Intended for healthcare professionals

Clinical Review ABC of heart failure

Clinical features and complications

BMJ 2000; 320 doi: (Published 22 January 2000) Cite this as: BMJ 2000;320:236
  1. R D S Watson,
  2. C R Gibbs,
  3. G Y H Lip

    Clinical features

    Patients with heart failure present with a variety of symptoms, most of which are non-specific. The common symptoms of congestive heart failure include fatigue, dyspnoea, swollen ankles, and exercise intolerance, or symptoms that relate to the underlying cause. The accuracy of diagnosis by presenting clinical features alone, however, is often inadequate, particularly in women and elderly or obese patients.

    Symptoms and signs in heart failure




    Paroxysmal nocturnal dyspnoea

    Reduced exercise tolerance, lethargy, fatigue

    Nocturnal cough


    Ankle swelling



    Cachexia and muscle wasting


    Pulsus alternans

    Elevated jugular venous pressure

    Displaced apex beat

    Right ventricular heave

    Crepitations or wheeze

    Third heart sound


    Hepatomegaly (tender)




    Exertional breathlessness is a frequent presenting symptom in heart failure, although it is a common symptom in the general population, particularly in patients with pulmonary disease. Dyspnoea is therefore moderately sensitive, but poorly specific, for the presence of heart failure. Orthopnoea is a more specific symptom, although it has a low sensitivity and therefore has little predictive value. Paroxysmal nocturnal dyspnoea results from increased left ventricular filling pressures (due to nocturnal fluid redistribution and enhanced renal reabsorption) and therefore has a greater sensitivity and predictive value. Nocturnal ischaemic chest pain may also be a manifestation of heart failure, so left ventricular systolic dysfunction should be excluded in patients with recurrent nocturnal angina.

    Common causes of lower limb oedema

    • Gravitational disorder—for example,immobility

    • Congestive heart failure

    • Venous thrombosis or obstruction, varicose veins

    • Hypoproteinaemia—for example,nephrotic syndrome,liver disease

    • Lymphatic obstruction

    Fatigue and lethargy

    Fatigue and lethargy in chronic heart failure are, in part, related to abnormalities in skeletal muscle, with premature muscle lactate release, impaired muscle blood flow, deficient endothelial function, and abnormalities in skeletal muscle structure and function. Reduced cerebral blood flow, when accompanied by abnormal sleep patterns, may occasionally lead to somnolence and confusion in severe chronic heart failure.

    Sensitivity, specificity, and predictive value of symptoms, signs, and chest × ray findings for presence of heart failure (ejection fraction <40%) in 1306 patients with coronary artery disease undergoing cardiac catheterisation

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    Sensitivity, specificity, and predictive value of symptoms, signs, and chest …

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