Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- dyspnoea
- neck vein distension
- S3 gallop
- cardiomegaly
- hepatojugular reflux
- rales
- orthopnoea and paroxysmal nocturnal dyspnoea
- nocturia
Other diagnostic factors
- tachycardia (heart rate >120 beats per minute)
- chest discomfort
- hepatomegaly
- ankle oedema
- night cough
- signs of pleural effusion
- fatigue, muscle weakness, or tiredness
- palpitations, pre-syncope, or syncope
- lethargy/confusion
Risk factors
- myocardial infarction (MI)
- hypertension
- diabetes mellitus
- dyslipidaemia
- old age
- male
- obesity
- low socio-economic status
- tobacco consumption
- excess alcohol consumption
- excess sodium intake
- excess coffee consumption
- exposure to cardiotoxic agents
- left ventricular dysfunction
- left ventricular hypertrophy
- renal insufficiency
- valvular heart disease
- tachycardia
- sleep apnoea
- depression/stress
- microalbuminuria
- elevated homocysteine
- cocaine abuse
- family history of heart failure
- atrial fibrillation
- thyroid disorders
- anaemia
- elevated tumour necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6)
- elevated C-reactive protein (CRP)
- decreased insulin-like growth factor-1 (IGF-1)
- elevated natriuretic peptides
- dilation of the left ventricle
- increased left ventricular mass
- abnormal left ventricular diastolic filling
Diagnostic investigations
1st investigations to order
- transthoracic echocardiogram
- ECG
- CXR
- B-type natriuretic peptide (BNP)/N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels
- FBC
- serum electrolytes (including calcium and magnesium)
- serum creatinine, blood urea nitrogen
- blood glucose
- LFT
- thyroid function tests (especially thyroid-stimulating hormone [TSH])
- blood lipids
- serum ferritin
- transferrin saturation
Investigations to consider
- non-invasive stress imaging (cardiovascular MRI, stress echocardiogram, SPECT, PET)
- standard exercise stress testing (bicycle or treadmill)
- coronary angiogram
- cardiac CT angiography
- cardiopulmonary exercise testing with VO₂ max
- 6-minute walking test exercise
- right heart catheterisation
- endomyocardial biopsy
- serum HIV enzyme-linked immunosorbent assay
- cardiac MRI
- biomarkers
- multi-slice computed tomography (MSCT)
Treatment algorithm
tolerance to ACE inhibitors
intolerance to ACE inhibitors
refractory to optimal medical treatment
Contributors
Authors
Syed Wamique Yusuf, FACC, FRCPI

Professor of Medicine
Department of Cardiology
University of Texas MD Anderson Cancer Center
Houston
TX
Disclosures
SWY declares that he has no competing interests.
Acknowledgements
Dr Syed Wamique Yusuf would like to gratefully acknowledge Dr Andrew R.J. Mitchell, Dr Grigorios Giamouzis, Dr Sonjoy Raja Laskar, and Dr Javed Butler, the previous contributors to this topic. ARJM, GG, SRL, and JB declare that they have no competing interests.
Peer reviewers
David Leaf, MD, MPH
Professor of Medicine
VA Greater Los Angeles Healthcare System
UCLA School of Medicine
Los Angeles
CA
Disclosures
DL declares that he has no competing interests.
Brian Griffin, MD
Director
Cardiovascular Training Program
Cleveland Clinic
Cleveland
OH
Disclosures
BG declares that he has no competing interests.
Abdallah Al-Mohammad, MD, FRCP(Edin.), FRCP(Lond.)
Consultant Cardiologist and Heart Failure Lead
Sheffield Teaching Hospitals NHS Foundation Trust (Northern General Hospital)
Sheffield
UK
Disclosures
AAM has accepted hospitality by NOVARTIS in 2008 to attend the American College of Cardiology meeting in Chicago, and had received honoraria for delivering educational talks before 2008. AAM is the co-author of the NICE chronic heart failure partial update of the guideline in 2010, and of several related articles.
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- Ageing/physical inactivity
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- Pneumonia
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