Overview

Congestive heart failure (CHF) is a clinical syndrome in which the heart fails to pump blood at
the rate required by the metabolizing tissues or in which the heart can do so only with an
elevation in filling pressure. igns of CHF are demonstrated in the image below.
Chest radiograph shows signs of congestive heart failure (CHF).
!he heart"s inability to pump a sufficient amount of blood to meet the needs of the body"s
tissues may be a result of insufficient or defective cardiac filling and#or impaired contraction
and emptying. Compensatory mechanisms increase blood volume$ as well as the cardiac
filling pressure$ heart rate$ and cardiac muscle mass$ to maintain the pumping function of the
heart and to cause a redistribution of blood flow. %espite these compensatory mechanisms$
the ability of the heart to contract and rela& declines progressively$ and heart failure (HF)
worsens.
!he clinical manifestations of HF vary enormously and depend on a variety of factors$
including the age of the patient$ the e&tent and rate at which cardiac performance becomes
impaired$ and which ventricle is initially involved in the disease process. ' broad spectrum of
severity of impairment of cardiac function is ordinarily included in the definition of HF. !hese
impairments range from the mildest forms$ which are manifest clinically only during stress$ to
the most advanced forms$ in which cardiac pump function is unable to sustain life without
e&ternal support.
()*
Echocardiography
+chocardiography is the preferred e&amination in CHF. !wo,dimensional and %oppler
echocardiography may be used to determine systolic and diastolic -. performance$ the
cardiac output (e/ection fraction)$ and pulmonary artery and ventricular filling pressures.
(0*
+chocardiography also may be used to identify clinically important valvular disease.
Radiography
1n cardiogenic cases$ radiographs may show cardiomegaly$ pulmonary venous hypertension$
and pleural effusions. 2ulmonary venous hypertension (2.H) may be divided into 3 grades. 1n
grade 1 2.H$ an upright e&amination demonstrates redistribution of blood flow to the
nondependent portions of the lungs and the upper lobes. 1n grade 11 2.H$ there is evidence of
interstitial edema with ill,defined vessels and peribronchial cuffing$ as well as interlobular
septal thic4ening. 1n grade 111 2.H$ perihilar and lower,lobe airspace filling is evident$ with
features typical of consolidation (eg$ confluent opacities$ air bronchogram and the inability to
see pulmonary vessels in the area of abnormality). !he airspace edema tends to spare the
periphery in the mid and upper lung.
1n noncardiogenic cases$ cardiomegaly and pleural effusions are usually absent. !he edema
may be interstitial but is more often consolidative. 5o cephalization of flow is noted$ though
there may be shift of blood flow to less affected areas. !he edema is diffuse and does not
spare the periphery of the mid or upper lungs.
1n cases of large$ acute myocardial infarction (61) and infarction of the mitral valve$ support
apparatus may produce atypical patterns of pulmonary edema that may mimic noncardiogenic
edema in patients who in fact have cardiogenic edema.
Computed tomography scanning
1n cases that are clinically troublesome$ multidetector,row gated computed tomography (C!)
scanning may provide e&cellent analysis of the heart and reveal the nature of the pulmonary
edema.
(3*
Electrocardiography
1n cardiogenic cases$ the electrocardiogram (+C7) may show evidence of 61 or ischemia. 1n
noncardiogenic cases$ the +C7 is usually normal.
!he +C7 image below depicts biventricular pacing.
+C7 shows biventricular pacing (double ventricular pacing spi4es).
Limitations of techniques
'lthough echocardiography is simple and noninvasive$ it proves to be inadequate in 8,)9: of
cases; in addition$ the results are difficult to interpret in patients with lung disease.
<adiography
!wo principal features of the chest radiograph are useful in the evaluation of patients with
congestive heart failure= ()) the size and shape of the cardiac silhouette$ and (0) edema at the
lung bases. (see the image below).
(>*
Chest radiograph shows signs of congestive heart failure (CHF).
!he size and shape of the cardiac silhouette provide important information concerning the
precise nature of the underlying heart disease. !he cardiothoracic ratio and the heart volume$
as determined on plain film$ are relatively specific but insensitive indicators of increased -.
end,diastolic volume. !here is a wea4 inverse correlation between the cardiothoracic ratio
and -. e/ection fraction (-.+F) in patients with HF; the relationship is not clinically useful in
the individual patient.
1n the presence of normal pulmonary capillary and venous pressures$ the lung bases are
better perfused than the apices when the patient is in the erect position$ and the vessels
supplying the lower lobes are significantly larger than those supplying the upper lobes. ?ith
elevation of left atrial and pulmonary capillary pressures$ interstitial and perivascular edema
develops; such edema is most prominent at the lung bases because hydrostatic pressure is
greater there.
?hen pulmonary capillary pressure is slightly elevated ()3,)@ mm Hg)$ the resultant
compression of pulmonary vessels in the lower lobes causes equalization in the size of the
vessels at the apices and bases (early grade 1 2.H). ?ith greater pressure elevation ()8,03
mm Hg)$ actual pulmonary vascular redistribution into nondependent portions of the lung
occurs (ie$ with the patient in an upright patient$ there is further constriction of the vessels that
lead to the lower lobes$ and there is dilatation of the vessels that lead to the upper lobes).
?hen pulmonary capillary pressures e&ceed 09,0A mm Hg$ interstitial pulmonary edema
occurs (grade 11 2.H). ?ith grade 11 2.H$ there is evidence of interstitial edema$ with ill,
defined vessels and peribronchial cuffing$ as well as interlobular septal thic4ening. !he
interlobular septal thic4ening is referred to as Berley C lines. +arly blunting of the lateral and
posterior costophrenic angles may occur; such blunting indicates the presence of pleural fluid.
?hen pulmonary capillary pressure e&ceeds 0A mm Hg$ images may show large pleural
effusions and grade 111 2.H$ with consolidative alveolar edema in a perihilar and lower,lobe
distribution.
?ith elevation of the systemic venous pressure$ the azygos vein$ brachiocephalic veins$ and
superior vena cava may become enlarged.
1n patients with chronic -. failure$ higher pulmonary capillary pressures may be
accommodated with fewer clinical and radiologic signs$ presumably because of enhanced
lymphatic drainage. 1n a study of 00 patients with advanced HF who were referred for cardiac
transplant evaluation and whose pulmonary capillary wedge pressure measurements were 0A
mm Hg or greater$ D8: had no or minimal pulmonary congestion$ as shown on chest
radiographs.
1n summary$ the typical findings of CHF on the plain radiograph are cardiomegaly; grade 1$ 11$
or 111 2.H; and increased central systemic venous volume$ with enlargement of the
mediastinal veins (including the azygous vein) and pleural effusions.
Degree of confidence
!he degree of confidence is low. !he wea4 negative correlation between the cardiothoracic
ratio and the e/ection fraction does not permit accurate determination of systolic function in
the absence of radiographic evidence of 2.H or pleural effusions in individual patients with
HF. For this reason$ a chest radiograph may not be very useful for determining the type of -.
dysfunction. %uring the treatment phase of CHF$ chest radiographic findings often lag behind
clinical improvement.
False,negative findings are frequent.
Computed !omography
C! scanning of the heart is usually not required in the routine diagnosis and management of
congestive heart failure.
6ultichannel C! scanning is useful in delineating congenital and valvular abnormalities;
however$ echocardiography and magnetic resonance imaging (6<1) may provide similar
information without e&posing the patient to ionizing radiation.
!he degree of confidence in C! scanning is moderate$ and the rates of false,positive and
false,negative findings in the modality are low.
6agnetic <esonance 1maging
Cecause of the widespread acceptance of echocardiography$ 6<1 is used only infrequently in
the wor4up of patients with congestive heart failure. 1ts main use involves delineation of
congenital cardiac abnormalities and assessment valvular heart disease; it is also used in
patients with other conditions.
(A*
!he degree of confidence in 6<1 is high$ and the rates of false,positive and false,negative
findings are low.
Eltrasonography
!wo,dimensional echocardiography is recommended as an initial part of the evaluation of
patients with 4nown or suspected congestive heart failure. .entricular function may be
evaluated$ and both primary and secondary valvular abnormalities may be accurately
assessed.
(D*
%oppler echocardiography may play a valuable role in determining diastolic function and in
establishing the diagnosis of diastolic HF.
HF in association with normal systolic function but abnormal diastolic rela&ation affects 39,
>9: of patients presenting with CHF. Cecause the therapy for this condition is distinctly
different from that for systolic dysfunction$ establishing the appropriate etiology and diagnosis
is essential. !he combination of 0,dimensional echocardiography and %oppler
echocardiography is effective for this purpose.
!wo,dimensional and %oppler echocardiography may be used to determine systolic and
diastolic -. performance$ cardiac output (e/ection fraction)$ and pulmonary artery and
ventricular filling pressures. +chocardiography may also be used to identify clinically
important valvular disease.
(>*
!he degree of confidence in echocardiography is high$ and the rates of false,positive and
false,negative findings are low.
5uclear 1maging
5uclear imaging can be used in the assessment of heart function and damage in CHF.
ECG-gated myocardial perfusion imaging
!he high photon flu& of compounds labeled with technetium,FFm (
FFm
!C) ma4es it feasible to
acquire myocardial perfusion images in an +C7,gated mode. +C7,gated myocardial
perfusion images may be displayed as an endless,loop cine on the computer screen. +C7,
gated single,photon emission C! (2+C!) images allow for assessment of global -.+F$
regional wall motion$ and regional wall thic4ening.
<egardless of whether the in/ection of radiopharmaceutical was performed during pea4 stress
or at rest$ because the acquisition is performed at rest$ +C7,gated 2+C! images reveal
resting global function and wall motion and resting wall thic4ening in areas with defects of
e&ercise,induced myocardial perfusion.
On +C7,gated 2+C! images$ regional wall thic4ening may be quantified as a percentage of
wall thic4ening in comparison to end,diastole. Commercially available and validated software
pac4ages are available for the automatic calculation of resting global -.+F$ -. volume$ and
regional wall thic4ening from +C7,gated 2+C! sections.
1n general$ -.+F from gated 2+C! agrees well with resting -.+F$ as determined with other
modalities. Guality assurance is important. %eterminations of -.+F with gated 2+C! may
be less accurate$ even invalidated$ in the presence of an irregular heart rate$ low count
density$ intense e&tracardiac radiotracer upta4e ad/acent to the -.$ or a small -..
Combined interpretation of perfusion and function on +C7,gated images substantially
increases the confidence of interpretation. !aillefer and associates reported that the
interpretation of stress and rest end,diastolic section$ rather than summed ungated sections$
may enhance the overall sensitivity for the detection of mild coronary artery disease (C'%).
+C7,gated images are useful for recognizing artifactual defects caused by attenuation
(breast and diaphragm) and thus are useful in the quality control of 2+C! imaging. +C7,
gated 2+C! imaging is presently considered the state of the art of radionuclide myocardial
perfusion imaging.
Assessment of myocardial viability
For patients with angina$ 4nown C'%$ previous infarction$ and -. dysfunction$ a reliable
method for assessing the presence$ e&tent$ and location of viable myocardium is of
considerable clinical importance. 1t is well established that global or regional ischemic -.
dysfunction is not always an irreversible condition. 'ppro&imately 0A,>9: of patients may
e&perience improvement in function after adequate revascularization.
!wo important practical issues need to be addressed in the evaluation of patients with
presumed ischemic dysfunction= ()) One should consider assessment of the relative regional
myocardial upta4e of thallium,09) (
09)
!l; often after rest rein/ection)$
FFm
!c,sestamibi$ or
FFm
!c,
tetrofosmin (often after rest administration of nitroglycerin). ?hen the resting upta4e of
radiotracer is greater than A9: of normal$ one may e&pect recovery of function after
revascularization. (0) One should consider assessment of the presence of demonstrable
ischemia (eg$ partially reversible defect) in a myocardial segment with decreased upta4e$
even if the resting upta4e is less than A9:.
Equilibrium radionuclide angiocardiography
+quilibrium radionuclide angiocardiography (+<5') uses +C7 events to define the temporal
relationship between the acquisition of nuclear data and the volumetric components of the
cardiac cycle.
ampling is performed repetitively over several hundred heartbeats$ with physiologic
segregation of nuclear data in accordance with their occurrence within the cardiac cycle.
%ata are quantified and displayed in an endless,loop$ cinegraphic format for additional
qualitative visual interpretation and analysis. +quilibrium blood,pool labeling is achieved by
use of
FFm
!c. !he intravascular label is affi&ed to the patient"s own red blood cells by use of an
in vitro or modified in vitro technique. Enlabeled stannous pyrophosphate is used to facilitate
this reaction. Conventional 'nger scintillation cameras are used for these studies. %ata are
analyzed by use of a computer$ generally with some operator interaction.
'nalysis may be obtained in either the frame or list mode. <adionuclide data are collected
and segregated temporally. !he process generally requires 3,)9 minutes for completion of
each view. Following data acquisition$ data from the several hundred individual beats are
summed$ processed$ and displayed as a single representative cardiac cycle.
%ata from the left anterior oblique (-'O) view are also used for qualitative analysis of global
-. function. On this view$ overlap of the 0 ventricles is minimal. 1n a count,based approach$
-.+F and other indices of filling and e/ection are calculated from the -. radioactivity preset at
various points throughout the cardiac cycle.
<ight ventricular function is best evaluated by first,pass techniques. !he -'O view provides
qualitative information concerning contraction of the septal$ inferoapical$ and lateral walls. !he
anterior view provides data concerning regional motion of the anterior and apical segments.
!he left lateral or left posterior oblique view provides optimal qualitative information
concerning contraction of the inferior wall and posterobasal segment.
.entricular aneurysm may be best assessed in the lateral views as well. +ach segment is
generally graded on a A,point scale$ with specific numerical grades assigned for dys4inesis$
a4inesis$ mild and severe hypo4inesis$ and normal function.
+<5' may easily be combined with additional physiologic stress testing or provocation$ which
may be in the form of either physiologic stress$ such as e&ercise; pharmacological stress$ with
the use of positive inotropic agents such as dobutamine or isoproterenol; or psychological
stress.
Degree of confidence
!he degree of confidence is moderately high.
False positivesnegatives
False,positive and false,negative findings are infrequent.
'ngiography
Cardiac catheterization and coronary angiography have a useful role in patients with
congestive heart failure$ those with valvular heart disease$ and those with congenial heart
disease$ as well as patients with other conditions.
For patients with CHF$ cardiac catheterization and coronary angiography are clearly indicated
in the following situations=
CHF caused by systolic dysfunction in association with angina or regional wall motion
abnormalities and#or scintigraphic evidence of reversible myocardial ischemia when
revascularization is being considered
Cefore cardiac transplantation
CHF secondary to postinfarction ventricular aneurysm or other mechanical
complications of 61
For these patients$ the procedures are frequently indicated when systolic dysfunction of
une&plained cause is present on noninvasive testing or when normal systolic function with
episodic HF suggests ischemically mediated -. dysfunction.
1n patients with valvular heart disease$ cardiac catheterization and coronary angiography are
clearly indicated in the following situations=
Cefore valve surgery or balloon valvotomy in an adult with chest discomfort$ ischemia
by noninvasive imaging$ or both
Cefore valve surgery in an adult who is free of chest pain but who has many ris4
factors for C'%
1nfective endocarditis with evidence of coronary embolization
1n patients with congenital heart disease$ cardiac catheterization and coronary angiography
are clearly indicated in the following situations=
Cefore surgical correction of congenital heart disease when chest discomfort or
noninvasive evidence is suggestive of associated C'%
Cefore surgical correction of suspected congenital coronary anomalies such as
congenital coronary artery stenosis$ coronary arteriovenous fistula$ and anomalous origin of
the left coronary artery
!he patient has a form of congenital heart disease that is frequently associated with
coronary artery anomalies that may complicate surgical management
Ene&plained cardiac arrest in a young patient
For these patients$ the procedures are frequently indicated before corrective open heart
surgery for congenital heart disease in an adult whose ris4 profile is associated with an
increased ris4 of coe&isting C'%.
1n patients with other conditions$ cardiac catheterization and coronary angiography are clearly
indicated in the following situations=
%iseases affecting the aorta when 4nowledge of the presence or e&tent of coronary
artery involvement is necessary for management (eg$ aortic dissection or aneurysm with
4nown C'%)
Hypertrophic cardiomyopathy with angina despite medical therapy when 4nowledge
of coronary anatomy might affect therapy
Hypertrophic cardiomyopathy with angina when heart surgery is planned
For these patients$ the procedures are frequently indicated in the following situations=
!here is a high ris4 of C'% when other cardiac surgical procedures are planned (eg$
pericardiectomy or removal of chronic pulmonary emboli)
2rospective immediate cardiac transplant donors have a ris4 profile that increases the
li4elihood of C'%
'symptomatic patients with Bawasa4i"s disease have coronary artery aneurysms on
echocardiography
Cefore surgery for aortic aneurysm#dissection in patients without 4nown C'%
<ecent blunt chest trauma and suspicion of acute 61$ without evidence of pree&isting
C'%
Degree of confidence
!he degree of confidence is moderately high.
False positivesnegatives
!he rates of false,positive and false,negative findings are low.