Diagnosing early heart failure can be a challenge, because the symptoms often can be similar to symptoms of other conditions. If you have one or more of the symptoms of heart failure, make an appointment to see a doctor—and begin keeping a medical diary. It could be extremely helpful to you and to your physician.
Symptoms that could make a doctor suspect heart failure call for a complete physical exam. Before the exam, start a written record of any symptoms and give a copy to your doctor when you arrive—even better, a day or two before your appointment, to give the physician time to look it over. The diary should describe your symptoms: how they make you feel, what activities bring them on, what makes them go away, and which ones are the most uncomfortable.
Other information you should provide:
A pad and pen are a patient's best friends. Jot down questions for the doctor whenever they occur to you. Bring them in, and write down the doctor's answers. They are easy to forget.
The doctor will be searching for signs of heart failure, as well as other illnesses that might be affecting your heart's pumping ability and producing symptoms.
Pulse: Your pulse reveals your heart's rate, rhythm, and regularity.
Blood pressure: A relaxed, resting adult whose blood pressure is higher than a systolic reading of 140 mmHg or a diastolic reading of 90 mmHg is considered to have hypertension in need of treatment. Alternatively, a low systolic blood pressure of <90 mmHg, especially when accompanied by symptoms of lightheadedness or dizziness, may be suggestive of heart failure. Age, heart condition, emotions, activity, and medication—even the time of day—can influence your blood pressure. A single elevated reading—especially in a doctor's office, where readings tend to run higher than at home (a well-known phenomenon called "white-coat syndrome")—does not necessarily mean you have high blood pressure. Your blood pressure may need to be checked at different times and in other places to establish what is "normal" for you.
Neck veins: This is probably the most important aspect of the physical examination that your cardiologist will perform. How dilated the internal jugular neck veins are give the physician a pretty accurate assessment of how much fluid is inside the body. Your doctor may look at your neck veins at different angles by adjusting the back of the examination chair. In addition, it is common to check to see how dilated the neck veins are as the physician presses on your liver, which provides additional information.
Heart sounds: Different sounds through a stethoscope reveal not only the heart's rate and rhythm, but also how well it is functioning. A murmur, or whooshing sound, might indicate a leaky valve. A stiff or narrowed valve clicks when it opens and closes. Other extra heart sounds may indicate severe heart failure. The stethoscope should always be in direct contact with the skin, with no shirt or sweater between.
Lung sounds: Excess fluid in the lungs as a result of heart failure can be heard as crackles (rales) when the physician listens to the lungs as the patient breathes in and out. Decreased breath sounds in the lung fields may also signify fluid layering in the lungs. Your physician may tap his or her finger on your back at different levels as another way to check for fluid in your lungs.
Abdomen: Your doctor may press deeply on your liver to feel if it pulsates. A “pulsating liver” can indicate heart failure or abnormal valves.
Skin: The color and warmth of your skin reveal whether your body is getting a good supply of oxygen-rich blood.
Swelling in ankles, feet, legs, arms, and abdomen: If swelling is present, your heart may not be pumping efficiently.
Chemical "biomarkers" in the blood help flag a condition or indicate how it is progressing. With heart failure, physicians generally look at several biomarkers, especially if a patient has known heart disease. Patients with higher than normal levels of one or more key biomarkers have been shown to have a far higher risk of developing congestive heart failure or of dying from heart disease than do individuals whose levels are normal.
The following lists typical blood tests and identifies the biomarkers of interest.
Chest X-ray: An enlarged heart is a sign of heart failure; the X-ray shows the size of the heart and reveals any buildup of fluid around the heart and lungs, which is another sign. You can learn more about this test at our chest X-ray page.
Echocardiogram: An ultrasound probe placed on the surface of the chest bounces ultrasound waves off the internal structures of the heart to create pictures of the valves and chambers, permitting the heart's pumping action to be assessed (referred to as ejection fraction, see below). Changes in the speed of blood flow through the heart valves and estimated pressures within the heart chambers can also be determined. You can learn more about this test below.
Ejection fraction (EF): The ejection fraction (EF) by echocardiography is a visual estimate of the percentage of blood that the heart can pump out relative to the amount of blood it receives with each heartbeat. This estimation is most commonly determined at the time of the echocardiogram, but it can also be determined at the time of other heart tests such as such as a multigated acquisition scan (MUGA), a nuclear ventriculogram, or a radionuclide scan. A normal EF is generally greater than 55 percent, meaning more than half of the blood volume is pumped out. Below 40 percent usually confirms a diagnosis of systolic heart failure. Someone with heart failure with preserved ejection fraction can have a normal EF, but still has signs and symptoms of heart failure.
Electrocardiogram (EKG or ECG): If the doctor has any reason to suspect a heart problem, you will have an electrocardiogram. A large number of adhesive sensors will be placed on your chest and other parts of the body. The electrical impulses traveling through the heart will be monitored and transcribed out on a strip of paper. The test itself is painless, but men with hairy chests will have to endure a few "ouch" moments when the sensors are removed.