Intended for healthcare professionals

Clinical Review

Investigation and management of congestive heart failure

BMJ 2010; 341 doi: (Published 14 July 2010) Cite this as: BMJ 2010;341:c3657
  1. Bruce Arroll, professor and head of general practice and primary health care 1,
  2. Robert Doughty, associate professor2,
  3. Victoria Andersen, PhD candidate1
  1. 1University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
  2. 2Department of Medicine, University of Auckland, Private Bag 92019
  1. Correspondence to: B Arroll b.arroll{at}

    Summary points

    • Perform echocardiography in patients with certain or probable heart failure to refine the diagnosis and plan treatment

    • Measure brain natriuretic peptide (BNP) in patients with an uncertain diagnosis

    • A normal BNP result is better than electrocardiography for diagnosing heart failure and rules out heart failure; if raised perform echocardiography

    • Echocardiography can determine the underlying structure and function of heart failure

    • It is crucial to distinguish heart failure with low ejection fraction from that with preserved ejection fraction because most high quality evidence on treatment is for patients with low ejection fraction

    • While waiting for echocardiography (or if not available) give an angiotensin converting enzyme inhibitor and β blocker (where possible) and uptitrate to maximum doses

    Congestive heart failure is a common condition that increases in prevalence with increasing age. In 2003, guidance from the National Institute for Health and Clinical Excellence acknowledged that the “rising epidemic of heart failure” is partly the result of people living longer and the more effective treatments for coronary heart disease now available. It also acknowledged, however, that average life expectancy is only about three years after diagnosis, which is much worse than for many other serious illnesses such as cancer of the breast or colon.1 The condition is associated with poor quality of life, frequent hospital admissions, and poor survival,2 although this may have changed with the advent of better treatments. Community estimates of prevalence vary from 1.6 to 4.6 cases per 1000 in men aged 45-74 years and from 0.9 to 2.2 cases per 1000 in women. About 1% of men develop heart failure after age 75 and almost 2% after 80 years.3 This review discusses the immediate management of patients who present with the clinical syndrome of heart failure (usually a combination of dyspnoea, fatigue, exercise intolerance, and fluid …

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