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) HFClinical 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)!!