History taking

Around a quarter of people with heart failure die within the first year and over half within 5 years.
  • Make a working diagnosis of heart failure and refer to confirm the diagnosis.
  • Manage symptoms, including breathlessness and fatigue, to increase exercise capacity, and improve quality of life.
  • Provide advice on self-management, driving, and fitness to fly.
  • Manage symptoms at the end of life and help plan end of life care.
  • Chronic heart failure can be difficult to diagnose because the symptoms and signs are often non-specific.
    • Ask about typical symptoms of heart failure:
      • Breathlessness — on exertion, at rest, on lying flat (orthopnoea), nocturnal cough, or waking from sleep (paroxysmal nocturnal dyspnoea).
      • Fluid retention (ankle swelling, bloated feeling, abdominal swelling, or weight gain).
      • Fatigue, decreased exercise tolerance, or increased recovery time after exercise.
      • Lightheadedness or history of syncope.
    • Ask about risk factors:
      • Coronary artery disease including previous history of myocardial infarction, hypertension, atrial fibrillation, and diabetes mellitus.
      • Drugs, including alcohol.
      • Family history of heart failure or sudden cardiac death under the age of 40 years.
    • Examine for:
      • Tachycardia (heart rate over 100 beats per minute) and pulse rhythm.
      • A laterally displaced apex beat, heart murmurs, and third or fourth heart sounds (gallop rhythm).
      • Hypertension. For more information, see the CKS topic on Hypertension.
      • Raised jugular venous pressure.
      • Enlarged liver (due to engorgement).
      • Respiratory signs such as tachypnoea, basal crepitations, and pleural effusions.
      • Dependent oedema (legs, sacrum), ascites.
      • Obesity. For more information, see the CKS topic on Obesity.
    • Review the person’s medication and if appropriate reduce or stop any drugs that may cause or worsen heart failure.
    • If symptoms are sufficiently severe, offer a loop diuretic such as:
      • Furosemide 20–40 mg daily.
      • Bumetanide 0.5–1.0 mg daily.
      • Torasemide 5–10 mg daily.
    • If higher doses are required to relieve the person’s symptoms, check adherence to treatment, check for alternative causes, and seek specialist advice or consider admission (based on clinical judgement).
    • Seek specialist advice for pregnant women before initiating any drug treatment.
    • If chronic heart failure is suspected:
      • Arrange admission if the person has severe symptoms. If there is uncertainty about the need for admission, seek specialist advice.
      • For pregnant women (or women who have given birth within 6 months) with suspected heart failure (HF), either arrange emergency admission (based on clinical judgement) or seek immediate specialist advice.
      • Measure N-terminal pro-B-type natriuretic peptide level (NT-pro-BNP).
        • If the NT-pro-BNP level is above 2000 ng/L (236 pmol/L), refer urgently for specialist assessment and echocardiography to be seen within 2 weeks.
        • If the NT-pro-BNP level is between 400–2000 ng/L (47–236 pmol/L), refer for specialist assessment and echocardiography to be seen within 6 weeks.
        • If NT-pro-BNP is less than 400 ng/L (47 pmol/L), be aware that a diagnosis of heart failure is less likely. Consider discussion with a physician with subspecialty training in heart failure if a clinical suspicion of heart failure persists.
        • Be aware that:
          • European Society of Cardiology guidelines suggest a lower threshold for normal values of 125 pg/mL [ESC, 2021].
          • The level of serum natriuretic peptide does not differentiate between heart failure with reduced ejection fraction, heart failure with mildly reduced ejection fraction, and heart failure with preserved ejection fraction.
      • Arrange a 12-lead ECG in all people.
      • Consider other tests to evaluate for possible aggravating factors and to exclude other conditions with similar presentations. Possible tests include:
        • Chest X-ray.
        • Blood tests such as urea and electrolytes, estimated glomerular filtration rate (eGFR), full blood count, iron studies (transferrin saturation and ferritin), thyroid function tests, liver function tests, HbA1c, and fasting lipids. Anaemia and high platelet to lymphocyte percentage (low lymphocyte count) are strong risk factors and prognostic markers of poor outcome.
        • Urine dipstick for blood and protein.
        • Lung function tests (peak flow and/or spirometry).
      • Assess for and manage any underlying causes where appropriate.
        • People with heart failure due to valve disease should be referred for specialist assessment and given advice regarding follow up.
      Evidence suggests levels of natriuretic peptide testing are increasing in the UK [Roalfe, 2021b], but only 39% of patients with HF symptoms have NT-pro-BNP levels measured or have an echocardiogram [Hayhoe, 2019].

      Interpretation of natriuretic peptide levels

      • Natriuretic peptide levels may be reduced by:
        • Body mass index (BMI) greater than 35 kg/m2.
        • Drugs including diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-II receptor antagonists (AIIRAs), beta-blockers, and mineralocorticoid receptor antagonists (such as spironolactone).
        • African-Caribbean family origin.