Practice 10-Minute Consultation

Diagnosis and management of chronic heart failure

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1429 (Published 12 February 2014) Cite this as: BMJ 2014;348:g1429
  1. Rupert P Williams, specialist registrar in cardiology, British Heart Foundation clinical research training fellow12,
  2. Pippa Oakeshott, reader in general practice3
  1. 1King’s College London British Heart Foundation Centre of Excellence, Rayne Institute, St Thomas’ Hospital, London SE1 7EH, UK
  2. 2National Institute for Health Research Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  3. 3Population Health Sciences, St George’s, University of London, UK
  1. Correspondence to: R P Williams rupert.williams{at}kcl.ac.uk
  • Accepted 13 November 2013

An 80 year old woman who rarely attends your surgery presents with a two month history of difficulty getting her shoes on due to swollen feet and breathlessness going upstairs.

What you should cover

Ask about

  • How far can she walk before feeling breathless? Does she wake at night feeling breathless? How many pillows does she use? Has she ever had chest pain or been told she’s had a heart attack? Any palpitations or feeling faint?

  • Risk factors or causes of heart failure:

    • - Any history of myocardial infarction or angina, hypertension, valvular heart disease, atrial fibrillation, diabetes, smoking, excessive alcohol intake, or family history of ischaemic heart disease or cardiomyopathy?

    • - Coronary heart disease is the most common cause of heart failure and requires a specialist referral within two weeks (see box 1).

  • Precipitating factors for heart failure:

    • - Any recent symptoms of tachyarrhythmias, hyperthyroidism, or anaemia?

    • - Is she taking any drugs that might exacerbate heart failure (such as non-steroidal anti-inflammatory drugs, steroids, diltiazem, or verapamil)?

  • Differential diagnoses:

    • - Consider other causes of breathlessness such as pulmonary emboli, lung malignancy, chronic obstructive pulmonary disease, and chest infection. Any cough, haemoptysis, pleuritic chest pain, smoking, or weight loss?

    • - Consider other causes of ankle swelling such as dependent oedema due to sleeping in a chair all night.

Clinical examination

  • Check pulse rate and rhythm (for tachycardia or atrial fibrillation), blood pressure, and listen for murmurs suggesting valvular heart disease.

  • Check respiratory rate …

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