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    Acute Heart Failure – Diagnosis

    Cardiovascular

    Last Updated Aug 07, 2020
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    Context

    • Leading cause of hospitalization for age 65+, with 30-day mortality ~11%.
    • Syndrome of impaired ventricular filling and/or ejection:
      • Diminished cardiac output and/or volume overload.
    • Causes of exacerbation:
      • Acute coronary syndrome (ACS).
      • Pulmonary embolism.
      • Valvular disease.
      • Arrhythmia.
      • Hypertension.
      • Infection (eg. pneumonia, endocarditis, sepsis).
      • Diet/medication non-compliance.

    Diagnostic Process

    • For suspected Acute Heart Failure (AHF):
      • Confirm diagnosis.
      • Determine etiology of exacerbation.

    • Diagnostic Tool (Framingham Heart Failure Diagnostic Criteria)
    • Recommended Investigations
      • ECG:
        • High negative predictive value if normal.
      • Chest Radiograph (Examples of Findings):
        • Normal CXR does not rule out heart failure.
        • Cardiomegaly.
        • Redistribution (of fluid into upper pulmonary vessels).
        • Interstitial edema.
          • Kerley-B lines = small, horizontal, peripheral straight lines demonstrated at the lung bases that represent thickened interlobular septa.
          • Less commonly referred to:
            • Kerley Alines = linear opacities extending from the periphery to the hila.
            • Kerley Clines = reticular opacities at the lung base.
          • Peribronchial cuffing.
          • Hazy contour of vessels.
        • Alveolar edema.
          • Consolidation.
          • Air bronchogram.
          • Cottonwool appearance.
        • Pleural effusion.
      • FAST Ultrasound:
        • B lines example (distinct from Kerley B lines).
        • Pleural effusion example.
        • Cardiac function.
        • IVC volume and variability with respiration.
      • Echocardiogram:
        • Evaluates cardiac function and may determine underlying cause.
        • Perform expeditiously when a life-threatening cardiac process is suspected.
      • Lab work:
        • CBC, electrolytes, urea, creatinine, liver function tests, TSH, glucose
        • +/- Troponin
          • Often elevated in HF without infarction.
          • Elevation indicates worse prognosis.
        • BNP or NT-proBNP
          • Sensitive but nonspecific – various causes for elevation aside from HF.
          • Most recommend use only if uncertainly remains after initial assessment. (More info –  2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure)
          • Caveat is that NP levels are useful to monitor ongoing management and have prognostic value.
          • BNP <100 nanograms/L or NT-proBNP <300 nanograms/L strong negative predictors of heart failure.
          • BNP >400 nanograms/L or NT-proBNP >900 (>1800 if age 75+) nanograms/L make heart failure more likely.
          • Adjustments:
            • GFR <60mL/min – halve the BNP or NT-proBNP value measured.
            • BMI >35 – double the BNP or NT-proBNP value measured.

    Quality Of Evidence?

    Justification

    While heart failure can be a difficult diagnosis there is overall agreement between sources on the necessary steps and investigations.

    Moderate

    Related Information

    Reference List

    1. Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., … & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975.


    2. Ezekowitz, J. A., O’Meara, E., McDonald, M. A., Abrams, H., Chan, M., Ducharme, A., … & Howlett, J. G. (2017). 2017 Comprehensive update of the Canadian Cardiovascular Society guidelines for the management of heart failure. Canadian Journal of Cardiology33(11), 1342-1433.


    3. Kuo, D. C., & Peacock, W. F. (2015). Diagnosing and managing acute heart failure in the emergency department. Clinical and experimental emergency medicine2(3), 141-149.


    4. R Teerlink, J., Alburikan, K., Metra, M., & E Rodgers, J. (2015). Acute decompensated heart failure update. Current cardiology reviews11(1), 53-62.


    5. Long, B., Koyfman, A., & Gottlieb, M. (2018). Management of heart failure in the emergency department setting: an evidence-based review of the literature. The Journal of emergency medicine55(5), 635-646.


    6. Allen, L. A., & O’Connor, C. M. (2007). Management of acute decompensated heart failure. Cmaj176(6), 797-805.


    7. Yusuf S. Acute exacerbation of congestive heart failure. BMJ Best Practice. Oct 2018.


    8. Wang, C. S., FitzGerald, J. M., Schulzer, M., Mak, E., & Ayas, N. T. (2005). Does this dyspneic patient in the emergency department have congestive heart failure?. Jama294(15), 1944-1956.


    9. Cremers, Simone, et al. “Chest X-Ray – Heart Failure.” Radiology Assistant, 1 Sept. 2010.


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