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Last reviewed: 28 Aug 2024
Last updated: 22 Apr 2024

Summary

Definition

History and exam

Key diagnostic factors

  • breathlessness
  • peripheral oedema
  • reduced exercise tolerance
  • fatigue
  • cold extremities
  • elevated jugular venous pressure
  • risk factors
  • displaced apex beat
  • gallop rhythm (third heart sound)

Other diagnostic factors

  • nocturnal cough
  • wheezing
  • dizziness
  • confusion
  • loss of appetite
  • nocturnal ischaemic pain
  • ascites
  • central cyanosis
  • narrow pulse pressure
  • altered mental status
  • oliguria
  • delayed capillary refill time
  • pulmonary crepitations
  • dullness to percussion/decreased air entry in lung bases

Risk factors

  • previous cardiovascular disease
  • older age
  • prior episode of heart failure
  • diabetes mellitus
  • family history of ischaemic heart disease or cardiomyopathy
  • excessive alcohol intake
  • smoking
  • cardiac arrhythmias
  • history of systemic conditions associated with heart failure
  • previous chemotherapy
  • medication
  • hypertension
  • valvular heart disease
  • pericardial disease
  • myocarditis
  • excessive salt intake
  • excessive catecholamine stimulation
  • abnormal thyroid function

Diagnostic investigations

1st investigations to order

  • ECG
  • chest x-ray
  • natriuretic peptides
  • troponin
  • full blood count
  • urea, electrolytes, and creatinine
  • glucose and HbA1c
  • liver function tests
  • thyroid function tests
  • C-reactive protein
  • D-dimer
  • echocardiography

Investigations to consider

  • venous or arterial blood gas
  • blood tests screening for myocarditis
  • bedside thoracic ultrasound

Treatment algorithm

Contributors

Expert advisers

Resham Baruah, MBBS, BSc, FRCP, MSc, PhD

Consultant Cardiologist

Heart Failure Lead

Chelsea and Westminster Hospital and the Royal Brompton and Harefield NHS Trust

London

UK

Biography

RB was a specialist advisor to the National Institute for Health and Care Excellence guideline on chronic heart failure in adults.

Disclosures

RB has received honorarium/speaker fees from Novartis and Boehringer Ingleheim.

Adam D. Hartley, MBBS, BSc, MRCP

Wellcome Trust Clinical Research Fellow

Imperial College London

Specialist Registrar in Cardiology

Imperial College Healthcare NHS Trust

London

UK

Disclosures

ADH declares that he has no competing interests.

Acknowledgements

Best Practice would like to gratefully acknowledge the previous expert contributor, whose work is retained in parts of the content:

Syed Wamique Yusuf, MBBS, FACC, FRCPI

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center

Houston

TX

Peer reviewers

Lisa Anderson, BSc, MB, ChB, MD

Consultant Cardiologist

Cardiovascular Clinical Academic Group

Molecular and Clinical Sciences Research Institute

St George's, University of London

St George's University Hospitals NHS Foundation Trust

London

UK

Disclosures

LA was deputy chair for the British Society of Heart Failure clinical advisory board for tafamidis, undertook consultancy services for tafamidis (Pfizer), received a research grant from Pfizer, was on the clinical advisory board for dapagliflozin (AstraZeneca), and received lecture fees from the British Society of Cardiology/AstraZeneca and Pfizer.

James Gamble, BM, BCh, DM, FRCP

Consultant Cardiologist

Oxford Heart Centre

John Radcliffe Hospital

Oxford

UK

Disclosures

JG has been reimbursed for delivering educational meetings by: Novartis, the manufacturer of sacubitril/valsartan; Boerhinger Ingelhiem, the manufacturer of empagliflocin; AstraZeneca, the manufacturer of dapagliflozin; and Medtronic, the manufacturer of implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices. He has been supported to attend educational meetings by Abbott, Medtronic, and Boston Scientific, who all manufacture ICD and CRT devices. All of these companies produce drugs or devices related to the treatment of heart failure.

Editors

Susan Mayor

Lead Section Editor, BMJ Best Practice

Disclosures

SM works as a freelance medical journalist and editor, video editorial director and presenter, and communications trainer. In this capacity, she has been paid, and continues to be paid, by a wide range of organisations for providing these skills on a professional basis. These include: NHS organisations, including the National Institute for Health and Care Excellence, NHS Choices, NHS Kidney Care, and others; publishers and medical education companies, including the BMJ Group, the Lancet group, Medscape, and others; professional organisations, including the British Thoracic Oncology Group, the European Society for Medical Oncology, the National Confidential Enquiry into Patient Outcome and Death, and others; charities and patients’ organisations, including the Roy Castle Lung Cancer Foundation and others; pharmaceutical companies, including Bayer, Boehringer Ingelheim, Novartis, and others; and communications agencies, including Publicis, Red Healthcare and others. She has no stock options or shares in any pharmaceutical or healthcare companies; however, she invests in a personal pension, which may invest in these types of companies. She is managing director of Susan Mayor Limited, the company name under which she provides medical writing and communications services.

Annabel Sidwell

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Rachel Wheeler

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Julie Costello

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

Expert advisers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee.

Paul Cockwell, PhD, FRCP

Consultant Nephrologist

Queen Elizabeth Hospital Birmingham

Professor of Nephrology (honorary)

University of Birmingham

Birmingham

UK

Disclosures

PC is president of UK Kidney Association (UKKA), which is the professional organisation that supports healthcare professionals involved in care for, and research, innovation and education in, kidney disease. UKKA has a broad remit with relationships with multiple partners and includes responsibility for UK Kidney Week, the major educational meeting for UK kidney professionals. PC holds grant funding from Kidney Research UK in areas related to chronic kidney disease, and has recently (within the last 3 years) held grants from the EU, NIHR, and MRC in research in areas related to chronic kidney disease. PC has a non-remunerated research partnership with Boehringer Ingelheim into the epidemiology of chronic kidney disease. PC is author of the BMJ Learning module on chronic kidney disease.

Rajiv Sankaranarayanan, MBBS, FRCP (Lon), FESC, FHFA, PhD

Consultant Cardiologist and Heart Failure Lead

Liverpool University Hospitals NHS Foundation Trust

Liverpool Centre for Cardiovascular Science and NIHR Research Scholar and Honorary Senior Clinical Lecturer

University of Liverpool

Liverpool

UK

Disclosures

RS has research grants from the British Heart Foundation, the NIHR, NHSX (Transformation Agency), AstraZeneca, Biotronik, and the University of Liverpool. RS has received speaker fees/honoraria and travel reimbursement for conferences from AstraZeneca, Novartis, Vifor, Medtronic, Biotronik, Pfizer, Daaichi Sankyo, and Boehringer. RS has been appointed to: NHS England PIFU Pathway Committee for Heart Failure (2021); British Society for Heart Failure Digital Pathway, Discharge and Virtual Ward Pathway panels; British Cardiac Society Digital and Communications Committee (2020); NIHR Research Scholar (Feb 2020); Clinical Advisory Board of UK’s patient-led charity Pumping Marvellous (2020); and NHS England HF Virtual Ward committee.

Rachael Evans, MBChB, FRCP (UK), PhD

Associate Professor (Clinical)

University of Leicester

Honorary Consultant Respiratory Physician

Glenfield Hospital

Leicester

UK

Disclosures

RAE has given lectures for non-promotional industry-led sessions on long COVID and provided consultancy for GSK, AstraZeneca, Boehringer, and Chiesi, for individual payment and travel expenses totalling <£4000.

Gerry Rayman, MD, FRCP

Consultant Physician and Head of Service

Diabetes and Endocrine Centre and the Diabetes Research Unit

Ipswich Hospitals NHS Trust

Ipswich

UK

Disclosures

GR received funding from Novo Nordisk in 2022 to attend the EASD conference. GR undertakes several research projects on behalf of East Suffolk and North Essex NHS Foundation Trust for pharmaceutical companies which are on the NIHR portfolio (he does not receive payment himself for these). GR has received lecture fees from Abbott Diabetes UK and Lilly UK.

Sotiris Posporelis, MD, MRCPsych

Consultant Liaison Neuropsychiatrist

King’s College Hospital

South London and Maudsley NHS Foundation Trust

Honorary Senior Clinical Lecturer

Institute of Psychiatry, Psychology & Neuroscience

King’s College London

London

UK

Disclosures

SP declares that he has no competing interests.

Asangaedem Akpan, MPH, FRCP

Consultant Geriatrician

Bunbury Regional Hospital

Western Australia Country Health Service

Bunbury

Western Australia

Visiting Professor

University of Cumbria

Carlisle

Honorary Clinical Associate Professor

University of Liverpool

Liverpool

UK

Disclosures

AA has a limited company that is seeking consultancy work offering reviews of healthcare services, facilitation of workshops, advice/review of publications. AA has received honorariums for giving lectures on behalf of Profile Pharma in 2021. AA was invited to be on a panel at the British Society for Heart Failure conference in 2022 with all expenses paid and has been invited to contribute to the European Union geriatric medicine conference (free conference registration) and British Society for Heart Failure conference (accommodation and travel expenses covered) in 2022. AA sat on the National Institute for Health and Care Excellence Quality Standards Committee on urinary tract infections in adults as an expert committee member in 2022 and is Deputy Chair of the British Geriatrics Society England Council and Ageing Specialty Research Lead CRN NWC. AA has received research funding from the Liverpool CCG and Applied Research Collaborative 2021-2022. AA contributed to developing a heart failure pathway tool for the British Society for Heart Failure in 2022. AA sits on advisory committees for the following research studies - VOICE2 (development and testing of communication skills training for hospital healthcare practitioners caring for people living with dementia), SWOP (social work in older people), and CFIN (cognitive frailty interdisciplinary network) 2022 -2023.

Acknowledgement: Professor Sanjay Agrawal

BMJ Best Practice would like to gratefully acknowledge Professor Sanjay Agrawal, National Speciality Advisor for tobacco dependency at NHS England and Chair of Royal College of Physicians tobacco advisory group, for his advice on the comorbidity content for 'current smoker'.

Professor Sanjay Agrawal, MBChB, FRCP

Consultant in Respiratory and Intensive Care Medicine

University Hospitals of Leicester NHS Trust

Leicester

UK

Disclosures

SA declares that he has no competing interests.

Peer reviewers: comorbidities

Martyn Patel, BMBcH, FRCP, MA

Consultant, Older People's Medicine

Norfolk and Norwich University Hospitals

NHS Foundation Trust

Norwich

UK

Disclosures

MP is a contributor to the Oxford Textbook of Otolaryngology, Oxford University Press, 2021, having written a chapter about mental capacity law, for which he received no fee. MP is the NHS representative on the board for Norwich Institute for Healthy Ageing (unpaid role). MP has spoken at the International Forum on Quality and Safety in Healthcare, virtual conference in November 2020 for which he received no fee.

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