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Last Updated: 4/9/2015  

Heart Failure

Diagnosis
  • Use echocardiography to screen for valvular heart disease in patients with significant murmurs. Do not use echocardiography to routinely screen for heart failure in asymptomatic patents without murmurs.

  • Obtain an electrocardiogram and chest x-ray in patients with suspicion for heart failure to aid in diagnosis and provide insight into the cause of ventricular dysfunction.

  • Perform echocardiography and use results to define the type and extent of ventricular dysfunction and to identify potentially reversible causes of heart failure.

  • Use noninvasive testing to confirm functional capacity in heart failure, to look for ischemia, and to differentiate it from other conditions.

  • Order lab studies to aid in diagnosis or to identify secondary causes of heart failure, including electrolytes, blood counts, and thyroid studies.

  • Measure BNP when diagnosis is uncertain or to risk-stratify patients.

Therapy
  • Advise patients with heart failure to limit salt to 2 g sodium and fluid intake to 2 quarts daily.

  • Use ACE inhibitors in all patients with heart failure with reduced EF regardless of functional class except in patients with a history of angioedema; use ARBs instead in patients intolerant of ACE inhibitors.

  • Use β-blockers in patients with all NYHA classes of heart failure who have a reduced EF.

  • Use hydralazine combined with nitrates as an alternative to ACE inhibitors or ARBs in patients intolerant to both, and consider adding it to standard therapy in African American patients with heart failure who have a reduced EF.

  • Use low doses of an aldosterone antagonist in patients with a reduced EF who have NYHA class II to IV heart failure on ACE inhibitors and β-blockers.

  • Use loop diuretics to control volume overload and improve the functional capacity of patients with heart failure.

  • Evaluate patients with heart failure and ventricular arrhythmias, syncope, sudden cardiac death, or EF less than 35% for ICD placement.

  • Consider CRT for patients with NYHA class III or IV heart failure, EF less than 35%, and prolonged QRS duration.

  • Manage patients with a normal EF to relieve symptoms and treat underlying cause.

DOI: 10.7326/d105
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Author(s) and Disclosures:
Lee R. Goldberg, MD, MPH received honorarium from GlaxoSmithKline, AstraZeneca, Scois, ResMed. Howard J. Eisen, MD is a consultant for Medtronic, Thoratec, Orqis, received honorarium from Medtronic, Boston Scientific, Thoratec, received grants from Medtronic, Boston Scientific, Thoratec, Orquis, St. Jude Medical. John Varras, MD has nothing to disclose.

One or more of the present or past ACP Smart Medicine physician editors worked on this module and had nothing to disclose: Davoren Chick, MD, FACP; Deborah Korenstein, MD, FACP; Marjorie Lazoff, MD; Richard Lynn, MD, FACP.

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