496
U N I T 5
Circulatory Function
sounds called
crackles,
which can be heard with a
stethoscope on chest auscultation. As fluid moves into
the larger airways, the crackles become louder and
coarser.
Diagnosis
Diagnostic methods in heart failure are directed toward
establishing the cause of the disorder and determin-
ing the extent of the dysfunction.
1,2
Because heart fail-
ure represents the failure of the heart as a pump and
can occur in the course of a number of heart diseases
or other systemic disorders, the diagnosis of heart fail-
ure often is based on signs and symptoms related to
the failing heart itself, such as dyspnea and fatigue.
Functional classification systems from the New York
Heart Association (NYHA) and the American College
of Cardiology Foundation/American Heart Association
(ACCF/AHA) provide important information about the
presence and severity of HF (Table 20-1). The NYHA
functional classification system is subjective, meaning
the patient describes their level of activity and symp-
toms. It is widely used in clinical practice and research
settings. The ACCF/AHA classification system is more
recent and emphasizes the progression of the disease
along with risk factors associated with HF, such as
hypertension (Stages A and B).
The methods used in the diagnosis of heart failure
include history and physical examination, laboratory
studies,electrocardiography,chestradiography,andecho-
cardiography. The history should include information
related to dyspnea, cough, nocturia, generalized fatigue,
exercise intolerance and other signs and symptoms of
heart failure. A complete physical examination includes
assessment of heart rate and rhythm, heart sounds, blood
pressure, jugular veins for venous congestion, lungs for
signs of pulmonary congestion, and lower extremities
for edema. Pulse oximetry can be used to measure the
percentage of hemoglobin oxygen saturation.
Laboratory tests are used in the diagnosis of ane-
mia and electrolyte imbalances and to detect signs of
chronic liver congestion. Measurements of BNP are
recommended to confirm the diagnosis of heart fail-
ure; to evaluate the severity of left ventricular com-
promise, estimate the prognosis, and evaluate the
effectiveness of treatment. BNP may not be as sensitive
in persons with heart failure who are obese or have
renal failure.
1,36
Echocardiography plays a key role in assessing ejec-
tion fraction, right and left ventricular wall motion (nor-
mal, akinesis, or hypokinesis), wall thickness, ventricular
chamber size, valve function, heart defects and pericar-
dial disease. Radionuclide ventriculography and cardiac
angiography are recommended if there is reason to sus-
pect coronary artery disease or ischemia as the underly-
ing cause for heart failure. Chest radiographs provide
information about the size and shape of the heart and
pulmonary vasculature, and also can indicate the relative
severity of the failure by revealing if pulmonary edema
is predominantly vascular or interstitial or has advanced
to the alveolar and bronchial stages. Cardiac magnetic
resonance imaging and cardiac computed tomography
TABLE 20-1
Comparison of ACCF/AHA Stages of HF and NYHA Functional Classification
ACCF/AHA Stages of HF
a
NYHA Functional Classification
b
A
At high risk for HF but without structural heart
disease or symptoms of HF
None
B
Structural heart disease but without signs or
symptoms of HF
I
No limitation of physical activity. Ordinary physical
activity does not cause symptoms of HF.
C
Structural heart disease with prior or current
symptoms of HF
I
No limitation of physical activity. Ordinary physical
activity does not cause symptoms of HF.
II
Slight limitation of physical activity. Comfortable at
rest, but ordinary physical activity causes symptoms
of HF.
III
Marked limitation of physical activity. Comfortable at
rest, but less-than-ordinary physical activity causes
symptoms of HF.
IV
Unable to carry on any physical activity without
symptoms of HF, or symptoms of HF at rest.
D
Refractory HF requiring specialized
interventions
a
From Hunt SA, AbrahamWT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005
guidelines for the diagnosis and management of heart failure in adults: A report of the American College
of Cardiology Foundation/American Heart AssociationTask Force on Practice Guidelines. J Am Coll Cardiol.
2009;53:e1–e90.
b
The Criteria Committee of the NewYork Heart Association. Nomenclature and Criteria for Diagnosis of
Diseases of the Heart and Great Vessels. Boston, MA: Little & Brown; 1994.
FromYancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a
report of the American College of Cardiology Foundation/American Heart AssociationTask Force on Practice
Guidelines. Circulation. 2013;128(16):e240–e319.
