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| <div align="center"> | | <div align="center"> |
| {| class="wikitable" border="1" width="80%" cellpading="2" cellspacing="2" | | {| class="wikitable" border="1" width="90%" cellpading="2" cellspacing="2" |
| |- | | |- |
| |align="center" bgcolor="#E3E4FA"|'''Table 1. Definition of heart failure''' | | |align="center" bgcolor="#E3E4FA"|'''Table 1. Definition of heart failure''' |
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| === Symptoms === | | === Symptoms === |
| {| class="wikitable" border="1" width="80%" cellpading="2" cellspacing="2"
| | HF can manifest with a multitude of different symptoms, but shortness of breath and tiredness are the most characteristic. |
| |-
| |
| | colspan="2" | '''Table 2. NYHA functional classification'''
| |
| |-
| |
| | colspan="2"|
| |
| |-
| |
| | colspan="2" style="border-top: 0; background-color: white;" | '''Severity based on symptoms and physical activity'''
| |
| |-
| |
| | width="100" valign="top" style="border-bottom: 0; background-color: #CCCCFF; border-right: 0;" | '''Class I'''
| |
| | width="350" style="border-bottom: 0; width: 350; background-color: #CCCCFF; border-left: 0;" | No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea.
| |
| |-
| |
| | width="100" valign="top" style="border-bottom: 0; background-color: white; border-right: 0; border-top: 0;" | '''Class II'''
| |
| | width="350" style="border-bottom: 0; width: 350; background-color: white; border-left: 0; border-top: 0;" | Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea.
| |
| |-
| |
| | width="100" valign="top" style="border-bottom: 0; background-color: #CCCCFF; border-right: 0; border-top: 0;" | '''Class III'''
| |
| | width="350" style="border-bottom: 0; width: 350; background-color: #CCCCFF; border-left: 0; border-top: 0;" | Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity results in fatigue, palpitation, or dyspnoea.
| |
| |-
| |
| | width="100" valign="top" style=" background-color: white; border-right: 0; border-top: 0;" | '''Class IV'''
| |
| | width="350" style="width: 350; background-color: white; border-left: 0; border-top: 0;" | Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased.
| |
| |}
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| HF can manifest with a multitude of different symptoms, but shortness of breath and tiredness are the most characteristic. Other symptoms include:
| | '''Other symptoms include:''' |
| * Orthopnoea | | * Orthopnoea |
| * Dyspnea at night | | * Dyspnea at night |
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| * Palpitations | | * Palpitations |
| * Syncope | | * Syncope |
| | |
| In general, correlation between the severity of symptoms and the severity of HF is weak (guidelines). The New York Heart Association functional classification is used most frequently to classify the severity of HF (Table 2). | | In general, correlation between the severity of symptoms and the severity of HF is weak (guidelines). The New York Heart Association functional classification is used most frequently to classify the severity of HF (Table 2). |
| | |
| | <div align="center"> |
| | {| class="wikitable" border="1" width="90%" cellpading="2" cellspacing="2" |
| | |- |
| | |colspan="2" align="center" bgcolor="#E3E4FA"|'''Table 2. NYHA functional classification''' |
| | |- |
| | |colspan="2"|'''Severity based on symptoms and physical activity''' |
| | |- |
| | | width="100px"|'''Class I''' |
| | | No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnoea. |
| | |- |
| | | '''Class II''' |
| | | Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnoea. |
| | |- |
| | | '''Class III''' |
| | | Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity results in fatigue, palpitation, or dyspnoea. |
| | |- |
| | | '''Class IV''' |
| | | Unable to carry on any physical activity without discomfort. Symptoms at rest. If any physical activity is undertaken, discomfort is increased. |
| | |} |
| | </div> |
|
| |
|
| ===== Physical examination ===== | | ===== Physical examination ===== |
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| ===== Echocardiography ===== | | ===== Echocardiography ===== |
| {| class="wikitable" border="1" style="float: right" width="600" | | |
| |-
| | Echocardiography is the cornerstone in diagnosing HF, and should routinely be performed, because ventricular function can be evaluated accurately with this technique. It can provide objective evidence of a structural or functional abnormality of the heart at rest besides signs and symptoms typical of heart failure. Important parameters that can be assessed include but are not limited to wall motion, valve function, and left ventricular ejection fraction and diastolic function. Diastolic dysfunction might be an important finding in symptomatic patients with a preserved ejection fraction. Please refer to Table 3 for common echocardiographic findings in HF. Transoesophageal echocardiography is indicated in patients with an inadequate thansthoracic echo window, suspected endocarditis, complicated valvular disease or to exclude a LV thrombus. If echocardiography provides inadequate information or in patients with suspected coronary artery disease, additional imaging includes CT scanning, cardiac magnetic resonance imaging or radionuclide imaging. |
| | colspan="3"| '''Table 3. Common echocardiographic abnormalities in heart failure'''
| | |
| | <div align="center"> |
| | {| class="wikitable" border="1" width="90%" cellpading="2" cellspacing="2" |
| |- | | |- |
| | colspan="3" style="border-bottom: 0; border-top: 0; background-color: white" | | | |colspan="3" align="center" bgcolor="#E3E4FA"|'''Table 3. Common echocardiographic abnormalities in heart failure''' |
| |- | | |- |
| | width="200" style="border-bottom: 0; background-color: #CCCCFF; border-right: 0" | '''Measurement'''
| | | '''Measurement''' |
| | width="200" style="border-bottom: 0; background-color: #CCCCFF; border-right: 0; border-left: 0;" | '''Abnormality'''
| | | '''Abnormality''' |
| | width="200" style="border-bottom: 0; background-color: #CCCCFF; border-left: 0" | '''Clinical implications'''
| | | '''Clinical implications''' |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0" | LVEF
| | | LVEF |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0; border-left: 0" | Reduced (<45 – 50%)
| | | Reduced (<45 – 50%) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-left: 0;" | Systolic dysfunction
| | | Systolic dysfunction |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0;" | LV ejection fraction
| | | LV ejection fraction |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0; border-left: 0;" | Akinesis, hypokinesis, dyskinesis
| | | Akinesis, hypokinesis, dyskinesis |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-left: 0;" | Myocardial infarction/ischaemia, cardiomyopathy, myocarditis
| | | Myocardial infarction/ischaemia, cardiomyopathy, myocarditis |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0;" | End-diastolic diameter
| | | End-diastolic diameter |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0; border-left: 0;" | Increased (>55 – 60 mm)
| | | Increased (>55 – 60 mm) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-left: 0" | Volume overload
| | | Volume overload |
| HF likely | | HF likely |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0" | End-systolic diameter
| | | End-systolic diameter |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-left: 0; border-right: 0" | Increased (>45 mm)
| | | Increased (>45 mm) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-left: 0" | Volume overload
| | | Volume overload |
| HF likely | | HF likely |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0" | Fractional shortening
| | | Fractional shortening |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0; border-left: 0" | Reduced (<25%)
| | | Reduced (<25%) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-left: 0" | Systolic dysfunction
| | | Systolic dysfunction |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0" | Left atrial size
| | | Left atrial size |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0; border-left: 0" | Increased (>40 mm)
| | | Increased (>40 mm) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-left: 0" | Increased filling pressures, mitral valve dysfunction, atrial fibrillation
| | | Increased filling pressures, mitral valve dysfunction, atrial fibrillation |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0" | Left ventricular thickness
| | | Left ventricular thickness |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0; border-left: 0" | Hypertrophy (>11 – 12 mm)
| | | Hypertrophy (>11 – 12 mm) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-left: 0" | Hypertention, aortic stenosis, hypertrophic cardiomyopathy
| | | Hypertention, aortic stenosis, hypertrophic cardiomyopathy |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0" | Valvular structure and function
| | | Valvular structure and function |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0; border-left: 0" | Valvular stenosis or regurgitation (especially aortic stenosis and mitral insufficiency)
| | | Valvular stenosis or regurgitation (especially aortic stenosis and mitral insufficiency) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-left: 0" | May be primary cause of HF or complicating factor
| | | May be primary cause of HF or complicating factor |
| Asses haemodynamic consequences | | Asses haemodynamic consequences |
| Consider surgery | | Consider surgery |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0" | Mitral diastolic flow profile
| | | Mitral diastolic flow profile |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0; border-left: 0" | Abnormalities of the early and late diastolic filling patterns
| | | Abnormalities of the early and late diastolic filling patterns |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-left: 0" | Indicates diastolic dysfunction and suggests mechanism
| | | Indicates diastolic dysfunction and suggests mechanism |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0" | Tricuspid regurgitation peak velocity
| | | Tricuspid regurgitation peak velocity |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0; border-left: 0" | Increased (>3 m/s)
| | | Increased (>3 m/s) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-left: 0" | Increased right ventricular systolic pressure
| | | Increased right ventricular systolic pressure |
| Suspect pulmonary hypertention | | Suspect pulmonary hypertention |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0" | Pericardium
| | | Pericardium |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-right: 0; border-left: 0" | Effusion, haemopericardium, thickening
| | | Effusion, haemopericardium, thickening |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: white; border-left: 0" | Consider tamponade, uraemia, malignancy, systemic disease, acute or chronic pericarditis, contrictive pericarditis
| | | Consider tamponade, uraemia, malignancy, systemic disease, acute or chronic pericarditis, contrictive pericarditis |
| |- | | |- |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0" | Aortic outflow velocity time integral
| | | Aortic outflow velocity time integral |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-right: 0; border-left: 0" | Reduced (<15 cm)
| | | Reduced (<15 cm) |
| | width="200" style="border-bottom: 0; border-top: 0; background-color: #CCCCFF; border-left: 0" | Reduced low stroke volume
| | | Reduced low stroke volume |
| |- | | |- |
| | width="200" style="border-top: 0; background-color: white; border-right: 0" | Inferior vena caval
| | | Inferior vena caval |
| | width="200" style="border-top: 0; background-color: white; border-right: 0; border-left: 0" | Dilated retrograde flow
| | | Dilated retrograde flow |
| | width="200" style="border-top: 0; background-color: white; border-left: 0" | Increased right atrial pressures, right ventricular dysfunction, hepatic congestion
| | | Increased right atrial pressures, right ventricular dysfunction, hepatic congestion |
| |} | | |} |
| Echocardiography is the cornerstone in diagnosing HF, and should routinely be performed, because ventricular function can be evaluated accurately with this technique. It can provide objective evidence of a structural or functional abnormality of the heart at rest besides signs and symptoms typical of heart failure. Important parameters that can be assessed include but are not limited to wall motion, valve function, and left ventricular ejection fraction and diastolic function. Diastolic dysfunction might be an important finding in symptomatic patients with a preserved ejection fraction. Please refer to Table 3 for common echocardiographic findings in HF. Transoesophageal echocardiography is indicated in patients with an inadequate thansthoracic echo window, suspected endocarditis, complicated valvular disease or to exclude a LV thrombus. If echocardiography provides inadequate information or in patients with suspected coronary artery disease, additional imaging includes CT scanning, cardiac magnetic resonance imaging or radionuclide imaging.
| | </div> |
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| ===== Laboratory tests ===== | | ===== Laboratory tests ===== |