CRITERIA OF THE AMERICAN COLLEGE OF CARDIOLOGY (ACC) AND AMERICAN HEART ASSOCIATION (AHA) FOR DIASTOLIC HEART FAILURE

Overview : The American College of Cardiology (ACC) and the American Heart Association (AHA) included general criteria for making the diagnosis of diastolic heart failure. This occurs when there is impaired relaxation of the ventricle during diastole. Criteria: (1) presence of typical signs and symptoms of heart failure (2) normal left ventricular ejection fraction (3) no valvular abnormalities found on echocardiography (4) exclusion of other disorders: (4a) restrictive cardiomyopathy (4b) pericardial constriction (4c) high output failure (as seen in thyrotoxicosis, arteriovenous fistula, anemia) (4d) pulmonary arterial hypertension with right heart failure (4e) atrial myxoma References: Aurigemma GP, Gaasch WH. Diastolic heart failure. N Engl J Med. 2004; 351: 1097-1105 (pages 10981099). Hunt SA, Baker SW, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 guidelines for the evaluation and management of heart failure). Circulation. 2001; 104: 2996-3007. (Section VI: Diastolic dysfunction).

DISCHARGE CRITERIA FOR A PATIENT HOSPITALIZED FOR HEART FAILURE Overview : A patient with heart failure should not be discharged until she or he meets specific criteria. Early discharge prior to achieving specific goals may increase the chances of early readmission. Goals: (1) clinical status (2) clinical stability (3) maintenance plan Clinical status goals: (1) has achieved dry weight (following diuresis) (2) walking without dyspnea or dizziness (3) optimal blood pressure range identified (with control of serious hypertension) Stability goals: (1) renal function stable or improving (2) in fluid balance, even when on oral diuretics (3) if intravenous inotropic agents used during admission, discontinued at least 48 hours before discharge (4) oral heart failure regimen stable for at least 24 hours Maintenance plan: (1) patient education (2) family or caregiver education (3) flexible diuretic plan (4) call to patient within 3 days scheduled (5) instructions for when to call health care provider and how to handle an emergency (6) followup visit with health care provider scheduled for 5-10 days after discharge Elements of education: (1) sodium restriction (2) fluid limitation (3) medication schedule (4) exercise prescription References:

Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. JAMA. 2002; 287: 628640. (pages 635-636; Box, page 636)

FRAMINGHAM CRITERIA FOR THE DIAGNOSIS OF CONGESTIVE HEART FAILURE Overview : A set of criteria for the diagnosis of congestive heart failure was proposed in the Framingham Study. Criteria for the definite diagnosis of congestive heart failure: (1) concurrent presence of 2 major, OR (2) concurrent presence of 1 major and 2 minor criteria Major criteria: (1) paroxysmal nocturnal dyspnea or orthopnea (2) cardiomegaly (3) acute pulmonary edema (4) S3 gallop (5) increased venous pressure > 16 cm of water (6) circulation time > 25 seconds (7) hepatojugular reflux Either major or minor: (1) weight loss > 4.5 kilograms in 5 days in response to treatment Minor criteria: (1) ankle edema (2) night cough (3) dyspnea on exertion (4) hepatomegaly (5) pleural effusion (6) vital capacity decreased one third from maximum (7) tachycardia with heart rate > 120 beats per minute where: 1 cm H2O = 0.736 mm Hg (10 / 13.6) References: Kannel WB, D'Agostino RB, et al. Profile for estimating risk of heart failure. Arch Intern Med. 1999; 159: 1197-1204. Marantz PR, Tobin JN, et al. The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation. 1988; 77: 607-612. McKee PA, Castell WP, et al. The natural history of congestive heart failure: The Framingham Study. N Engl J Med. 1971; 285: 1441. Redfield MM. Chapter 16: Evaluation of congestive heart failure. pages 569-587 (Table 16-6, page 574). IN: Giuliani ER, Gersh BJ, et al. Mayo Clinic Practice of Cardiology, Third Edition. Mosby. 1996.

RISK FACTORS ASSOCIATED WITH DECOMPENSATED HEART FAILURE Overview : The presence of one or more risk factors may cause a patient's heart failure to become decompensated. NOTE: Previous sections contain some but not all of the following items. Risk factors: (1) excess sodium and/or fluid intake (failure to comply with salt and water restrictions) (2) noncompliance with medications (3) inappropriate reduction or discontinuation in heart failure medications (4) volume overload and/or blood transfusion (5) uncontrolled or poorly controlled hypertension (6) myocardial infarction or ischemia (7) valvular heart failure (8) cardiac arrhythmia (bradyarrhythmia, atrial fibrillation, ventricular tachyarrhythmia) (9) comorbid conditions (see below)

(10) (11) (12) (13) (14) (15) (16)

ethanol abuse adverse drug effects (see below) lack of understanding or unawareness about heart failure delayed presentation for health care after onset of symptoms cardiotoxin exposure progression in cardiomyopathy lack of social support

Comorbid conditions: (1) fever, infection, pneumonia, and/or sepsis (2) hyper or hypothyroidism (3) anemia (4) renal insufficiency (5) thiamine or other nutritional deficiency (6) acute hypoxemia due to worsening of COPD, asthma or progression of lung disease (7) pulmonary embolism (8) uncontrolled or poorly controlled diabetes mellitus (9) syndrome of inappropriate ADH secretion (SIADH) or other endocrine cause for abnormal salt and/or water retention Adverse drug effects: (1) NSAIDS (2) corticosteroids (3) drugs with negative inotropic effect (calcium channel blocker, other) References: Francis GS, Tang WHW, Adams KF Jr. Chapter 6: Pathophysiology of the spectrum of acute heart failure: de novo heart failure, decompensated heart failure, and advanced refractory heart failure. pages 87-93 (pages 90-91). IN: O'Connor CM, Stough WG, et al (editors). Managing Acute Decompensated Heart Failure. Taylor & Francis. 2005. Teerlink JR, Drazner MH. Chapter 9: Evaluation of the acute heart failure patient: assessment of dyspnea and other physical examination parameters. pages 127-149 (page 132). IN: O'Connor CM, Stough WG, et al (editors). Managing Acute Decompensated Heart Failure. Taylor & Francis. 2005.

THE PRIDE ACUTE HEART FAILURE SCORE OF BAGGISH ET AL Overview : Baggish et al developed an score the diagnosis of acute heart failure in the Emergency Department. The acronym PRIDE was derived from ProBNP Investigation of Dyspnea in the Emergency Department. The authors are from Massachusetts General Hospital in Boston and Christchurch Hospital in New Zealand. Risk factors: (1) NT-proBNP (2) chest X-ray (3) orthopnea (4) fever (5) loop diuretic therapy (6) age (7) lung physical exam (8) cough Parameter Finding NT-proBNP age < 50 and > 450 pg/mL age < 50 and <= 450 pg/mL age >= 50 and > 900 pg/mL age >= 50 and <= 900 pg/mL chest X-ray interstitial edema present interstitial edema absent orthopnea present absent Points 4 0 4 0 2 0 2 0

fever absent present loop diuretic therapy currently being taken none or not being taken age <= 75 years > 75 years lung physical examination rales present rales absent cough absent present

2 0 1 0 0 1 1 0 1 0

total score = = SUM(points for all 8 parameters) Interpretation: minimum score: 0 maximum score: 14 A cutoff of >= 6 was used to diagnose acute heart failure. Performance: A cutoff of 6 had a sensitivity of 96% and specificity of 84%. A cutoff of 7 had a sensitivity of 92% and specificity of 89% has a marginally better Youden index. References: Baggish AL, Siebert U, et al. A validated clinical and biochemical score for the diagnosis of acute heart failure: The ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Acute Heart Failure Score. Am Heart J. 2006; 151: 48-54.

THE TWO MINUTE ASSESSMENT OF THE HEMODYNAMIC PROFILE FOR A PATIENT PRESENTING WITH POSSIBLE HEART FAILURE Overview : The Two-Minute Assessment of a patient's hemodynamic profile can be used to quickly separate a patient being evaluated for heart failure into meaningful categories. These categories can help guide the optimum therapy for the patient. Measures: (1) Is congestion (elevated filling pressure) present at rest? (wet vs dry) (2) Is there evidence of low perfusion? (warm vs cold) Findings indicative of congestion and elevated filling pressure: (1) orthopnea (shortness of breath except in an upright position) (2) elevated jugular venous pressure (3) increasing S3 (4) loud P2 (pulmonic component of the second heart sound) (5) edema (6) ascites (7) rales (uncommon) (8) abdominojugular reflux (9) square wave during Valsalva Findings indicative of poor perfusion: (1) narrow pulse pressure (2) pulsus alternans (3) cool forearms and legs (distal extremities) (4) sleepy and/or obtunded (5) ACE-inhibitor-associated symptomatic hypotension

(6) declining serum sodium level (fluid retention) (7) worsening renal function Congestion at Rest yes (wet) yes (wet) no (dry) no (dry) Perfusion low (cold) not low (warm) low (cold) not low (warm) Group cold and wet (C) warm and wet (B) cold and dry (L) warm and dry (A)

Interpretation: Patients in the warm and dry group (A) with symptoms at rest or after minimal exertion may have a condition other than heart failure as the cause for the symptoms. Therapy is targeted to prevent disease progression. Management for each type is given on pages 631-632. If wet, the goal is to diurese; if cold, the goal is to increase perfusion. References: Nohria A, Lewis E, Stevenson LW. Medical management of advanced heart failure. JAMA. 2002; 287: 628640. (Figure 1, page 630) Grady KL, Dracup K, et al. Team management of patients with heart failure: a statement for healthcare professionals from the Cardiovascular Nursing Council of the American Heart Association. Circulation. 2000; 102: 2443-2456. Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA. 1989; 261: 884-888.