Chronic Heart Failure (CHF)

Chronic Heart Failure (CHF)

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Chronic heart failure (CHF) is a clinical syndrome involving reduced cardiac output because of impaired cardiac contraction. Typical clinical symptoms of CHF include shortness of breath, fatigue and ankle swelling.

CHF prevalence is 1-2%, rising to 10% in those over 70 years old.



Stroke volume requires:

  • adequate preload
  • optimal myocardial contractility (Frank-Starling mechanism)
  • decreased afterload

As a result, cardiac output (CO) can be reduced by any of the following factors (potentially causing CHF):

  • decreased heart rate
  • decreased preload
  • decreased contractility
  • increased afterload

Cardiac output (CO) = Heart rate (HR) x Stroke volume (SV)

Causes of heart failure

The most common causes of heart failure in the UK are coronary heart disease (myocardial infarction), atrial fibrillation, valvular heart disease and hypertension.

Other causes of heart failure include:

  • Endocrine disease: hypothyroidism, hyperthyroidism, diabetes, adrenal insufficiency, Cushing's syndrome
  • Medications: calcium antagonists, anti-arrhythmics, cytotoxic medication, beta-blockers.

High-output cardiac failure occurs in states where demand exceeds normal cardiac output such as pregnancy, anaemia and sepsis.

Clinical features


Patients with CHF often present with symptoms that have gradually worsened over months to years.

Typical symptoms of CHF include:

  • Dyspnoea on exertion
  • Fatigue limiting exercise tolerance
  • Orthopnoea: the patient may be using several pillows to reduce this symptom.
  • Paroxysmal nocturnal dyspnoea (PND): attacks of severe shortness of breath in the night that are relieved by sitting up (pathognomonic for CHF).
  • Nocturnal cough with or without the characteristic ‘pink frothy sputum’.

History Taking and Clinical Examination in Heart Failure

When taking a history for suspected heart failure (CHF), important areas to consider include any pre-syncope or syncope and reduced appetite. Additionally, it is important to gather information regarding the patient's past medical history, family history, medications they are taking, and any social risk factors such as smoking, excess alcohol intake, and recreational drug use.

Clinical Examination

On cardiovascular examination of a suspected CHF patient, clinical findings may include:

  • Tachycardia at rest
  • Hypotension
  • Narrow pulse pressure
  • Raised jugular venous pressure
  • Displaced apex beat
  • Right ventricular heave
  • Gallop rhythm on auscultation
  • Murmurs associated with valvular heart disease
  • Pedal and ankle oedema

On respiratory examination of a suspected CHF patient, clinical findings may include:

  • Tachypnoea
  • Bibasal end-inspiratory crackles and wheeze on auscultation of the lung fields
  • Reduced air entry on auscultation with stony dullness on percussion (pleural effusion)

On abdominal examination of a suspected CHF patient, clinical findings may include:

  • Hepatomegaly
  • Ascites


NICE recommends performing certain investigations after history taking and clinical examination for suspected heart failure.

Bedside Investigations

Relevant bedside investigations include:

  • ECG: should be performed on all patients with suspected heart failure. An ECG may identify evidence of previous myocardial infarction, arrhythmias, and a normal ECG makes heart failure unlikely.
  • Urinalysis: may show glycosuria or proteinuria.
ECG Findings

ECG findings associated with heart failure include:

  • Tachycardia
  • Atrial fibrillation
  • Left-axis deviation
  • P wave abnormalities
  • Prolonged PR interval
  • Wide QRS complexes

Laboratory Investigations

Relevant laboratory investigations include:

  • FBC: anaemia
  • U&Es: renal failure, electrolyte abnormalities due to fluid overload

Investigating Chronic Heart Failure

The investigation of chronic heart failure (CHF) should begin with a range of blood tests, including:

  • U&E: renal impairment (e.g. hyponatraemia)
  • LFTs: hepatic congestion
  • Troponin: if considering recent myocardial infarction
  • Lipids/HbA1c: ischaemic risk profile
  • TFTs: hyperthyroidism/hypothyroidism
  • Cardiomyopathy screen
  • N-terminal pro-B-type natriuretic peptide

Cardiomyopathy screen

Screening for cardiomyopathy includes the following blood tests:

  • Serum iron and copper studies
  • Rheumatoid factor, ANCA/ANA, ENA, dsDNA
  • Serum ACE
  • Serum-free light chains

N-terminal pro-B-type natriuretic peptide

N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in all patients presenting with symptoms and clinical signs of heart failure to inform the type and urgency of further investigations such as echocardiography:

  • NT-proBNP level >2000 ng/L -refer urgently
  • NT-proBNP level 400-2000ng/L -refer routinely
  • NT-proBNP level <400 ng/L -heart failure unlikely

Other conditions in which NT-proBNP may be raised include left ventricular hypertrophy, tachycardia, liver cirrhosis, diabetes and acute or chronic renal disease.



All patients with suspected chronic heart failure should undergo transthoracic echocardiography, with the urgency determined by their NT-proBNP level.

Chest X-ray

Typical chest X-ray findings associated with CHF include alveolar oedema, kerley B lines, cardiomegaly, dilated upper lobe vessels and effusions.

Cardiac MRI

Cardiac MRI is the gold standard investigation for assessing ventricular mass, volume and wall motion. It can be used with contrast to identify infiltration, inflammation or scarring. It is typically used when echocardiography has provided inadequate views.

Congestive Heart Failure

Chronic heart failure (CHF) is a condition in which the heart is unable to pump enough blood throughout the body. It can be classified structurally based on left ventricular ejection fraction (LVEF). LVEF measures the percentage of blood that enters and is subsequently pumped out of the left ventricle. It usually is measured with transthoracic echocardiography, but can also be done through MRI, nuclear medicine scans, and transoesophageal echocardiography.

The New York Heart Association's (NYHA) classification system relies on patient symptoms and level of function: Class I (no symptoms during physical activity), Class II (slight limitation of physical activity by symptoms), Class III (less than ordinary activity leads to symptoms), Class IV (inability to carry out any activity without symptoms).


CHF management focuses on improving cardiac function, quality of life, preventing hospitalization, and reducing mortality.

General management

Lifestyle management

Lifestyle management includes: fluid and salt restriction, regular exercise, smoking cessation, and reduced alcohol intake.


Everyone with CHF should be offered vaccinations for influenza and pneumococcal disease.

Medication review

A medication review should be done to identify any medications that can be harmful to those with heart failure, such as calcium channel blockers, tricyclic antidepressants, lithium, NSAIDs, COX-2 inhibitors, corticosteroids, and QT-prolonging medications.


Patients with CHF need to be monitored for functional capacity, fluid status, cardiac rhythm, cognitive status, nutritional status, and renal function. The frequency of monitoring depends on clinical condition.

Management of co-morbidities

Coronary artery disease

If heart failure is caused by coronary artery disease, statins and aspirin may be prescribed for secondary prevention.

Atrial fibrillation

Oral anticoagulation is prescribed for patients with heart failure and atrial fibrillation (paroxysmal or permanent) due to the risk of stroke.

Pharmacological management

Pharmacological treatment is aimed at increasing cardiac output by optimizing preload and contractility while decreasing afterload.

Medications to Treat Heart Failure

The medications discussed below are aimed to target the pathological sympathetic responses and renin-angiotensin-aldosterone system (RAAS) activation that occurs in chronic heart failure (CHF).


Diuretics are prescribed to alleviate symptoms associated with fluid overload such as shortness of breath and peripheral oedema. They work by increasing sodium excretion via diuresis, which ultimately reduces cardiac afterload. Doses should be adjusted according to clinical response and renal function should be closely monitored.

ACE Inhibitors

All patients with CHF and reduced ejection fraction (LVEF ≤ 40%) should be prescribed an ACE inhibitor, unless contraindicated. ACE inhibitors have been proven to improve ventricular function and reduce mortality. Urine and electrolytes should be tested prior to treatment and after 1-2 weeks. Contraindications for ACE inhibitors include a history of angioedema, bilateral renal artery stenosis, hyperkalaemia (> 5 mmol/L), severe renal impairment (serum creatinine > 220 μmol/L) and severe aortic stenosis.


Beta-blockers (e.g. bisoprolol) should be prescribed to all patients suffering from symptomatic heart failure and reduced LVEF (≤40%) unless there are contraindications. Beta-blockers lower heart rate and myocardial oxygen demand and reduce RAAS activation. Blood pressure and heart rate should be monitored when doses are adjusted. Contraindications include asthma, 2nd or 3rd degree AV block, sick sinus syndrome and sinus bradycardia.

Angiotensin-II Receptor Antagonists (ARBs)

If a patient is unable to tolerate an ACE inhibitor (usually due to persistent cough) an ARB (e.g. candesartan) should be prescribed as an alternative. Patients must have normal serum potassium and adequate renal function to commence an ARB.

Mineralocorticoid/Aldosterone Receptor Antagonists (MRAs)

A low-dose aldosterone antagonist (e.g. spironolactone or eplerenone) should be prescribed if a patient experiences persistent symptoms of heart failure despite diuretics, ACE inhibitors and beta-blockers. MRAs antagonise aldosterone, increasing sodium excretion via diuresis, reducing cardiac afterload.

Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors

SGLT2 inhibitors (e.g. dapagliflozin) are used as add-on therapy for patients with a LVEF < 40%. Dapagliflozin is known to reduce the risk of cardiovascular events and hospital admission, regardless of the patient's glycaemic control.

Specialist Pharmacological Treatments


Ivabradine inhibits the sinoatrial node, decreasing heart rate of patients in sinus rhythm and increasing stroke volume while preserving myocardial contractility. It has been shown to reduce cardiovascular death or hospitalisation for heart failure by 18%.

ARNI (Angiotensin Receptor and Neprilysin Inhibitor)

ARNIs increase BNP levels by blocking the enzyme neprilysin, which breaks down BNP. An increase in BNP triggers natriuresis/diuresis, thus reducing cardiac afterload.

Chronic Heart Failure: Management and Prognosis

Chronic heart failure (CHF) is a clinical syndrome resulting in reduced cardiac output due to reduced cardiac contraction. Common causes in the UK are coronary heart disease and hypertension. Symptoms include shortness of breath, fatigue and ankle swelling.

Investigations required for diagnosis include ECG, NT-proBNP and echocardiography.


Management of CHF involves a combination of lifestyle modification, pharmacological therapies and, in some cases, surgical intervention. A visual summary of pharmacological management is shown in Figure 2.

Other Management Options

If heart failure is caused or worsened by other conditions, these should be managed appropriately:

  • Revascularisation (e.g. coronary artery bypass grafting)
  • Valve surgery (e.g. aortic valve replacement)
  • Implantable cardiac defibrillator (ICD): inserted if EF <30% for prevention of fatal arrhythmias
  • Cardiac resynchronisation therapy + defibrillator (CRT-D): a biventricular pacemaker for EF <30% + QRS >130 m/sec to re-synchronise left and right ventricular contraction to improve EF
  • Cardiac transplantation is rare and strict criteria must be met for consideration.


Complications of CHF include:

  • Arrhythmias: atrial fibrillation and ventricular arrhythmias
  • Depression and impaired quality of life
  • Loss of muscle mass
  • Sudden cardiac death

The prognosis of CHF is poor overall, with approximately 50% of people with heart failure dying within five years of diagnosis.

Key Points

  • Chronic heart failure (CHF) is a clinical syndrome resulting in reduced cardiac output due to impaired cardiac contraction.
  • The most common causes of heart failure in the UK are coronary heart disease and hypertension.
  • Typical symptoms of CHF include shortness of breath, fatigue and ankle swelling.
  • Investigations required for diagnosis include ECG, NT-proBNP and echocardiography.
  • Management involves a combination of lifestyle modification, pharmacological therapies and in some cases surgical intervention.
  • The prognosis of CHF is generally poor with sudden cardiac death common.


  • European Society of Cardiology. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Published in 2016. Available from LINK.
  • Chronic heart failure in adults -diagnosis and management; NICE Guidance (Sept 2018). Available from: LINK.
  • Penn Medicine. Heart Failure Classification -Stages of Heart Failure and Their Treatments. Published in 2014.
  • Mikael Häggström. Public domain. Available from: LINK.
  • NICE. Dapagliflozin for treating chronic heart failure with reduced ejection fraction. 2021. Available from: LINK.
  • NICE. Visual summary of chronic heart failure management. All rights reserved. Subject to notice of rights.
  • Dr Colin Tidy. Heart failure. Published November 2018. Available from: LINK.

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