3/28/2017 HeartFailureClinicalPresentation:History,PhysicalExamination,PredominantRightSidedHeartFailure

HeartFailureClinicalPresentation
Updated:Jan11,2016
Author:IoanaDumitru,MDChiefEditor:HenryHOoi,MD,MRCPImore...

PRESENTATION

History
Inevaluatingheartfailurepatients,theclinicianshouldaskaboutthefollowingcomorbiditiesand/orrisk
factors[3]:

Myopathy
PreviousMI
Valvularheartdisease,familialheartdisease
Alcoholuse
Hypertension
Diabetes
Dyslipidemia
Coronary/peripheralvasculardisease
Sleepdisorderedbreathing
Collagenvasculardisease,rheumaticfever
Pheochromocytoma
Thyroiddisease
Substanceabusehistory
Historyofchemotherapy/radiationtothechest

TheHeartFailureSocietyofAmerica(HFSA)alsohasthefollowingrecommendationsforgenetic
evaluationofcardiomyopathy[54]:

Forallpatientswithcardiomyopathy,takeadetailedfamilyhistoryforatleast3generations
(hypertrophiccardiomyopathy[HCM],dilatedcardiomyopathy[DCM],arrhythmicrightventricular
dysplasia[ARVD],leftventricularnoncompaction[LVNC],restrictivecardiomyopathy[RCM],and
cardiomyopathiesassociatedwithextracardiacmanifestations)
Carefullyassessthepatient'smedicalhistoryaswellasthatofasymptomaticfirstdegree
relatives,withspecialfocusonheartfailuresymptoms,arrhythmias,presyncope,andsyncope
Screenasymptomaticfirstdegreerelativesforcardiomyopathy(HCM,DCM,ARVD,LVNC,RCM,
andcardiomyopathiesassociatedwithextracardiacmanifestations)
Screenforcardiomyopathyatintervalsinasymptomaticatriskrelativeswhoareknowntocarry
thediseasecausingmutation(s)(fordetails,seeRecommendations17.2eand17.2finHFSA
GuidelineApproachtoMedicalEvidenceforGeneticEvaluationofCardiomyopathy)
Screenforcardiomyopathyinasymptomaticatriskfirstdegreerelativeswhohavenotundergone
genetictestingorinwhomadiseasecausingmutationhasnotbeenidentified

Note:Duetothecomplexityofgeneticevaluation,testing,andcounselingofpatientswith
cardiomyopathy,itisrecommendedthatpatientsbereferredtocenterswithexpertiseinthesematters
andinfamilybasedmanagement.[54]

TheNewYorkHeartAssociation(NYHA)classificationofheartfailureiswidelyusedinpracticeandin
clinicalstudiestoquantifyclinicalassessmentofheartfailure(seeHeartFailureCriteriaand
Classification).Breathlessness,acardinalsymptomofLVfailure,maymanifestwithprogressively
increasingseverityasthefollowing:

Exertionaldyspnea
Orthopnea
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Paroxysmalnocturnaldyspnea
Dyspneaatrest
Acutepulmonaryedema

Othercardiacsymptomsofheartfailureincludechestpain/pressureandpalpitations.Common
noncardiacsignsandsymptomsofheartfailureincludeanorexia,nausea,weightloss,bloating,fatigue,
weakness,oliguria,nocturia,andcerebralsymptomsofvaryingseverity,rangingfromanxietytomemory
impairmentandconfusion.FindingsfromtheFraminghamHeartStudysuggestthatsubclinicalcardiac
dysfunctionandnoncardiaccomorbiditiesareassociatedwithincreasedincidenceofheartfailure,
supportingtheideathatheartfailureisaprogressivesyndromeandthatnoncardiacfactorsare
extremelyimportant.[26,27,55]

Exertionaldyspnea
Theprincipaldifferencebetweenexertionaldyspneainpatientswhoarehealthyandexertionaldyspnea
inpatientswithheartfailureisthedegreeofactivitynecessarytoinducethesymptom.Asheartfailure
firstdevelops,exertionaldyspneamaysimplyappeartobeanaggravationofthebreathlessnessthat
occursinhealthypersonsduringactivity,butasLVfailureadvances,theintensityofexerciseresultingin
breathlessnessprogressivelydeclineshowever,subjectiveexercisecapacityandobjectivemeasuresof
LVperformanceatrestinpatientswithheartfailurearenotcloselycorrelated.Exertionaldyspnea,in
fact,maybeabsentinsedentarypatients.

Orthopnea

Orthopneaisanearlysymptomofheartfailureandmaybedefinedasdyspneathatdevelopsinthe
recumbentpositionandisrelievedwithelevationoftheheadwithpillows.Asinthecaseofexertional
dyspnea,thechangeinthenumberofpillowsrequiredisimportant.Intherecumbentposition,
decreasedpoolingofbloodinthelowerextremitiesandabdomenoccurs.Bloodisdisplacedfromthe
extrathoraciccompartmenttothethoraciccompartment.ThefailingLV,operatingontheflatportionof
theFrankStarlingcurve,cannotacceptandpumpouttheextravolumeofblooddeliveredtoitwithout
dilating.Asaresult,pulmonaryvenousandcapillarypressuresrisefurther,causinginterstitialpulmonary
edema,reducedpulmonarycompliance,increasedairwayresistance,anddyspnea.

Orthopneaoccursrapidly,oftenwithinaminuteortwoofrecumbency,anddevelopswhenthepatientis
awake.Orthopneamayoccurinanyconditioninwhichthevitalcapacityislow.Markedascites,
regardlessofitsetiology,isanimportantcauseoforthopnea.InadvancedLVfailure,orthopneamaybe
soseverethatthepatientcannotliedownandmustsleepsittingupinachairorslumpedoveratable.

Cough,particularlyduringrecumbency,maybean"orthopneaequivalent."Thisnonproductivecough
maybecausedbypulmonarycongestionandisrelievedbythetreatmentofheartfailure.

Paroxysmalnocturnaldyspnea
Paroxysmalnocturnaldyspneausuallyoccursatnightandisdefinedasthesuddenawakeningofthe
patient,afteracoupleofhoursofsleep,withafeelingofsevereanxiety,breathlessness,and
suffocation.Thepatientmayboltuprightinbedandgaspforbreath.Bronchospasmincreases
ventilatorydifficultyandtheworkofbreathingandisacommoncomplicatingfactorofparoxysmal
nocturnaldyspnea.Onchestauscultation,thebronchospasmassociatedwithaheartfailure
exacerbationcanbedifficulttodistinguishfromanacuteasthmaexacerbation,althoughotherclues
fromthecardiovascularexaminationshouldleadtheexaminertothecorrectdiagnosis.Bothtypesof
bronchospasmcanbepresentinasingleindividual.

Incontrasttoorthopnea,whichmayberelievedbyimmediatelysittingupinbed,paroxysmalnocturnal
dyspneamayrequire30minutesorlongerinthispositionforrelief.Episodesmaybesofrighteningthat
thepatientmaybeafraidtoresumesleeping,evenafterthesymptomshavesubsided.

Dyspneaatrest

Dyspneaatrestinheartfailureistheresultofthefollowingmechanisms:

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Decreasedpulmonaryfunctionsecondarytodecreasedcomplianceandincreasedairway
resistance
Increasedventilatorydrivesecondarytohypoxemiaduetoincreasedpulmonarycapillarywedge
pressure(PCWP)ventilation/perfusion(V/Q)mismatchingduetoincreasedPCWPandlow
cardiacoutputandincreasedcarbondioxideproduction
Respiratorymuscledysfunction,withdecreasedrespiratorymusclestrength,decreased
endurance,andischemia

Pulmonaryedema
AcutepulmonaryedemaisdefinedasthesuddenincreaseinPCWP(usuallymorethan25mmHg)as
aresultofacuteandfulminantleftventricularfailure.Itisamedicalemergencyandhasaverydramatic
clinicalpresentation.Thepatientappearsextremelyill,poorlyperfused,restless,sweaty,tachypneic,
tachycardic,hypoxic,andcoughing,withanincreasedworkofbreathingandusingrespiratory
accessorymusclesandwithfrothysputumthatonoccasionisbloodtinged.

Chestpain/pressureandpalpitations

Chestpain/pressuremayoccurasaresultofeitherprimarymyocardialischemiafromcoronarydisease
orsecondarymyocardialischemiafromincreasedfillingpressure,poorcardiacoutput(andtherefore
poorcoronarydiastolicfilling),orhypotensionandhypoxemia.[56]

Palpitationsarethesensationapatienthaswhentheheartisracing.Itcanbesecondarytosinus
tachycardiaduetodecompensatedheartfailure,ormorecommonly,itisduetoatrialorventricular
tachyarrhythmias.

Fatigueandweakness
Fatigueandweaknessareoftenaccompaniedbyafeelingofheavinessinthelimbsandaregenerally
relatedtopoorperfusionoftheskeletalmusclesinpatientswithaloweredcardiacoutput.Althoughthey
aregenerallyaconstantfeatureofadvancedheartfailure,episodicfatigueandweaknessarealso
commoninearlierstages.

Nocturiaandoliguria

Nocturiamayoccurrelativelyearlyinthecourseofheartfailure.Recumbencyreducesthedeficitin
cardiacoutputinrelationtooxygendemand,renalvasoconstrictiondiminishes,andurineformation
increases.Nocturiamaybetroublesomeforpatientswithheartfailurebecauseitmaypreventthemfrom
obtainingmuchneededrest.Oliguriaisalatefindinginheartfailureandisfoundinpatientswith
markedlyreducedcardiacoutputfromseverelyreducedLVfunction.

Cerebralsymptoms

Thefollowingmayoccurinelderlypatientswithadvancedheartfailure,particularlyinthosewith
cerebrovascularatherosclerosis:

Confusion
Memoryimpairment
Anxiety
Headaches
Insomnia
Baddreamsornightmares
Rarely,psychosiswithdisorientation,delirium,orhallucinations

PhysicalExamination
Patientswithmildheartfailureappeartobeinnodistressafterafewminutesofrest,buttheymaybe
obviouslydyspneicduringandimmediatelyaftermoderateactivity.PatientswithLVfailuremaybe

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dyspneicwhenlyingflatwithoutelevationoftheheadformorethanafewminutes.Thosewithsevere
heartfailureappearanxiousandmayexhibitsignsofairhungerinthisposition.

Patientswithrecentonsetofheartfailurearegenerallywellnourished,butthosewithchronicsevere
heartfailureareoftenmalnourishedandsometimesevencachectic.Chronicmarkedelevationof
systemicvenouspressuremayproduceexophthalmosandseveretricuspidregurgitationandmaylead
tovisiblepulsationoftheeyesandoftheneckveins.Centralcyanosis,icterus,andmalarflushmaybe
evidentinpatientswithsevereheartfailure.

Inmildormoderateheartfailure,strokevolumeisnormalatrestinsevereheartfailure,itisreduced,as
reflectedbyadiminishedpulsepressureandaduskydiscolorationoftheskin.Withverysevereheart
failure,particularlyifcardiacoutputhasdeclinedacutely,systolicarterialpressuremaybereduced.The
pulsemaybeweak,rapid,andthreadytheproportionalpulsepressure(pulsepressure/systolic
pressure)maybemarkedlyreduced.Theproportionalpulsepressurecorrelatesreasonablywellwith
cardiacoutput.Inonestudy,whenpulsepressurewaslessthan25%,itusuallyreflectedacardiacindex
oflessthan2.2L/min/m2.

Ascitesoccursinpatientswithincreasedpressureinthehepaticveinsandintheveinsdrainingintothe
peritoneumandusuallyreflectslongstandingsystemicvenoushypertension.Fevermaybepresentin
severedecompensatedheartfailurebecauseofcutaneousvasoconstrictionandimpairmentofheat
loss.

Increasedadrenergicactivityismanifestedbytachycardia,diaphoresis,pallor,peripheralcyanosiswith
pallorandcoldnessoftheextremities,andobviousdistentionoftheperipheralveinssecondaryto
venoconstriction.Diastolicarterialpressuremaybeslightlyelevated.

Ralesheardoverthelungbasesarecharacteristicofheartfailureofatleastmoderateseverity.With
acutepulmonaryedema,ralesarefrequentlyaccompaniedbywheezingandexpectorationoffrothy,
bloodtingedsputum.Theabsenceofralescertainlydoesnotexcludeelevationofpulmonarycapillary
pressureduetoLVfailure.

Systemicvenoushypertensionismanifestedbyjugularvenousdistention.Normally,jugularvenous
pressuredeclineswithrespirationhowever,itincreasesinpatientswithheartfailure,afindingknownas
theKussmaulsign(alsofoundinconstrictivepericarditis).Thisreflectsanincreaseinrightatrial
pressureandthereforerightsidedheartfailure.

Hepatojugularrefluxisthedistentionofthejugularveininducedbyapplyingmanualpressureoverthe
liverthepatient'storsoshouldbepositionedata45angle.Hepatojugularrefluxoccursinpatientswith
elevatedleftsidedfillingpressuresandreflectselevatedcapillarywedgepressureandleftsidedheart
failure.

Althoughedemaisacardinalmanifestationofheartfailure,itdoesnotcorrelatewellwiththelevelof
systemicvenouspressure.InpatientswithchronicLVfailureandlowcardiacoutput,extracellularfluid
volumemaybesufficientlyexpandedtocauseedemainthepresenceofonlyslightelevationsin
systemicvenouspressure.Usually,asubstantialgainofextracellularfluidvolume(ie,aminimumof5L
inadults)mustoccurbeforeperipheraledemadevelops.Edemaintheabsenceofdyspneaorother
signsofLVorRVfailureisnotsolelyindicativeofheartfailureandcanbeobservedinmanyother
conditions,includingchronicvenousinsufficiency,nephroticsyndrome,orothersyndromesof
hypoproteinemiaorosmoticimbalance.

Hepatomegalyisprominentinpatientswithchronicrightsidedheartfailure,butitmayoccurrapidlyin
acuteheartfailure.Whenhepatomegalyoccursacutely,theliverisusuallytender.Inpatientswith
considerabletricuspidregurgitation,aprominentsystolicpulsationoftheliver,attributabletoan
enlargedrightatrialVwave,isoftennoted.Apresystolicpulsationoftheliver,attributabletoan
enlargedrightatrialAwave,canoccurintricuspidstenosis,constrictivepericarditis,restrictive
cardiomyopathyinvolvingtherightventricle,andpulmonaryhypertension(primaryorsecondary).

Hydrothoraxismostcommonlyobservedinpatientswithhypertensioninvolvingboththesystemicand
pulmonarycirculation.Itisusuallybilateral,althoughwhenunilateral,itisusuallyconfinedtotheright
sideofthechest.Whenhydrothoraxdevelops,dyspneausuallyintensifiesbecauseoffurtherreductions
invitalcapacity.

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3/28/2017 HeartFailureClinicalPresentation:History,PhysicalExamination,PredominantRightSidedHeartFailure

Cardiacfindings

Protodiastolic(S3)gallopistheearliestcardiacphysicalfindingindecompensatedheartfailureinthe
absenceofseveremitralortricuspidregurgitationorlefttorightshunts.ThepresenceofanS3gallopin
adultsisimportant,pathologic,andoftenthemostapparentfindingoncardiacauscultationinpatients
withsignificantheartfailure.

Cardiomegalyisanonspecificfindingthatnonethelessoccursinmostpatientswithchronicheartfailure.
NotableexceptionsincludeheartfailurefromacuteMI,constrictivepericarditis,restrictive
cardiomyopathy,valveorchordaetendineaerupture,orheartfailureduetotachyarrhythmiasor
bradyarrhythmias.

Pulsusalternans(duringpulsepalpation,thisisthealternationof1strongand1weakbeatwithouta
changeinthecyclelength)occursmostcommonlyinheartfailureduetoincreasedresistancetoLV
ejection,asoccursinhypertension,aorticstenosis,coronaryatherosclerosis,anddilated
cardiomyopathy.PulsusalternansisusuallyassociatedwithanS3gallop,signifiesadvancedmyocardial
disease,andoftendisappearswithtreatmentofheartfailure.

AccentuationofP2heartsoundisacardinalsignofincreasedpulmonaryarterypressureitdisappears
orimprovesaftertreatmentofheartfailure.Mitralandtricuspidregurgitationmurmursareoftenpresent
inpatientswithdecompensatedheartfailurebecauseofventriculardilatation.Thesemurmursoften
disappearordiminishwhencompensationisrestored.Notethatcorrelationbetweentheintensityofthe
murmurofmitralregurgitationanditssignificanceinpatientswithheartfailureispoor.Severemitral
regurgitationmaybeaccompaniedbyanunimpressivelysoftmurmur.

Cardiaccachexiaisfoundinlongstandingheartfailure,particularlyoftherightventricle,becauseof
anorexiafromhepaticandintestinalcongestionandsometimesbecauseofdigitalistoxicity.
Occasionally,impairedintestinalabsorptionoffatoccurs,andrarely,proteinlosingenteropathyoccurs.
Patientswithheartfailuremayalsoexhibitincreasedtotalmetabolismsecondarytoaugmentationof
myocardialoxygenconsumption,excessiveworkofbreathing,lowgradefever,andelevatedlevelsof
circulatingtumornecrosisfactor(TNF).

PredominantRightSidedHeartFailure
Ascites,congestivehepatomegaly,andanasarcaduetoelevatedrightsidedheartpressurestransmitted
backwardintotheportalveincirculationmayresultinincreasedabdominalgirthandepigastricandright
upperquadrant(RUQ)abdominalpain.Othergastrointestinalsymptoms,causedbycongestionofthe
hepaticandgastrointestinalvenouscirculation,includeanorexia,bloating,nausea,andconstipation.In
preterminalheartfailure,inadequatebowelperfusioncancauseabdominalpain,distention,andbloody
stools.Distinguishingrightsidedheartfailurefromhepaticfailureisoftenclinicallydifficult.

Dyspnea,prominentinLVfailure,becomeslessprominentinisolatedrightsidedheartfailurebecause
oftheabsenceofpulmonarycongestion.Ontheotherhand,whencardiacoutputbecomesmarkedly
reducedinpatientswithterminalrightsidedheartfailure(asmayoccurinisolatedRVinfarctionandin
thelatestagesofprimarypulmonaryhypertensionandpulmonarythromboembolicdisease),severe
dyspneamayoccurasaconsequenceofthereducedcardiacoutput,poorperfusionofrespiratory
muscles,hypoxemia,andmetabolicacidosis.

HeartFailureinChildren
Inchildren,manifestationsofheartfailurevarywithage.[57]Signsofpulmonaryvenouscongestionin
aninfantgenerallyincludetachypnea,respiratorydistress(retractions),grunting,anddifficultywith
feeding.Often,childrenwithheartfailurehavediaphoresisduringfeedings,whichispossiblyrelatedto
acatecholaminesurgethatoccurswhentheyarechallengedwitheatingwhileinrespiratorydistress.

Rightsidedvenouscongestionischaracterizedbyhepatosplenomegalyand,lessfrequently,with
edemaorascites.Jugularvenousdistentionisnotareliableindicatorofsystemicvenouscongestionin
infants,becausethejugularveinsaredifficulttoobserve.Also,thedistancefromtherightatriumtothe
angleofthejawmaybenomorethan810cm,evenwhentheindividualissittingupright.
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Uncompensatedheartfailureinaninfantprimarilymanifestsasafailuretothrive.Inseverecases,
failuretothrivemaybefollowedbysignsofrenalandhepaticfailure.

Inolderchildren,leftsidedvenouscongestioncausestachypnea,respiratorydistress,andwheezing
(cardiacasthma).Rightsidedcongestionmayresultinhepatosplenomegaly,jugularvenousdistention,
edema,ascites,and/orpleuraleffusions.Uncompensatedheartfailureinolderchildrenmaycause
fatigueorlowerthanusualenergylevels.Patientsmaycomplainofcoolextremities,exercise
intolerance,dizziness,orsyncope.

Formoreinformation,seetheMedscapeReferencearticlePediatricCongestiveHeartFailure.

HeartFailureCriteria,Classification,andStaging
Framinghamsystemfordiagnosisofheartfailure
IntheFraminghamsystem,thediagnosisofheartfailurerequiresthateither2majorcriteriaor1major
and2minorcriteriabepresentconcurrently,asshowninTable1below.[1]Minorcriteriaareaccepted
onlyiftheycannotbeattributedtoanothermedicalcondition.

Table1.FraminghamDiagnosticCriteriaforHeartFailure(OpenTableinanewwindow)

MajorCriteria MinorCriteria

Paroxysmalnocturnaldyspnea Nocturnalcough

Dyspneaonordinary
Weightlossof4.5kgin5daysinresponsetotreatment
exertion

Adecreaseinvitalcapacity
Neckveindistention byonethirdthemaximal
valuerecorded

Rales Pleuraleffusion

Tachycardia(rateof120
Acutepulmonaryedema
bpm)

Hepatojugularreflux Hepatomegaly

S3gallop Bilateralankleedema

Centralvenouspressure>16cmwater

Circulationtimeof25sec

Radiographiccardiomegaly

Pulmonaryedema,visceralcongestion,orcardiomegalyatautopsy

Source:HoKK,PinskyJL,KannelWB,LevyD.Theepidemiology
ofheartfailure:theFraminghamStudy.JAmCollCardiol.1993
Oct22(4supplA):6A13A.[1]

NYHAclassificationoffunctionalheartfailure
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TheNewYorkHeartAssociation(NYHA)functionalclassificationofheartfailureisbasedonthe
patient'ssymptomseverityandtheamountofexertionthatisneededtoprovoketheirsymptoms.See
Table2below.

Table2.NYHAFunctionalClassificationofHeartFailure(OpenTableinanewwindow)

Functional
Class
Capacity

Patients
without
I limitationof
physical
activity

Patients
withslight
limitationof
physical
activity,in
which
ordinary
physical
activity
II
leadsto
fatigue,
palpitation,
dyspnea,or
anginal
painthey
are
comfortable
atrest

Patients
with
marked
limitationof
physical
activity,in
whichless
than
ordinary
III activity
resultsin
fatigue,
palpitation,
dyspnea,or
anginal
painthey
are
comfortable
atrest

IV Patients
whoarenot
onlyunable
tocarryon
any
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physical
activity
without
discomfort
butwho
alsohave
symptoms
ofheart
failureor
theanginal
syndrome
evenat
restthe
patient's
discomfort
increasesif
any
physical
activityis
undertaken

Source:AmericanHeartAssociation.Classesofheartfailure.Availableat:
http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes
ofHeartFailure_UCM_306328_Article.jsp.Accessed:September6,2011.[2]

ACC/AHAstagesofheartfailure

TheAmericanCollegeofCardiology/AmericanHeartAssociation(ACC/AHA)developedaclassification
thatdescribedthedevelopmentandprogressionofheartfailureandthat"recognizesthatthereare
establishedriskfactorsandstructuralprerequisitesforthedevelopmentofHFandthattherapeutic
interventionsintroducedevenbeforetheappearanceofLVdysfunctionorsymptomscanreducethe
populationmorbidityandmortalityofHF."[3]Table3,below,summarizesthedevelopmentofheart
failure.

Table3.ACC/AHAStagesofHeartFailureDevelopment(OpenTableinanewwindow)

level Description Examples Notes

Patientswith
coronary
artery Patientswith
disease, predisposing
Athighriskfor
hypertension, riskfactorsfor
heartfailurebut
ordiabetes developing
without
mellitus heartfailure
A structuralheart
without Corresponds
diseaseor
impairedLV withpatients
symptomsof
function, withNYHA
heartfailure
hypertrophy, classIheart
orgeometric failure
chamber
distortion

B Structuralheart Patientswho
diseasebut are
without asymptomatic
butwhohave
LVHand/or
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LVHand/or
signs/symptoms impairedLV
ofheartfailure function

Patientswith
Themajority
known
ofpatients
structural
withheart
Structuralheart heartdisease
failurearein
diseasewith and
thisstage
C currentorpast shortnessof
Corresponds
symptomsof breathand
withpatients
heartfailure fatigue,
withNYHA
reduced
classIIandIII
exercise
heartfailure
tolerance

Patientsinthis
stagemaybe
eligibleto
receive
mechanical
circulatory
support,
receive
continuous
Patientswho
inotropic
havemarked
Refractoryheart infusions,
symptomsat
failurerequiring undergo
D restdespite
specialized proceduresto
maximal
interventions facilitatefluid
medical
removal,or
therapy
undergoheart
transplantation
orother
procedures
Corresponds
withpatients
withNYHA
classIVheart
failure

Sources:(1)HuntSA,American
CollegeofCardiology,andthe
AmericanHeartAssociationTask
ForceonPracticeGuidelines(Writing
CommitteetoUpdatethe2001
GuidelinesfortheEvaluationand
ManagementofHeartFailure).
ACC/AHA2005guidelineupdatefor
thediagnosisandmanagementof
chronicheartfailureintheadult:a
reportoftheAmericanCollegeof
Cardiology/AmericanHeartAssociation
TaskForceonPracticeGuidelines.J
AmCollCardiol.2005Sep
2046(6):e182.[4]and(2)HuntSA,
AbrahamWT,ChinMH,etal.2009
Focusedupdateincorporatedintothe
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3/28/2017 HeartFailureClinicalPresentation:History,PhysicalExamination,PredominantRightSidedHeartFailure

ACC/AHA2005Guidelinesforthe
DiagnosisandManagementofHeart
FailureinAdultsAReportofthe
AmericanCollegeofCardiology
Foundation/AmericanHeart
AssociationTaskForceonPractice
GuidelinesDevelopedinCollaboration
WiththeInternationalSocietyforHeart
andLungTransplantation.JAmColl
Cardiol.Apr14200953(15):e1e90.[3]

ACC/AHAStaging
StageA

ACC/AHAstageApatientsareathighriskforheartfailurebutdonothavestructuralheartdiseaseor
symptomsofheartfailure.Thus,managementinthesecasesfocusesonprevention,throughreduction
ofriskfactors.Measuresincludethefollowing[58]:

Treathypertension
Encouragesmokingcessation
Treatlipiddisorders
Encourageregularexercise
Discouragealcoholintakeandillicitdruguse

Patientswhohaveafamilyhistoryofdilatedcardiomyopathyshouldbescreenedwithacomprehensive
historyandphysicalexaminationtogetherwithechocardiographyandtransthoracicechocardiography
every25years.[5]

StageB

ACC/AHAstageBpatientsareasymptomatic,withLVdysfunctionfrompreviousMI,LVremodelingfrom
LVhypertrophy,andasymptomaticvalvulardysfunction,whichincludespatientswithNewYorkHeart
Association(NYHA)classIheartfailure(seeHeartFailureCriteriaandClassificationforadescriptionof
NYHAclasses).[3]Inadditiontotheheartfailureeducationandaggressiveriskfactormodificationused
forstageA,treatmentwithanACEI/ARBand/orbetablockadeisindicated.

Evaluationforcoronaryrevascularizationeitherpercutaneouslyorsurgically,aswellascorrectionof
valvularabnormalities,maybeindicated.[3]TreatmentwithanICDforprimarypreventionofsudden
deathinpatientswithanLVEFoflessthan30%thatismorethan40dayspostMIisreasonableif
expectedsurvivalismorethan1year.

ThereislessevidenceforimplantationofanICDinpatientswithnonischemiccardiomyopathy,anLVEF
lessthan30%,andnoheartfailuresymptoms.Thereisnoevidenceforuseofdigoxininthese
populations.[59]AldosteronereceptorblockadewitheplerenoneisindicatedforpostMILVdysfunction.

StageC

ACC/AHAstageCpatientshavestructuralheartdiseaseandcurrentorprevioussymptomsofheart
failureACC/AHAstageCcorrespondswithNYHAclassIIandIIIheartfailure.Thepreventivemeasures
usedforstageAdiseaseareindicated,asisdietarysodiumrestriction.

DrugsroutinelyusedinthesepatientsincludeACEI/ARBs,betablockers,andloopdiureticsforfluid
retention.Forselectedpatients,therapeuticmeasuresincludealdosteronereceptorblockers,
hydralazineandnitratesincombination,andcardiacresynchronizationwithorwithoutanICD(see
ElectrophysiologicIntervention).[58]

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AmetaanalysisperformedbyBadveetalsuggestedthatthesurvivalbenefitoftreatmentwithbeta
blockersextendstopatientswithchronickidneydiseaseandsystolicheartfailure(riskratio0.72).[60]

StageD
ACC/AHAstageDpatientshaverefractoryheartfailure(NYHAclassIV)thatrequiresspecialized
interventions.TreatmentincludesallthemeasuresusedinstagesA,B,andC.Treatment
considerationsincludehearttransplantationorplacementofanLVassistdeviceineligiblepatients
pulmonarycatheterizationandoptionsforendoflifecare.[3]Forpalliationofsymptoms,continuous
intravenousinfusionofapositiveinotropemaybeconsidered.

DifferentialDiagnoses

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