Evaluating the likelihood of emerging acute or decompensated heart failure – Part 1

Contributed by: Naheed Rajabali, BSc (Hon), MSc, MD, FRCPC – View bio

Case

Meet Kanwar, a 72-year-old retired engineer. Five years ago, he suffered a myocardial infarction (MI) and received a stent. His medical history includes atrial fibrillation and hypertension. Kanwar lives at home with his wife who is of the same age. While he manages his daily tasks well, he's noticed a decline in strength over the past three years. Fortunately, his wife helps with strenuous chores like shoveling snow and yard work. Kanwar's medication regimen includes Perindopril 4mg daily, Bisoprolol 2.5mg daily, Apixaban 5mg twice daily and Atorvastatin 40mg daily.

Recently Kanwar reported experiencing shortness of breath, especially during activities like walking at the mall. Fatigue sets in quickly, necessitating longer rest periods. He's also been less inclined to exercise or engage in social activities. While he denies chest tightness similar to his previous MI, he mentioned occasional bloating and a reduced appetite. On examination, a third heart sound (S3) is noted, and due to atrial fibrillation, jugular venous pressure is challenging to assess. However, his breath sounds are equal, without crackles, and peripheral edema is absent.

Part 1: Objectives

1. Evaluate the likelihood of emerging acute or decompensated heart failure, particularly in seniors.        
2. Shed light on the atypical presentation of heart failure.

Background

Heart Failure

Heart failure is a significant health care issue in Canada, impacting more than 600,000 Canadians aged 40 and above.¹ It is the primary cause of hospitalizations for those aged 65 and older.²

Heart failure often goes undiagnosed among the elderly, with misdiagnosis rates ranging from 16.1% to 68.5%, depending on the setting.^3,4 Accurate diagnosis is missed in roughly 50% of cases.^5,6 In frail older patients, the majority of heart failure cases remain undiagnosed, while three-quarters of previously documented cases are misdiagnosed.⁷ Frail patients may not often present with “typical” signs and symptoms of heart failure or atypical symptoms may be more pronounced than typical symptoms.^8,9

Despite concerns about polypharmacy, research highlights a troubling undertreatment of heart failure in individuals aged 65 and older, with only 13.2% receiving optimal guideline-directed medical therapy (GDMT).¹⁰

“Seniors”

The designation of age 65 as the threshold for "seniors" is somewhat arbitrary.¹¹ The World Health Organization (WHO) recognizes that chronological age is heterogeneous and of limited use for individual diagnosis, prognosis and treatment guidance.^12,13

The WHO has eliminated the term "old age" from its ICD-11 classification system, acknowledging the limited utility of chronological age in planning population health, healthy aging and social care.^12,13 Evidence indicates that physiological reserves (or intrinsic capacity or fitness-frailty) vary across the chronologic age spectrum, in various settings, including patients with heart failure.^14,15 Many clinical tools have been developed to capture “intrinsic capacity” or “physiological reserves” in various clinical settings, including in the area of heart disease¹⁶ and heart failure.¹⁷

Evidence    

Diagnostic criteria: 

The new Universal Definition of Heart Failure, endorsed by the Canadian Heart Failure Society:⁸

Symptoms and/or signs of heart failure caused by structural/functional cardiac abnormalities and at least one of: 

1. elevated natriuretic peptides

or

2. objective evidence of cardiogenic pulmonary or systemic congestion

Past medical history, signs and symptoms  

*The likelihood of this patient in the emergency department to have heart failure with this past medical history.¹⁸  

Symptoms of heart failure
 

Signs of heart failure

Investigations

Back to the case

You send the patient for investigations and the results show: 

• NTproBNP: 1100pg/mL
• Chest X-Ray report: interstitial edema
• Creatinine: egfr 47 (low) from 90 (six months ago)   

Is this patient likely in heart failure?

Yes. The probability is high based on past medical history, typical and atypical findings, physical examination and investigations.

You start him on Lasix 40mg daily and he reports that his shortness of breath has improved. His fatigue has subsided, but his energy levels are not quite to what they were four months ago. His repeat Creatinine is back to normal, in keeping with type 1 cardiorenal syndrome. 

Summary

The “ageing” demographic is heterogenous with a mix of both fit and frail patients across the numeric age spectrum.

Heart failure often goes undiagnosed in those who are chronologically older, where there is a higher prevalence of frail patients.

Typical presentations may not be present or be overshadowed by atypical symptoms, especially in those who are frail.

The absence of peripheral edema does not rule out emerging acute heart failure.

High BNP or NTproBNP levels and chest X-ray findings of cardiomegaly and pulmonary edema increase the probability of heart failure.

Low BNP or NTproBNP levels can help to rule out emerging acute heart failure.

The absence of cardiomegaly and pulmonary edema on a chest X-ray does not rule out heart failure.

Next steps

In Part 2, we will explore supplementary diagnostic investigations to confirm the diagnosis and guide the effective utilization of guideline-directed medical therapy (GDMT) for heart failure. Additionally, we will delve into essential non-pharmacological management strategies aimed at enhancing both the quality of life and overall outcomes in heart failure.

References 

1. Report from the Canadian Chronic Disease Surveillance System: Heart Disease in Canada, 2018 https://www.canada.ca/en/public-health/services/publications/diseases-conditions/report-heart-disease-Canada-2018.html
2. Jarjour M, Henri C, de Denus S, Fortier A, Bouabdallaoui N, Nigam A, O’Meara E, Ahnadi C, White M, Garceau P, Racine N, Parent MC, Liszkowski M, Giraldeau G, Rouleau JL, Ducharme A. J Am Coll Cardiol HF. 2020 Sep;8(9):725–738
3. Long B, Koyfman A, Gottlieb M. Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review. West J Emerg Med. 2019 Oct 24;20(6):875-884
4. Oudejans I, Mosterd A, Bloemen JA, Valk MJ, van Velzen E, Wielders JP, Zuithoff NP, Rutten FH, Hoes AW. Clinical evaluation of geriatric outpatients with suspected heart failure: value of symptoms, signs, and additional tests. Eur J Heart Fail. 2011;13:518–527.
5. Barents M, van der Horst I, Voors A, Hillege J, Muskiet F, de Jongste M. Prevalence and misdiagnosis of chronic heart failure in nursing home residents: the role of B-type natruiretic peptides. Neth Heart J. 2008;16:123–128
6. Davies M, Hobbs F, Davis R, Kenkre J, Roalfe AK, Hare R, Wosornu D, Lancashire RJ. Prevalence of left ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study. Lancet. 2001;358:439–444
7. Hancock HC, Close H, Mason JM, Murphy JJ, Fuat A, Singh R, Wood E, de Belder M, Brennan G, Hussain N, Kumar N, Wilson D, Hungin APS. Eur J Heart Fail. 2013 Feb;15(2):158–165.
8. Bozkurt B, Coats AJ, Tsutsui H, Abdelhamid M, Adamopoulos S, Albert N, Anker SD, Atherton J, Böhm M, Butler J, Drazner MH, Felker GM, Filippatos G, Fonarow GC, Fiuzat M, Gomez-Mesa JE, Heidenreich P, Imamura T, Januzzi J, Jankowska EA, Khazanie P, Kinugawa K, Lam CS P, Matsue Y, Metra M, Ohtani T, Piepoli MF, Ponikowski P, Rosano GMC, Sakata Y, SeferoviĆ P, Starling RC, Teerlink JR, Vardeny O, Yamamoto K, Yancy C, Zhang J, Zieroth S. Universal Definition and Classification of Heart Failure: A Report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. J Card Fail. 2021
9. Glenny, C, Heckman, G, McKelvie, R.  Heart Failure in older persons:  considerations for the primary care physician. GJS Journal of CME 2012;2;9-17
10. Wahid M, Aghanya V, Sepehrvand N, Dover DC, Kaul P, Ezekowitz J. Use of Guideline-Directed Medical Therapy in Patients Aged ≥ 65 Years After the Diagnosis of Heart Failure: A Canadian Population-Based Study. CJC Open. 2022 Aug 11;4(12):1015-1023.
11. Tamara Mann , "Should Age Matter? How 65 Came to Be Old and Old Came to Be Ill" , Origins: Current Events in Historical Perspective. December, 2012  https://origins.osu.edu/article/should-age-matter-how-65-came-be-old-and-old-came-be-ill?language_content_entity=en.
12. Rabheru K, Byles JE, Kalache A. How “old age” was withdrawn as a diagnosis from ICD-11. Volume 3, Issue 7, E457-E459, July 2022.
13. Muscedere J. The need to implement frailty in the International Classification of Disease (ICD). J Frailty Aging. 2020; 9: 2-3
14. Kehler DS, Ferguson T, Stammers AN, Bohm C, Arora RC, Duhamel TA, Tangri N. Prevalence of frailty in Canadians 18–79 years old in the Canadian Health Measures Survey. BMC Geriatr. 2017;17:28
15. Hamada T, Kubo T, Kawai K, Nakaoka Y, Yabe T, Furuno T, Yamada E, Kitaoka H, YOSACOI study group. Clinical characteristics and frailty status in heart failure with preserved vs. reduced ejection fraction. ESC Heart Fail. 2022 Jun;9(3):1853–1863
16. Rajabali N, Rolfson D, Bagshaw SM. Assessment and Utility of Frailty Measures in Critical Illness, Cardiology, and Cardiac Surgery. Can J Cardiol. 2016 Sep;32(9):1157-65
17. Sze S, Pellicori P, Zhang J, Weston J, Clark AL. Identification of Frailty in Chronic Heart Failure. JACC: Heart Failure. April 2019;7(4):291-302
18. 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. doi:10.1001/jama.294.15.1944