Diagnosis and Evaluation of Chronic Heart Failure (CHF)

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Diagnosis and Evaluation of Chronic Heart Failure (CHF)
Guidelines Being Compared:

► 1. European Society of Cardiology (ESC). ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J 2008 Oct;29(19):2388-442. [252 references]
http://guidelines.gov/content.aspx?id=13411

Guideline Title
ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008.

Bibliographic Source(s)
Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, Stromberg A, van Veldhuisen DJ, Atar D, Hoes AW, Keren A, Mebazaa A, Nieminen M, Priori SG, Swedberg K, ESC Committee for Practice Guidelines (CPG), Vahanian A, Camm J, De Caterina R, Dean V, Dickstein K, Filippatos G, Funck-Brentano C, Hellemans I, Kristensen SD, McGregor K, Sechtem U, Silber S, Tendera M, Widimsky P, Zamorano JL, Document Reviewers, Tendera M, Auricchio A, Bax J, Bohm M, Corra U, Della Bella P, Elliott PM, Follath F, Gheorghiade M, Hasin Y, Hernborg A, Jaarsma T, Komajda M, Kornowski R, Piepoli M, Prendergast B, Tavazzi L, Vachiery JL, Verheugt FW, Zamorano JL, Zannad F. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force [trunc]. Eur Heart J 2008 Oct;29(19):2388-442. [252 references] PubMed

Guideline Status
This is the current release of the guideline.

This guideline updates previous versions: Task Force on Acute Heart Failure of the European Society of Cardiology. Guidelines on the diagnosis and treatment of acute heart failure. Sophia Antipolis (FR): European Society of Cardiology; 2005. 36 p.

Swedberg K, Cleland J, Dargie H, Drexler H, Follath F, Komajda M, Tavazzi L, Smiseth OA, Gavazzi A, Haverich A, Hoes A, Jaarsma T, Korewicki J, Levy S, Linde C, Lopez-Sendon JL, Nieminen MS, Pierard L, Remme WJ. Guidelines for the diagnosis and treatment of chronic heart failure: full text (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Sophia Antipolis (FR): European Society of Cardiology (ESC); 2005. 45 p.



► 2. Heart Failure Society of America (HFSA). Evaluation of patients for ventricular dysfunction and heart failure: HFSA 2006 comprehensive heart failure practice guideline. J Card Fail 2006 Feb;12(1):e16-25. [33 references]
http://guidelines.gov/content.aspx?id=9320

Guideline Title
Evaluation of patients for ventricular dysfunction and heart failure: HFSA 2006 comprehensive heart failure practice guideline.

Bibliographic Source(s)
Heart Failure Society of America. Evaluation of patients for ventricular dysfunction and heart failure. J Card Fail 2006 Feb;12(1):e16-25. [33 references] PubMed

Guideline Status
This is the current release of the guideline.

This guideline updates a previous version: Heart Failure Society of America. Heart Failure Society of America (HFSA) practice guidelines. HFSA guidelines for management of patients with heart failure caused by left ventricular systolic dysfunction--pharmacological approaches. J Card Fail 1999 Dec;5(4):357-82.



► 3. National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHFA/CSANZ). Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006. Sydney (Australia): National Heart Foundation of Australia; 2006 Nov. 79 p. [335 references]
http://guidelines.gov/content.aspx?id=10372

Guideline Title
Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006.

Bibliographic Source(s)
National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand, Chronic Heart Failure Guidelines Expert Writing Panel. Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006. Sydney (Australia): National Heart Foundation of Australia; 2006 Nov. 79 p. [335 references]

Guideline Status
This is the current release of the guideline.

This guideline updates a previous version: National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand. Guidelines on contemporary management of the patient with chronic heart failure in Australia. Sydney (Australia): National Heart Foundation of Australia; 2002.



► 4. Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic heart failure. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2007 Feb. 53 p. (SIGN publication; no. 95). [155 references]
http://guidelines.gov/content.aspx?id=10587

Guideline Title
Management of chronic heart failure. A national clinical guideline.

Bibliographic Source(s)
Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic heart failure. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2007 Feb. 53 p. (SIGN publication; no. 95). [155 references]

Guideline Status
This is the current release of the guideline.

This guideline updates a previous version: Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 1999. 68 p. (SIGN publication; no. 35).

This guideline was issued in 2007 and will be considered for review in three years. Any updates to the guideline in the interim period will be noted on the Scottish Intercollegiate Guidelines Network (SIGN) Web site .



A direct comparison of recommendations presented in the above guidelines for the diagnosis and evaluation of chronic heart failure is provided below.

Areas of Agreement
Clinical Presentation/Assessment of Signs and Symptoms
There is overall agreement that the evaluation of patients with suspected HF focuses on interpretation of signs and symptoms, as they are what have led to consideration of the diagnosis and are the key to early detection. All of the groups stress the importance of taking a thorough history and careful physical examination, and they agree that the physical examination should include observation, palpation, auscultation, and assessment of vital signs. The groups also agree that the classic symptom of CHF is breathlessness (dyspnea). Other possible symptoms/signs include fatigue, orthopnea, PND, elevated JVP, third heart sound, lateral displacement of the apex beat, basal crepitations, ascites, and peripheral oedema. There is overall agreement, however, that a purely clinical diagnosis is unreliable and problematic and that evaluation of cardiac structure and function using more objective tests is necessary to confirm the diagnosis, determine the cause of symptoms, and to evaluate the degree of underlying cardiac pathology.

Diagnostic Investigations
While the groups agree that the assessment of signs and symptoms plays an important role in the diagnosis of CHF, they further agree that diagnostic investigations aimed at assessing cardiac function are necessary to establish a diagnosis of CHF. All four groups recommend that patients with suspected CHF should receive a variety of basic tests, and that the specific tests to be performed will vary according to the clinical presentation. There is overall agreement, however, that initial diagnostic workup will typically include a full blood count and urinalysis, as well as investigation of urea, electrolytes, creatinine, and glucose.

All of the groups recommend that a chest x-ray be performed in patients with suspected CHF to support a possible diagnosis of CHF and to investigate other potential causes of breathlessness. ESC, HFSA and NHFA/CSANZ also recommend an ECG be performed in every patient with suspected heart failure. There is overall agreement that if the ECG is normal, the diagnosis of heart failure is highly unlikely and alternative diagnoses should be considered. Refer to Areas of Difference below for SIGN recommendations regarding ECG, as well as the four groups' recommendations for echocardiography. An additional routine investigation recommended by ESC is sampling of Troponin I or T in suspected HF when the clinical picture suggests an acute coronary syndrome.

Other imaging modalities are addressed by ESC and NHFA/CSANZ. According to ESC, in patients in whom echocardiography at rest has not provided adequate information and in patients with suspected CAD, further non-invasive imaging may include CMR, cardiac CT, or radionuclide imaging. NHFA/CSANZ notes that nuclear cardiology, stress echocardiography, and PET can be used to assess reversibility of ischaemia and viability of myocardium in patients with CHF who have myocardial dysfunction and CHD. They add that protocols have been developed using MRI to assess ischaemia and myocardial viability, and to diagnose infiltrative disorders.

ESC, HFSA, and NHFA/CSANZ agree that measurement of plasma BNP concentration has a high negative predictive value and can be valuable in the diagnostic workup of suspected CHF. While none of the groups recommends routine measurement of BNP or NT-proBNP, there is overall agreement that it is an appropriate investigation to be performed when the diagnosis is uncertain. SIGN recommends that BNP testing be performed following the clinical examination and basic investigations, either alone or in addition to ECG, in order to determine the need for echocardiogram (they recommend echocardiography only in patients with raised BNP/NT-proBNP levels and/or abnormal electrocardiogram).

With regard to cardiac catheterization, there is overall agreement between the groups that address it (ESC, HFSA, and NHFA/CSANZ) that it is not routinely indicated for the diagnosis and management of heart failure, but that it may be appropriate in patients with certain clinical presentations. ESC and NHFA/CSANZ agree that coronary angiography should be considered in HF patients with a history of exertional angina or suspected ischaemic LV dysfunction. ESC also cites other instances in which coronary angiography would be appropriate. An additional type of cardiac catheterization addressed by the groups is endomyocardial biopsy. There is overall agreement that it is helpful in the diagnosis of specific myocardial disorders. HFSA and NHFA/CSANZ cite specific instances in which myocardial biopsy may be appropriate.

Areas of Difference
Diagnostic Investigations
While ESC, HFSA and NHFA/CSANZ recommend ECG be performed in every patient with suspected heart failure, SIGN, in contrast, recommends that the patient undergo either an ECG or BNP test or (both depending on local circumstances) to determine the need for echocardiogram.

While ESC and NHFA/CSANZ recommend an echocardiogram be performed in every patient with suspected heart failure in order to establish a diagnosis and determine the mechanism of heart failure, SIGN, in contrast, recommends it be performed only in patients who have either a raised BNP or NT-pro-BNP level or abnormal ECG.

According to HFSA, selected groups of high-risk patients and patients with signs and symptoms of HF should undergo echocardiographic examination to assess cardiac structure and function. Included in this select group are patients with cardiomegaly, S3 gallop, or potentially significant heart murmurs detected during the physical examination.

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