Download Dia 1 - EPCCS

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
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
Hypertension, diabetes, COPD
64 years old
‘no’ comorbidity
30 pack years smoking
30 pack years smoking
slowly increase in dyspnoea, fatigue
166/92, 92 bpm
acute dyspnoea, orthopnoea,
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
JVP
Age
Prior MI, CABG, PCI
Apical impulse
crepitations
Murmur
JVP
Male sex
Prior MI
crepitations
oedema
AUC 0.75
LVSD (LVEF <50%)
Fahey et al. Fam Pract 2007;24:628-
AUC 0.82
(>700 patients)
Kelder et al. Submitted
AUC 0.66-0.79
(MICE, 6 of 9 studies)
Mant et al. HTA 2009;13:no 32
Clinical models to detect or exclude HF in suspected patients from PC
Age
Male sex
Prior MI, CABG, PCI
Diabetes
Orthopnoea
Crepitations, elevated JVP, S3 gallop, ankle oedema
AUC 0.79
Kelder et al Heart 2011
Clinical model (screening) elderly stable COPD
Prior MI, CABG, PCI
Apical impulse
Heart rate >90 bpm
BMI >30 kg/m²
AUC 0.70
(screening elderly COPD patients)
Rutten et al. BMJ 2005;331:1379
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
wall motion abnormalities
other cardiac abnormalities
causes of HF
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
+ ECG
0.75
0.86
Clinical model
+ ECG
+ Chest X-ray
+ ntproBNP
0.82
0.83
0.84
0.86
Clinical model
+ ECG
+ ntproBNP
0.66-0.79
0.76-0.83
0.83-0.93
Clinical model
+ ECG
+ Chest X-ray
+ ntproBNP
0.79
0.85
0.84
0.91-0.92
Fahey et al. Fam Pract 2007;24:628
Kelder et al. Submitted
(6 of 9 studies)
Mant et al. HTA 2009;13:no 32
Kelder et al. Heart 2011;97:959
Multivariable models for detection/exclusion (slow onset) HF
Fahey et al. Fam Pract 2007;24:628-
Clinical model
+ ECG
+ Chest X-ray
+ ntproBNP
0.70
0.75
0.73
0.77
(screening elderly COPD patients)
Rutten et al. BMJ 2005;331:1379
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
Heart failure
very unlikely
ECG abnormal or
NT-proBNP≥400 pg/ml
BNP≥100 pg/ml
ECG abnormal or
NT-proBNP≥ 125 pg/ml
BNP≥ 35 pg/ml
Echocardiography
ECG normal and
NT-proBNP<125 pg/ml
BNP< 35 pg/ml
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
in elderly persons, male sex, prior CAD, diabetes
•
•
•
•
essentials
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)!!