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Heart failure - Diagnosis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of heart failure.

Alternative Names

Cardiomyopathy; Congestive heart failure

Diagnosis:

Doctors can often make a preliminary diagnosis of heart failure by medical history and careful physical examination.

A thorough medical history may identify risks for heart failure that include:

  • High blood pressure
  • Diabetes
  • Poor cholesterol levels
  • Heart disease or history of heart attack
  • Thyroid problems
  • Obesity
  • Lifestyle factors (such as smoking, alcohol use, and drug use)

The following physical signs, along with medical history, strongly suggest heart failure:

  • Enlarged heart
  • Abnormal heart sounds
  • Abnormal sounds in the lungs
  • Swelling or tenderness of the liver
  • Fluid retention in legs and abdomen
  • Elevation of pressure in the veins of the neck

Laboratory Tests

Both blood and urine tests are used to check for problems with the liver and kidneys and to detect signs of diabetes. Lab tests can measure:

  • Complete blood counts to check for anemia
  • Kidney function blood and urine tests
  • Sodium, potassium, and other electrolytes
  • Cholesterol and lipid levels
  • Blood sugar (glucose)
  • Thyroid function
  • Brain natriuretic peptide (BNP), a hormone that increases during heart failure. BNP testing can be very helpful in correctly diagnosing heart failure in patients who come to the emergency room complaining of shortness of breath (dyspnea).

Electrocardiogram

An electrocardiogram (ECG) cannot diagnose heart failure, but it can indicate underlying heart problems. It is also called an EKG. The test is simple and painless to perform. It may be used to diagnose:

  • Enlargement of the heart muscle, which may help to determine long-term outlook
  • The presence of coronary artery disease
  • Abnormal cardiac rhythms
  • A finding called a prolonged QT interval may indicate people with heart failure who are at risk for severe complications and therefore need more aggressive therapies.

If a patient has a completely normal ECG they are unlikely to have heart failure.

The electrocardiogram (ECG, EKG) is used extensively to diagnose heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. There are several different types of electrocardiograms.
ECG

Echocardiography

The best diagnostic test for heart failure is echocardiography. Echocardiography is a noninvasive, entirely safe test that uses ultrasound to image the heart as it is beating. Cardiac ultrasounds provide the following information:

  • Evaluations of valve function
  • Important measurements about how well the heart is pumping, especially a measurement called left ventricle ejection fraction (LVEF)
  • Type of heart failure
  • Changes in the structure of the heart that may be a result of heart failure

Doctors use information from the echocardiogram for calculating the ejection fraction (how much blood is pumped out during each heartbeat), which is important for determining the severity of heart failure. Stress echocardiography may be needed if coronary artery disease is suspected.

Angiography

Doctors may recommend angiography if they suspect that blockage of the arteries is contributing to heart failure. This procedure is invasive.

  • A thin tube called a catheter is inserted into one of the large arteries in the arm or leg.
  • It is gently guided through the artery until it reaches the heart.
  • The catheter measures internal blood pressure at various locations, giving the doctor a comprehensive picture of the extent and nature of the heart failure.
  • Dye is then injected through the tube into the heart.
  • X-rays called angiograms are taken as the dye moves through the heart and arteries.
  • These images help locate problems in the heart's pumping action or blockage in the arteries.


Click the icon to see an image of cardiac catheterization.

Other Imaging Tests

X-Rays. Chest x-rays can show whether the heart is enlarged. Computed tomography (CT) and magnetic resonance imaging (MRI) may also be used to evaluate the heart valves and arteries.

Radionuclide Ventriculography. Radionuclide ventriculography is an imaging technique that uses a tiny amount of radioactive material (called a trace element). It is very sensitive in revealing heart enlargement or evidence of fluid accumulation around the heart and lungs. It is may be done at the same time as coronary artery angiography. It can help diagnose or exclude the presence of coronary artery disease and helps demonstrate how the heart works during exercise.

Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) scans that use contrast dyes to improve resolution may help identify whether there is any heart muscle that can be helped by opening up the arteries feeding it. Damage appears as very bright areas on the scan.

Exercise Stress Test

The exercise stress test measures heart rate, blood pressure, electrocardiographic changes, and oxygen consumption while a patient is performing physically, usually walking on a treadmill. Can help determine heart failure symptoms. Doctors also use exercise tests to gauge long-term outlook and the effects of particular treatments. A stress test may be done using echocardiography or may be done as a nuclear stress test.

Resources

References

Bibbins-Domingo K, Pletcher MJ, Lin F, Vittinghoff E, Gardin JM, et al. Racial differences in incident heart failure among young adults. N Engl J Med. 2009 Mar 19;360(12):1179-90.

Birks EJ, Tansley PD, Hardy J, George RS, Bowles CT, Burke M, et al. Left ventricular assist device and drug therapy for the reversal of heart failure. N Engl J Med. 2006 Nov 2;355(18):1873-84.

Carlson MD, Wilkoff BL, Maisel WH, Carlson MD, Ellenbogen KA, Saxon LA, et al. Recommendations from the Heart Rhythm Society Task Force on Device Performance Policies and Guidelines Endorsed by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) and the International Coalition of Pacing and Electrophysiology Organizations (COPE). Heart Rhythm. 2006 Oct;3(10):1250-73.

Epstein AE, Dimarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, Gettes LS, et al. ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities. Heart Rhythm. 2008 Jun;5(6):e1-62. Epub 2008 May 21.

Gissi-HF Investigators, Tavazzi L, Maggioni AP, Marchioli R, Barlera S, Franzosi MG, et al. Effect of n-3 polyunsaturated fatty acids in patients with chronic heart failure (the GISSI-HF trial): a randomised, double-blind, placebo-controlled trial. Lancet. 2008 Oct 4;372(9645):1223-30. Epub 2008 Aug 29.

Hare JM. The dilated, restrictive, and infiltrative cardiomyopathies. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 64.

Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA, Clark AM. A meta-analysis of the effect of exercise training on left ventricular remodeling in heart failure patients: the benefit depends on the type of training performed. J Am Coll Cardiol. 2007 Jun 19;49(24):2329-36. Epub 2007 Jun 4.

Hess OM and Carroll JD. Clinical assessment of heart failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 23.

Hildebrandt P. Systolic and nonsystolic heart failure: equally serious threats. JAMA. 2006 Nov 8;296(18):2259-60.

Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. Epub 2009 Mar 26

Konstam MA, Gheorghiade M, Burnett JC Jr, Grinfeld L, Maggioni AP, Swedberg K, et al. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA. 2007 Mar 25; [Epub ahead of print]

Khush KK, Waters DD, Bittner V, Deedwania PC, Kastelein JJ, Lewis SJ, et al. Effect of high-dose atorvastatin on hospitalizations for heart failure: subgroup analysis of the Treating to New Targets (TNT) study. Circulation. 2007 Feb 6;115(5):576-83. Epub 2007 Jan 29.

Liu PP and Schultheiss H-P. Myocarditis. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 66.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 25.

McAlister FA, Ezekowitz J, Dryden DM, Hooton N, Vandermeer B, Friesen C, et al. Cardiac Resynchronization Therapy and Implantable Cardiac Defibrillators in Left Ventricular Systolic Dysfunction. Evidence Report/Technology Assessment No. 152 (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. 290-02-0023). AHRQ Publication No. 07-E009. Rockville, MD: Agency for Healthcare Research and Quality. June 2007.

Naka Y and Rose EA. Assisted circulation in the Treatment of Heart Failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007; chap 28.

Rich S and McLaughlin VV. Pulmonary hypertension. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 73.

Schocken DD, Benjamin EJ, Fonarow GC, Krumholz HM, Levy D, Mensah GA, et al.Prevention of heart failure: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation. 2008 May 13;117(19):2544-65. Epub 2008 Apr 7.

  • Reviewed last on: 5/13/2009
  • Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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