Controversies in heart failure diagnosis
Dr. Frans Rutten, Utrecht, The Netherlands
Heart failure occurs when the ventricles have a reduced ability to fill or to eject blood, resulting in an insufficient cardiac output to satisfy the metabolic needs of the body. There is a common perception that heart failure is a disease of the elderly, which has a slow onset in primary care and is always left sided. In actual fact, 65-75% of those with low ejection fraction heart failure are under 75 years of age. Furthermore, the prevalence of the condition is 1-1.5% which suggests that there would be 20-30 patients with a diagnosis of this in a typical General Practice population.
Research has shown that 30% of patients with a GP label of heart failure do not in fact have the condition, whilst 30% of those with actual heart failure remain undiagnosed. It is therefore important for GPs to consider the possibility of heart failure in any patient with shortness of breath, exercise intolerance/fatigue or peripheral oedema. This is particularly so for those at high risk such as the elderly, those with a prior myocardial infarction, Type 2 diabetes, hypertension, COPD or renal dysfunction.
The ESC guidelines 2008 only recommend adding an aldosterone antagonist for those in whom symptoms persist after therapy with a diuretic, ACE inhibitor and betablocker. However, eplerenone is advisable in anyone with an ejection fraction of less than 30% and this will be reflected in the new ECS guidance which is due to be published in 2012. BNP is now used as a diagnostic tool for heart failure and is also useful in monitoring. For those with “slow onset” symptoms a BNP of less than 125 pg/ml can be considered to be normal, though this threshold is raised to 400 pg/ml in the acute setting. Nonetheless, an echocardiogram is still needed to determine the possible cause of any heart failure (e.g. valvular disease) and to assess whether the ejection fraction is preserved or not. For those with a raised BNP, symptoms of heart failure but a normal ejection fraction, the priority is to treat any co-morbidities.
View the EPCCS Expert Opinion
Dr. Frans Rutten clarifies which symptoms are suspicious for heart failure and which tests can be used .