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 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

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

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

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 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

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 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 0.66-0.79 (MICE, 6 of 9 studies) oedema Mant et al. HTA 2009;13:no 32 Fahey et al. Fam Pract 2007;24:628-

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

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 abnormalities other cardiac abnormalities

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

Multivariable models for detection/exclusion (slow onset) HF Clinical 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 + 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 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

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)!!