Chronic congestive heart failure

Last reviewed: 8 Jan 2023
Last updated: 16 Jun 2021



History and exam

Key diagnostic factors

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

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
Other diagnostic factors

Risk factors

  • myocardial infarction (MI)
  • hypertension
  • diabetes mellitus
  • dyslipidemia
  • old age
  • male
  • obesity
  • low socioeconomic 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 apnea
  • depression/stress
  • microalbuminuria
  • elevated homocysteine
  • cocaine abuse
  • family history of heart failure
  • atrial fibrillation
  • thyroid disorders
  • anemia
  • 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
More risk factors

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
More 1st investigations to order

Investigations to consider

  • noninvasive 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 catheterization
  • endomyocardial biopsy
  • serum HIV enzyme-linked immunosorbent assay
  • cardiac MRI
  • biomarkers
  • multi-slice computed tomography (MSCT)
More investigations to consider

Treatment algorithm


tolerance to ACE inhibitors

intolerance to ACE inhibitors


refractory to optimal medical treatment



Syed Wamique Yusuf, FACC, FRCPI
Syed Wamique Yusuf

Professor of Medicine

Department of Cardiology

University of Texas MD Anderson Cancer Center




SWY declares that he has no competing interests.


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



DL declares that he has no competing interests.

Brian Griffin, MD


Cardiovascular Training Program

Cleveland Clinic




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)




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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