Congestive Heart Failure

Overview

Diagnosing early heart failure can be a challenge, because the symptoms often can be similar to symptoms of other conditions. If you have one or more of the symptoms of heart failure, make an appointment to see a doctor—and begin keeping a medical diary. It could be extremely helpful to you and to your physician.

This section on testing and diagnose includes information on:

• Communicating with your doctor
• The physical exam
• Laboratory tests
• Other tests

Communicating with your doctor

Symptoms that could make a doctor suspect heart failure call for a complete physical exam. Before the exam, start a written record of any symptoms and give a copy to your doctor when you arrive—even better, a day or two before your appointment, to give the physician time to look it over. The diary should describe your symptoms: how they make you feel, what activities bring them on, what makes them go away, and which ones are the most uncomfortable.

Other information you should provide:

• Relevant personal and family history: whether you or any first-degree relatives (parents, siblings, or children) have or had heart or blood vessel disease, cardiomyopathy, diabetes, kidney disease, or high blood pressure.
• Personal habits and information: whether you smoke, what you eat (especially whether you eat a lot of salty or fatty foods), whether you drink any form of alcohol (and if so, how much), and how satisfied you are with your home life, your job, and your sexual activity.
• A list of all medications you are taking—prescription, over-the-counter, herbals, and supplements—along with the dosages.
• Any allergies.
• Records of visits to any other doctors or to an emergency room.
• A record of your weight, recorded every morning after urinating but before eating (if requested).
• A record of your blood sugar or blood pressure (if requested).

A pad and pen are a patient's best friends. Jot down questions for the doctor whenever they occur to you. Bring them in, and write down the doctor's answers. They are easy to forget.

The physical exam

The doctor will be searching for signs of heart failure, as well as other illnesses that might be affecting your heart's pumping ability and producing symptoms.

Skin: The color and warmth show whether your body is getting a good supply of oxygen-rich blood.

Pulse: The pulse shows your heart's rate, rhythm, and regularity.

Swelling in ankles, feet, legs, arms, and abdomen: If swelling is present, your heart may not be pumping efficiently.

Heart sounds: Different sounds through a stethoscope reveal not only the heart's rate and rhythm but also how well it is functioning. A murmur, or whooshing sound, might indicate a leaky valve. A stiff or narrowed valve clicks when it opens and closes. The stethoscope should always be in direct contact with the skin, with no shirt or sweater between.

Blood pressure: A relaxed, resting adult whose blood pressure is higher than a systolic reading of 140 or a diastolic reading of 90 is considered to have hypertension in need of treatment. Age, heart condition, emotions, activity, and medication—even the time of day—can influence the reading. A single elevated reading—especially in a doctor's office, where readings tend to run higher than at home (a well-known phenomenon called "white-coat syndrome")—does not necessarily mean you have high blood pressure. Your blood pressure may need to be checked at different times and in other places to establish what is "normal" for you.

Laboratory tests

Chemical "biomarkers" in the blood help flag a condition or indicate how it is progressing. With heart failure, physicians generally look at several biomarkers, especially if a patient has known heart disease. Patients with higher than normal levels of one or more key biomarkers have been shown to have a far higher risk of developing congestive heart failure or of dying from heart disease than do individuals whose levels are normal.

The following lists typical blood tests and identifies the biomarkers of interest.

• Lipid blood tests: Measures the amount of LDL (the bad cholesterol), HDL (the good cholesterol), and triglycerides, another fatty substance. You can learn more about this test at our lipid blood tests page.
• Enzymes: When heart cells are damaged, several enzymes are released. These include creatine kinase (look for CK on the lab printout), creatine phosphokinase (CPK), lactic dehydrogenase (LD or LDH), troponin, and myoglobin. You can learn more about this test at our enzymes page.
• C-reactive protein (CRP): Indicates the presence of inflammation, which may in turn contribute to heart attacks, stroke, and other cardiovascular problems. You can learn more about this test at our C-reactive protein page.
• Homocysteine: High levels of homocysteine are now considered by many physicians to be an independent predictor of heart disease. (Supplemental folic acid and vitamins B12 and B6 almost always bring high homocysteine down to normal.) You can learn more about this test at our homocysteine page.
• Electrolytes: Primarily sodium and potassium, to be sure that too much or too little sodium or potassium is not causing heart symptoms. You can learn more about this test at our electrolytes page.
• BNP: When heart failure occurs or worsens, the pumping chambers, or ventricles, produce a substance that breaks down to form two proteins: B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (NT-pro-BNP). Both BNP and NT-pro-BNP are secreted into the bloodstream, and their levels rise when heart failure symptoms worsen and fall when symptoms improve. In recent tests, patients who had an elevated level of either protein had a higher risk of death and illness from heart failure. BNP and NT-pro-BNP help determine if you have heart failure rather than another condition that may cause similar symptoms. They also can help the doctor determine if your heart failure has worsened, meaning that more aggressive treatments are needed. Which test your doctor orders (i.e., BNP or NT-pro-BNP) depends on what is available at that medical center. Both tests have been shown to be beneficial.
• Kidney function: Creatinine and blood urea nitrogen (BUN). If the creatinine blood test raises questions, a urinalysis for creatinine will confirm how well the kidneys are working.
• Thyroid function: An overactive thyroid gland—hyperthyroidism—can produce symptoms resembling those of heart failure, so checking the function of the thyroid gland is important.
• Hemoglobin: An oxygen-containing substance carried by the red cells.

Other tests

Chest X-ray: An enlarged heart is a sign of heart failure; the X-ray shows the size of the heart and reveals any buildup of fluid around the heart and lungs, which is another sign. You can learn more about this test at our chest X-ray page.

Echocardiogram: A wand placed on the surface of the chest bounces ultrasound waves off the internal structures of the heart to create pictures of the valves and chambers, permitting the heart's pumping action to be assessed. An echocardiogram is often combined with another ultrasound test to detect changes in the velocity of blood flow through the valves and to gauge the pressure within the pumping chambers. You can learn more about this test at our echocardiogram page.

Ejection fraction (EF): This is a more advanced test, which determines how much of the blood held in the heart's pumping chambers is ejected with each heartbeat. A normal EF is generally greater than 50 percent, meaning more than half of the blood volume is pumped out. Below 40 percent usually confirms a diagnosis of systolic heart failure. Someone with diastolic failure can have a normal EF. EF is measured with various types of nuclear scans, such as a multigated acquisition scan (MUGA), a nuclear ventriculogram, or a radionuclide scan. During a MUGA scan, for example, adhesive electrodes are attached to the chest and connected to an electrocardiograph monitor to chart the heart's electrical activity. An intravenous line is inserted into a vein in the arm. A small amount of blood is withdrawn, mixed with a radioactive tracer that binds to the red blood cells, and reinjected. A large overhead camera focused on the heart analyzes the volume of red blood cells pumped out with each heartbeat. The test takes one to two hours.

Electrocardiogram (EKG): If the doctor has any reason to suspect a heart problem, you will have an electrocardiogram. A large number of adhesive sensors will be placed on your chest and other parts of the body. The electrical impulses traveling through the heart will be monitored and transcribed out on a strip of paper. The test itself is painless, but men with hairy chests will have to endure a few "ouch" moments when the sensors are removed.