History and exam

Key diagnostic factors

common

breathlessness

Assess the degree of dyspnoea, including:

  • Respiratory rate[1]

  • Breathlessness when lying flat[22]

  • Effort of breathing[22] 

  • Degree of hypoxia.

Dyspnoea may be acute, but also includes orthopnoea and paroxysmal nocturnal dyspnoea.[25]

peripheral oedema

Leg oedema is usually bilateral and pitting.

Ankle swelling often reduces when the patient’s legs have been elevated for a sustained period of time (e.g., in bed overnight).

reduced exercise tolerance

Due to poor cardiac functioning.

fatigue

Fatigue, tiredness, and an increased time to recover after exercise are common signs of acute heart failure.

Due to poor cardiac functioning.

cold extremities

A sign of poor perfusion. Other signs of poor perfusion include:

  • Narrow pulse pressure[1] 

  • Altered mental status[1] 

  • Oliguria[1] 

  • Dizziness[1]

  • Central cyanosis

  • Delayed capillary refill time.

elevated jugular venous pressure

A sign of congestion.

Always check above the level of the patient’s earlobes for an elevated jugular venous pressure because this is easily missed. However, an elevated jugular venous pressure can be difficult to spot, even for a heart failure specialist.

risk factors

Ask about risk factors for heart failure if the patient has not previously been diagnosed, including:

  • Previous cardiovascular disease; coronary heart disease is the most common cause of heart failure[10] 

  • Older age[1] 

    • Prevalence of heart failure is ≥10% in people >70 years of age[1] 

  • Diabetes[10]

  • Family history of ischaemic heart disease or cardiomyopathy[10]

  • Excessive alcohol intake or smoking[10]

  • Cardiac arrhythmias including tachyarrhythmia or bradyarrhythmia

  • History of systemic conditions associated with heart failure (e.g., sarcoidosis and haemochromatosis)

  • Previous chemotherapy.

Ask about recent drug history. Drugs that may exacerbate heart failure include non-steroidal anti-inflammatory drugs, steroids, diltiazem, and verapamil.[10]

displaced apex beat

A common sign of acute heart failure.

gallop rhythm (third heart sound)

A common sign of acute heart failure.

Other diagnostic factors

uncommon

nocturnal cough

Due to pulmonary congestion.

Frothy sputum suggests that it is alveolar in origin and not bronchial.

wheezing

A sign of congestion.

dizziness

A sign of poor perfusion. Other signs of poor perfusion include:

  • Cold extremities

  • Narrow pulse pressure[1] 

  • Altered mental status[1]  

  • Oliguria[1]  

  • Central cyanosis

  • Delayed capillary refill time.

confusion

May be a sign of acute heart failure, especially in older people.

loss of appetite

A less common sign of acute heart failure.

nocturnal ischaemic pain

A less common sign of acute heart failure.

ascites

A less common sign of acute heart failure. Due to portal hypertension.

central cyanosis

A sign of poor perfusion. Other signs of poor perfusion include:

  • Cold extremities

  • Narrow pulse pressure[1]  

  • Altered mental status[1] 

  • Oliguria[1]  

  • Dizziness[1]

  • Delayed capillary refill time.

narrow pulse pressure

A sign of poor perfusion. Other signs of poor perfusion include:

  • Cold extremities

  • Altered mental status[1]  

  • Oliguria[1] 

  • Dizziness[1] 

  • Central cyanosis

  • Delayed capillary refill time.

altered mental status

A sign of poor perfusion. Other signs of poor perfusion include:

  • Cold extremities

  • Narrow pulse pressure[1] 

  • Oliguria[1] 

  • Dizziness[1] 

  • Central cyanosis

  • Delayed capillary refill time.

oliguria

A sign of poor perfusion. Other signs of poor perfusion include:

  • Cold extremities

  • Narrow pulse pressure[1] 

  • Altered mental status[1]

  • Dizziness[1] 

  • Central cyanosis

  • Delayed capillary refill time.

delayed capillary refill time

A sign of poor perfusion. Other signs of poor perfusion include:

  • Cold extremities

  • Narrow pulse pressure[1] 

  • Altered mental status[1] 

  • Oliguria[1]

  • Dizziness[1] 

  • Central cyanosis.

pulmonary crepitations

A sign of congestion.

The sound of the crackles heard on chest auscultation in heart failure is described as ‘wet’ and sounding like Velcro. Crackles in heart failure are usually fine and quiet rather than the coarse sounds that are more commonly heard in lung disease. They can be mistaken for the bilateral crackles of lung fibrosis, but patients with fibrotic lungs are more likely to be hypoxic with exertional desaturation.

dullness to percussion/decreased air entry in lung bases

A sign of congestion.

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