On the diagnosis of heart failure

The diagnosis of heart failure is of consequence to hospitalists. It can easily be confused with other conditions that cause dyspnea, weakness, edema and lung opacities. The regulatory environment drives a rush toward a specific diagnostic label. When heart failure is diagnosed in error harm may result as inappropriate core measures and care pathways are triggered. There is a certain amount of leeway for throwing labels around. For example, to stretch the point, according to the ABCD classification anyone with hypertension or diabetes but no structural heart disease or cardiac symptoms has heart failure stage A. In the day to day clinical world certain tests such as echocardiography and BNP are inappropriately used as surrogates for clinical assessment. So how should the hospitalist approach this?

The most practical definition of heart failure is that of a clinical syndrome, so its diagnosis is primarily a clinical one. The Framingham criteria may be the best starting point. BNP testing is ancillary. It has utility in helping differentiate heart failure from other causes of dyspnea when the findings are unclear. Echocardiography, rather than a tool to diagnose heart failure, is indicated to assess for certain forms of structural heart disease and to categorize the heart failure syndrome physiologically, thus guiding treatment.