspnoea and fatigue but
  complain of oedema
• As not all pts have evidence of volume overload
  the term congestive cardiac failure has been
  replaced with heart failure

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Various causes of heart failure

• Nearly all forms of heart disease may result in
  heart failure including disorders of the
  pericardium, myocardium, endocardium, great
  vessels, valves and rhythm disorders.
• Heart failure may be associated with a wide
  spectrum of LV functional abnormalities ranging
  from normal LV size and preserved ejection
  fraction, to severe dilatation and/or markedly
  reduced ejection fraction

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• The majority of patients presenting with chronic
  heart failure have left ventricular systolic
  dysfunction from one of
• Coronary artery disease
• Hypertension
• (Idiopathic) dilated cardiomyopathy

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Mr W McM Age 60 Myocardial infarction
1998 Gradually deteriorating angina for several
years.
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• Coronary artery disease is the underlying cause
  of HF in approximately two thirds of patients
  with left ventricular systolic dysfunction
• The remainder have non-ischaemic causes of
  systolic dysfunction and may have an identifiable
  cause (e.g., hypertension, valvular disease,
  myocardial toxins, or myocarditis) or may have no
  discernible cause (e.g., idiopathic dilated
  cardiomyopathy up to 30 genetic).

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• There is no single diagnostic test for heart
  failure because it is largely a clinical
  diagnosis based on history and physical
  examination
• A complete history and physical examination are
  the first steps in evaluating the structural
  abnormality or cause responsible for the
  development of HF.

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Typical Presentation of ChronicHeart Failure

• Decreased exercise tolerance
• Pitfalls attributed to ageing, deconditioning or
  other illness
• Fluid retention
• Pitfalls orthostatic oedema
• Or with no symptoms and incidentally discovered
  left ventricular dysfunction

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• Physical evaluation
• Cardiomegaly
• Third heart sound
• Murmur (mitral regurgitation)
• Peripheral oedema
• Raised jugular venous pressure
• Hepatomegaly
• Ascities
• Weight loss (cardiac cachexia)

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Important Elements in the History

• Hypertension
• Diabetes
• Valvular heart disease
• Angina/MI
• Peripheral vascular disease
• Rheumatic fever
• Cardiotoxic agents
• Alcohol
• Phaeochromocytoma
• Family history (haemochromatosis, cardiomyopathy)
• Acute pulmonary oedema

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Acute pulmonary oedema
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Clinical diagnosis of heart failure in general
practice may be inaccurate

• In Edinburgh, only 26 of treated patients and 8
  of untreated patients referred with suspected
  heart failure had impaired LV function
• In Dundee, 50 of patients treated for CCF in the
  community had normal echos
• Francis BMJ 1995310634
• Wheeldon QJMed 19938617

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• Although the history and physical examination may
  provide important clues about the nature of the
  underlying cardiac abnormality, identification of
  the structural abnormality leading to HF
  generally requires either noninvasive or invasive
  imaging of the cardiac structures.

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How to assess LV FunctionWhich technique?

• Clinical evaluation
• Echocardiography
• Contrast ventriculography (cardiac
  catheterisation)
• Radionuclide ventriculography
• Electron beam computed tomography (EBCT)
• Magnetic resonance imaging
• Type B natriuretic peptide (BNP)