From the Guidelines
The diagnosis of heart failure according to the American College of Cardiology (ACC) is based on a comprehensive clinical assessment, including patient history, physical examination, laboratory tests, and imaging studies, with a focus on identifying typical symptoms and signs, such as dyspnea, fatigue, and fluid retention, and using natriuretic peptides and echocardiography to support the diagnosis. The ACC stages of heart failure, as outlined in the 2022 AHA/ACC/HFSA guideline 1, include Stage A (at risk for heart failure), Stage B (pre-heart failure), Stage C (symptomatic heart failure), and Stage D (advanced heart failure). Clinicians should evaluate patients for these stages, using criteria such as structural heart disease, reduced left or right ventricular systolic function, and evidence of increased filling pressures. Laboratory testing, including natriuretic peptides (BNP or NT-proBNP), complete blood count, comprehensive metabolic panel, thyroid function tests, and hemoglobin A1c, is essential to identify contributing factors and support the diagnosis. Echocardiography is crucial to assess cardiac structure and function, particularly left ventricular ejection fraction (LVEF), which classifies heart failure as reduced (HFrEF, LVEF ≤40%), mildly reduced (HFmrEF, LVEF 41-49%), or preserved (HFpEF, LVEF ≥50%) 1.
Some key points to consider in the diagnosis of heart failure include:
- Typical symptoms, such as dyspnea, fatigue, and fluid retention
- Signs, including elevated jugular venous pressure, pulmonary crackles, and peripheral edema
- Laboratory testing, including natriuretic peptides and echocardiography
- Classification of heart failure based on LVEF, including HFrEF, HFmrEF, and HFpEF
- ACC stages of heart failure, including Stage A, Stage B, Stage C, and Stage D.
The 2022 AHA/ACC/HFSA guideline 1 provides the most recent and highest-quality evidence for the diagnosis of heart failure, and should be used to guide clinical practice. The diagnosis of heart failure ultimately requires clinical judgment, integrating these findings, as no single test definitively establishes heart failure.
From the Research
Diagnostic Criteria for Heart Failure
The American College of Cardiology (ACC) has established diagnostic criteria for heart failure, which include:
- Evaluation of left ventricular (LV) function for all patients presenting with heart failure 2
- Use of angiotensin-converting enzyme (ACE) inhibitors for all patients with LV systolic dysfunction (LVSD) unless contraindicated 2
- Use of hydralazine and isosorbide dinitrate in patients who cannot use ACE inhibitors 2
- Use of digoxin in patients with HF due to LVSD but not adequately responsive to ACE inhibitors and diuretics, and in those with atrial fibrillation and rapid ventricular rates 2
- Use of diuretics for symptomatic patients with evidence of fluid overload 2
- Use of anticoagulation in patients with atrial fibrillation or a history of systemic or pulmonary embolism 2
- Classification of HF into four stages, including patients who are at high risk for developing HF 2
Role of Natriuretic Peptides in Diagnosis
Natriuretic peptides, such as B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP), are useful in diagnosing heart failure and guiding management:
- BNP and NT-proBNP have high sensitivity and low negative likelihood ratio, making them useful for ruling out heart failure 3
- Optimal NT-proBNP cut points for HFpEF rule out and rule in have been derived and tested, stratified by obesity and atrial fibrillation 4
- Current recommended rule-out NT-proBNP threshold <125 pg/mL has 82% sensitivity, but this decreases to 67% with a BMI ≥35 kg/m2 4
- A lower rule-out NT-proBNP threshold <50 pg/mL displays good sensitivity with a BMI <35 kg/m2, with a modest decline in sensitivity with a BMI ≥35 kg/m2 4