Beginning >> Diseases >> Diagnosis >> Diagnosis of chronic heart failure

Diagnosis of chronic heart failure

Table of contents
Diagnosis of chronic heart failure
Symptoms and clinical signs
Algorithm of diagnosis

The main thing in diagnosis of chronic heart failure — to remember the principle: the characteristic symptom has to be combined with the tool signs confirming injury of heart. In doubtful cases estimate reaction to therapy (more often diuretic). Positive reaction (reduction of an asthma, improvement of health) testifies in favor of chronic heart failure. But before research is better not to lead up and execute the qualified KG Echo.

Principles of diagnosis of chronic heart failure

There are two opposite views on diagnosis of HSN. Supporters of the first recognize from situation that heart failure is a clinical syndrome. In this regard, in their opinion, in diagnosis of chronic heart failure the detailed assessment of the anamnesis of a disease and full clinical inspection has the leading value. It is considered that the syndrome of HSN is rather well diagnosed on the basis of only clinical data and therefore, at statement of the diagnosis it is optional to use all arsenal of additional tests and researches at all. Authors of the real grant are opponents of trivial approach to diagnosis of chronic heart failure.
In editorial article "What is heart failure? How it is better to diagnose it?" Heart failure magazine Yu. N. Belenkov and soavt. give the fragment of conversation of interns of the 1st year of training which is very colourfully showing the similar simplified approach to diagnosis: "... to diagnose heart failure? — there is nothing more simply: short wind, hypostases, rattles in lungs..."
We had to face even more primitive categorical judgment of "experienced" cardiologists: "For diagnosis of heart failure it is enough at the patient with an asthma to estimate temperature of brushes: cold hands ("cold" cyanosis) unambiguously testify to HSN whereas warm ("warm" cyanosis) — about a disease of lungs".
The clinical stage of diagnosis, undoubtedly, is very important (necessary) in recognition of HSN. However without verification stage diagnosis of HSN is not always faultless, and the diagnosis is imperfect. So, coincidence of opinions of different specialists in a question of existence or absence at the patient of symptoms of HSN (cross reproducibility) is observed not in each case. Sensitivity (a share of patients from chronic heart failure who have a positive symptom) such "student's" symptoms of HSN as hypostases and wet rattles in lungs obviously does not reach 100% (tab. 1).
Table 1. Symptoms, the most characteristic of patients from chronic heart failure


Symptom

The expected frequency of occurrence (%)

Actual frequency of occurrence (%)

Asthma

99

98,4

Hypostases

98

73

Heartbeat

91,8

80,4

Orthopnea

84,7

28

Rattles

84,7

38,6

Fatigue

73,5

94,3

Cough

70,4

45,6

Results of the Russian research IMPROVEMENT demonstrate that the most frequent symptom of HSN in real practice is an asthma — 98,4%, symptoms, the second and third on frequency, are fatigue — 94,3% and heartbeat — 80,4%, but do not swell or rattles which occupy much more modest positions in the list of symptoms.
It is not necessary to revaluate also the diagnostic importance (the predictive value of a positive take is a probability of HSN at a positive symptom) HSN symptoms, first of all — asthmas. According to W. R. Harlan and soavt., sensitivity of the last symptom at HSN — only 66%, at a smaller specificity (a share of persons with a negative take of search of a symptom in population without HSN) which makes 52% (tab. 2).
Table 2. Sensitivity, specificity and the predictive importance of clinical signs and symptoms in diagnosis of chronic heart failure


Sign/symptom

Feeling
telnost

Spetsifich
nost

Positive predictive importance

Asthma

66

52

23

Orthopnea

21

81

2

Asthma attacks at night

33

76

26

Hypostases in the anamnesis

23

80

22

Heart rate of more than 100 in 1 min. at rest

7

99

6

Wet rattles in lungs

13

91

27

Hypostases according to physical inspection

10

93

3

III cardiac sound

31

95

61

The bulked-up cervical veins

10

97

2

The same can be told concerning other "popular" find at HSN — fatigue. Quite often an asthma and fatigue at an exercise stress are taken for manifestation of HSN, meanwhile as patients with obesity, respiratory diseases, anemia, hypo - and a hyperthyroidism, astenisation after the postponed infections and many other diseases can show similar complaints. At last, the same symptoms at rather expressed physical efforts can be noted also at healthy, but unexercised people, especially at elderly people. Besides it is necessary to remind that many symptoms of HSN — are extremely subjective.
Results of physical inspection also should not be revaluated as HSN signs revealed at the same time, possessing rather high specificity, are not sensitive (tab. 2) — at survey, a palpation, percussion and auscultation the doctor can not reveal any considerable changes (especially at rest) until the disease does not reach a certain degree of manifestation.
Thus, results of numerous researches testify — the accuracy of clinical diagnosis of HSN leaves much to be desired. There are bases to believe that results of Fremingemsky research during which a number of criteria (the main and additional) was formulated by HSN (tab. 3) will allow to facilitate clinical diagnosis. Presence of two main criteria or one basic and one-two additional allows with sufficient degree of reliability to assume existence of HSN at the patient.
However, as on the basis of complaints, data of the anamnesis (if of course the patient has no detailed extract from clinic with the high level of diagnosis) and the general survey it is only possible to take cognizance of the diagnosis of HSN, but in most cases it is required not to put with confidence expanded inspection.
In the International guide to SN it is specified: "It is necessary to take for the rule not to be limited to a clinical assessment of signs and symptoms of heart failure, and to try one way or another, for example, by means of an echocardiography, to investigate... the LZh function before making the diagnosis to heart failure...".
Table 3. Diagnostic criteria of HSN (on But K.K. et al., 1993)

MAIN CRITERIA

SMALL CRITERIA (matter only in that case when other diseases are excluded)

  1. Paroxysmal night asthma or orthopnea
  2. The bulked-up jugular veins
  3. Wet rattles in lungs
  4. Cardiomegaly
  5. Fluid lungs
  6. The cantering rhythm caused by pathological III tone
  7. Venous pressure is more than 160 mm w.g.
  8. Gepatoyugulyarny reflux
  9. Blood-groove time> 25 with
  1. Hypostasis of the lower extremities
  2. Night cough
  3. Asthma at an exercise stress
  4. Hepatomegalia
  5. Liquid in a pleural cavity
  6. Sinus tachycardia (heart rate> 120 in a minute)
  7. Reduction of indicators of vital capacity of lungs on 1/3

Decrease in body weight> 4,5 kg in 5 days in response to therapy of HSN


According to recent Recommendations of the European society of cardiologists, and also National Recommendations about diagnosis and treatment of HSN, definition of HSN is possible on the basis of three key criteria: 1) characteristic symptoms and clinical signs of heart failure; 2) objective proofs that these symptoms are connected with heart dysfunction, but not any other bodies and systems (for example, diseases of lungs, anemia, a renal failure); 3) an affirmative answer on treatment (in doubtful cases of ex juvantibus) HSN, in particular, diuretics (tab. 4). As in it is visible from the data provided to tab. 4, symptoms and clinical signs can be present at rest and/or at loading while objective symptoms of dysfunction of heart have to come to light surely at rest! It is connected with the fact that, for example, the low fraction of emission or change of indicators of the LZh diastolic function at loading can be signs not of HSN, and coronary insufficiency. In the latter case it is about the induced loading of acute ischemic dysfunction.


Table 4. Definition of HSN

  1. Existence of symptoms and/or clinical signs of heart failure (at rest or at loading)
  2. Existence of objective symptoms of dysfunction of heart (at rest)
  3. In     doubtful cases — an affirmative answer on therapy of HSN

Existence of criteria 1 and 2 is obligatory in all cases
Detailing of the main criteria used when determining HSN is provided to tab. 5.
Table 5. The criteria used when determining HSN

I. Symptoms (complaints)

II. Clinical signs

III. Objective symptoms of dysfunction of heart

  1. Asthma (from insignificant to asthma)
  2. Fast fatigue
  3. Heartbeat
  4. Cough
  5. Orthopnea
  1. Stagnation in lungs (rattles, a X-ray analysis)
  2. Peripheral hypostases
  3. Tachycardia
  4. The bulked-up jugular veins
  5. Hepatomegalia
  6. Cantering rhythm (S3)
  7. Cardiomegaly
  1. ECG, thorax X-ray analysis
  2. Systolic dysfunction (4 contractilities)
  3. Diastolic dysfunction (doppler-EhoKG — DZLA)
  4. Hyperreactivity of MNP

In doubtful cases efficiency of treatment of exjuvantibus is estimated

Note. An ECG — an electrocardiography; DZLA — pressure of jamming of a pulmonary artery; MNP — brain natriuretic peptide.
Only one positive dynamics of a condition of the patient during treatment with the drugs used for treatment of chronic heart failure, insufficiently for diagnosis of this syndrome, nevertheless, the diagnosis becomes more reliable if against similar treatment (for example, purpose of diuretic drugs) manages to be reached rather fast weakening of manifestation of symptoms and/or signs of SN. In most cases it is not necessary to begin therapy until is sufficient confidence in correctness of the diagnosis.



 
"Diagnosis of the chronic small tortoiseshell   Diagnosis of diseases of the broken digestion and absorption at children"