ALGORITHM ANNOTATIONS

HEART FAILURE SUSPECTED

With history and symptoms:

• Respiratory distress, SOB, DOE, orthopnea, PND, new or increased cough.
• Weight gain, edema.
• GI symptoms, hepatic congestion symptoms, abdominal pain, ascites, decreased appetite.
• Fatigue, decreased exercise tolerance.
• Altered mental status, fainting, confusion.

INITIAL EVALUATION

History

• Previous cardiac history, angina, abnormal heart rhythm. rheumatic fever, valvular disease, bacterial endocarditis.
• Family history of hypertension, diabetes, hyperlipidemia, peripheral vascular disease, chest radiation.
• ETOH and drug abuse, chemotherapy, recent viral illness, recent pregnancy, blunt chest trauma, foreign travel, thyroid dysfunction symptoms, exposure to sexually transmitted diseases.

Physical Examination

• Vital signs, include weight.
• Evaluate jugular venous pressure, positive hepato-jugular reflux.
• Lungs rales.
• S3, significant heart murmur.
• Bilateral lower extremity edema.
• Increased abdominal size, liver enlargement and tender, ascites.

INITIAL LABORATORY EVALUATION

• Complete blood count, sodium, potassium, BUN, creatinine.
• CXR, ECG, UA
• CPK, troponin (if patient presents with chest pain).
• Serum protein, TSH, LFT, blood lipids.
• BNP test
• (In special cases may include studies for hemochromatosis, pheochromocytoma, connective tissue disease, HIV)

INITIAL EVALUATION OF LEFT VENTRICULAR FUNCTION

Test	Advantages	Disadvantages
Echocardiogram	- Evaluate left ventricular systolic (and diastolic) function, LV size, LVH, valvular disease, right heart size and crude systolic function, pulmonary hypertension, pericardial disease-effusion. - More readily available.	- Technically inadequate study in about 10%, particularly in obese or lung disease patients. Some of this problem can be overcome with new contrast study.
Radionuclide	- Thought to be more accurate in measurement of left ventricular ejection fraction. - Assessment of RV function is possible.	- Less readily available. - Requires venepuncture. - Radiation exposure.
To assess ischemic induced left ventricular systolic dysfunction, will require stress (physical or pharmacological) radionuclide or echocardiographic studies.

Comment:

• Determination of left ventricular systolic function provides information that can be useful for prognosis and treatment for both symptomatic and asymptomatic left ventricular systolic dysfunction patients.
• Left ventricular systolic or diastolic (or combine) dysfunction may be an important cause or only a contributing cause of the patient with heart failure syndrome.
• Care must be taken to determine the cause of these left ventricular dysfunctions so that the therapy can be instituted properly, such as treatment of ischemia, valvular disease, hypertension, pericardial disease. etc.
• Heart failure symptoms may not correlate well with level of ejection fraction.
• Left ventricular diastolic dysfunction of some degree is commonly associated with systolic dysfunction. Isolated diastolic dysfunction may be seen with left ventricular hypertrophy, constrictive pericarditis, infiltrative diseases such as amyloid heart disease before systolic dysfunction develops.
• There are principal differences in treatment of patients with left ventricular systolic and diastolic dysfunction.