10 Steps to Assess Volume

Status in Congestive Heart

Failure
Thinking back to being a student, I can recall the struggle volume
status and fluid overload. Congestive heart failure is the No. 1 cause
of hospital admission in the United States, so we run into this all the
time.

Sometimes it is easy to determine whether or not a patient has

decompensated congestive heart failure. However, I have found it
quite challenging to figure out in a number of patients.

Is Decompensated Congestive Heart Failure

Present?
Are the patientʼs symptoms from heart failure, or are they
pulmonary in etiology? Are the physical exam findings cardiac, or
are they from other causes? Wouldnʼt it be nice if this was a simple
question to answer? Let's look at how we can tell if a patient is
volume-overloaded from heart failure in 10 steps.

Step 1. Consider history of HF, risk factors for

congestive HF.
Certainly, a patient with a history of congestive heart failure is more
likely to be volume-overloaded from this cause than other issues,
right? That is correct. This means that itʼs always important to not
only view the patient as if he or she has congestive HF, but also look
at the most recent echocardiograms or other testing to see what
the systolic and diastolic function looks like.
Even if the patient does not have a history or direct evidence of
congestive HF, risk factors should be considered. The American
College of Cardiology/American Heart Association Heart Failure
Classification categorizes patients with risk factors for HF i.e.
hypertension, coronary artery disease, etc. as Stage A. If
structural heart abnormalities including reduced ejection fraction or
left ventricular hypertrophy already exist, patients are classified as
Stage B even if they have never had definite symptoms.

Step 2. Look for weight increase.

Hopefully, this information will be available, as it can sometimes
easily solve the problem. If the patient has gained 40 pounds in a
month, it is probably fluid, and they have decompensated heart
failure.

Look through the chart or office visits to find the most recent weight
to compare to the current. Ask the patient if they watch their weight.
Attentive heart failure patients should monitor their weight and
document it on a daily bases.

Some other conditions can cause fluid retention and weight gain
including liver failure (ascites) and renal failure.

Step 3. Ask about orthopnea, paroxysmal

nocturnal dyspnea.
Orthopnea, the sensation of dyspnea while laying flat, occurs when
fluid redistributes to the lungs from the abdomen or legs because
when upright gravity acts to pull fluid away from the lungs. Ask what
position the patient sleeps in; if on 3 to 4 pillows or up in a recliner,
then be concerned that he or she has decompensated heart failure.

Note that orthopnea is different than platypnea.

Step 4. Examine pitting edema.
Sounds simple, right? Although the presence of pitting edema may
be a sign of heart failure, it is not a perfect method to determine if a
patientʼs symptoms are from volume overload.

Venous insufficiency can also cause pitting edema and is quite

common. A patientʼs legs can be the size of tree trunks with skin
breakdown and weeping of fluid just from venous insufficiency. If
you see that diagnosis on the chart, then donʼt use pitting edema
alone as a measure of volume status. But if you examined the
patient 1 month ago, and you see the legs are bigger, that will work
fine.

Some patients with decompensated heart failure just donʼt seem to

retain fluid in the legs especially the younger patients, who may
retain fluid more centrally. This means a patient can be volume-
overloaded without any pitting edema at all, which is why using all
these steps are important.

Step 5. Observe jugular venous pressure,

jugular venous distension.
The jugular venous pressure is a quick way to assess volume status.
When a patient is fluid-overloaded, the right heart pressures
increase and transmit back to the jugular vein, causing jugular
venous distention.

The patient needs to be at a 45 degree angle for proper evaluation;

gravity lessens JVP if upright and increases JVP if supine. Have the
patient turn their head to the left, then examine the jugular vein.
While jugular venous pressure waveform analysis is somewhat
complex, just observe how high the pulsations go for the purpose of
volume assessment.

When pulsations are not visible, the patient is likely not volume-
overloaded. When pulsations are visible up to the angle of the jaw,
the patient certainly has elevated right heart pressures.

Caveat: It is sometimes impossible to evaluate individuals with

overweight or obesity for JVD.

Caveat: Severe tricuspid valve regurgitation causes large V waves in

the jugular venous pulsation that can trick you into thinking a patient
is volume-overloaded when that is not the case. Listen for a murmur
of tricuspid regurgitation holosystolic and best heard at the left
lower sternal border. This video shows the large systolic pulsations
from tricuspid regurgitation:

Step 6. Consider chest X-ray, lung exam

results.
The chest X-ray can be quite helpful. There are three things to look
for here:

_. Cardiac enlargement: Cardiac size greater than half the width

of the thoracic cavity (on AP films, not portable)
`. Pulmonary edema: “Fluffy” appearance of the pulmonary
vascularity
c. Pleural effusions: Fluid that has accumulated outside the lungs
in the pleural space (HF causes right-sided pleural effusions
much more than left-sided)

Here is a chest X-ray showing pulmonary edema:

The lung exam can also offer critical information. If you hear “rales”
or “crackles” on a lung exam, it may be from pulmonary edema due
to decompensated heart failure. However, recall that fibrotic lung
conditions can do the same. Decreased breath sounds at the base
can be from pleural effusions, as well.

Step 7. Look for ascites.

A distended or tense abdomen can be from ascites. Certainly, right
heart failure can cause hepatic congestion, resulting in increased
portal pressures and accumulation of fluid in the peritoneal cavity.

Ascites from HF is more likely to happen when there is severe

pulmonary hypertension, severe tricuspid regurgitation or
conditions such as constrictive pericarditis or restrictive
cardiomyopathy.
Step 8. Measure BNP, NT-pro BNP levels.
This one is nice and easy. If the B-type natriuretic peptide level is
greater than 800 pg/mL, then decompensated heart failure is more
likely to be the cause of a patientʼs dyspnea. Likewise, if the NT-pro
BNP number is high, then heart failure is more likely the cause of
symptoms although the exact cutoff for NT-pro BNP is not as
clear.

It is helpful to compare prior and current BNP levels to look for an

increase. Likewise, clinicians frequently trend the BNP (it is a
relatively inexpensive test) to monitor if the diuresis is working.

Some patients have chronically-elevated BNP level, especially when

systolic function is quite poor and/or when chronic kidney disease is
present. The trend is even more important in these situations.
Also, decompensated heart failure can definitely be present with a
normal or minimally-elevated BNP, especially if the heart failure is
diastolic, right-sided, valvular or from constrictive pericarditis (rare).

Step 9: Use echocardiography.

If you want an easy, non-invasive way of measuring cardiac-filling
pressures, echocardiography is the way to go. The left atrial
pressure can be estimated quite accurately and, if elevated,
indicates that decompensated heart failure is likely present.

But is it really that easy? Not all the time. One of my mentors and
“echo gurus” during my cardiology training, Dr. William Jacobs
the fat man in the book “House of God” said once during a
conference “I have read two full textbooks on diastolic function ...
and hell! I still donʼt understand it!”

Diastolic assessment via echo takes some time to learn; I've

summarized it here. Also, sometimes the numbers come back
making no sense. A Mayo Clinic echo course I attended stressed
that it is alright to say the numbers donʼt make sense, “the diastolic
assessment was equivocal” and be done with it.

For this purpose of this article, just know an echocardiogram can

most of the time measure the cardiac pressures and reveal if a
patient is in decompensated heart failure.

Step 10: Conduct hemodynamic evaluation

with cardiac catheterization.
This is Step 10 because it should be last resort. Invasive
hemodynamic assessment does carry some risk i.e. bleeding,
infection, etc. More than one measurement can be taken invasively
to determine the cardiac pressures and learn if decompensated
congestive heart failure is present.

Left Ventricular End Diastolic Pressure, LVEDP: This can be

measured with a catheter in the left ventricle itself. When you read
reports of coronary angiograms, this number is universally
measured. If this is greater than 12 mm Hg, then the pressure is high
and diuresing the patient may improve symptoms of heart failure to
some degree.

Pulmonary Capillary Wedge Pressure, or PCWP: If this is greater

than 12 mm Hg, then the left heart pressures are elevated. This can
be measured via a Swan-Ganz catheter (right heart catheterization),
which is nice because it requires only venous access (jugular,
subclavian or femoral vein).

Caveat: The dry and “cold” heart failure patient can trick you.

Remember there could be symptoms from heart failure even

when the volume status looks normal after going through the above
10 steps. I like the idea of placing patients with heart failure into one
of four categories based on their volume status (wet or dry) and
their cardiac output (“warm” if adequate, “cold” if very poor). This
helps guide the treatment of HF, which is discussed elsewhere.

The wet and “warm” heart failure patient is the most common.
These individuals have a large amount of fluid in their system but a
good enough cardiac output to perfuse their system; hence they
feel warm.

When you see a dry and “cold” heart failure patient, it is not good.
Things like cardiogenic shock or severely reduced cardiac output
can cause this. Feel the legs, and note they are cold (although poor
circulation can cause cold legs/feet, as well). Symptoms in this
setting can be from heart failure, even with a normal volume status.
These are the patients in which the “cardiorenal syndrome” is
frequently present that is, acute renal failure due to poor cardiac
output decreasing renal perfusion.

Diuresing the wet and “cold” patient, or giving inotropes to the dry
and “cold”patient, can actually improve the renal function.

To Diurese or Not to Diurese – That is the

Question.
The last thing you want to do is give IV Lasix to a patient who is
dehydrated or give fluids to a patient who is actually volume-
overloaded. Because figuring out the volume status is not always
that easy, itʼs critical to keep an eye out for those tricky patients
described above.

Donʼt get me wrong. Sometimes it is quite obvious when a patient

with a history of congestive heart failure comes in with increasing
dyspnea, a 40-pound weight gain, pitting edema in the lower
extremities, orthopnea and PND; then, you examine their jugular
pressure at 45 degrees and observe it up to the angle of the jaw,
rales on pulmonary exam and their BNP level is markedly elevated.
But there are times when other issues can complicate the picture,
making the diagnosis a bit more challenging.

Hopefully it will be easier for you to figure it out now and make
the right call for your patient!