Result card

  • CUR7: What is the disease or health condition in the scope of this assessment?
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What is the disease or health condition in the scope of this assessment?

Authors: Ingrid Wilbacher, Nadine Berndt, Francesca Gillespie

Internal reviewers: Alessandra Lo Scalzo, Christian Vladescu, Christina Mototolea, Kristina Lampe, Maria Camerlingo

The basic search for the CUR domain was used to answer this question with 1 article. Moreover, a manual search was done to find relevant information about the HF syndrome as published in evidence-based guidelines and in 8 additional scientific studies on HF. European and American guidelines for the diagnosis and treatment of acute and chronic HF were consulted by doing a manual search on the website of the ESC and the AHA, and the references of the ESC guidelines published in 2008 and 2012 and the AHA practice guideline published in 2013 were reviewed and these led occasionally to an additional article that was relevant for this assessment element. Moreover, the ICD-10 of the World Health Organization was consulted. The searches for the ICD-10 and guidelines were additionally conducted the 06th of January 2015 by one of the investigators.

HF is not a disease but a collection of signs, symptoms, and pathophysiology {86}. HF is generally characterized by an underlying structural abnormality or cardiac dysfunction that impairs the ability of the left ventricle to either fill with blood or contract to eject blood, especially during physical activity. Its prevalence, incidence, and clinical outcome are related to a range of cardiovascular and non-cardiovascular conditions that cause cardiac impairment {86}. HF is associated with significant reduced quality of life, morbidity, and mortality. Moreover, it puts a considerable burden on the healthcare systems around the globe, largely due to high hospital admission and readmission rates, and long hospital stays. In fact, HF patients have a high risk of readmission especially in the first weeks after hospital discharge, with 20-30 % of the patients being readmitted with a month. This rises up to 60 % after six months of hospital discharge {90}. 

According to the ESC, HF is a complex clinical syndrome in which patients have typical symptoms and signs resulting from an abnormality of cardiac structure or function. Although often life-threatening, typical symptoms and signs resulting from the abnormality of cardiac structure or function (as present in HF), lead to failure of delivering oxygen {77}. The most typical symptoms of HF are shortness of breath at rest or during exertion, fluid retention reflected in pulmonary congestion or peripheral edema (ankle swelling), fatigue, and dizziness  {19},{75}. The most typical clinical signs HF patients may have are tachycardia, tachhypnoa, pleural effusion, hepatomegaly, elevated jugular peripheral edema, pulmonary edema, venous pressure, pulmonary crackles, fluid overload, and displaced apex beat. According to the ESC guideline published in 2008, most definitions emphasize the need for both the presence of HF symptoms and physical signs of fluid retention {19}.

There is no single diagnostic test for HF but it is rather a clinical diagnosis based on a careful history and physical examination {115}. The diagnosis of HF can be difficult when relying solely on symptoms and signs. Objective evidence of an abnormality of the cardiac structure is required. Many of the symptoms of HF are of limited diagnostic value to discriminate between HF and other health abnormalities because they are non-specific. One typical symptom of HF is peripheral edema, but because it has other causes as well, it is particularly non-specific. More specific symptoms (i.e. orthopnoea and paroxysmal nocturnal dyspnoea) are less common, especially in patients with milder symptoms, and are, therefore, insensitive. More specific signs, such as elevated jugular venous pressure and displacement of the apical impulse, are hard to detect and, thus, less reproducible (i.e. agreement between different physicians examining the same patient may be poor) {74},{89},{27},{55}. Symptoms and signs may be difficult to identify and interpret in specific patients, such as obese individuals, elderly, patients with pulmonary disease, and patients with a poor physical condition or ischemia {38}. Many of the HF signs result from sodium and water retention (e.g. peripheral edema). These symptoms may, however, be absent or lead to quick symptomatic improvements in patients receiving diuretic therapy. Therefore, these symptoms are also not specific. In case of uncertainty, a favorable response to treatment directed towards HF is warranted. Nonetheless, a clinical response to treatment for HF is not sufficient for the diagnosis, but it can aid when the diagnosis remains unclear after appropriate diagnostic tests. To the diagnosis of HF, an underlying cardiac cause has to be demonstrated. Conditions that cause pressure overload (eg. hypertension, aortic stenosis), idiopathic dilated cardiomyopathy, and abnormalities of ventricular diastolic function, heart valves, pericardium, endocardium, heart rhythm, and conduction can cause HF. However, HF usually results from myocardial infarction causing an impaired systolic left ventricular function {77}.

Table 1 Symptoms and signs typical for heart failure

Typical symptoms

More specific signs

Breathlessness

Orthopnoea

Paroxysmal nocturnal dyspnoea

Reduced exercise tolerance

Fatigue, tiredness, increased time

to recover after exercise

Ankle swelling

Elevated jugular venous pressure

Hepatojugular reflux

Third heart sound (gallop rhythm)

Laterally displaced apical impulse

Cardiac murmur

 

Less typical symptoms

Less specific signs

Nocturnal cough

Wheezing

Weight gain (>2 kg/week)

Weight loss (in advanced HF)

Bloated feeling

Loss of appetite

Confusion (especially in the elderly)

Depression

Palpitations

Syncope

Peripheral edema (ankle, sacral, scrotal)

Pulmonary crepitations

Reduced air entry and dullness to percussion at lung bases (pleural effusion)

Tachycardia

Irregular pulse

Tachypnoea (>16 breaths/min)

Hepatomegaly

Ascites

Tissue wasting (cachexia)

Systolic versus Diastolic Heart Failure

HF is mainly described using a measurement of the left ventricle ejection fraction (usually measured by echocardiography or, in a minority of cases, with use of radionuclide technique or MRI). The ejection fraction has a prognostic value since a reduced ejection fraction indicates a poorer survival. Most clinical trials select patients based upon the ejection fraction. A normal ejection fraction in healthy subjects is generally considered to be > 50 % {77}. 

 

A distinction is frequently made between systolic and diastolic HF. Most patients have both abnormalities of systolic and diastolic dysfunction {115}. The weakened ability of the left ventricle to contract and empty is known as ‘systolic dysfunction’. In patients having left ventricular systolic dysfunction, the heart is unable to pump sufficient blood into the body circulation during systole due to an inability to pump efficiently {19},{77}. Left ventricular systolic dysfunction is a complication of myocardial infarction that greatly increases the risk of HF. Besides myocardial infarction leading to left ventricular systolic dysfunction and subsequent HF, myocardial infarction may lead to papillary muscle dysfunction and mitral regurgitation or provoke arrhythmias, like atrial fibrillation, which in turn leads to HF. In other patients, preexisting myocardial ischemia may impair myocardial relaxation impeding the left ventricle to dilate {12}. Echography is most often utilized to assess left ventricular systolic dysfunction or systolic HF, which according to the ESC signifies a reduced ejection fraction of ≤ 35 %. In fact, the heart ejects a smaller fraction of a larger volume while stroke volume is maintained by an increase in the end-diastolic volume because the left ventricle dilates. The major clinical trials have also included patients with systolic HF with a reduced left ventricular ejection fraction (HFREF) ≤ 35 %. Nevertheless, uncertainties concerning the appropriate threshold remain {19},{77}.

 

Generally speaking, diastolic HF is HF with an inability of the heart to relax normally at diastole. As a result, it does not fill properly. The syndrome is an impaired filling of the left ventricle in response to a volume load, despite normal ventricular contraction. It is characterized with a preserved left ventricular ejection fraction (HFPEF) which signifies an ejection fraction of > 40-45 % {19},{77}. HFPEF has, however, also been classified as EF 50 % and ≥ 55 %, leading to variable prevalence rates of HFPEF which generally is around 50 % {115}. In HFPEF, patients have a normal left ventricular function, i.e. the heart contracts normally, but higher filling pressures are needed to obtain a normal end-diastolic volume of the left ventricle. These patients do not have an entirely normal ejection fraction but also no major reduction in systolic function. Therefore, these patients are considered to have HF with a ‘preserved’ ejection fraction. More recent trials have included diastolic HF patients with an ejection fraction > 40-45 % and no other causal cardiac abnormality. Patients with an ejection fraction varying between 35 % and 50 % probably have a mild ‘systolic dysfunction’ and represent a grey area. The diagnosis of HF with a ‘preserved’ ejection fraction is difficult because potential non-cardiac causes may account for the patient’s symptoms (e.g. anemia or chronic pulmonary disease). Nevertheless, most have evidence of diastolic dysfunction, which is generally accepted as the likely cause of HF in these patients. Therefore, the term diastolic HF is common to describe this specific syndrome of HF {19},{77}.

 

In sum, patients with diastolic HF have symptoms and/or signs of HF and a preserved left ventricular ejection fraction (LVEF) > 40–50 % and patients with systolic HF have symptoms and/or signs of HF and a reduced left ventricular ejection fraction (HF-REF) ≤35 %. There is no agreement concerning the cut-off for preserved versus reduced EF {19},{77}.

 

The current 10th edition of the International Classification (ICD) system classifies HF as an intermediate, not underlying cause of death. It describes HF as congestive HF including congestive heart disease and right ventricular failure. HF is also defined as left ventricular failure including cardiac asthma, left HF, and heart disease (unspecified) or HF with edema of lung and pulmonary edema. HF is further defined as the incidence of HF due to rheumatic heart disease, hypertensive heart disease, ischemic heart disease and inflammatory heart disease. Complicating abortion or ectopic or molar pregnancy, obstetric surgery and procedures are excluded from the classical definition of HF by the ICD-10. Moreover, HF due to hypertension (with renal disease), HF following cardiac surgery or due to presence of cardiac prosthesis, and neonatal cardiac failure are excluded {113}.

Critical
Completely
Wilbacher I et al. Result Card CUR7 In: Wilbacher I et al. Health Problem and Current Use of the Technology In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=305

References