Intended for healthcare professionals

Clinical Review ABC of heart failure


BMJ 2000; 320 doi: (Published 29 January 2000) Cite this as: BMJ 2000;320:297
  1. M K Davies,
  2. C R Gibbs,
  3. G Y H Lip

    Clinical assessment is mandatory before detailed investigations are conducted in patients with suspected heart failure, although specific clinical features are often absent and the condition can be diagnosed accurately only in conjunction with more objective investigation, particularly echocardiography. Although open access echocardiography is now increasingly available, appropriate pre-referral investigations include chest radiography, 12 lead electrocardiography, and renal chemistry.

    Investigations if heart failure is suspected

    Initial investigations
    • Chest radiography

    • Electrocardiography

    • Echocardiography, including Doppler studies

    • Haematology tests

    • Serum biochemistry, including renal function and glucose concentrations, liver function tests, and thyroid function tests

    • Cardiac enzymes (if recent infarction is suspected)

    Other investigations
    • Radionuclide imaging

    • Cardiopulmonary exercise testing

    • Cardiac catheterisation

    • Myocardial biopsy—for example,in suspected myocarditis

    Chest x ray examination

    The chest x ray examination has an important role in the routine investigation of patients with suspected heart failure, and it may also be useful in monitoring the response to treatment. Cardiac enlargement (cardiothoracic ratio >50%) may be present, but there is a poor correlation between the cardiothoracic ratio and left ventricular function. The presence of cardiomegaly is dependent on both the severity of haemodynamic disturbance and its duration:cardiomegaly is frequently absent, for example, in acute left ventricular failure secondary to acute myocardial infarction, acute valvar regurgitation, or an acquired ventricular septal defect. An increased cardiothoracic ratio may be related to left or right ventricular dilatation, left ventricular hypertrophy, and occasionally a pericardial effusion, particularly if the cardiac silhouette has a globular appearance. Echocardiography is required to distinguish reliably between these different causes, although in decompensated heart failure other radiographic features may be present, such as pulmonary congestion or pulmonary oedema.

    Chest radiographs showing gross cardiomegaly in patient with dilated cardiomyopathy (top); cardiomegaly and pulmonary congestion with fluid in horizontal fissure (bottom)

    In left sided failure, pulmonary venous congestion occurs, initially in the upper zones (referred to as upper lobe diversion or congestion). When the pulmonary venous pressure increases …

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