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Evaluation of the patient with heart failure or cardiomyopathy

Evaluation of the patient with heart failure or cardiomyopathy


Author
Wilson S Colucci, MD
Section Editor
Stephen S Gottlieb, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Oct 2012. | This topic last updated: Oct 8, 2009.
INTRODUCTION Heart failure (HF) is a common clinical syndrome caused by a variety of
cardiac diseases [1]. Evaluation of the etiology and severity of heart failure is discussed here.
Initial evaluation of suspected heart failure and the management and prognosis of HF are
discussed separately. (See "Evaluation of the patient with suspected heart failure" and "Overview
of the therapy of heart failure due to systolic dysfunction" and "Prognosis of heart failure".)
DEFINITION AND CLASSIFICATION Heart failure (HF) is a complex clinical syndrome
that can result from any structural or functional cardiac disorder that impairs the ability of the
ventricle to fill with or eject blood. It is characterized by specific symptoms, such as dyspnea and
fatigue, and signs, such as fluid retention. There are many ways to assess cardiac function.
However, there is no diagnostic test for HF, since it is largely a clinical diagnosis that is based
upon a careful history and physical examination (table 1).
Classification of HF severity The history, including assessment of NYHA functional class,
and physical examination in conjunction with the diagnostic tests reviewed below should both
establish the primary cause of the heart failure and provide a reasonable estimate of its severity.
The classification system that is most commonly used to quantify the degree of functional
limitation imposed by HF is one first developed by the New York Heart Association (NYHA).
This system assigns patients to one of four functional classes, depending on the degree of effort
needed to elicit symptoms (table 2):

Class I symptoms of HF only at activity levels that would limit normal individuals
Class II symptoms of HF with ordinary exertion
Class III symptoms of HF with less than ordinary exertion
Class IV symptoms of HF at rest

Stages in the development of HF There are several stages in the evolution of HF, as outlined
by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines [2]:

Stage A High risk for HF, without structural heart disease or symptoms

Stage B Heart disease with asymptomatic left ventricular dysfunction


Stage C Prior or current symptoms of HF
Stage D Refractory end stage HF

This staged system, in contrast to the NYHA classification, emphasizes the progressive nature of
HF and defines the appropriate therapeutic approach for each stage.
The long-term prognosis can also be estimated. The peak VO2 is the most accurate predictor of
prognosis, but functional class and exercise capacity, the magnitude of the reduction in ejection
fraction with systolic dysfunction, serum BNP concentrations, and a variety of other factors are
also important. (See "Predictors of survival in heart failure due to systolic dysfunction" and
"Prognosis of heart failure", section on 'Predictive models'.)
Etiology There are two basic pathophysiologic mechanisms that cause reduced cardiac output
and HF: systolic dysfunction and diastolic dysfunction. Systolic and diastolic dysfunction each
may be due to a variety of etiologies. Effective management is often dependent upon establishing
the correct etiologic diagnosis. As an example, coronary revascularization may be beneficial in
patients with ischemic cardiomyopathy who have evidence of hibernating myocardium (see
'Detection of coronary artery disease' below).
Systolic dysfunction The most common causes of systolic dysfunction are coronary
(ischemic) heart disease, idiopathic dilated cardiomyopathy (DCM), hypertension, and valvular
disease. Effective therapy of hypertension has led to a changing pattern in which coronary
disease has become more prevalent as a cause of HF [3,4]. In one review, coronary disease and
hypertension accounted for 62 and 10 percent of cases, respectively [3]. (See "Epidemiology and
causes of heart failure".)

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