Chronic heart failure diagnosis: symptoms, signs, and the ECG

The clinical history aims to elicit the symptoms that are commonly experienced by patients with heart failure such as dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea, and fatigue. The history may also provide clues as to the aetiology of heart failure and symptoms that suggest alternative diagnoses. Similarly, signs that are elicited on clinical examination are used to support the diagnosis of heart failure. In addition, they can be used to determine prognosis and assess response to treatment or the need for more intensive treatment. Common signs such as peripheral oedema, jugular venous distension, and pulmonary crackles are less specific for the diagnosis of heart failure than others such as a third heart sound. The presence of some clinical signs may help determine the aetiology of heart failure and indicate other potential diagnoses that may present like heart failure but require very different treatment. While signs and symptoms are used in conjunction with imaging evidence and raised natriuretic peptides to make the diagnosis of heart failure, the electrocardiogram (ECG) still plays a central role. The ECG can be used to determine underlying aetiology (such as evidence of prior myocardial infarction) and guide therapeutic decision-making such as the need for cardiac resynchronization therapy in those with bundle branch block. Information on symptoms, signs, and investigations such as the ECG need to be integrated to ensure the accurate diagnosis and optimal treatment of patients with heart failure.