The strength of evidence (A, B, C) and strength of recommendations are defined at the end of the "Major Recommendations" field.
Evaluation of Patients at Risk
- Evaluation with a routine history, physical examination, chest X-ray, and electrocardiogram (ECG) is recommended in patients with the medical conditions or test findings listed in Table 4.1, below. (Strength of Evidence = B)
Table 4.1: Indications for Evaluation of Patients at Risk for Heart Failure (HF)
| Conditions |
Hypertension
Diabetes
Obesity
Coronary artery disease (e.g., after myocardial infarction [MI], revascularization)
Peripheral arterial disease or cerebrovascular disease
Valvular heart disease
Family history of cardiomyopathy in a first-degree relative
History of exposure to cardiac toxins
Sleep-disordered breathing
|
| Test Findings |
Sustained arrhythmias
Abnormal ECG (e.g., left ventricular hypertrophy [LVH], left bundle branch block, pathologic Q waves)
Cardiomegaly on chest x-ray
|
- Assessment of Cardiac Structure and Function. Echocardiography with Doppler is recommended to determine left ventricular (LV) size and function in patients without signs or symptoms suggestive of HF who have the risk factors listed in Table 4.2, below. (Strength of Evidence = B)
Table 4.2: Risk Factors Indicating the Need to Assess Cardiac Structure and Function in Patients at Risk for HF
- Coronary artery disease (e.g., after myocardial infarction [MI], revascularization)
- Valvular heart disease
- Family history of cardiomyopathy in a first-degree relative
- Atrial fibrillation or flutter
- Electrocardiographic evidence of left ventricular hypertrophy (LVH), left bundle branch block, or pathologic Q waves
- Complex ventricular arrhythmia
- Cardiomegaly, S3 gallop, or potentially significant heart murmurs by physical examination
|
- Determination of plasma B-type natriuretic peptide (BNP) or N-terminal (NT) pro-BNP concentration is not recommended as a routine part of the evaluation for structural heart disease in patients at risk but without signs and symptoms of HF. (Strength of Evidence = B)
Evaluation of Patients Suspected of Having HF
- Symptoms Consistent with HF. The symptoms listed in Table 4.3, below, suggest the diagnosis of HF. It is recommended that each of these symptoms be solicited and graded in all patients in whom the diagnosis of HF is being considered. (Strength of Evidence = B)
Table 4.3: Symptoms Suggesting the Diagnosis of HF
| Symptoms |
Dyspnea at rest or on exertion
Reduction in exercise capacity
Orthopnea
Paroxysmal nocturnal dyspnea (PND) or nocturnal cough
Edema
Ascites or scrotal edema
|
| Less specific presentations of HF |
Early satiety, nausea and vomiting, abdominal discomfort
Wheezing or cough
Unexplained fatigue
Confusion/delirium
|
- Physical Examination. It is recommended that patients suspected of having HF undergo careful physical examination with determination of vital signs and be carefully evaluated for signs and symptoms shown in Table 4.4, below. (Strength of Evidence = C)
Table 4.4: Signs to Evaluate in Patients Suspected of Having HF
| Cardiac Abnormality |
Sign |
| Elevated cardiac filling pressures and fluid overload |
Elevated jugular venous pressure
S3 gallop
Rales
Hepatojugular reflux
Ascites
Edema
|
| Cardiac enlargement |
Laterally displaced or prominent apical impulse
Murmurs suggesting valvular dysfunction
|
- It is recommended that BNP or NT-proBNP levels be assessed in all patients suspected of having HF when the diagnosis is not certain. (Strength of Evidence = B)
- Differential Diagnosis. The differential diagnoses in Table 4.5, below, should be considered as alternative explanations for signs and symptoms consistent with HF. (Strength of Evidence = C)
Table 4.5: Differential Diagnosis for HF Symptoms and Signs
- Myocardial ischemia
- Pulmonary disease (pneumonia, asthma, chronic obstructive pulmonary disease, pulmonary embolus, primary pulmonary hypertension)
- Sleep-disordered breathing
- Obesity
- Deconditioning
- Malnutrition
- Anemia
- Hepatic failure
- Renal failure
- Hypoalbuminemia
- Venous stasis
- Depression
- Anxiety and hyperventilation syndromes
|
Initial Evaluation of Patients with HF
- It is recommended that patients with a diagnosis of HF undergo evaluation as outlined in Table 4.6, below. (Strength of Evidence = C)
Table 4.6: Initial Evaluation of Patients with a Diagnosis of HF
- Assess clinical severity of HF by history and physical examination
- Assess cardiac structure and function
- Determine the etiology of HF
- Evaluate for coronary disease and myocardial ischemia
- Evaluate the risk of life-threatening arrhythmia
- Identify any exacerbating factors for HF
- Identify comorbidities which influence therapy
- Identify barriers to adherence and compliance
|
Common Errors in Initial Assessment
- Routine endomyocardial biopsy is not recommended in cases of new-onset HF. Endomyocardial biopsy should be considered in patients with rapidly progressive clinical HF or ventricular dysfunction, despite appropriate medical therapy. Endomyocardial biopsy also should be considered in patients suspected of having myocardial infiltrative processes, such as sarcoidosis or amyloidosis, or in patients with malignant arrhythmias out of proportion to LV dysfunction, where sarcoidosis and giant cell myocarditis are considerations. (Strength of Evidence = C)
Follow-up Evaluation
Table 4.9: Elements to Determine at Follow-Up Visits of HF Patients
- Functional capacity and activity level
- Changes in body weight
- Patient understanding of and compliance with dietary sodium restriction
- Patient understanding of and compliance with medical regimen
- History of arrhythmia, syncope, presyncope, or palpitation
- Compliance and response to therapeutic interventions
- The presence or absence of exacerbating factors for HF, including worsening ischemic heart disease, hypertension, and new or worsening valvular disease
|
- Routine reevaluation of cardiac function by noninvasive or invasive methods is not recommended. Repeat measurements of ventricular volume and ejection fraction (EF) should be considered under limited circumstances:
- After at least 3 months of medical therapy when a prophylactic internal cardioverter defibrillator (ICD) placement is being considered in order to determine that EF criteria for internal cardioverter defibrillator placement are still met. (Strength of Evidence = B)
- In patients who show substantial clinical improvement (for example, in response to beta-blocker treatment). Such change may denote improved prognosis, although it does not in itself mandate alteration or discontinuation of specific treatments (see Section 7 in the original guideline document). (Strength of Evidence = C)
Repeat determination of EF is usually unnecessary in patients with previously documented LV dilatation and low EF who manifest worsening signs or symptoms of HF. Repeat measurement should be considered when it is likely to prompt a change in patient management, such as cardiac transplantation. (Strength of Evidence = C)
- It is recommended that reevaluation of electrolytes and renal function occur at least every 6 months in clinically stable patients and more frequently following changes in therapy or with evidence of change in volume status. More frequent assessment of electrolytes and renal function is recommended in patients with severe HF, those receiving high doses of diuretics, and those who are clinically unstable. (Strength of Evidence = C) See the National Guideline Clearinghouse (NGC) summary of the Heart Failure Society of American (HFSA) guideline Heart Failure in Patients with Left Ventricular Systolic Dysfunction for recommendations for patients on an angiotensin receptor blocker.
Definitions:
Strength of Evidence
Level A: Randomized, Controlled, Clinical Trials
May be assigned based on results of a single trial
Level B: Cohort and Case-Control Studies
Post hoc, subgroup analysis, and meta-analysis
Prospective observational studies or registries
Level C: Expert Opinion
Observational studies – epidemiologic findings
Safety reporting from large-scale use in practice
Strength of Recommendations
"Is recommended": Part of routine care
Exceptions to therapy should be minimized.
"Should be considered": Majority of patients should receive the intervention.
Some discretion in application to individual patients should be allowed.
"May be considered": Individualization of therapy is indicated
"Is not recommended": Therapeutic intervention should not be used
