What are the major Framingham criteria for Congestive Heart Failure (CHF)?

Major Framingham Criteria for Congestive Heart Failure

The American College of Cardiology identifies seven major clinical findings that constitute the major Framingham criteria for diagnosing CHF: paroxysmal nocturnal dyspnea or orthopnea, jugular venous distension, pulmonary rales, S3 gallop rhythm, cardiomegaly on chest radiograph, acute pulmonary edema on chest radiograph, and hepatojugular reflux. 1

Diagnostic Algorithm Using Framingham Criteria

To diagnose heart failure using Framingham criteria, you must identify EITHER 2 or more major criteria OR 1 major criterion plus 2 minor criteria in patients with symptoms of heart failure. 1

The Seven Major Criteria:

1. Paroxysmal nocturnal dyspnea or orthopnea - Difficulty breathing when lying flat or awakening from sleep with breathlessness 1

2. Jugular venous distension - Elevated jugular venous pressure indicating elevated right atrial pressure 1

3. Pulmonary rales (crackles) - Audible on lung auscultation, indicating pulmonary congestion 1

4. S3 gallop rhythm - Third heart sound indicating ventricular dysfunction and poor prognosis 1, 2

5. Cardiomegaly - Enlarged cardiac silhouette on chest radiograph 1

6. Acute pulmonary edema - Visible on chest radiograph 1

7. Hepatojugular reflux - Increased jugular venous pressure with abdominal compression 1

Minor Criteria (Supporting Findings):

The minor criteria include dyspnea on exertion, nocturnal cough, ankle edema, tachycardia (>120 bpm), hepatomegaly, and pleural effusion, which support the diagnosis when combined with at least one major criterion. 1

Critical Modern Context and Limitations

The American College of Cardiology emphasizes that Framingham criteria should NOT be used in isolation for contemporary heart failure diagnosis. 1 The Universal Definition of Heart Failure now requires symptoms/signs PLUS either elevated natriuretic peptides (BNP/NT-proBNP) or objective evidence of cardiogenic congestion. 1

Essential Complementary Testing:

• Natriuretic peptides (BNP or NT-proBNP) are critical for confirming the diagnosis, particularly in obese patients and the elderly where clinical signs become difficult to interpret 1, 3

• Echocardiography must be performed to confirm cardiac structural/functional abnormalities and determine ejection fraction 1, 3

• A completely normal ECG makes heart failure unlikely, providing valuable negative predictive value 1

Common Pitfalls to Avoid:

In obese patients and elderly individuals, clinical signs of heart failure are particularly difficult to interpret, making objective testing with natriuretic peptides and echocardiography even more critical. 1 The Framingham criteria were developed decades ago and, while historically important for research standardization 3, they lack the sensitivity and specificity of modern biomarkers and imaging modalities for clinical practice. 1

The criteria are most useful when integrated into a comprehensive diagnostic approach that includes clinical assessment, biomarkers, ECG, chest radiograph, and echocardiography rather than being applied as a standalone diagnostic tool. 1, 3