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In the Clinic |

Heart Failure

Lee R. Goldberg, MD, MPH
Ann Intern Med. 2010;152(11):ITC6-1. doi:10.7326/0003-4819-152-11-201006010-01006
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 The ACC/AHA Guidelines for Stages of Heart Failure

  • Stage A: At risk for heart failure (coronary artery disease, hypertension, or diabetes mellitus) but has yet to show impaired left ventricular function or hypertrophy.

  • Stage B: Asymptomatic left ventricular dysfunction (has never had symptomatic heart failure).

  • Stage C: Current or past symptoms of heart failure associated with underlying structural heart disease.

  • Stage D: Has truly refractory heart failure and may be eligible for specialized, advanced treatment strategies, such as mechanical circulatory support, procedures to facilitate fluid removal, continuous inotropic infusions, or cardiac transplantation or other innovative or experimental surgical procedures, or for end-of-life care, such as hospice.


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Heart Failure
Posted on July 30, 2012
Roberto J. Colon, MD, Irina Overman, MD
Wright State University Boonshoft School of Medicine
Conflict of Interest: None Declared

To the Editor,We have repeatedly enjoyed the exceptional summary provided by the In The Clinic Heart Failure article reviewing most aspects of this condition quite thoroughly. However, during a recent discussion, we discovered an error regarding the effect of obesity on B-type natriuretic peptide (BNP) levels. The article incorrectly stated that obesity can lead to elevated BNP levels. The cited article in fact concludes the opposite, that obesity actually results in lower circulating BNP levels (1). Additional studies have confirmed that obesity lowers the circulating BNP, even during episodes of decompensated heart failure, and further suggest the need for BNP cut points based on BMI to account for this relationship (2, 3). Given the obesity epidemic in our country, along with the increasing prevalence of heart failure, recognition of influences in BNP from obesity are likely to become more important in our management of this chronic condition.


1 Wang TJ, Larson MG, Levy D, et al. Impact of obesity on plasma natriuretic peptide levels. Circulation. 2004;109:594-600. [PMID: 14769680]

2 Das SR, Drazner, MH, Dries DL, et al. Impact of body mass and body composition on circulating levels of natriuretic peptides: results from the Dallas Heart Study. Circulation. 2005;112:112:2163-68. [PMID: 16203929]

3 Christenson RH, Azzazy HM, Duh S, et al. Impact of increased body mass index on accuracy of B-type natriuretic peptide (BNP) and N-terminal proBNP for diagnosis of decompensated heart failure and prediction of all cause mortality. Clin Chem. 2010;56:633-41. [PMID: 20167699]

(Examination of the) Heart Failure
Posted on July 23, 2014
James L. Meisel, MD
Boston University
Conflict of Interest: None Declared

It is unfortunate that the editors chose to reproduce the photograph of a clinical encounter in black and white rather than color, for how else might the reader surmise that this was a patient being examined for heart failure rather than a death pronouncement? (1)

In the context of the excellent review of heart failure, my mind's eye and ears sought the third heart sound, expecting to see the stethoscope's bell pressed lightly to the patient's bare skin at the apex. The imagined presence of an S3 gallop would have increased the likelihood that the patient has a depressed ejection fraction, elevated left atrial pressure, and elevated B-type natriuretic peptide, with likelihood ratios of 3.4-4.1, 5.7, and 10.1, respectively; increased overall mortality if he has a history of congestive heart failure; and, if this were a preoperative evaluation, a markedly increased risk of pulmonary edema (LR =14.6).(2) In the photo, however, the examining physician auscultates through the patient's undershirt, leaving our imaginations able to glean only that heart sounds were present but perhaps agonal.

Despite the knowledge that approximately 88% of diagnosis still resides in a diligently obtained history and physical examination (3) the photograph implicitly sanctions a deterioration of clinical skills that many fear has become rampant (4).

The only illustration of bedside assessment that remained was the examination of his skin. Were only modern technology used to its best advantage, we could know that this patient's skin remains pink, and rest assured that he is alive, well and receiving thoughtful, sophisticated medical care.

1. Goldberg LR. Heart failure. Annals Int Med 2010;152:ITC6-15.
2. McGee S. Evidence Based Physical Diagnosis. 2nd edition. Copyright 2007 by Saunders Elsevier. Pp. 437-440.
3. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992;156:163-5.
4. Wu EH, Fagan MJ, Reinert SE, Diaz JA. Self-confidence in and perceived utility of the physical examination: a comparison of medical students, residents, and faculty internists. J Gen Intern Med. 2007;22:1725-1730.
Conflict of Interest:
None declared
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