Heart Failure

Clinical Background

Heart failure (HF) is a clinical syndrome in which the heart muscle is unable to pump enough blood to meet tissue demands and is often referred to as congestive heart failure (CHF)

Epidemiology

Prevalence
- 10% in patients >80 years
- 1% in patients <50 years
Age - 65 years and older

Risk Factors

Hypertension
Diabetes mellitus
Alcoholism
Hyperlipidemia
Coronary artery disease
Thyroid disease

Etiology - numerous

Cardiac
- Myocardial infarction/ischemic heart disease
- Arrhythmias (atrial fibrillation is most common)
- Hypertension
- Myocarditis
- Congenital heart disease
- Valvular disease (aortic stenosis)
Infectious
- Sepsis
- Endocarditis
Pulmonary
- Embolism
- Hypertension
- Chronic obstructive pulmonary disease
High output forms
- Anemia
- Thyrotoxicosis

Categorization

Diastolic versus systolic dysfunction
Low output versus high output
Acute versus chronic
Left-sided versus right-sided

Clinical Presentation

Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
Fatigue and weakness
Nausea and anorexia
Physical examination includes tachycardia, S3/S4, pulsus alternans, pulmonary rales, ascites, hepatomegaly, jaundice, pedal edema, cachexia

See Also

Cardiovascular Disease (Non-traditional Risk Markers) - Risk Markers - CVD (Non-traditional)

Cardiovascular Disease (Traditional Risk Markers) - Risk Markers - CVD (Traditional)

Diabetes Mellitus Diagnosis

Ischemic Heart Disease - IHD

Metabolic Syndrome

Tests

Tests generally appear in the order most useful for common clinical situations

Test name: proBrain Natriuretic Peptide, NT

ARUP #: 0050083

Methodology: Electrochemiluminescent Immunoassay

Use:

Aid in assessing severity of congestive heart failure (CHF) in symptomatic and asymptomatic patients

Monitor therapy in patients with known CHF

Pro-BNP may provide slightly better prognostic information than BNP

Limitations:

In patients with renal insufficiency, NT-proBNP may accumulate to concentrations that no longer correlate with New York Heart Association functional classifications

Do not use as a stand alone test; assess clinical presentation and other evaluation; eg, chest X-ray, echocardiogram

Follow-up:

Can order sequentially to monitor therapy

Test name: B-Type Natriuretic Peptide

ARUP #: 0030191

Methodology: Chemiluminescent Immunoassay

Use:

Aid in assessing severity of CHF in symptomatic and asymptomatic patients

Monitor therapy in patients with known CHF

Limitations:

Blood concentrations of natriuretic peptides may be elevated in patients with myocardial infarction and in patients who are candidates for or undergoing renal dialysis

False-positive results more common in females >75 years of age

Do not use as a stand alone test; assess clinical presentation and other evaluation; eg, chest X-ray, echocardiogram

Follow-up:

Can order sequentially to monitor therapy

Additional Tests Available

Test name: Digitoxin

ARUP #: 0090085

Methodology: Fluorescence Polarization Immunoassay

Comments:

Test name: Digoxin

ARUP #: 0090080

Methodology: Enzyme Immunoassay

Comments:

Test name: Amiodarone & Metabolite

ARUP #: 0090161

Methodology: High Performance Liquid Chromatography

Comments:

Additional Information

ProBrain Natriuretic Peptide, NT test

Concentrations expected to exceed diagnostic cutoff in 90% of patients with CHF
Useful to rule out CHF due to high negative predictive value (>98%)
Generally more sensitive but less specific than BNP
Results should be interpreted in conjunction with other laboratory results and clinical findings

Clinical Sensitivity and Specificity of NT-proBNP
Age (years)	<45	45-54	55-64	65-74	greater than or equal to 75
Diagnostic Cutoff (pg/mL)	<125	<125	<125	<125	<450
Males, Clinical Sensitivity	82	88	90	92	87
Males, Clinical Specificity	96	93	88	87	89
Females, Clinical Sensitivity	87	91	89	94	82
Females, Clinical Specificity	85	86	80	58	88

B-Type Natriuretic Peptide test

Cutoff of 100 pg/mL provides maximal combination of sensitivity, specificity and negative predictive value for contributing to diagnosis of (CHF)
BNP value greater than or equal to 100 pg/mL consistent with diagnosis of CHF in clinical setting.
False-positive results more common in females >75 years of age
Blood concentrations of natriuretic peptides may be elevated with myocardial infarction and in patients who are candidates for or are undergoing renal dialysis

References

Guidelines

ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American College of Cardiology Foundation - Medical Specialty Society American Heart Association - Professional Association. 1995 Nov 1 (revised 2005 Aug 16). 82 pages. NGC:004463

Heart failure in adults. Institute for Clinical Systems Improvement - Private Nonprofit Organization. 1997 Oct (revised 2007 Aug). 119 pages. NGC:005972

Cited References

Braunwald E. Heart Failure and Cor Pulmonale. In Kasper D et al. eds. Harrison's Principles of Internal Medicine,16th ed. New York: McGraw-Hill, 2005. pp. 1367-1378.

General References

Davenport C, Cheng EY, Kwok YT, Lai AH, Wakabayashi T, Hyde C, Connock M. Assessing the diagnostic test accuracy of natriuretic peptides and ECG in the diagnosis of left ventricular systolic dysfunction: a systematic review and meta-analysis. Br J Gen Pract. 2006;56(522):48-56.

Januzzi JL Jr, Camargo CA, Anwaruddin S, Baggish AL, Chen AA, Krauser DG, Tung R, Cameron R, Nagurney JT, Chae CU, Lloyd-Jones DM, Brown DF, Foran-Melanson S, Sluss PM, Lee-Lewandrowski E, Lewandrowski KB. The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol. 2005;95(8):948-954.

Januzzi JL Jr. Natriuretic peptide testing: a window into the diagnosis and prognosis of heart failure. Cleve Clin J Med. 2006;73(2):149-7.

Liang F, O'Rear J, Schellenberger U, Tai L, Lasecki M, Schreiner GF, Apple FS, Maisel AS, Pollitt NS, Protter AA. Evidence for functional heterogeneity of circulating B-type natriuretic peptide. J Am Coll Cardiol. 2007;49(10):1071-1078.

Melanson SE, Lewandrowski EL. Laboratory testing for B-type natriuretic peptides (BNP and NT-proBNP): clinical usefulness, utilization, and impact on hospital operations. Am J Clin Pathol. 2005;124 Suppl:S122-S128.

Moe GW. B-type natriuretic peptide in heart failure. Curr Opin Cardiol. 2006;21(3):208-214.

Moe GW. BNP in the diagnosis and risk stratification of heart failure. Heart Fail Monit. 2005;4(4):116-122.

Mueller C, Laule-Kilian K, Schindler C, Klima T, Frana B, Rodriguez D, Scholer A, Christ M, Perruchoud AP. Cost-effectiveness of B-type natriuretic peptide testing in patients with acute dyspnea. Arch Intern Med. 2006;166(10):1081-1087.

Nohria A, Mielniczuk LM, Stevenson LW. Evaluation and monitoring of patients with acute heart failure syndromes. Am J Cardiol. 2005;96(6A):32G-40G.

Sepe V, Libetta C, Zucchi M, Adamo G, Giuliano MG, Soccio G, Dal Canton A. B-type natriuretic peptide dialysis clearance and renal function in patients with decompensated heart failure. Am J Kidney Dis. 2006;47(3):562-563.

Vuolteenaho O, la-Kopsala M, Ruskoaho H. BNP as a biomarker in heart disease. Adv Clin Chem. 2005;40:1-36.

Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. 2005;294(15):1944-1956.

References from the ARUP Institute for Clinical and Experimental Pathology Research®

McMillin GA, Owen WE, Lambert TL, De BK, Frank EL, Bach PR, Annesley TM, Roberts WL. Comparable effects of DIGIBIND and DigiFab in thirteen digoxin immunoassays. Clin Chem. 2002;48(9):1580-1584.

Rawlins ML, Owen WE, Roberts WL. Performance characteristics of four automated natriuretic peptide assays. Am J Clin Pathol. 2005;123(3):439-445.

Medical Reviewers

Lehman, Christopher M., M.D. Co-Medical Director, University Hospital Clinical Laboratory; Associate Professor, Clinical Pathology, University of Utah

Meikle, A. Wayne, M.D. Medical Director, RIA and Endocrinology at ARUP Laboratories; Professor of Internal Medicine and Pathology, University of Utah

Roberts, William L. , M.D., Ph.D. Medical Director, Automated Core Laboratory at ARUP Laboratories; Professor, Pathology, University of Utah

Comprehensive Review: March 2008
Last Update: March 2008