Chronic heart failure (CHF) is a clinical syndrome involving reduced cardiac output because of impaired cardiac contraction. Typical clinical symptoms of CHF include shortness of breath, fatigue and ankle swelling.1
CHF prevalence is 1-2%, rising to 10% in over 70-year-olds.4
For more information on the acute presentation of heart failure, see the Geeky Medics guide to acute heart failure.
Patients with CHF often present with symptoms that have gradually worsened over months to years.
Typical symptoms of CHF include:
Dyspnoea on exertion
Fatigue limiting exercise tolerance
Orthopnoea: the patient may be using several pillows to reduce this symptom.
Paroxysmal nocturnal dyspnoea (PND): attacks of severe shortness of breath in the night that are relieved by sitting up (pathognomonic for CHF).
Nocturnal cough with or without the characteristic ‘pink frothy sputum’.
Other important areas to cover in the history include:
Past medical history: hypertension, coronary artery disease and valvular heart disease (common causes of CHF)
Medication history: several medications can cause or worsen CHF including calcium antagonists, antiarrhythmics, cytotoxic medication and beta-blockers (in the acute phase, but long term provide prognostic benefit).
Family history: specifically close relatives with cardiac issues such as cardiomyopathy (e.g. HOCM) or coronary artery disease.
Social history: risk factors for CHF include smoking, excess alcohol intake and recreational drug use.
After a comprehensive history and clinical examination have been performed, the following investigations are recommended by NICE.2
Relevant bedside investigations include:
ECG: should be performed on all patients with suspected heart failure. An ECG may identify evidence of previous myocardial infarction (e.g. ‘Q’ waves) or arrhythmias (AV block or atrial fibrillation). A normal ECG makes heart failure unlikely.1
Urinalysis: may show glycosuria (diabetes) or proteinuria (renal disease)
ECG findings associated with heart failure include:
Atrial fibrillation (due to enlarged atria)
Left-axis deviation (due to left ventricular hypertrophy)
P wave abnormalities (e.g. P.mitrale/P.pulmonale due to atrial enlargement)
Prolonged PR interval (due to AV block)
Wide QRS complexes (due to ventricular dyssynchrony)
Relevant laboratory investigations include:
U&Es: renal failure, electrolyte abnormalities due to fluid overload (e.g. hyponatraemia)
LFTs: hepatic congestion
Troponin: if considering recent myocardial infarction
Lipids/HbA1c: ischaemic risk profile
Cardiomyopathy screen (see below)
N-terminal pro-B-type natriuretic peptide (see below)
Screening for cardiomyopathy includes the following blood tests:
Serum iron and copper studies (to rule out haemochromatosis and Wilson’s disease)
Rheumatoid factor, ANCA/ANA, ENA, dsDNA (to rule out autoimmune disease)
Serum ACE (to rule out sarcoidosis)
Serum-free light chains (to rule out amyloidosis)
N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in all patients presenting with symptoms and clinical signs of heart failure to inform the type and urgency of further investigations such as echocardiography:
NT-proBNP level >2000 ng/L – refer urgently for specialist assessment and transthoracic echocardiography within 2 weeks
NT-proBNP level 400-2000ng/L – refer routinely for specialist assessment and transthoracic echocardiography within 6 weeks
Cardiac MRI is the gold standard investigation for assessing ventricular mass, volume and wall motion. It can also be used with contrast to identify infiltration (e.g. amyloidosis), inflammation (e.g. myocarditis) or scarring (e.g. myocardial infarction). It is typically used when echocardiography has provided inadequate views.5
Chronic heart failure can be classified structurally based on left ventricular ejection fraction (LVEF).
LVEF is the percentage of blood that enters the left ventricle in diastole that is subsequently pumped out in systole.
LVEF is usually measured using transthoracic echocardiography, however, MRI, nuclear medicine scans and transoesophageal echocardiography can also be used.1,2
The New York Heart Association’s (NYHA) classification system relies on patient symptoms and level of function:3
Class I: no symptoms during ordinary physical activity
Class II: slight limitation of physical activity by symptoms
Class III: less than ordinary activity leads to symptoms
Class IV: inability to carry out any activity without symptoms
The focus of CHF management is to improve cardiac function and quality of life, prevent hospitalisation and reduce mortality.
Lifestyle management strategies include:
Fluid and salt restriction
Reduced alcohol intake
All patients with CHF should be offered vaccination for influenza and pneumococcal disease.
A medication review should be performed to identify medications which may be harmful in the context of heart failure such as:
A low-dose aldosterone antagonist (e.g. spironolactone or eplerenone) should also be prescribed if a patient continues to have symptoms of heart failure despite diuretics, ACE inhibitors and beta-blockers.
Cardiac resynchronisation therapy + defibrillator (CRT-D): a biventricular pacemaker for EF <30% + QRS >130 m/sec to re-synchronise left and right ventricular contraction to improve EF
Cardiac transplantation is rare and strict criteria must be met for consideration.
Complications of CHF include:
Arrhythmias: atrial fibrillation and ventricular arrhythmias
Depression and impaired quality of life
Loss of muscle mass
Sudden cardiac death
Prognosis is poor overall, with approximately 50% of people with heart failure dying within five years of diagnosis.5
Chronic heart failure (CHF) is a clinical syndrome resulting in reduced cardiac output as a result of impaired cardiac contraction.
The most common causes of heart failure in the UK are coronary heart disease (myocardial infarction, atrial fibrillation, heart block) and hypertension.
Typical symptoms of CHF include shortness of breath, fatigue and ankle swelling.1
Investigations required for diagnosis include ECG, NT-proBNP and echocardiography.
Management involves a combination of lifestyle modification, pharmacological therapies and in some cases surgical intervention.
The prognosis of CHF is generally poor with sudden cardiac death common.
Dr Steven Sutcliffe
Dr Chris Jefferies
European Society of Cardiology. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Published in 2016. Available from [LINK].
Chronic heart failure in adults – diagnosis and management; NICE Guidance (Sept 2018). Available from: [LINK]
Penn Medicine. Heart Failure Classification – Stages of Heart Failure and Their Treatments. Published in 2014. Available from: [LINK]
Mikael Häggström. Public domain. Available from: [LINK]
Dr Colin Tidy. Patient.info. Heart failure. Published November 2018. Available from: [LINK]
NICE. Visual summary of chronic heart failure management. All rights reserved. Subject to notice of rights.