Heart failure learning module 2: diagnosis

Released1 November 2017     Expires: 01 November 2019      Programme:

Chronic heart failure

The vast majority of patients with heart failure receive active treatment so that following a presentation with an acute episode of heart failure (either to the emergency department or GP), venous congestion is treated.

Table 4. NYHA classification
Table 4. New York Heart Association (NYHA) classification

The chronic heart failure syndrome is what affects patients with heart failure once they are taking appropriate combination therapy.7

Common symptoms of chronic heart failure are:

  • dyspnoea
  • orthopnoea & paroxysmal nocturnal dyspnoea
  • fatigue and exercise intolerance.

The New York Heart Association (NYHA) is the most widely used symptom classification (table 4).

Acute heart failure – new onset or acute decompensation of heart failure

Screen shot 2014-01-28 at 17.58.57

In acute or decompensated heart failure, the majority of patients present with fluid in the wrong place.7 The fluid can be in the lungs (pulmonary oedema) or predominantly in the tissues (peripheral oedema).

A patient may present with symptoms and signs of pulmonary oedema, and cardiogenic shock. This is usually following an acute insult to the myocardium such as a myocardial infarction or arrhythmia.

The clinical features include:

  • dyspnoea
  • tachypnoea, hypoxia and respiratory failure
  • tachycardia
  • symptoms and signs of coronary ischaemia
  • reduced capillary refill time (<2 seconds)
  • rapid atrial and/or ventricular arrhythmia.
Figure 1
Figure 3. Pedal oedema during and after the application of pressure to the skin

The patient is extremely short of breath; they have to sit upright and may well be pale and clammy, often with high blood pressure (sympathetic outflow). They are unable to form clear sentences and they may cough up oedema fluid.
Some patients develop cardiogenic shock following a large infarct (figure 3), in which case the clinical features of a low-output state may be more predominant (mental alteration, hypotension and oliguria).
At the other end of the spectrum, patients with acute heart failure present with fluid retention, with the ankles usually the first affected (figure 4). The oedema progressively rises up the legs and then affects the abdominal wall. Pleural effusions, ascites and thoracic wall oedema may develop.7,3

Clinical features include:

  • pitting oedema (figure 3)
  • sinus tachycardia or atrial fibrillation
  • low systemic blood pressure
  • lung crackles – usually at both lung bases
  • a raised jugular venous pressure (JVP) (figure 4)
  • hepatic congestion
  • pleural effusion – dull percussion note, reduced breath sounds.

Figure 4. Jugular venous pressure (Click arrow below to play, or bottom-right for full screen)


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