What are the signs of heart failure exacerbation?

Signs of Heart Failure Exacerbation

Heart failure exacerbation requires at least ONE symptom AND objective evidence consisting of at least TWO physical examination findings OR one physical finding plus one laboratory criterion. 1

Symptoms of Worsening Heart Failure

Patients must present with at least ONE of the following new or worsening symptoms: 1

• Dyspnea (exertional dyspnea, dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough when supine, tachypnea) 1
• Decreased exercise tolerance (reduced ability to perform activities involving dynamic movement of large skeletal muscles due to dyspnea or fatigue) 1
• Fatigue (lack of energy and motivation in mental and physical activities, easily tiring, inability to complete usual activities, sometimes with dizziness or lightheadedness) 1
• Worsened end-organ perfusion (manifested by dizziness, lightheadedness, syncope, confusion, altered mental status, restlessness, cognitive decline, nausea, vomiting, abdominal pain or fullness, cold clammy extremities, discoloration of extremities or lips, reduced urine output, darkening of urine, chest pain, palpitations) 1
• Volume overload symptoms (lower extremity swelling, pitting edema in legs/ankles/lower back, increased abdominal girth, right-sided abdominal fullness or tenderness, weight gain, skin breakdown in lower extremities) 1

Physical Examination Findings (Objective Evidence)

At least TWO of the following physical findings are required (or one physical finding plus one laboratory criterion): 1

Most Specific Signs:

• Peripheral edema (pitting indentation in feet, ankles, legs, thighs, upper extremities, scrotum, presacral area, or abdominal wall) 1
• Increased abdominal distention or ascites (in absence of primary hepatic disease) 1
• Pulmonary rales/crackles/crepitations 1
• Elevated jugular venous pressure and/or hepatojugular reflux 1
• S3 gallop (third heart sound) 1
• Clinically significant or rapid weight gain (usually >3-4 pounds in 3-4 days) thought related to fluid retention 1

Supportive Physical Findings:

Additional findings that support but don't fulfill diagnostic criteria include: decline in systolic or diastolic blood pressure, orthostatic hypotension, cool/mottled/clammy skin, lip discoloration and cyanosis, tachypnea, irregular breathing patterns (Cheyne-Stokes respirations), tachycardia or bradycardia, arrhythmia, displaced point of maximum impulse, right ventricular heave, loud S2, diminished S1, S4, valvular murmurs, reduced urine output, hepatomegaly, pleural effusion findings, narrow pulse pressure, and wheezing. 1

Laboratory Evidence

Laboratory criteria must be obtained within 24 hours of presentation: 1

• Elevated BNP or NT-proBNP concentrations (new or worsened) 1

The American College of Cardiology emphasizes that BNP/NT-proBNP should be measured in patients with dyspnea when the contribution of heart failure is uncertain, though final diagnosis requires interpreting results in context of all clinical data and should not be a stand-alone test. 1

Common Precipitating Factors to Identify

Recognition of these precipitating factors is critical to guide therapy: 1

• Acute coronary syndromes/coronary ischemia 1
• Severe hypertension 1
• Atrial and ventricular arrhythmias 1
• Infections 1
• Pulmonary emboli 1
• Renal failure 1
• Medical or dietary noncompliance (sodium/fluid restriction, medication adherence) 1
• Recent addition of negative inotropic drugs (verapamil, nifedipine, diltiazem, beta blockers) 1
• NSAIDs 1
• Excessive alcohol or illicit drug use 1
• Endocrine abnormalities (diabetes, hyperthyroidism, hypothyroidism) 1

Essential Initial Assessment

The diagnosis requires determining: 1

1. Adequacy of systemic perfusion 1
2. Volume status 1
3. Contribution of precipitating factors and/or comorbidities 1
4. Whether heart failure is new onset or exacerbation of chronic disease 1
5. Whether associated with preserved ejection fraction 1

Key diagnostic tests include: chest radiographs, electrocardiogram, and echocardiography. 1 Acute coronary syndrome should be promptly identified by electrocardiogram and cardiac troponin testing. 1

Clinical Pitfalls

Symptoms and signs are particularly difficult to identify in: obese individuals, elderly patients, and those with chronic lung disease. 1 In obese patients specifically, peripheral edema is particularly non-specific, and assessment of intravascular volume on exam is limited. 2 Signs resulting from sodium and water retention resolve quickly with diuretic therapy, making assessment more difficult in patients already treated. 1

The European Society of Cardiology notes that more specific signs like elevated jugular venous pressure and displaced apical impulse are harder to detect and less reproducible. 1 There is poor correlation between symptoms and severity of cardiac dysfunction. 1