1. Controversies in heart failure diagnosis
Dr. Frans Rutten, Utrecht, The Netherlands

2. 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

3. ESC 2008 definition of heart failure
I. Symptoms typical of heart failure
and (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 obligatory
Objective evidence of (left) ventricular dysfunction
- decreased LVEF (LVEF <45%) : HFREF
- LV filling and relaxation abnormalities, ‘normal’ LVEF : HFPEF

4. 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)

5. Diagnosing heart failure is not easy!
COPD HF rest
30 causes of dyspnoea  65 years: multimorbidity

6. a complex clinical syndrome
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

7. symptoms and signs of HF

8. ESC guidelines 2008
Dickstein et al. Eur J Heart Fail 2008;10:933-

9. primary care ED
Chance of having new onset HF? Chance of having new onset HF?
Possible cause? Possible cause?

10. primary care ED 79 years old 64 years old
Hypertension, diabetes, COPD ‘no’ comorbidity
30 pack years smoking 30 pack years smoking
slowly increase in dyspnoea, fatigue acute dyspnoea, orthopnoea,
166/92, 92 bpm 166/92, 92 bpm
Displaced apex, no fluid overload raised JVP, crepitations,oedema

11. 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)

12. Signs crepitations raised JVP fluid overload oedema
apical impulse displaced or sustained
S3 gallop very rare
heart murmur not very typical
tachycardia, irregular pulse

13. Palpation of the apical impulse

14. Clinical models to detect or exclude HF in suspected patients from PC
Male sex Orthopnoea Prior MI AUC 0.75 LVSD (LVEF <50%) JVP Age Prior MI, CABG, PCI Apical impulse AUC 0.82 (>700 patients) crepitations Murmur JVP Kelder et al. Submitted Prior MI AUC (MICE, 6 of 9 studies) oedema Mant et al. HTA 2009;13:no 32
Fahey et al. Fam Pract 2007;24:628-

15. Clinical model (screening) elderly stable COPD
Clinical models to detect or exclude HF in suspected patients from PC
Age Male sex Prior MI, CABG, PCI Diabetes AUC 0.79 Orthopnoea Crepitations, elevated JVP, S3 gallop, ankle oedema Kelder et al Heart 2011 Apical impulse AUC 0.70 (screening elderly COPD patients) Heart rate >90 bpm BMI >30 kg/m² Rutten et al. BMJ 2005;331:1379
Clinical model (screening) elderly stable COPD

16. 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

17. 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 abnormalities
other cardiac abnormalities

18. ESC guidelines 2008 5 key diagnostic 'tests'
Dickstein et al. Eur J Heart Fail2008; 10:933-

19. Multivariable models for detection/exclusion (slow onset) HF
Clinical model ECG 0.86 Clinical model ECG Chest X-ray ntproBNP 0.86 Kelder et al. Submitted Clinical model (6 of 9 studies) + ECG ntproBNP Mant et al. HTA 2009;13:no 32 Clinical model ECG ntproBNP Kelder et al. Heart 2011;97:959
Fahey et al. Fam Pract 2007;24:628

20. Multivariable models for detection/exclusion (slow onset) HF
Clinical model 0.70 (screening elderly COPD patients) + ECG Chest X-ray ntproBNP 0.77 Rutten et al. BMJ 2005;331:1379
Fahey et al. Fam Pract 2007;24:628-

21. Dutch adaptation of the ESC guidelines 2008
Suspected heart failure symptoms and signs
Acute
Slow onset
ECG, (NT-pro)BNP, chest X-ray
ECG, (NT-pro)BNP, chest X-ray
ECG normal and
NT-proBNP<400 pg/ml
BNP<100 pg/ml
ECG abnormal or
NT-proBNP≥400 pg/ml
BNP≥100 pg/ml
ECG abnormal or
NT-proBNP≥ 125 pg/ml
BNP≥ 35 pg/ml
ECG normal and
NT-proBNP<125 pg/ml
BNP< 35 pg/ml
Heart failure
very unlikely
Echocardiography
Heart failure
very unlikely
Hartfalen richtlijn. Hoes et al. 2010

22. 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

23. 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)!!