Last reviewed: 11 Apr 2021
Last updated: 08 Jan 2019



History and exam

Key diagnostic factors

  • dyspnea
  • neck vein distention
  • S3 gallop
  • cardiomegaly
  • hepatojugular reflux
  • rales
  • orthopnea and paroxysmal nocturnal dyspnea
  • nocturia

Other diagnostic factors

  • tachycardia (heart rate >120 beats per minute)
  • chest discomfort
  • hepatomegaly
  • ankle edema
  • night cough
  • signs of pleural effusion
  • fatigue, muscle weakness, or tiredness
  • palpitations, presyncope, or syncope
  • lethargy/confusion

Risk factors

  • myocardial infarction (MI)
  • diabetes mellitus
  • dyslipidemia
  • old age
  • male
  • hypertension
  • left ventricular dysfunction
  • low socioeconomic status
  • cocaine abuse
  • tobacco consumption
  • excess alcohol consumption
  • excess sodium intake
  • excess coffee consumption
  • exposure to cardiotoxic agents
  • left ventricular hypertrophy
  • obesity
  • renal insufficiency
  • valvular heart disease
  • tachycardia
  • sleep apnea
  • depression/stress
  • microalbuminuria
  • elevated homocysteine
  • elevated tumor necrosis factor-alfa (TNF-alfa) 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
  • family history of heart failure
  • atrial fibrillation
  • thyroid disorders
  • anemia

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
  • CBC
  • serum electrolytes (including calcium and magnesium)
  • serum creatinine, BUN
  • blood glucose
  • LFT
  • thyroid function tests (especially thyroid-stimulating hormone [TSH])
  • blood lipids
  • serum ferritin
  • transferrin saturation

Investigations to consider

  • standard exercise stress testing (bicycle or treadmill)
  • cardiopulmonary exercise testing with VO₂ max
  • 6-minute walking test exercise
  • right heart catheterization
  • endomyocardial biopsy
  • serum HIV enzyme-linked immunosorbent assay
  • cardiac MRI

Emerging tests

  • biomarkers
  • multi-slice computed tomography (MSCT)

Treatment algorithm


Syed Wamique Yusuf

Professor of Medicine

Department of Cardiology

University of Texas MD Anderson Cancer Center




SWY is co-director of the American College of Cardiology annual board review course and in this capacity delivers educational lectures for the board review course.

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 reviewersVIEW ALL

Professor of Medicine

VA Greater Los Angeles Healthcare System

UCLA School of Medicine

Los Angeles



DL declares that he has no competing interests.


Cardiovascular Training Program

Cleveland Clinic




BG declares that he has no competing interests.

Consultant Cardiologist and Heart Failure Lead

Sheffield Teaching Hospitals NHS Foundation Trust (Northern General Hospital)




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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