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Controversies in heart failure diagnosis
Dr. Frans Rutten, Utrecht, The Netherlands
Background• Disease of the elderly (1% of HF aged <65 years) • (Early) diagnosis of slow onset HF is in primary care• ‘always’ left sided; only <1% cor pulmonale• Prevalence 1-1.5% (20-30 patients per practice)
• 30% with a GP’s HF label: No HF• 30% of HF patients unknown
* never detected * detected (much) later in time course
ESC 2008 definition of heart failure
I. Symptoms typical of heart failureand (not always!)
II. Signs typical of heart failure and III. Objective evidence of a structural or functional abnormality of the heart at rest
2005: Only symptoms obligatoryObjective evidence of (left) ventricular dysfunction
- decreased LVEF (LVEF <45%) : HFREF - LV filling and relaxation abnormalities, ‘normal’ LVEF : HFPEF
When should we think of HF?• Any patient with * shortness of breath
* exercise intolerance/fatigue * peripheral oedema
Especially in:• Elderly (oldest old, multimorbidity, ‘fragile’)• Prior myocardial infarction, other CHD (HFREF)• Diabetes type II (HFPEF)• Longstanding hypertension (HFPEF)• Atrial fibrillation, (suspected) valvular disease • COPD (labeled as COPD and ‘really’ COPD). Every year!• Renal dysfunction (eGFR<30-45 ml/min/1.73m²)
Diagnosing heart failure is not easy!
COPD HF rest
30 causes of dyspnoea 65 years: multimorbidity
What is heart failure ?
a complex clinical syndrome • (left) ventricular dysfunction with origin in heart : HFREF• (left) ventricular dysfunction in response to endothelial
dysfunction (DM, etc) and pressure overload (HT): HFPEF
reduced ability of the ventricle(s) to fill with or eject blood
The heart is unable to provide sufficient cardiac output to satisfy the metabolic needs of the body.
backward failure forward failure
Fluid retention compensation exercise intolerance tachycardia fatigue apical beat
symptoms and signs of HF
ESC guidelines 2008
Dickstein et al. Eur J Heart Fail 2008;10:933-
primary care ED
Chance of having new onset HF? Chance of having new onset HF?
Possible cause? Possible cause?
primary care ED
79 years old 64 years oldHypertension, diabetes, COPD ‘no’ comorbidity 30 pack years smoking 30 pack years smokingslowly increase in dyspnoea, fatigue acute dyspnoea, orthopnoea, 166/92, 92 bpm 166/92, 92 bpm Displaced apex, no fluid overload raised JVP, crepitations,oedema
Symptoms
• breathlessness (with exercise)
• exercise intolerance always
• Fatigue
• ankle oedema (chronic venous insufficiency) not always!
• orthopnoea/paroxysmal nocturnal dyspnoea - early phase
• Increased urinating at night (>2x) - diuretic use
• weight gain (>2 kg/wk)
Signs
• crepitations
• raised JVP fluid overload
• oedema
• apical impulse displaced or sustained
• S3 gallop very rare
• heart murmur not very typical
• tachycardia, irregular pulse
Palpation of the apical impulse
Clinical models to detect or exclude HF in suspected patients from PC
Male sexOrthopnoeaPrior MI AUC 0.75 LVSD (LVEF <50%) JVP
AgePrior MI, CABG, PCIApical impulse AUC 0.82 (>700 patients)crepitationsMurmurJVP Kelder et al. Submitted
Male sex Prior MI AUC 0.66-0.79 (MICE, 6 of 9 studies) crepitationsoedema Mant et al. HTA 2009;13:no 32
Fahey et al. Fam Pract 2007;24:628-
Clinical model (screening) elderly stable COPD
AgeMale sexPrior MI, CABG, PCIDiabetes AUC 0.79OrthopnoeaCrepitations, elevated JVP, S3 gallop, ankle oedema Kelder et al Heart 2011
Prior MI, CABG, PCIApical impulse AUC 0.70 (screening elderly COPD patients)Heart rate >90 bpmBMI >30 kg/m² Rutten et al. BMJ 2005;331:1379
Clinical models to detect or exclude HF in suspected patients from PC
Essentials of clinical diagnostic models
• Signs or symptoms of fluid overload (diuretics, early phase)• Displaced/broadened apical impulse• murmur
in elderly persons, male sex, prior CAD, diabetes
Screening COPD:• HR >90 bpm• BMI >30 kg/m²
Additional tests
slow onset acute onset • test treatment with diuretics : NO test treatment with diuretics ?
• ECG: when normal HF <10% ECG: when normal HF <2%
• Chest X-ray ? Chest X-ray ?• NTproBNP: when normal HF <10% NTproBNP: when normal HF <2%
Echocardiogram
valvular disease LVH, CMP causes of HF
wall motion abnormalitiesother cardiac abnormalities
ESC guidelines 2008
Dickstein et al. Eur J Heart Fail2008; 10:933-
5 key diagnostic 'tests'
Multivariable models for detection/exclusion (slow onset) HF
Clinical model 0.75 + ECG 0.86
Clinical model 0.82 + ECG 0.83 + Chest X-ray 0.84 + ntproBNP 0.86 Kelder et al. Submitted
Clinical model 0.66-0.79 (6 of 9 studies) + ECG 0.76-0.83 + ntproBNP 0.83-0.93 Mant et al. HTA 2009;13:no 32
Clinical model 0.79 + ECG 0.85 + Chest X-ray 0.84 + ntproBNP 0.91-0.92 Kelder et al. Heart 2011;97:959
Fahey et al. Fam Pract 2007;24:628
Multivariable models for detection/exclusion (slow onset) HF
Clinical model 0.70 (screening elderly COPD patients) + ECG 0.75 + Chest X-ray 0.73 + ntproBNP 0.77 Rutten et al. BMJ 2005;331:1379
Fahey et al. Fam Pract 2007;24:628-
Dutch adaptation of the ESC guidelines 2008
Hartfalen richtlijn. Hoes et al. 2010
Heart failurevery unlikely
Suspected heart failure symptoms and signs
Slow onset
ECG normal andNT-proBNP<400 pg/ml BNP<100 pg/ml
ECG abnormal orNT-proBNP≥400 pg/ml BNP≥100 pg/ml
ECG abnormal orNT-proBNP≥ 125 pg/ml BNP≥ 35 pg/ml
ECG normal andNT-proBNP<125 pg/ml BNP< 35 pg/ml
Acute
ECG, (NT-pro)BNP, chest X-ray
EchocardiographyHeart failurevery unlikely
ECG, (NT-pro)BNP, chest X-ray
Causes for elevated ntproBNP levels
acute dyspnoea slow onset dyspnoea
• ACS age >75 years
• pulmonary embolism atrial fibrillation
• acute renal failure renal dysfunction
• pulmonary artery hypertension LVH
• sepsis severe COPD
Conclusions• Dyspnoea, exercise intolerance/ fatigue, ankle oedema: Always think of HF
• Signs or symptoms of fluid overload (diuretics, early phase)• Displaces/broadened apical impulse, murmur essentials
in elderly persons, male sex, prior CAD, diabetes
• Additional tests: ntproBNP most valuable• Lower exclusionary cut-points ntproBNP for slow onset than acute onset HF• Echocardiogram for diagnosis AND cause(s) AND whether HFPEF/HFREF• Always consider cause of HF, especially treatable ones (valves)!!