Acute Heart Failure – Diagnosis
- 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.
- Infection (eg. pneumonia, endocarditis, sepsis).
- Diet/medication non-compliance.
- For suspected Acute Heart Failure (AHF):
- Confirm diagnosis.
- Determine etiology of exacerbation.
- Diagnostic Tool (Framingham Heart Failure Diagnostic Criteria)
- Recommended Investigations
- High negative predictive value if normal.
- Chest Radiograph (Examples of Findings):
- Normal CXR does not rule out heart failure.
- 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.
- Air bronchogram.
- Cottonwool appearance.
- Pleural effusion.
- FAST Ultrasound:
- 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.
- GFR <60mL/min – halve the BNP or NT-proBNP value measured.
- BMI >35 – double the BNP or NT-proBNP value measured.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
While heart failure can be a difficult diagnosis there is overall agreement between sources on the necessary steps and investigations.
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.
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 Cardiology, 33(11), 1342-1433.
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 medicine, 55(5), 635-646.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Aug 07, 2020
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