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See what questions
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Anthony F. Jerant
Congestive heart failure (CHF) is the most frequent reason for hospitalization among older adults in the United States. Nearly one-third of a national cohort of 170,239 Medicare enrollees hospitalized for the first time with CHF died within a year of discharge (1).
CHF is a syndrome, not a disease. Attempt to elucidate which type of CHF is present and search for causes and exacerbating factors to optimize therapy.
A. Types of CHF. Two types of CHF are seen, each with many potential causes (Table 7.2).
B. Special concerns: CHF associated with hypoxia, hypotension, angina, myocardial infarction (MI), florid pulmonary edema, or severe complicating illness (e.g., pneumonia). Emergent stabilization and hospitalization are indicated in such cases (2).
A. Common presenting symptoms. Does the patient have orthopnea, paroxysmal nocturnal dyspnea, or dyspnea on exertion? How much exertion triggers dyspnea? These are relatively specific symptoms for CHF. Less specific symptoms include swelling of the legs, increasing weight, and generalized fatigue. Older patients with CHF may not have dyspnea on exertion because of a sedentary baseline status; they often present with atypical symptoms such as dry cough, daytime oliguria with nocturia, and confusion (3).
B. Past medical history. Are conditions present that can cause CHF (Table 7.2)? If so, are they well-controlled with lifestyle changes, medications, or both? Uncontrolled hypertension, myocardial ischemia, and medication noncompliance frequently trigger CHF.
C. Psychosocial history. Is there current or previous heavy alcohol use, tobacco use, or stimulant drug use? Is the patient consuming too much dietary sodium (> 2 g/d)? Are symptoms hindering the patient’s ability to perform daily activities? Is the patient depressed? How is the family coping? Poor understanding of lifestyle factors, depression, and limited family resources can lead to noncompliance and frequent CHF exacerbations.
A. Focused physical examination. In general, the physical examination is more sensitive in detecting acute CHF than it is in detecting chronic CHF. Evaluate the following:
1. Vital signs. Note the blood pressure; hypertension with acute CHF suggests diastolic dysfunction (4). Obtain pulse, respiratory rate, and pulse oximetry to detect hypoxia.
2. Neck. Look for jugular venous distension, one of the more reliable physical examination indicators of CHF (4).
3. Lungs. Rales are commonly heard, but wheezing (“cardiac asthma”) can also appear.
4. Heart. Palpate the apical impulse. If laterally displaced, diffuse, and especially of sustained duration, CHF caused by reduced left ventricular (LV) systolic function is likely (4). Listen for murmurs, gallops, and rubs. An S3 gallop is generally suggestive of CHF (4), whereas an S4 gallop may be a nonpathologic, age-related finding in elderly patients (3).
5. Abdomen. Assess for hepatosplenomegaly and try to elicit abdominojugular reflux.
6. Extremities. Look for leg edema (pitting in acute CHF, brawny in chronic CHF).
B. Additional physical examination. Further examination is appropriate if the history suggests specific causes for CHF: funduscopic examination to search for hypertensive retinopathy; thyroid palpation and auscultation; palpation of peripheral pulses; and carotid palpation and auscultation for evidence of stenosis, a marker of coronary atherosclerosis.
A. Preliminary evaluation. Obtain the following when acute CHF is suspected to assess for confirmatory signs, triggers, and associated conditions: electrocardiogram (MI) or ischemia, dysrhythmia; chest radiograph (cardiomegaly, pulmonary vascular redistribution, alveolar edema); serum electrolytes, albumin, blood urea nitrogen, creatinine (hypokalemia, hypoalbuminemia, acute renal failure); complete blood count (anemia); and urinalysis (nephrosis).
1. In the setting of suggestive symptoms, anterior Q waves and left bundle branch block on electrocardiography are each nearly 90% specific for LV systolic dysfunction (4).
B. Confirmatory evaluation. Echocardiography (ECHO) should be expeditiously obtained in all patients when new-onset CHF is suspected clinically. An LV ejection fraction (EF) ≤ 40% indicates systolic dysfunction, whereas a normal EF accompanied by findings suggestive of increased LV end-diastolic pressure suggests diastolic dysfunction. ECHO is technically inadequate in up to 18% of patients (2). Radionuclide ventriculography can be used in such cases, but it is less able to detect valvular disease and LV hypertrophy.
C. Additional testing. Because of frequent comorbid lung disease, pulmonary function testing should be considered in older patients before dyspnea is attributed to CHF. The need for other tests (e.g., thyroid-stimulating hormone) is determined by findings on the history and physical examination.
The two keys to the diagnosis of CHF are:
A. A high index of suspicion in patients with potential causes and suggestive symptoms. However, findings on history and physical examination are neither sensitive nor specific. Half of all CHF diagnoses made in the primary care setting using clinical indicators alone are inaccurate (5).
B. ECHO. This critical diagnostic study may also indicate which type of CHF is present which, in turn, facilitates the selection of an appropriate therapeutic regimen. Nevertheless, ECHO has some limitations. Current techniques cannot provide definitive proof of diastolic dysfunction, so a thorough search for other causes of CHF with preserved systolic function should be conducted before accepting this diagnosis. Furthermore, LV systolic dysfunction can be a transient phenomenon in patients with acute myocardial ischemia. Therefore, a repeat ECHO should be obtained after stabilization of such patients.
References
1. Croft JB, Giles WH, Pollard RA, Keenan NL, Casper ML, Anda RF. Heart failure survival among older adults in the United States. Arch Intern Med 1999;159:505–510.
2. Agency for Health Care Policy and Research. Clinical practice guideline. Heart failure: evaluation and care of patients with left-ventricular systolic dysfunction. Silver Spring, MD: Agency for Health Care and Research, 1994.
3. Tresch DD. The clinical diagnosis of heart failure in older patients. J Am Geriatr Soc 1997;45:1128–1133.
4. Badgett RG, Lucey CR, Mulrow CD. Can the clinical examination diagnose left-sided heart failure in adults? JAMA 1997;227:1712–1719.
5. Vasan RS, Benjamin EJ, Levy D. Congestive heart failure with normal left ventricular systolic function. Arch Intern Med 1996;156:146–157.
Read excerpts from these other book chapters related to Heart failure:
Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
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More About This Book:
Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X 
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