Heart failure (HF) often develops gradually — and therefore frequently goes undetected for a long time. Many patients only become aware of it once their heart function is already significantly impaired or repeated episodes of decompensation occur. Yet an early diagnosis can enable the timely initiation of guideline-based therapy, thereby sustainably improving prognosis, quality of life, and reducing the risk for hospitalizations.

These five measures help primary care physicians recognize early-stage HF and guide their patients toward evidence-based treatment.

Tip 1: Ask Specific Questions About Symptoms

The diagnosis of HF begins with a thorough medical history. Older adults, in particular, often attribute shortness of breath, fatigue, or a gradual decline in physical performance to their age and do not always mention these symptoms on their own. It is therefore advisable to actively ask about typical warning signs.

In addition to exertional dyspnea, particular attention should be paid to nocturnal shortness of breath, orthopnea, rapid fatigue, reduced exercise tolerance, ankle edema, and unexplained weight gain. Recurrent respiratory infections or reduced physical activity can also be early indicators. Particularly in patients with HF with preserved ejection fraction (HFpEF), symptoms often develop gradually and remain nonspecific for a long time.

The guidelines of the European Society of Cardiology (ESC) recommend evaluating typical symptoms in conjunction with clinical examination and biomarkers as the basis for early diagnosis.

Tip 2: Specifically Measure B-Type Natriuretic Peptide (BNP) and N-terminal pro BNP (NT-proBNP)

Natriuretic peptides are among the most important diagnostic tools in primary care today. The ESC guidelines recommend measuring BNP or NT-proBNP as soon as chronic HF is suspected.

Normal levels highly likely rule out clinically relevant HF. They help avoid unnecessary referrals or further testing. Elevated concentrations warrant prompt further diagnostic evaluation.

Laboratory results should always be interpreted within the clinical context. Age, chronic kidney disease (CKD), or atrial fibrillation (AF) can elevate levels, whereas obesity can lead to lower BNP or NT-proBNP concentrations.

A consensus paper from the Heart Failure Association of the ESC proposes age-adjusted cut-off values as well as adjustments for obesity, renal insufficiency, and AF, and describes the appropriate use of natriuretic peptides in the early diagnostic algorithm.

Tip 3: Identify Risk Groups

Not every patient requires specific evaluation for HF. However, physicians should be particularly vigilant with certain risk groups.

These include people with hypertension, coronary artery disease, diabetes, CKD, obesity, or AF. Patients who have had a myocardial infarction or are undergoing potentially cardiotoxic cancer therapies are also at increased risk.

According to the ESC guidelines, natriuretic peptides can aid in the early diagnostic evaluation of these patients and help better assess the need for further diagnostic testing, particularly echocardiography (see Tip 2).

Tip 4: Order Echocardiograms Early

Echocardiography is the diagnostic gold standard for confirming HF. It provides crucial information on pumping function, wall motion, valvular disease, and diastolic function, while also enabling differentiation between HF with reduced, mildly impaired, or HFpEF.

The ESC therefore recommends offering echocardiography as soon as possible to patients with typical symptoms and elevated BNP or NT-proBNP levels. This often allows the diagnosis to be made before the first signs of decompensation occur.

Tip 5: Consider Comorbidities in the Diagnostic Process

HF rarely occurs in isolation. Most patients suffer from multiple chronic conditions simultaneously, which influence both diagnosis and treatment.

For example, CKD alters the concentration of natriuretic peptides; diabetes significantly increases the risk for HF; and AF complicates the clinical interpretation of dyspnea and reduced exercise tolerance. Obesity can also complicate the interpretation of biomarkers.

The authors of the ESC guidelines therefore emphasize that every case of HF should be assessed within the context of the patient’s overall multimorbidity. Only in this way can diagnosis and treatment be optimally tailored to the individual patient.

Conclusion

HF often develops insidiously and frequently remains undiagnosed for a long time in its early stages. However, particularly in primary care practice, there are good opportunities to recognize early warning signs in a timely manner.

A structured medical history, the targeted use of BNP or NT-proBNP, the identification of high-risk patients, the early ordering of an echocardiogram, and the consistent consideration of comorbidities form the basis of modern early detection and prompt treatment.

This story was translated from Medscape’s German edition.