Chronic Heart Failure (CHF) | Geeky Medics (2023)


Chronic heart failure (CHF) is a clinical syndrome involving reduced cardiac output because ofimpaired cardiac contraction. Typical clinical symptoms of CHF include shortness of breath, fatigue and ankle swelling.1

CHF prevalence is 1-2%, rising to 10% in over 70-year-olds.4

For more information on the acute presentation of heart failure, see the Geeky Medics guide to acute heart failure.

You might also be interested in our medical flashcard collection which contains over 2000 flashcards that cover key medical topics.



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 failureoccurs in states where demand exceeds normal cardiac output such as pregnancy, anaemia and sepsis.


The acronym HIGH-VIS is useful to remember some of the causes of CHF:

  • Hypertension (common cause)
  • Infection/immune: viral (e.g. HIV), bacterial (e.g. sepsis), autoimmune (e.g. lupus, rheumatoid arthritis)
  • Genetic: hypertrophic obstructive cardiomyopathy (HOCM), dilated cardiomyopathy (DCM)
  • Heart attack: ischaemic heart disease (common cause)
  • Volume overload: renal failure, nephrotic syndrome, hepatic failure
  • Infiltration: sarcoidosis, amyloidosis, haemochromatosis
  • Structural: valvular heart disease, septal defects

Clinical features


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

(Video) Congestive heart failure (CHF) - systolic, diastolic, left side, right side, & symptoms

Typicalsymptoms 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’.
  • Pre-syncope/syncope
  • Reduced appetite

Other important areas to cover in the history include:

  • Past medical history: hypertension, coronary artery disease and valvular heart disease (common causes of CHF)
  • Medication history: several medications can cause or worsen CHF including calcium antagonists, antiarrhythmics, cytotoxic medication and beta-blockers (in the acute phase, but long term provide prognostic benefit).
  • Family history: specifically close relatives with cardiac issues such as cardiomyopathy (e.g. HOCM) or coronary artery disease.
  • Social history: risk factors for CHF include smoking, excess alcohol intake and recreational drug use.

Clinical examination

Clinical findings on cardiovascular examination may include:

  • Tachycardia at rest
  • Hypotension
  • Narrow pulse pressure
  • Raised jugular venous pressure
  • Displaced apex beat (due to left ventricular dilatation)
  • Right ventricular heave
  • Gallop rhythm on auscultation (pathognomic for CHF)
  • Murmurs associated with valvular heart disease (e.g. an ejection systolic murmur in aortic stenosis)
  • Pedal and ankle oedema

Clinical findings on respiratory examination 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)

Clinical findings on abdominal examination may include:

  • Hepatomegaly
  • Ascites


After a comprehensive history and clinical examination have been performed, the following investigations are recommended by NICE.2

Bedside investigations

Relevantbedside investigations include:

  • ECG: should be performed on all patients with suspected heart failure. An ECG may identify evidence of previous myocardial infarction (e.g. ‘Q’ waves) or arrhythmias (AV block or atrial fibrillation). A normal ECG makes heart failure unlikely.1
  • Urinalysis: may show glycosuria (diabetes) or proteinuria (renal disease)
ECG findings

ECG findings associated with heart failure include:

  • Tachycardia
  • Atrial fibrillation (due to enlarged atria)
  • Left-axis deviation (due to left ventricular hypertrophy)
  • P wave abnormalities (e.g. P.mitrale/P.pulmonale due to atrial enlargement)
  • Prolonged PR interval (due to AV block)
  • Wide QRS complexes (due to ventricular dyssynchrony)

Laboratory investigations

Relevant laboratory investigations include:

  • FBC: anaemia
  • U&Es: renal failure, electrolyte abnormalities due to fluid overload (e.g. hyponatraemia)
  • LFTs: hepatic congestion
  • Troponin: if considering recent myocardial infarction
  • Lipids/HbA1c: ischaemic risk profile
  • TFTs: hyperthyroidism/hypothyroidism
  • Cardiomyopathy screen (see below)
  • N-terminal pro-B-type natriuretic peptide (see below)

Cardiomyopathy screen

Screening for cardiomyopathy includes the following blood tests:

  • Serum iron and copper studies (to rule out haemochromatosis and Wilson’s disease)
  • Rheumatoid factor, ANCA/ANA, ENA, dsDNA (to rule out autoimmune disease)
  • Serum ACE (to rule out sarcoidosis)
  • Serum-free light chains (to rule out amyloidosis)


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 for specialist assessment and transthoracic echocardiography within 2 weeks
  • NT-proBNP level 400-2000ng/L – refer routinely for specialist assessment and transthoracic echocardiography within 6 weeks
  • NT-proBNP level <400 ng/L – heart failure unlikely

Other conditions in which NT-proBNP may be raised include:

(Video) Congestive Heart Failure (CHF) for Nursing & NCLEX

  • Left ventricular hypertrophy
  • Tachycardia
  • Liver cirrhosis
  • Diabetes
  • 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 as discussed above.

Chest X-ray

Typical chest X-ray findings associated with CHF include:

  • Alveolar oedema (perihilar/bat-wing opacification)
  • Kerley B lines (interstitial oedema)
  • Cardiomegaly (cardiothoracic ratio >50%)
  • Dilated upper lobe vessels
  • Effusions (e.g. pleural effusions – blunted costophrenic angles)

Cardiac MRI

Cardiac MRI is the gold standard investigation for assessing ventricular mass, volumeand wall motion. It can also be used with contrast to identify infiltration (e.g. amyloidosis), inflammation (e.g. myocarditis) or scarring (e.g. myocardial infarction). It is typically used when echocardiography has provided inadequate views.5

Figure 1. Typical CXR signs associated with heart failure.4


Structural classification

Chronic heart failure can be classified structurally based on left ventricular ejection fraction (LVEF).

LVEF is the percentage of blood that enters the left ventricle in diastole that is subsequently pumped out in systole.

LVEF is usually measured using transthoracic echocardiography, however, MRI, nuclear medicine scans and transoesophageal echocardiography can also be used.1,2

Symptomatic/functional classification

The New York Heart Association’s (NYHA) classification system relies on patient symptoms and level of function:3

  • Class I: no symptoms during ordinary 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


The focus of CHF management is to improve cardiac function and quality of life, prevent hospitalisation and reduce mortality.

General management

Lifestyle management

Lifestyle management strategies include:

  • Fluid and salt restriction
  • Regular exercise
  • Smoking cessation
  • Reduced alcohol intake


All patients with CHF should be offered vaccination for influenza and pneumococcal disease.

Medication review

A medication review should be performed to identify medications which may be harmful in the context of heart failure such as:

  • Calcium channel blockers (e.g. verapamil, diltiazem)
  • Tricyclic antidepressants
  • Lithium
  • NSAIDs and COX-2 inhibitors
  • Corticosteroids
  • QT-prolonging medications


All patients with chronic heart failure require monitoring of:

  • Functional capacity, fluid status, cardiac rhythm, cognitive status and nutritional status
  • Renal function

The frequency of monitoring depends on the patient’s clinical condition.

(Video) Treatment of Congestive Heart Failure (CHF)

Management of co-morbidities

Coronary artery disease

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

Atrial fibrillation

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

Pharmacological management

Pharmacological treatment aims to increase cardiac output ­by optimising preload and contractility whilst decreasing afterload.

The medications below target the pathological sympathetic response and renin-angiotensin-aldosterone system (RAAS) activation that occurs in CHF.


Diuretics should be prescribed to relieve symptoms of fluid overload (e.g. shortness of breath, peripheral oedema).

Diuretics (e.g. furosemide) work by increasing sodium excretion via diuresis, ultimately reducing cardiac afterload.

Doses should be titrated according to clinical response and renal function should be closely monitored.

ACE inhibitors

All patients with CHF and a reduced ejection fraction (≤40%) should be commenced on an ACE inhibitor unless contraindicated.

ACE inhibitors have been shown to improve ventricular function and reduce mortality.

U&Es should be checked prior to starting treatment and then after 1-2 weeks of treatment.

Contraindications 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 for all patients with symptomatic heart failure and reduced LVEF (≤40%) unless contraindicated.

Beta-blockers decrease heart rate, myocardial oxygen demand and RAAS activation.

(Video) Pathophysiology of Congestive Heart Failure (CHF)

Blood pressure and heart rate need to be monitored carefully when adjusting doses.

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 also be prescribed if a patient continues to have symptoms of heart failure despite diuretics, ACE inhibitors and beta-blockers.

MRAs antagonise aldosterone, increasing sodium excretion via diuresis, ultimately decreasing cardiac afterload.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors

SGLT2 inhibitors (e.g.dapagliflozin) can be used as add-on therapy in patients with areduced LVEF(<40%). Dapagliflozin has been shown to reduce the risk of cardiovascular events and hospital admission. This benefit occurs regardless of the patient’s glycaemic control.5

Specialist pharmacological treatments


Ivabradine inhibits the sinoatrial node, slowing the heart rate of patients in sinus rhythm, increasing stroke volume whilst preserving myocardial contractility.

It has been shown to reduce cardiovascular death or hospitalisation for heart failure by 18%.

ARNI (angiotensin receptor and neprilysin inhibitor)

ARNI’s increase BNP levels by inhibiting the neprilysin enzyme which breaks down BNP.

Higher BNP causes natriuresis/diuresis, therefore decreasing cardiac afterload.

Figure 2. NICE visual summary of pharmacological management of CHF.6

Other management options

If heart failure is caused or worsened by other conditions, these should be managed appropriately:2

  • 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:

(Video) Medical Coding for Congestive Heart Failure (CHF)

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

Prognosis is poor overall, with approximately 50% of people with heart failure dying within five years of diagnosis.7

Key points

  • Chronic heart failure (CHF) is a clinical syndrome resulting in reduced cardiac output as a result of impaired cardiac contraction.
  • The most common causes of heart failure in the UK are coronary heart disease (myocardial infarction, atrial fibrillation, heart block) and hypertension.
  • Typical symptoms of CHF include shortness of breath, fatigue and ankle swelling.1
  • Investigationsrequired 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 poorwith sudden cardiac death common.


Dr Steven Sutcliffe

Consultant Cardiologist


Dr Chris Jefferies


  1. 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].
  2. Chronic heart failure in adults – diagnosis and management; NICE Guidance (Sept 2018). Available from: [LINK]
  3. Penn Medicine. Heart Failure Classification – Stages of Heart Failure and Their Treatments. Published in 2014.
  4. Mikael Häggström. Public domain. Available from: [LINK]
  5. NICE. Dapagliflozin for treating chronic heart failure with reduced ejection fraction. 2021. Available from: [LINK]
  6. NICE. Visual summary of chronic heart failure management. All rights reserved. Subject to notice of rights.
  7. Dr Colin Tidy. Heart failure. Published November 2018. Available from: [LINK]


Is chronic heart failure the same as CHF? ›

Heart failure — sometimes known as congestive heart failure — occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.

How do you deal with CHF? ›

5 ways to manage your heart failure
  1. Take your medications. ...
  2. Keep as active as you can. ...
  3. Report new or worsening symptoms to a doctor or nurse. ...
  4. Weigh yourself every day, before you eat or drink. ...
  5. Avoid excess salt.

How is chronic CHF treated? ›

Some of the main medicines for heart failure include:
  1. ACE inhibitors.
  2. angiotensin-2 receptor blockers (ARBs or AIIRAs)
  3. beta blockers.
  4. mineralocorticoid receptor antagonists.
  5. diuretics.
  6. ivabradine.
  7. sacubitril valsartan.
  8. hydralazine with nitrate.

What is the life expectancy of a congestive heart failure patient? ›

In general, about half of all people diagnosed with congestive heart failure will survive 5 years. About 30% will survive for 10 years. In patients who receive a heart transplant, about 21% of patients are alive 20 years later.

What is the main cause of congestive heart failure? ›

The most common cause of congestive heart failure is coronary artery disease. Risk factors for coronary artery disease include: high levels of cholesterol and/or triglyceride in the blood.

Is congestive heart failure considered a terminal illness? ›

CHF is NOT a death sentence

While serious, congestive heart failure diagnosis doesn't mean your life is over. It's important to understand how manageable it is. By taking the right steps, patients can learn to live a happy and fulfilling life. Will there be necessary lifestyle changes?

Is congestive heart failure a big deal? ›

Congestive heart failure (CHF) is a chronic, progressive condition that affects the heart's ability to pump blood around the body. Despite its name, CHF does not mean that the heart has completely failed. However, it can be life threatening if left untreated.

Should you rest with heart failure? ›

People with heart failure feel better when they stay active.

Can heart failure go back to normal? ›

Treatments. Although heart failure is a serious condition that progressively gets worse over time, certain cases can be reversed with treatment. Even when the heart muscle is impaired, there are a number of treatments that can relieve symptoms and stop or slow the gradual worsening of the condition.

Can you live a good life with congestive heart failure? ›

It is possible to lead a normal life, even if you have Heart Failure. Understanding and taking control of Heart Failure is the key to success. Your doctor and healthcare providers will provide guidelines and a treatment plan. It is your responsibility to follow the treatment plan and manage your Heart Failure.

What is the first stage of congestive heart failure? ›

Congestive heart failure stages
StageMain symptoms
Class 1You don't experience any symptoms during typical physical activity.
Class 2You're likely comfortable at rest, but normal physical activity may cause fatigue, palpitations, and shortness of breath.
2 more rows

Can you survive chronic heart failure? ›

One study says that people with heart failure have a life span 10 years shorter than those who don't have heart failure. Another study showed that the survival rates of people with chronic heart failure were 80% to 90% for one year, but that dropped to 50% to 60% for year five and down to 30% for 10 years.

Can you live longer than 5 years with CHF? ›

Life expectancy with congestive heart failure varies depending on the severity of the condition, genetics, age, and other factors. According to the Centers for Disease Control and Prevention (CDC), around one-half of all people diagnosed with congestive heart failure will survive beyond five years.

How quickly does heart failure progress? ›

Symptoms can develop quickly (acute heart failure) or gradually over weeks or months (chronic heart failure).

What are the signs of worsening heart failure? ›

Signs of Worsening Heart Failure
  • Shortness of breath.
  • Feeling dizzy or lightheaded.
  • Weight gain of three or more pounds in one day.
  • Weight gain of five pounds in one week.
  • Unusual swelling in the legs, feet, hands, or abdomen.
  • A persistent cough or chest congestion (the cough may be dry or hacking)

What is the best drink for your heart? ›

6 Drinks to Boost Heart Health
  • Pomegranate juice. According to experts, pomegranates are uniquely healthy fruits for your heart. ...
  • Coffee. Studies have shown that people who drink 3-5 cups of coffee per day have a significantly lower risk of heart disease, stroke and heart failure. ...
  • Tea. ...
  • Tomato juice. ...
  • Green juice. ...
  • Smoothies.

What stage of heart failure is shortness of breath? ›

Stage 2 of Congestive Heart Failure

Stage two of congestive heart failure will produce symptoms such as fatigue, shortness of breath, or heart palpitations after you participate in physical activity. As with stage one, lifestyle changes and certain medication can help improve your quality of life.

What does heart failure fatigue feel like? ›

Tiredness, fatigue

...a tired feeling all the time and difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries or walking. The heart can't pump enough blood to meet the needs of body tissues.

What activities should be avoided with heart failure? ›

Avoid exercises that require or encourage holding your breath, such as pushups, situps, and isometric exercises. Wait at least one hour after eating to exercise. Avoid actions that need quick bursts of energy. Exercise when you have the most energy.

How much water should a person with heart failure drink? ›

Your health care provider may ask you to lower the amount of fluids you drink: When your heart failure is not very bad, you may not have to limit your fluids too much. As your heart failure gets worse, you may need to limit fluids to 6 to 9 cups (1.5 to 2 liters) a day.

Can the heart repair itself after congestive heart failure? ›

The heart is unable to regenerate heart muscle after a heart attack and lost cardiac muscle is replaced by scar tissue. Scar tissue does not contribute to cardiac contractile force and the remaining viable cardiac muscle is thus subject to a greater hemodynamic burden.

Will a pacemaker help congestive heart failure? ›

A pacemaker can slow down the progression of heart failure. It may help keep you out of the hospital and help you live longer. If you get a pacemaker, you still need to take medicines for heart failure. You'll also need to follow a healthy lifestyle to help treat heart failure.

Can I fly with heart failure? ›

National Institute for Health and Care Excellence (NICE) guidance says that most people with heart failure can travel by plane. However, during the flight, legs and ankles tend to swell and breathing may become more difficult for people with severe heart failure.

How can you prevent heart failure from getting worse? ›

How Can I Prevent Heart Failure From Getting Worse?
  1. Treat you high blood pressure. ...
  2. Monitor your own symptoms. ...
  3. Maintain fluid balance. ...
  4. Limit how much salt (sodium) you eat. ...
  5. Monitor your weight and lose weight if needed. ...
  6. Monitor your symptoms. ...
  7. Take your medications as prescribed. ...
  8. Schedule regular doctor appointments.
20 Aug 2022

How long can a 60 year old live with congestive heart failure? ›

Prognosis at different ages

A report averaging several smaller studies found that people under age 65 generally had a 5-year survival rate of 78.8 percent following CHF diagnosis. The same report found that people over age 75 had an average 5-year survival rate of 49.5 percent following diagnosis.

Does heart failure mean death? ›

Heart failure happens when the heart cannot pump enough blood and oxygen to support other organs in your body. Heart failure is a serious condition, but it does not mean that the heart has stopped beating. Although it can be a severe disease, heart failure is not a death sentence, and treatment is now better than ever.

What happens just before heart failure? ›

Main symptoms

fatigue – you may feel tired most of the time and find exercise exhausting. swollen ankles and legs – this is caused by a build-up of fluid (oedema); it may be better in the morning and get worse later in the day. feeling lightheaded and fainting.

Do oxygen levels drop with heart failure? ›

With heart failure, your heart becomes a weaker pump. Over time it becomes less effective at pumping oxygen-rich blood through your body. This may cause your oxygen levels to drop. When oxygen levels drop, you may become short of breath or winded.

What are 3 things that can worsen heart failure and why? ›

All of the lifestyle factors that increase your risk of heart attack and stroke – smoking, being overweight, eating foods high in fat and cholesterol and physical inactivity – can also contribute to heart failure.

Does heart failure affect the brain? ›

Introduction. Heart failure (HF) is a common condition, where heart injury leads to reduced pump efficiency of the heart muscle and decreased general blood flow. A common consequence can be insufficient oxygen supply to the entire organism, including the brain.

What is the most common complication of heart failure? ›

Atrial fibrillation.

It is a major cause of stroke, especially for people with heart failure. Atrial fibrillation can also make other aspects of a patient's heart failure more difficult to manage.

Is there another name for congestive heart failure? ›

Congestive heart failure (also called heart failure) is a serious condition in which the heart doesn't pump blood as efficiently as it should. Despite its name, heart failure doesn't mean that the heart has literally failed or is about to stop working.

What are the 4 types of heart failure? ›

What are the different types of heart failure?
  • Left-sided heart failure. Left-sided heart failure is the most common type of heart failure. ...
  • Right-sided heart failure. The right heart ventricle is responsible for pumping blood to your lungs to collect oxygen. ...
  • Diastolic heart failure. ...
  • Systolic heart failure.

How do you know when heart failure is near the end? ›

You may even have physical symptoms like sweating, shortness of breath, or fatigue. Depression or anxiety may be even more likely with advanced heart failure.

How much water should you drink if you have congestive heart failure? ›

Your health care provider may ask you to lower the amount of fluids you drink: When your heart failure is not very bad, you may not have to limit your fluids too much. As your heart failure gets worse, you may need to limit fluids to 6 to 9 cups (1.5 to 2 liters) a day.

What are the warning signs of congestive heart failure? ›

Some of the signs and symptoms of congestive heart failure include:
  • Shortness of Breath. If your loved one has CHF, they may experience shortness of breath. ...
  • Fatigue. ...
  • Edema (Swelling, in the Feet, Ankles, and Legs) ...
  • Arrhythmia (Irregular Heartbeat) ...
  • Persistent Cough. ...
  • Wheezing. ...
  • Changes in Urination. ...
  • Swelling of the Abdomen.
8 Apr 2019


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