Chronic heart failure in older adults

Abstract

Assessment and management of heart failure (HF) in older adults may be simplified and structured by the mnemonic DEFEAT-HF: Diagnosis, Etiology, Fluid volume, Ejection fraction, And Treatment of Heart Failure. A clinical diagnosis and etiology of HF can often be established during history and physical examination. Fluid volume status must be assessed by estimating jugular venous pressure in centimeters of water by identifying the top of the jugular venous pulsation in the neck and estimating its vertical height from the right atrium. Left ventricular ejection fraction must be obtained to classify patients into systolic and diastolic HF and to guide evidence-based therapy.

Figure 1

The jugular venous pressure (JVP) is the vertical height of the top of the jugular venous pulsation from the right atrium (RA), expressed in centimeters of water. To estimate JVP, one needs to use the sternal angle (SA) as a landmark. After first estimating the “SA to the top of the jugular venous pulsation” distance (7 cm in this case), one needs to add this number to the “RA to SA” distance (10 cm in this case). Of note, the top of the jugular venous pulsation would be lower than the SA when the JVP is low, in which case the “SA to the top of the jugular pulsation” distance needs to be subtracted from the “RA to SA” distances (see Fig. 2), which would vary depending on the body position. It is helpful to remember 3 “RA to SA” distances: about 5 cm in supine position, about 8 cm at a 30 degree incline, and about 10 cm at 45 degree or higher inclines.

Figure 2

To estimate the jugular venous pressure (JVP), the jugular venous pulsation must be displayed in the middle of the neck. This requires positioning patients at various inclines, depending on the JVP level. Also, the “right atrium to sternal angle” distance varies, depending on the body position. Of note, when JVP is low (left panel), the “sternal angle to top of jugular pulsation” distance is “negative” and must be subtracted from the “right atrium to sternal angle” distance to obtain the estimated JVP in cm of water. Adopted from Ahmed A, Jones L, Hays CI. DEFEAT heart failure: assessment and management of heart failure in nursing homes made easy. J Am Med Dir Assoc. 2008;9:383-389 (page 386).