3.2: Definition and diagnosis (2024)

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    Definition of heart failure

    The term heart failure (HF) (congestive heart failure or cardiac decompensation or decompensatio cordis) describes an acute or chronic situation in which the amount of blood pumped through the circulation by the heart, is insufficient to meet the body’s demands at a normal cardiac filling pressure. According to the guidelines of the European Society of Cardiology, HF is defined as a syndrome in which the patient has the following triad of features: (1) symptoms typical of HF; (2) signs typical of HF; and most importantly (3) objective evidence of a structural or functional abnormality of the heart at rest (Table 3.2.1).

    Symptoms Typical of Heart Failure Signs Typical of Heart Failure Objective evidence of a structural or functional abnormality of the heart at rest
    • Breathlessness
    • Orthopnoea
    • Paroxysmal nocturnal dyspnoea
    • Reduced exercise tolerance
    • Fatigue
    • Tiredness
    • Ankle swelling
    • Elevated jugular venous pressure
    • Hepatomegaly
    • Third heart sound
    • Pulmonary rales
    • Pleura effusion
    • Peripheral oedema
    • Hepatojugular reflux
    • Cardiomegaly on X-ray of the thorax
    • Abnormal echocardiogram
    • Abnormal pump function on nuclear imaging or on MRI

    Table 3.2.1: Definition of Heart Failure

    Prevalence

    The prevalence of HF in the Western world is estimated to be 1-2%, and the incidence is approximately 5-10 per 1000 persons per year (7,9). Coronary heart disease at a young age is more prevalent in men than women, and so the prevalence of HF is also higher in this group compared to age matched women. In older age groups, the prevalence of HF is equal between the sexes.

    Acute and chronic heart failure

    Heart failure may become a chronic condition, in which HF is persistent either with recurrences or with slow progression. A patient may be described as decompensated when chronic stable HF deteriorates. Acute HF has traditionally been used to describe the nature of the clinical presentation, as severe or of recent onset. Different clinical presentations fall under this definition.

    Systolic versus diastolic heart failure

    Heart failure patients may be broadly classified into one of two groups, or a combination of both, depending on the left ventricular ejection fraction (LVEF). The LVEF is most often assessed with echocardiography (see Table 3.3.2). When the LVEF is less than 45%, systolic pump function is abnormal and it is named systolic HF.[3] If LVEF is preserved (>50%), symptoms are attributed to impaired relaxation of the heart during diastole and therefore this condition is diagnosed as diastolic HF or HF with a preserved LVEF.[3][4] As a result of impaired relaxation, end diastolic pressure and, subsequently, left atrial- and pulmonary pressure will rise; alveolar pulmonary edema develops as a consequence of these changes. LF diastolic dysfunction may be present in asymptomatic patients, and it is considered an important precursor of heart failure.[5] Frequently, patients have both systolic and diastolic heart failure at the same time, but the term for this ailment is still systolic heart failure. The term heart failure is not limited to a failing left ventricle; the right ventricle may also be involved in the process and there may also be isolated right ventricular heart failure.

    Pathophysiology of heart failure

    HF is caused by a loss of cardiac pump function, which can be due to a structural abnormality of the heart muscle (e.g. myocardial infarction) or a change in the heart function (and often structure) in response to an abnormal load (e.g. aortic valve stenosis). The relationship between loading the ventricle (by filling it) and its output was described by Frank and Starling in 1918 and has become the cornerstone in understanding heart failure and how to treat it. The relationship states that as a result of loading the heart (increasing its filling or its pressure), the output increases (Figure 3.2.1).

    3.2: Definition and diagnosis (2)

    A heart that has a lower output can be improved by increasing its volume and its loading pressure. This is what naturally happens (LV dilatation and increased filling pressure) when the heart does not pump out enough volume, and, in the first phase of disease, compensates for the loss of contractility. It takes more energy from the heart to work at an increased loading, but the heart has a reasonable energy reserve. In a chronic situation, remodeling of the heart progresses (by hypertrophy of the myocytes and dilatation by increasing myocyte length and matrix changes), which, in the long term, leads to a further loss in function. The result of this dysfunction is further increased loading pressures in the heart and, by communicating the diastolic loading pressures to the left atrium and pulmonary veins, the pulmonary capillaries may become overloaded and leak water into the lungs. This is the practical restriction of further filling the heart as a tool to improve its function; even poor left ventricles may be filled more to increase their output [6] but the patients’ pulmonary capillaries cannot tolerate these hydrostatic pressures and start to leak water.

    Hemodynamic explanations (the heart as a pump) use the concept of preload (filling) and afterload (workload of the heart, which is wall tension and arterial pressure or vascular resistance). In this way, the progression of left sided heart failure towards right sided heart failure is explained as follows: prolonged left ventricular failure increases pressures in the left atrium (preload), which in time leads to a subsequent increased resistance in the pulmonary vascular system (which is the afterload of the right ventricle) and eventually may also lead to right ventricular failure. Another relevant issue is afterload of the left ventricle influencing the output of the heart: as the afterload of the aortic pressure also influences the timing of closure of the aortic valve, a high aortic pressure will close the aortic valve early and will, therefore, diminish the output. Decreasing (theoretically diastolic, but more practically systolic) aortic pressure will increase the stroke volume by latter closure of the aortic valves. (Figure 3.2.2)

    3.2: Definition and diagnosis (3)

    Hormonal/ sympathetic system mechanisms (RAAS/ Sympathetic overstimulation) of heart failure are as important as the hemodynamic mechanisms of heart failure.

    A decreased cardiac output leads to diminished renal perfusion and release of hormones in the RAA-system: renin is released into the circulation by the renal juxtaglomerular apparatus, which stimulates the cleavage of angiotensinogen into angiotensin I and II during its passage through the lungs. Angiotensin II stimulates vasoconstriction in the kidneys, and in other vascular systems, increasing blood pressure; the second effect of angiotensin is to stimulate the release of aldosterone from the adrenals into the plasma, which retains sodium from the kidney tubules in the blood and thereby water. The RAA –system, which works as a compensatory mechanism for heart failure to increase blood pressure and blood volume, also stimulates hypertrophy of muscle cells and the formation of fibrosis, which in the long term are detrimental to heart failure.

    The other compensatory mechanism for heart failure, stimulation of the sympathetic nervous system, increases heart rate to increase cardiac output, which is a powerful compensatory mechanism. However, chronic stimulation of the sympathetic nerves to the heart, leading to higher heart rates, is toxic to the heart, because of continuous release of norepinephrine to the myocyte. In addition, as a result of their continued stimulation, the betareceptors for norepinephrine are downregulated in heart failure, which further diminishes the function and functional reserve of the heart.

    Management

    When a patient presents with symptoms of heart failure, it is worthwhile to have a dedicated diagnostic and therapeutic plan, in the order as indicated below (Figure 3.2.3). Clinical aspects are important for diagnosis, but the final diagnosis is only made after objective evidence of heart dysfunction.

    3.2: Definition and diagnosis (4)
    3.2: Definition and diagnosis (2024)

    FAQs

    What is clinical assessment and diagnosis? ›

    Clinical assessment is a way of diagnosing and planning treatment for a patient that involves evaluating someone in order to figure out what is wrong. There are many types of psychological assessments, all of which have their own strengths and weaknesses.

    Is there a difference between the terms diagnosis and assessment? ›

    Final answer: Diagnosis refers to the process of determining the nature and cause of a disease or condition, while assessment refers to the evaluation and measurement of a patient's overall health status.

    What is assessment and diagnosis? ›

    An assessment is a process of collecting information to be used to gain insight into the problem being presented by the client. This information is then used to make a diagnosis. Assessments are also conducted after the problem has been diagnosed and a plan to address that problem is implemented.

    What manual provides definitions for more than 200 mental disorders? ›

    The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders. DSM contains descriptions, symptoms and other criteria for diagnosing mental disorders.

    What is considered a clinical diagnosis? ›

    The process of identifying a disease, condition, or injury based on the signs and symptoms a patient is having and the patient's health history and physical exam. Further testing, such as blood tests, imaging tests, and biopsies, may be done after a clinical diagnosis is made.

    What are the five categories in order in mental status exam? ›

    The MSE can be divided into the following major categories: (1) General Appearance, (2) Emotions, (3) Thoughts, (4) Cognition, (5) Judgment and Insight. These are described in more detail in the following sections.

    What is the standard definition of diagnosis? ›

    The process of identifying a disease, condition, or injury from its signs and symptoms. A health history, physical exam, and tests, such as blood tests, imaging tests, and biopsies, may be used to help make a diagnosis.

    What are the criteria for diagnosis? ›

    Diagnostic criteria are a set of signs, symptoms, and tests used to determine the diagnosis of a person. Diagnostic criteria may be broad to accurately identify as many people with the condition as possible if the signs and symptoms of a disease, or symptom or progression severity, varies from person to person.

    What is the legal definition of diagnosis? ›

    DIAGNOSIS Definition & Legal Meaning

    A medical term, meaning the discovery of the source of a patient's illnessor the determination of the nature of his disease from a study of its symptoms.

    What comes first, diagnosis or assessment? ›

    Once complete, the assessment will help establish either a tentative or definitive diagnosis. With this information, the clinician can inform the patient of the results, and treatment can begin.

    What are the three types of diagnosis? ›

    Types of medical diagnosis are:
    • Provisional: Based on physical exam and clinical findings.
    • Histopathological: Done by a pathologist after examining sample tissue under a microscope.
    • Final: Done based on provisional diagnosis and investigations.

    Is a doctor's assessment a diagnosis? ›

    In the United States only a licensed medical professional is legally allowed to make a diagnosis. Assessment, on the other hand, is an evaluation made by a healthcare provider to make an informed decision on whether or not to provide service, and if yes, what approach to take.

    What is the most prominent symptom that defines schizophrenia? ›

    Auditory hallucinations, or “hearing voices,” are the most common in schizophrenia and related psychotic disorders. Disorganized thinking and speech refer to thoughts and speech that are jumbled or do not make sense.

    What is the most common mental illness in the United States? ›

    The most common are anxiety disorders major depression and bipolar disorder. Below is more information on these disorders and how ACCESS can help.

    What are the four major mental disorders? ›

    mood disorders (such as depression or bipolar disorder) anxiety disorders. personality disorders. psychotic disorders (such as schizophrenia)

    What is clinical examination and diagnosis? ›

    Clinical examination is the first examination of all medical examination and treatment processes. Clinical examination helps doctors determine the initial disease status, orienting to appoint appropriate paraclinical tests from which to diagnose the disease.

    What is the clinical definition of assessment? ›

    1. An appraisal or evaluation of a patient's condition by a physician, nurse, or other health care provider, based on clinical and laboratory data, medical history, and the patient's account of symptoms. 2. The process by which a patient's condition is appraised or evaluated.

    What is an example of diagnostic assessment? ›

    Some common types of diagnostic assessments in education include: Pre-Assessment: Purpose: Conducted before a new unit or course to gauge students' prior knowledge and skills. Examples: Pre-tests, concept mapping, and K-W-L (Know, Want to know, Learned) charts.

    What is the main purpose of diagnostic assessment? ›

    Diagnostic assessments are intended to help teachers identify what students know and can do in different domains to support their students' learning. These kinds of assessments may help teachers determine what students understand in order to build on the students' strengths and address their specific needs.

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