Heart Failure

February 1, 2012

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.

Communicating with your doctor

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:

  • Relevant personal and family history: whether you or any first-degree relatives (parents, siblings, or children) have or had heart or blood vessel disease, cardiomyopathy, diabetes, kidney disease, or high blood pressure.
  • Personal habits and information: whether you smoke, what you eat (especially whether you eat a lot of salty or fatty foods), whether you drink any form of alcohol (and if so, how much), and how satisfied you are with your home life, your job, and your sexual activity.
  • A list of all medications you are taking—prescription, over-the-counter, herbals, and supplements—along with the dosages.
  • Any allergies.
  • Records of visits to any other doctors or to an emergency room.
  • A record of your weight, recorded every morning after urinating but before eating (if requested).
  • A record of your blood sugar or blood pressure (if requested).

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 physical exam

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.

Laboratory tests

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.

  • Lipid blood tests: Measures total cholesterol, the amount of LDL (the bad cholesterol), HDL (the good cholesterol), and triglycerides, another fatty substance.
  • Enzymes: When heart cells are damaged, several enzymes are released. These include creatine kinase (look for CK on the lab printout), creatine phosphokinase (CPK), lactic dehydrogenase (LD or LDH), troponin, and myoglobin.
  • C-reactive protein (CRP): Indicates the presence of inflammation, which may in turn contribute to heart attacks, stroke, and other cardiovascular problems.
  • Homocysteine: High levels of homocysteine are now considered by many physicians to be an independent predictor of heart disease. (Supplemental folic acid and vitamins B12 and B6 almost always bring high homocysteine down to normal.) You can learn more about this test at our homocysteine page.
  • Electrolytes: Primarily sodium and potassium, to be sure that too much or too little sodium or potassium is not causing heart symptoms. You can learn more about this test at our electrolytes page.
  • BNP: When heart failure occurs or worsens, the pumping chambers, or ventricles, produce a substance that breaks down to form two proteins: B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (NT-pro-BNP). Both BNP and NT-pro-BNP are secreted into the bloodstream, and their levels rise when heart failure symptoms worsen and fall when symptoms improve. In recent tests, patients who had an elevated level of either protein had a higher risk of death and illness from heart failure. BNP and NT-pro-BNP help determine if you have heart failure rather than another condition that may cause similar symptoms. They also can help the doctor determine if your heart failure has worsened, meaning that more aggressive treatments are needed. Which test your doctor orders (i.e., BNP or NT-pro-BNP) depends on what is available at that medical center. Both tests have been shown to be beneficial.
  • Kidney function: Creatinine and blood urea nitrogen (BUN). If the creatinine blood test raises questions, a urinalysis for creatinine will confirm how well the kidneys are working.
  • Thyroid function: An overactive or underactive thyroid gland—hyperthyroidism or hypothyroidism, respectively—can produce symptoms resembling those of heart failure, so checking the function of the thyroid gland is important.
  • Hemoglobin: An oxygen-containing substance carried by the red cells.
  • Liver enzymes: Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT). Elevation of these liver enzymes in the absence of primary liver dysfunction may signify that the liver is not receiving enough blood due to heart failure.

Other tests

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.