Last reviewed: 18 Apr 2021
Last updated: 27 Mar 2019



History and exam

Key diagnostic factors

  • presence of risk factors
  • exertional dyspnoea

Other diagnostic factors

  • orthopnoea
  • paroxysmal nocturnal dyspnoea
  • abdominal fullness
  • rales
  • jugular venous distension
  • hepatojugular reflux
  • congestive hepatomegaly
  • lower extremity oedema
  • laterally displaced apical impulse
  • gallop sounds

Risk factors

  • hypertension
  • female sex
  • age >70 years
  • obesity
  • coronary artery disease/ischaemia
  • diabetes mellitus
  • chronic kidney disease
  • myocardial and pericardial disorders
  • obstructive sleep apnoea

Diagnostic investigations

1st investigations to order

  • serum electrolytes
  • renal function tests
  • liver enzymes
  • B-natriuretic peptide (BNP)/N-terminal prohormone B-natriuretic peptide (NT-pro-BNP)
  • FBC
  • 12-lead ECG
  • CXR
  • Doppler echocardiography
  • tissue Doppler imaging (TDI)

Investigations to consider

  • cardiac magnetic resonance (CMR) imaging
  • CT angiography
  • radionuclide ventriculography (MUGA scan)
  • stress testing
  • cardiac catheterisation and coronary angiography

Treatment algorithm


Consultant Cardiologist

Guys and St Thomas’ NHS Foundation Trust




GCW has been reimbursed by Pfizer, Astra Zenica, Bayer, Medtronic, St Jude, and Sanofi for attending conferences. He has attended Advisory Boards for Medtronic, St Jude, Novartis, Shire, Sanofi and Servier, and has a joint working venture with Novartis for a community pharmacist post.

Cardiology Specialist Registrar

Guys and St Thomas’ NHS Foundation Trust




JW declares that she has no competing interests.

Dr Gerald Carr-White and Dr Jessica Webb would like to gratefully acknowledge Dr Gerard Aurigemma, Dr Lokesh Tejwani, Dr Marc E. Del Rosario, and Dr Kul Aggarwal, previous contributors to this topic. GA, LT, MEDR, and KA declare that they have no competing interests.

Peer reviewersVIEW ALL

Professor of Medicine

Cardiovascular Division

Washington University School of Medicine

St. Louis



EG has lectured for Novartis, Forest, Merck, and Pfizer.

Consultant Cardiologist

Darlington Memorial Hospital




Not disclosed.

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