6th May 2025

Diagnosis

Heart failure is a clinical diagnosis and careful history taking and examination is key to identifying the key signs, symptoms and risk factors of heart failure. Dyspnoea on exertion or at rest is the most common presenting complaint of heart failure (sensitivity 84-100%; specificity 17-34%). Patients may also present with peripheral oedema (93% sensitivity; 10% specificity) and abdominal distension (sensitivity 23%, specificity 80%) due to fluid overload.

Symptoms

Right ventricular symptoms	Left ventricular symptoms	Functional symptoms
Bloating Postprandial satiety Bilateral leg swelling	Breathlessness Paroxysmal nocturnal dyspnoea Orthopnoea Bendopnoea Cough Wheezing	Fatigue/weakness/lethargy Loss of appetite Decline in cognition Functional ability can be measured with the NYHA classification

Table 1: Main symptoms of heart failure

NYHA classification	Symptoms
Class I	Patients with cardiac disease with no resulting physical limitations. Asymptomatic with normal activities.
Class II	Patients with cardiac disease and some limitation of strenuous physical activity but are comfortable at rest.
Class III	Patients with cardiac disease and marked limitation of physical activity but are comfortable at rest. Symptomatic with less than ordinary physical activity.
Class IV	Unable to carry out physical activity without discomfort. May be symptomatic even at rest.

Table 2: New York Heart Association (NYHA) classification

Right ventricular signs	Left ventricular signs
Raised JVP (jugular venous pressure) Abdominal distension Shifting dullness Hepatomegaly Hepatojugular reflux Pitting oedema	Bibasal crackles on auscultation of the lungs Tachypnoea Neck vein distension Third heart sound Summation gallop with third and fourth heart sounds Displaced apex beat

Table 3: Key signs of heart failure

Risk factors

Demographics: Old age, male sex,
Cardiac history: Myocardial infarction, left ventricular hypertrophy, valvular heart disease, congenital heart disease, atrial fibrillation
Past medical history: Diabetes mellitus, hypertension, dyslipidaemia, renal insufficiency, thyroid disorders, anaemia
Drug history: Exposure to cardiotoxic agents, use of recreational drugs (ie: cocaine)
Family history: Heart failure, hereditary hemochromatosis, Wilson’s disease
Social history: Tobacco use, alcohol use, dietary habits

Framingham Heart Failure Diagnostic Criteria

The key symptoms of congestive heart failure can be summarised with the Framingham Criteria. A diagnosis of heart failure can be made with 2+ major criteria, or with 1 major and 2 minor criteria.

Major Criteria	Minor Criteria
Acute pulmonary oedema Cardiomegaly Hepatojugular reflux Neck vein distension Paroxysmal nocturnal dyspnoea or orthopnoea Pulmonary rales Third heart sound Weight loss >4.5kg in 5 days response to treatment)	Ankle oedema Dyspnoea on exertion Hepatomegaly Nocturnal cough Pleural effusion Tachycardia (HR>120)

Table 4: Major and minor criteria of the Framingham heart failure diagnostic criteria

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