Evaluating and Diagnosing Heart Failure

Transcript: Deepak L. Bhatt, MD, MPH: Let’s move on and discuss guidelines for initiating therapies in heart failure. Maybe we can start with the basics, Akshay. How is heart failure diagnosed? At what stage is it typically diagnosed? Is it underrecognized? Of course, as a heart failure expert, you’re going to say yes. But what are your thoughts?

Akshay S. Desai, MD, MPH: I think it is underrecognized, and I think it’s largely because heart failure is identified based on the presence of typical signs and symptoms. The trouble is that those symptoms overlap with a lot of other common disorders. The primary presenting symptoms for most of our patients are shortness of breath and fatigue, which are ubiquitous and caused by a lot of different problems—being out of shape, being anemic, having underlying lung disease, having an infectious pneumonia complication, or having COVID-19 [coronavirus disease 2019], as the case might be. But certainly, one of the important differential causes of dyspnea is heart failure. I think the likelihood of heart failure in a patient who’s short of breath is amplified by the presence of other typical signs and symptoms. We like to think about symptoms that are more specific to failure, like orthopnea, difficulty breathing when one lies flat, awakening short of breath in the middle of the night, rapid weight gain, peripheral edema, the abdominal distention that comes on rapidly. These are things that might suggest heart failure.

Then on visual inspection, there are a number of physical examination signs that suggest that heart failure may be playing a role. Filling pressures might be elevated. The jugular venous pressure might be high. A lung exam might reveal pulmonary rales or crackles. There may be extra heart sounds, like an S3 [third heart sound]. The abdomen may be distended with ascites. There may be palpable edema. There are a number of other signs. I think we are starting to use laboratory testing to help augment our clinical acumen, and natriuretic peptides have emerged as useful tools in that regard. If you have a high BNP [B-type natriuretic peptide] or NT [N-terminal]-pro hormone BNP in a dyspneic patient, that suggests heart failure might be contributing. But I think in general, we’re much better at recognizing heart failure when patients present with overt signs and symptoms, and probably a little less good at identifying those with subclinical disease, which tends to come to light when we’re looking at other problems and happen to find, by an echocardiogram, that the ejection fraction is low or there’s structural heart disease we didn’t suspect.

Deepak L. Bhatt, MD, MPH: Very interesting. Javed, what are the goals for therapy in terms of dietary and other goals?

Javed Butler, MD, MPH, MBA: Let’s take it back a step. I would say that the first goal of heart failure treatment is to look for specific etiologies. So before we go into a generic therapy for heart failure, there’s a lot of reversible or at least some kind of etiology that can mitigate the syndrome of heart failure that we never use. So ischemic heart disease. There is a lot of literature out there that nuances heart failure, and ischemia has never been evaluated in those patients. There are other specific niche diseases like amyloidosis and a lot of interest right now with very specific targeted therapies. So I think evaluating the etiology is probably one of the most important goals.

And then, as Nancy mentioned, the main goal is to give them guideline-directed therapy for all the goals that we generally think about. One is to mitigate or reverse the disease process. The ultimate goal is to improve survival for the patients. Also, reduce the burden of health care for both the patient and the caregiver. So recurrent hospitalizations and coming to the clinic and whatnot to improve their well-being. Lately, we obviously consider other patient-oriented endpoints, like quality of life and functional capacity. And how can we not only think about making people live longer, but also healthier so they can be more engaged in their life?

But none of this is going to happen if we just sort of write the prescription and don’t educate our patients. I would say that educating the patient is really one of the goals of therapy. As far as I’m concerned, we are sort of the coaches and the patients are the players. We cannot play the game for them. They have to be engaged in the game by themselves. So adherence and compliance. Taking their medications and refilling their medications. And then the diet recommendation. And fluid and salt. Actually, the data are pretty clear on prevention of heart failure with a low-sodium diet. The data are a little bit unclear about treatment of heart failure with a low-sodium diet. But, again, the data are pretty consistent if you are congested, if you have hyponatremia, if you have class IV symptoms. For those patients who are really stable, who are weighing themselves daily and their weight is really stable, whether or not a very strict salt diet is necessarily for them can be argued.

But I think providing guideline-directed care, looking for etiologic factors, and educating patients well would lead to all the goals that I talked about. I will also say that I think it’s incumbent on all clinicians, doctors, and nurses to make participating in clinical trials part of the goal of treating heart failure, if not for that particular patient but for heart failure in general. There are a lot of unmet needs for these patients. I will end by saying that we all need to be astute in looking for signs and symptoms when things are not going well. If things are not going well, and if at some point the patient needs to be reported for transplant or a medically assisted device, that should be part of your thinking process.

Transcript Edited for Clarity