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“Doctor, I’m short of breath:
is this heart failure?”
Dyspnea is the most common presenting symptom of heart failure (HF). Mr. Roberts and Dr.
Rajda review the utility of various clinical tools for diagnosing HF in patients presenting with
dyspnea.
Derek J. Roberts, BSc (Pharm); and Miroslaw Rajda, MD, FRCPC
eart failure (HF) is a clinical diagnosis
requiring integration of risk factors for HF,
signs and symptoms and other objective data.
Breathlessness (dyspnea) is the most common
presenting symptom of HF. However, dyspnea is
also commonly present in diseases such as:
• chronic obstructive pulmonary disease
(COPD),
• obesity,
• nephrotic syndrome and
• cirrhosis,
• among others.
H
Ken’s Dyspnea
Ken, 65, has a history of hypertension and
previous ST-segment elevation MI. He presents to
his FP with a nocturnal cough and increasing
dyspnea with exertion over the last three weeks.
Four days ago, he also began experiencing
difficulty breathing when lying flat.
Ken’s physical examination displays bilateral
lower extremity edema and elevated jugular
venous pressure (JVP). Auscultation reveals a
third heart sound (S3), but no pulmonary rales.
For more on Ken, turn to page 32.
Risk factors and
comorbidities for HF
Each patient presenting with dyspnea should be
investigated for risk factors or comorbidities that
predispose to development of HF. Findings that
should increase suspicion of HF in patients presenting with dyspnea can be found in Table 1.
fluid from gravity dependent areas after lying
down. Orthopnea can be functionally defined as
breathlessness beginning less than or equal to one
minute after lying supine. The severity can be
quantified
©by the number of pillows utilized by
the patients to relieve their breathlessness.
Specific symptoms for HF
However, it is important tonldifferentiate
from
oad,
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n
Symptoms that are common but non-specific to habit pillow use,
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e regularly use
sers sonal us
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HF include:
multiple
pillows.
d
rise for per
utho Paroxysmal
• fatigue,
nocturnal dyspnea (PND) shares a
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• dyspnea,
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pathophysiologic
mechanism with orthops
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• weight gain, oris
nea and is characterized by breathlessness that typan
th
viewand
,
y
• abdominal
ically
occurs four hours after the onset of sleep or
Unaufullness/bloating
a
l
disp
• reduced exercise tolerance.
lying supine. After awakening from sleep, patients
Symptoms that are more specific for HF include: sit up or even walk around for 10 minutes to 30
• orthopnea and
minutes to get relief and they often have a wheeze
• paroxysmal nocturnal dyspnea (PND)1-3.
and a cough.
Orthopnea occurs as a result of an increase in
venous return after redistribution of interstitial
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Perspectives in Cardiology / October 2006 29
Heart Failure
Table 1
Risk factors and predisposing
conditions for development of HF
•
•
•
•
•
•
•
•
•
•
•
•
Coronary artery disease
Previous MI
Hypertension
Valvular heart disease
Elevated JVP
JVP is an estimate of right atrial pressure that is
useful in the diagnosis and management of
patients with HF. An elevated JVP (> 3 cm above
the level of the sternal angle) is a specific but
insensitive marker that increases the likelihood of
HF approximately five fold (sensitivity 39% and
specificity is 94%).1-2
Alcohol/cardiotoxins
Family history of dilated cardiomyopathy
Positive abdominojugular reflex
Age
A positive abdominojugular reflex makes the
diagnosis of HF six times more likely.2
Thus, examination of the neck veins in
conjunction with abdominojugular reflex is one
of the best clinical tools for determining the fluid
status in patients with dyspnea (sensitivity and
specificity is around 80%).
Renal dysfunction
Diabetes
Congenital heart anomalies
Obesity
Other causes
HF: Heart Failure
Sensitive and specific physical
signs for HF
The physical signs of HF depend on whether it is
right, left, or biventricular cardiac dysfunction. In
predominant left-sided HF, only a third heart
sound (S3) and pulmonary rales should be present. Common signs of HF include:
• elevated neck veins/jugular venous
pressure (JVP),
• a positive abdominojugular reflex,
• pulmonary rales, or
• pleural effusion,
• presence of S3,
• tachycardia,
• ascites and
• lower extremity edema.
About the authors...
Mr. Roberts is a Medical Student, Faculty of
Medicine, Dalhousie University, Halifax, Nova
Scotia.
Dr. Rajda is an Assistant Professor of Medicine,
Division of Cardiology, Department of Medicine,
Dalhousie University, Halifax, Nova Scotia.
30 Perspectives in Cardiology / October 2006
S3
The presence of S3 is extremely specific for HF
(specificity is 99%).4 However, many clinicians
may have trouble detecting its presence. The optimal way to appreciate the S3 is to place the
patient in the left lateral decubitus position and,
lightly using the bell of the stethoscope, listen at
the apex for an early, low-pitched, rumbling diastolic sound.
Lower extremity edema
Lower extremity edema has a sensitivity and
specificity of approximately 67% for HF.2
However, it can also occur in patients who:
• have been sitting or standing in one
position for a long period of time,
• have varicose veins or
• are taking certain medications, such as
dihydropyridine calcium channel blockers
(e.g., nifedipine).
Pulmonary rales
Rales are very specific for HF.2 However, they are
also very insensitive and their absence does not
indicate that the patient is not in HF.1-2
Heart Failure
Therefore, in contrast to JVP and
orthopnea/PND, the absence of pulmonary
rales tells you little about the fluid status in
patients with dyspnea.
he most commonly
reported finding on
chest radiographs in
patients with HF is
cardiomegaly as decided
by cardiothoracic ratio
T
Diagnostic tests for HF
Chest radiography
The chest radiograph plays an essential role in the
routine investigation of patients with suspected
HF.3 The most commonly reported finding on
chest radiographs in patients with HF is cardiomegaly as decided by cardiothoracic ratio. A
ratio > 0.5 is considered abnormal. Other findings include:
• vascular redistribution,
• peri-bronchial cuffing and
• pleural effusions.
However, one in five patients presenting to the ED
with acute HF will have a negative chest X-ray.
Chest radiography also provides valuable information about non-cardiac causes of dyspnea.
ECG
The 12 lead electrocardiographic tracing is
abnormal in most patients with HF, although
there are no specific features diagnostic of HF.
Common abnormalities include:
• Q waves,
• abnormalities in the T wave and ST segment,
• left ventricular hypertrophy,
• bundle branch block and
• atrial fibrillation.
The combination of a normal chest X-ray and
electrocardiographic tracing makes a cardiac
cause of dyspnea unlikely.
B-type natriuretic peptide
testing in patients with dyspnea
B-type natriuretic peptide (BNP) is a peptide hormone produced by the ventricular myocardium in
response to ventricular fluid overload such as that
which occurs in HF. Multiple clinical trials have
found that in patients presenting to the ED with
dyspnea, BNP testing is cost-effective and the
higher the level of BNP, the greater the chance
and severity of HF.4-6 These studies also found
that low levels of BNP rule out the diagnosis of
HF.4,6 Processes such as pulmonary embolism,
cor pulmonale and acute coronary syndromes
may cause ventricular stretch and lead to mild-tomoderate BNP secretion. As a result, a moderately elevated BNP needs to be interpreted in light of
the patient's clinical presentation.
Referring for an ECHO
The echocardiogram (ECHO) is a paramount
diagnostic test for HF. ECHO can accurately
determine:
• left ventricular size,
• systolic and diastolic function,
• ejection fraction,
• valvular abnormalities and
• other abnormalities which can result in HF.
A transthoracic ECHO should be performed in
all patients with suspected HF.3
Perspectives in Cardiology / October 2006 31
Heart Failure
Back to Ken
Ken exhibits many signs that are highly specific
to HF including:
• an elevated JVP,
• orthopnea and
• the presence of an S3.
Therefore, his primary care physician started him
on a regimen of HF medications and referred him
to a cardiologist for further investigation.
The cardiologist sent Ken for an echocardiogram,
which revealed a dilated left ventricle with an ejection fraction of 19%.
Summary
Now I have a story
to tell my grandchildren.
All patients presenting with dyspnea should have:
• a careful history taken, including HF risk
factors,
• a physical examination,
• a chest X-ray and ECG,
• BNP testing should be performed (if
available)
• a transthoracic echocardiogram. PCard
References
1. Butman SM, Ewy GA, Standen JR, et al: Bedside cardiovascular
examination in patients with severe chronic heart failure:
Importance of rest or inducible jugular venous distension. J Am Coll
Cardiol 1993; 22(4):968-74.
2. Wang CS, FitzGerald JM, Schulzer M, et al: Does this dyspneic
patient in the emergency department have congestive heart failure?
JAMA 2005; 294(15):1944-56.
3. Arnold JMO, Liu P, Demers C, et al: Canadian Cardiovascular Society
consensus conference recommendations on heart failure 2006:
Diagnosis and management. Can J Cardiol 2006; 22(1):23-45.
4. Mueller C, Laule-Kilian K, Schindler C, et al: Cost-effectiveness of Btype natriuretic peptide testing in patients with acute dyspnea. Arch
Intern Med 2006; 166(10):1081-7.
5. Maisel AS, Krishnaswamy P, Nowak RM, et al: Rapid measurement
of B-type natriuretic peptide in the emergency diagnosis of heart
failure. N Engl J Med 2002; 347(3):161-7.
6. Dao Q, Krishnaswamy P, Kazanegra R, et al: Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an
urgent-care setting. J Am Coll Cardiol 2001; 37(2):379-85.
32 Perspectives in Cardiology / October 2006
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