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Last reviewed: 19 Oct 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 immediate past-president and a trustee of UK Kidney Association (UKKA), which is the UK 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 is medical director for long-term conditions and prevention for NHS Birmingham and Solihull, with responsibilities that include commissioning and transformation of clinical care including areas relevant to the information on chronic kidney disease in the BMJ Best Practice Comorbidity Manager. 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, Roche, and Boehringer. RS has been appointed to: NHS England GIRFT Clinical Lead; NHS England HF Clinical Lead for Cheshire and Merseyside ICB; NHS England PIFU Pathway Committee for Heart Failure (2021); British Cardiovascular Society Vice President-Elect Digital, Communications and Media Committee; British Society for Heart Failure Board Councillor; Clinical Advisory Board of UK’s patient-led charity Pumping Marvellous (2020); and NHS England HF Expert Group.

Rachael Evans, MBChB, FRCP (UK), PhD

Associate Professor (Clinical)

University of Leicester

Honorary Consultant Respiratory Physician

Glenfield Hospital

Leicester

UK

Disclosures

RAE has given a lecture for a non-promotional industry-led session on long COVID by Moderna and provided consultancy for a long COVID project for AstraZeneca totalling <£3000. RAE is the Chief Investigator for a long COVID study funded by Genentec Roche by a grant awarded to the University of Leicester.

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 Menarini in 2023 to attend the European Association for the Study of Diabetes 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).

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.

Sanjay Agrawal, MBChB, FRCP

Consultant in Respiratory and Intensive Care Medicine

University Hospitals of Leicester NHS Trust

Leicester

UK

Disclosures

SA is a board member of Action for Smoking for Health (ASH), a healthcare charity related to tobacco control advocacy. SA is the National Specialty Advisor on Tobacco for NHS England and the Special Advisor for Tobacco for the Royal College of Physicians. SA undertakes research on the field of tobacco control but is not chief investigator for any studies at the time of making this declaration nor has he received any money or grants from pharmaceutical companies.

Acknowledgement: Professor Martin Cowie

BMJ Best Practice would like to gratefully acknowledge Professor Martin Cowie for his work on the cardiovascular comorbidity information in the Comorbidities Manager.

Martin Cowie MD, MSc, FRCP, FRCP (Ed), FESC, FHFA, FACC

Professor of Cardiology

Imperial College London (Royal Brompton Hospital)

London

UK

Disclosures

MC is chair of the European Society of Cardiology Digital Health Committee and a trustee of the Atrial Fibrillation Society. He has previously been a non-executive director of the National Institute for Health and Care Excellence. MC provides consultancy advice to AstraZeneca, Servier, Abbott, Medtronic, Boston Scientific, and Genomics PLC. MC declares that none of these interests is directly related to topics advised on for this project.

Acknowledgement: Andrew Lewington

BMJ Best Practice would like to gratefully acknowledge Dr Andrew Lewington for his work on the chronic kidney disease information in the Comorbidities Manager.

Andrew Lewington, BSc (Hons), MBBS, MEd, MD, FRCP

Consultant Renal Physician

Honorary Associate Professor

Nephrology Department

Leeds Teaching Hospitals NHS Trust

Head of MBChB

School of Medicine

University of Leeds

Leeds

UK

Disclosures

AL has been the principal applicant/co-applicant for several grants including: Engineering and Physical Sciences Research Council Research - multiplexed AKI biomarker detection with a single molecule biosensor; Leeds Cares - a novel, non-invasive diagnostic approach to assess kidney transplant health through the targeted measurement of biomarkers of kidney injury and immune response in kidney transplant recipients at the Leeds Teaching Hospitals NHS Trust; Kidney Research Yorkshire - use of enhanced technology to characterise haemodialysis treatment for acute kidney injury (AKI); Bringing It Home - validation of a micro-sampling technique for measuring tacrolimus and creatinine remotely, and to fund a research nurse; British Renal Society - renal function assessment with point of care creatinine in diverse populations (RAPID), and several NIHR grants including on a) Improving the quality of post-discharge care following AKI b) An investigation into the use of remote blood sample collection to reduce health inequalities in patients with mental health disorders c) A comparison of remote blood collection devices: a human factor use study d) Defining the characteristics for a novel automatic device to monitor urine output in catheterised patients e) Leeds Medtech and In-vitro Diagnostic Cooperative Grant Extension f) Surgical MedTech Co-operative for the 2019/20 proof-of-principle funding stream g) A pilot investigation into the use of beta-trace protein for residual renal function estimation in haemodialysis h) Application of functional MRI to improve assessment of chronic kidney disease (AFiRM study) i) SuperResPath-Renal: Quantitative super-resolution technology for a fast, decentralised clinical diagnosis of renal pathologies. AL is the co-author of several manuscripts including on extracorporeal treatments, AKI, kidney function testing prior to contrast-enhanced CT, plasma exchange and glucocorticoids in severe ANCA-associated vasculitis, COVID-19 rapid diagnostics, multimodal image-guided ablation on management of renal cancer in Von-Hippel-Lindau syndrome, and a summary of NICE guidance on CKD. AL is the author of several book chapters on nephrology and AKI. AL has received expenses for accommodation and travel for conferences at which he has given lectures, other than those delivered virtually. AL was a member of the AKI Scientific Program Committee for the ISN World Congress of Nephrology 2020-2021 and Chair of this same committee in 2021-2022.

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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