The approach to the patient with suspected Congestive Heart Failure includes a history and physical examination, chest radiograph, and a series of diagnostic tests to assess both the acuity and severity.
History alone is insufficient to make the diagnosis of heart failure, but often provides clues to the cause (myocardial infarction or uncontrolled hypertension), the precipitating event (noncompliance with diet or medications), and the severity.
The symptoms of heart failure can be related to either the reduction of cardiac output (fatigue, weakness) or to excess fluid retention (dyspnea, orthopnea, and “cardiac wheezing”). With progression to right-heart failure there may be hepatic congestion (with right upper-quadrant discomfort), early satiety, anorexia, and discomfort with bending.
Fluid Retention
Fluid retention also results in peripheral edema and occasionally in increasing abdominal girth secondary to ascites. Absence of dyspnea on exertion essentially rules out heart failure due to left ventricular dysfunction.
Pulmonary congestion (with crackles and wheezing) is predominant in acute or subacute disease. Although commonly taught as an absolute finding in Congestive Heart Failure or CHF, crackles are present in only 20% of patients with chronic CHF. In addition, lower-extremity edema presents in about 25% of patients younger than 70 years of age.
Overload
The most reliable indicator of volume overload is the presence of elevated jugular venous pulsation (estimated by distention of the jugular veins with the patient sitting at 45°), which correlates with elevated pulmonary-artery occlusion pressure 80% of the time.
Ventricular enlargement can be estimated by precordial palpation, and an apical pulsation displaced laterally to the midclavicular line is usually indicative of left-ventricular enlargement. In patients with dyspnea, a chest radiograph is a useful first test for differentiating patients with heart failure from patients with primary pulmonary disease.
Radiographic findings suggestive of heart failure include cardiomegaly (cardiac-to-thoracic ratio above 50%), cephalization of blood vessels, increased interstitial markings, and pleural effusions.
Patients with previous evidence of heart disease, diabetes mellitus, hypertension, or documented coronary-artery disease are at increased risk for Congestive Heart Failure, and one should always consider CHF in the differential diagnosis of acute respiratory failure in these patients.
