Vol 1 March 2009 Clinical Pharmacist 113

Heart failure accounts for at least one in 20 admissions to hospitals in the UK. It occurs most

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For personal use only. Not to be reproduced without permission of the editor ([email protected])

commonly in older people, with prevalence rates doubling for every decade of ageing

Heart failure
clinical features and diagnosis
By Mojgan Sani, DPharm, MRPharmS
SUMMARY
eart failure is a major and growing health concern

H in the UK and is still associated with a high

morbidity and mortality despite progress in its
diagnosis and treatment. The National Service Framework
Heart failure is a complex syndrome resulting from structural or
functional cardiac disorder. The syndrome is characterised by symptoms
and signs of breathlessness, fatigue and fluid retention. Many risk
factors cause heart failure, including coronary artery disease,
for coronary heart disease (CHD) sets national standards hypertension, congenital heart disease, arrhythmias, alcohol and some
of care relating to CHD, including providing better care medicines.
for patients with heart failure. The National Institute for Heart failure is a major and growing health problem among older
Health and Clinical Excellence and the Scottish people. Diagnostic and therapeutic options have advanced over the years,
Intercollegiate Guidelines Network have both issued together with national and international standards and guidelines focused
guidelines for the management of people with chronic on improving the care of patients with heart failure.
heart failure.

Definition
Many definitions of heart failure have been documented Heart failure can also been defined as:
over the past 50 years. These definitions tend to include
the features of heart failure such as haemodynamics, ● New-onset
oxygen consumption, or exercise capacity. Guidelines ● Transient
from the European Society of Cardiology (2008)1 set out ● Chronic
the defining features of heart failure (shown in Box 1,
p115). New-onset heart failure refers to the first presentation
of the disease. Transient heart failure refers to
symptomatic heart failure over a limited period of time
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after which patients recover from the syndrome. Examples

include patients with mild myocarditis, post myocardial
infarction (heart failure resolved by diuretics administered
in a coronary care unit), or heart failure due to ischaemia
(resolved by coronary revascularisation).
Chronic heart failure is the most common type that
requires hospital admission. Treatment is based on
patients’ clinical presentation (see accompanying article,
p120).

Classification
Two classifications of the severity of heart failure are
described in the ESC guidelines, as shown in Box 2 (p115).1
The New York Heart Association functional classification
is based on symptoms and exercise capacity and is

Mojgan Sani is head of cardiac pharmacy at the

Regional Wessex Cardiac Centre. Dr Sani was also a
member of the guideline development group for the
National Institute for Health and Clinical Excellence’s
2003 clinical guideline on heart failure.
E: [email protected]
 Vol 1 March 2009 Clinical Pharmacist 115

routinely used in clinical trials. The American College of study reported that the age-adjusted prevalence of heart

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Cardiology and American Heart Association classification failure was similar for men and women during the 1980s.
describes stages of heart failure based on structural This prevalence increased significantly with increasing
changes and symptoms. age (doubling the rate of prevalence with each decade of
ageing).
Epidemiology Heart failure accounts for at least 5% of admissions to
Lack of universal agreement on the definition of heart hospitals in the UK.3,4 Hospital admission for heart
failure over the years has made epidemiological studies failure accounts for approximately 1% of the total
difficult. healthcare expenditure in the UK. Epidemiological
The Framingham heart study, which had a cohort of studies have shown that the financial burden of heart
5,209 subjects, has been followed up biennially since 1948. failure on health services is increasing.3 Hospital
This dataset has been used to obtain some information on admissions and GP consultations occur frequently
the incidence and prevalence of heart failure, defined following diagnosis and readmission rates among the
using clinical and radiographic criteria.2 The Framingham elderly range from 29% to 47% within three to six
months of the initial hospital discharge.3,4
The prevalence of heart failure is 2–3%, rising sharply
at around 75 years of age.1 In the younger population,
Box 1: Definition of heart failure heart failure is more common in men, with the cause
attributed to coronary heart disease. Prevalence is similar
Heart failure is a clinical syndrome in which patients
have the following features:
between older men and women. Although some patients
live for many years, overall 50% of patients will have died
● Symptoms such as breathlessness at rest or with four years after diagnosis.
exercise, fatigue, tiredness, ankle swelling
● Signs such as tachycardia, tachypnoea, Causes
pulmonary rales, pleural effusion, raised jugular ESC guidelines state that the most common reasons for
venous pressure, peripheral oedema, functional deterioration of the heart are damage or loss of
hepatomegaly heart muscle, acute or chronic ischaemia, increased
● Objective evidence of structural or functional vascular resistance with hypertension, or the development
abnormality of the heart at rest — cardiomegaly, of a tachyarrhythmia such as atrial fibrillation.
third heart sound, cardiac murmurs, abnormality Causes of heart failure therefore include:
on echocardiogram, raised natriuretic peptide
concentration ● Coronary artery disease (myocardial infarction,
ischaemia)
● Hypertension
Box 2: Heart failure classification ● Cardiomyopathy
● Congenital heart disease
ACC/AHA STAGES OF HEART FAILURE NYHA FUNCTIONAL CLASSIFICATION ● Arrhythmias (tachycardia and bradycardia)
(STAGES OF HEART FAILURE BASED ON (SEVERITY BASED ON SYMPTOMS AND PHYSICAL ● Alcohol
STRUCTURE AND DAMAGE TO HEART MUSCLE) ACTIVITY) ● Medicines (calcium antagonists, antiarrhythmics,
Stage A Class I cytotoxic drugs)
At high risk for developing heart failure. No limitation of physical activity.
No identified structural or functional Ordinary physical activity does not Pathophysiology
abnormality; no signs or symptoms cause undue fatigue, palpitation or Heart failure is a multisystem disorder associated with
dyspnoea systolic and diastolic dysfunction of the myocardial tissue.
Stage B Class II It is characterised by abnormalities of cardiac, skeletal
Developed structural heart disease that Slight limitation of physical activity. muscle and renal function; stimulation of the sympathetic
is strongly associated with the Comfortable at rest but ordinary nervous system; and a complex pattern of neurohormonal
development of heart failure, but physical activity results in fatigue, changes.
without signs and symptoms palpitation or dyspnoea
Myocardial systolic dysfunction Myocardial systolic
Stage C Class III
dysfunction is described by impairment of left ventricular
Symptomatic heart failure associated Marked limitation of physical activity.
function, which leads to a fall in cardiac output. This in
with underlying structural heart disease Comfortable at rest but less than
turn leads to activation of neurohormonal compensatory
ordinary physical activity results in
mechanisms aiming to improve the mechanical capacity of
fatigue, palpitation or dyspnoea
the heart, as shown in Figure 1 (p116). It has been
Stage D Class IV estimated that 30–40% of patients with heart failure have
Advanced structural heart disease and Unable to carry out any physical normal ventricular systolic contraction.5
marked symptoms of heart failure at activity without discomfort. Symptoms
rest despite maximal medical therapy at rest. If any physical activity is Myocardial diastolic dysfunction Myocardial diastolic
undertaken discomfort is increased dysfunction occurs because myocardial relaxation is
ACC/AHA = American College of Cardiology and American Heart Association compromised, causing stiffness in the ventricular wall and
NYHA = New York Heart Association
impairment of diastolic ventricular filling.5
116 Clinical Pharmacist March 2009 Vol 1

Figure 1: Neurohormonal mechanism and compensatory mechanism in heart failure value for heart failure, a completely normal ECG would
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mean that systolic dysfunction is unlikely.

Left ventricular dysfunction Common ECG abnormalities in patients with heart
failure can include: sinus tachycardia; sinus bradycardia;
atrial tachycardia, flutter or fibrillation; ventricular
Heart failure arrhythmias; ischaemia; left ventricular hypertrophy; and
atrioventricular block.
Reduced stroke volume and cardiac output
Chest X-ray Chest X-ray is an important diagnostic tool
for patients with suspected heart failure and it can also be
Neurohormonal response used to monitor the response to therapy. Chest X-ray may
show cardiac enlargement (including cardiomegaly),
pulmonary venous congestion, pleural effusion, and
Activation of sympathetic Activation of renin-angiotensin-
nervous system aldosterone system pulmonary infection or infiltration.

Natriuretic peptides The heart secretes natriuretic

Vasoconstriction Vasoconstriction peptides as a homeostatic signal to maintain stable blood
(increased catecholamines) (increased angiotensin) pressure and prevent excess salt and water retention.
Atrial natriuretic peptide (ANP) has been identified in the
atrial myocardium. B-type natriuretic peptide (BNP) is
Raised heart rate and Increased blood volume, salt
contractility and water retention (aldosterone) primarily secreted by the ventricles in the heart as a
response to ventricular stretching or wall tension.6
BNP levels can be used to assess cardiac function, to
Ventricular wall dilatation (remodelling) help diagnose heart failure, including diastolic
and further heart failure dysfunction, and to monitor the success of treatment.
However, the use of BNP testing has been controversial
because of its cost and also because BNP levels can be
increased in pulmonary or renal diseases. Nevertheless,
Symptoms BNP concentrations are thought to correlate well with
The most common symptoms of chronic heart failure severity of heart failure and prognosis.
include dyspnoea, fatigue, lethargy and oedema.
Breathlessness on exertion is particularly common in Troponins Troponin I or T levels are mainly used to
heart failure, particularly in patients with comorbid determine myocyte necrosis in acute coronary syndrome
pulmonary disease. and hence can identify potential candidates for coronary
Orthopnoea is thought to be a more specific symptom, revascularisation. Troponin levels are also raised in acute
and paroxysmal nocturnal dyspnoea has a greater myocarditis and in severe heart failure or during a period
predictive value for heart failure as it results from of acute fluid overload (ie, decompensation, for example
increased left ventricular filling pressure. Fatigue and due to ischaemia or sepsis).
lethargy are related to skeletal muscle abnormalities and The combination of increased troponin levels and an
impaired muscle blood flow. Swelling of ankles and feet increased BNP level is a strong marker for the presence of
(oedema) is also commonly seen when patients present heart failure.
with heart failure.
Although there seems to be a poor relationship Echocardiography Echocardiography is the most useful
between symptoms and the severity of cardiac non-invasive tool for the assessment of left ventricular
dysfunction, symptoms tend to correlate well with dysfunction and, ideally, should be used for all patients
prognosis. Symptom control can be used effectively for with suspected heart failure.
monitoring the effects of therapy.

Diagnosis Box 3: Clinical examination

There are several diagnostic techniques that can be used
to determine heart failure. NICE’s diagnostic algorithm is Appearance Alertness, nutritional state, weight
reproduced in Figure 2 (p119).
Pulse Rate, rhythm and character
Clinical examination The symptoms and signs of heart Blood pressure Systolic, diastolic and pulse pressure
failure are crucially important for early identification of
Fluid overload Jugular venous pressure, peripheral
heart failure. The ESC guidelines recommend the clinical
oedema (ankles and sacrum),
assessments described in Box 3, including observation,
hepatomegaly, ascites
palpation and auscultation.
Lungs Respiratory rate, rales, pleural effusion
Electrocardiogram An electrocardiogram (ECG) is Heart Apex displacement, gallop rhythm,
taken routinely for all patients with suspected heart third heart sound and murmurs
failure. Although an abnormal ECG has little predictive
 Vol 1 March 2009 Clinical Pharmacist 119

Echocardiography allows a quantitative measurement Prognosis

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of the left ventricular ejection fraction (LVEF normal Determining an individual heart failure patient’s
>45%), which in turn is well correlated with the prognosis is difficult, with many factors complicating the
outcome and survival of patients with heart failure.7 picture. These factors include: advanced age; ischaemia;
Advances in echocardiography using contrast agents have arrhythmias; marked elevation of BNP; low LVEF; and
allowed for observation of left ventricular walls in more presence of other diseases such as diabetes, renal
detail. dysfunction, anaemia, chronic obstructive pulmonary
Common echocardiographic abnormalities observed disease and depression.
in heart failure include: reduced left ventricular ejection
fraction, increased left atrial size, left ventricular References
thickness, and valvular stenosis or regurgitation. 1 Task force for diagnosis and treatment of acute and chronic heart failure
2008 of the European Society of Cardiology. ESC guidelines for the
Greater availability of echocardiography services for diagnosis and treatment of chronic heart failure 2008. European Heart
heart failure patients in primary care has the potential to Journal 2008;29:2388–442.
2 Ho KK, Pinsky JL, Kannel WB, et al. The epidemiology of heart failure:
improve patient’s prognosis through speedier diagnosis. Framingham study. Journal of the American College of Cardiology
1993;22:6–13A.
3 Cowie MR, Mosterd A, Wood DA, et al. The epidemiology of heart failure.
Cardiac catheterisation Cardiac catheterisation is not European Heart Journal 1997;18:208–25.
used routinely for the diagnosis or management of heart 4 Cowie MR, Wood DA, Coats AJS, et al. Incidence and aetiology of heart
failure: a population-based study. European Heart Journal 1999;20:421–8.
failure. It is considered useful for heart failure patients
5 Grossman W. Diastolic dysfunction in congestive heart failure. New
with a history of angina or ischaemic left ventricular England Journal of Medicine 1991;325:1557–64.
dysfunction. It may also be used for patients with 6 Yasue H, Yoshimura M, Surhida H, et al. Localisation and mechanism of
secretion of B-type natriuretic peptide in comparison with those of A-
refractory heart failure of unknown cause. type natriuretic peptide in normal subjects and patients with heart
failure. Circulation 1994;90:195–203.
7 Cheesman MG, Leech G, Chambers J, et al. Central role of
Pulmonary function testing Spirometry is useful echocardiography in the diagnosis and assessment of heart failure. Heart
for excluding respiratory causes of breathlessness and 1998;80(s1):S1–5.

to evaluate the severity of concomitant pulmonary 8 National Institute for Health and Clinical Excellence. Management of
chronic heart failure in adults in primary and secondary care.
disease. www.nice.org.uk (accessed 17 February 2009).

Figure 2: Diagnostic algorithm for heart failure

?
This algorithm, which summarises recommendations for KEY
the diagnosis of heart failure, forms part of a clinical BNP = B-type natriuretic peptide
How can
guideline published by the National Institute for Health ECG = Electrocardiogram you fit
and Clinical Excellence in 2003.8 The guideline is being FBC = Full blood count
reviewed by NICE and a partial update is expected in 2010 LFTs = Liver function tests
TFTs = Thyroid function tests
diploma
U&Es = Urea and electrolytes tutoring into your
Suspected heart failure busy workload
(history, signs and symptoms)

Other recommended tests to

Seek to exclude heart failure exclude other conditions
through ● Chest X-ray
● 12-lead echocardiogram ● Blood tests: U&Es, creatinine, FBC,
● and/or natriuretic peptide (eg, BNP) TFTs, LFTs, glucose and lipids
where available ● Urinalysis and peak flow/spirometry
CAREER DEVELOPMENT

Both normal
Heart failure unlikely,
One of more abnormal
(p141)
consider alternative diagnosis Imaging by echocardiography

Abnormal
No abnormality detected Assess heart failure severity, cause,
Heart failure unlikely, but if diagnostic precipitating and exacerbating factors
doubt persists consider diastolic and type of cardiac dysfunction.
dysfunction and consider referral for Correctable causes must be identified.
specialist assessment Consider referral