Assessment - Professor Richard Kirk 2023

Professor Richard Kirk
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Careful assessment of the extent (severity and staging) of cardiac failure and is important and should be recorded to enable the likelihood and speed of progression to be predicted. For those patients presenting acutely the clinical profile determines the treatment strategy. Heart failure symptoms and stages are classified in the tables below.

Investigations should be directed to assessing the underlying cause of heart failure and documenting its severity and response to treatment accurately.
Classification & Staging
Severity Classification
INo limitations of physical activityNo limitations or symptoms
IIMay experience fatigue, palpitations, dyspnoea or angina during moderate exercise, but not at rest
Mild tachypnoea or diaphoresis with feeding
IIISymptoms with minimal exertion that interfere with normal daily activityInfants with growth failure and marked tachypnoea or diaphoresis on feeding, older children with marked dyspnoea on exertion
Unable to carry out physical activity as have HF at rest that worsens with any activity
Symptoms at rest of tachypnoea, retractions, grunting or diaphoresis
Disease Staging
AAt increased risk of HF, but with normal function and chamber size
Exposure to cardiotoxic agents, family history of heritable cardiomyopathy, single ventricle anatomy
Abnormal cardiac morphology or function with no past or current HF symptoms
Aortic regurgitation with LV dilation, history of anthracycline exposure and LV dysfunction
Past or current HF symptoms and structural or functional heart disease
Cardiomyopathy or CHD patients with symptomatic ventricular dysfunction
Marked symptoms at rest despite maximal medical management
Requiring specialist interventions - continuous inotropes, mechanical support, transplant tor hospice care
Clinical Assessment
The profiles of acute heart failure are shown in the table opposite. Congestion may be pulmonary with breathlessness and orthopnoea, systemic with peripheral oedema, raised jugular venous pressure, hepatomegaly, ascites and gut congestion (GI symptoms) or a combination of both. Diuretics is the mainstay of treatment.

Inadequate perfusion is recognised by cold, sweating extremities, oliguria, mental confusion, dizziness and a narrow pulse pressure. Hypotension is not necessary for the diagnosis but may occur when hypoperfusion is severe. Treatment is with inotropic therapy, ensuring that the circulatory volume is adequate.

Congestion and inadequate perfusion may occur in combination and then a combined treatment approach is necessary.
Acute Heart Failure Clinical Profiles

No Congestion
Adequate Perfusion
"Warm and Dry"
Optimal profile focus on preventing disease progression/decompensation
"Warm and Wet"
Diuresis with continuation of normal therapy
Inadequate Perfusion
"Cold and Dry"
Support circulation with inotropes or mechanical support
"Wet and Cold"
Diuresis and support circulation with inotropes
Last Updated: April 2023
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