Heart Failure

1. Overview

Heart failure is a clinical syndrome caused by structural or functional cardiac abnormality leading to impaired ventricular filling, reduced cardiac output, or both. It commonly presents with breathlessness, fatigue, reduced exercise tolerance and fluid retention.

In an OSCE, the key task is to identify whether the patient has acute decompensated heart failure or chronic stable heart failure, assess severity, identify triggers, look for signs of congestion and poor perfusion, and outline appropriate investigations and management.

Types of heart failure

• Heart failure with reduced ejection fraction: impaired systolic function.
• Heart failure with mildly reduced ejection fraction.
• Heart failure with preserved ejection fraction: often associated with hypertension, ageing, obesity, diabetes and atrial fibrillation.
• Left-sided heart failure: pulmonary congestion and breathlessness.
• Right-sided heart failure: peripheral oedema, raised JVP, hepatomegaly and ascites.
• Biventricular failure: features of both left-sided and right-sided failure.
• Acute decompensated heart failure: sudden worsening requiring urgent assessment.

Common causes

• Ischaemic heart disease and previous myocardial infarction.
• Hypertension.
• Valvular heart disease.
• Atrial fibrillation and other arrhythmias.
• Cardiomyopathy.
• Diabetes mellitus.
• Myocarditis.
• Alcohol-related cardiomyopathy.
• Congenital heart disease.
• Pulmonary hypertension or chronic lung disease causing right heart failure.

Common precipitants of decompensation

• Acute coronary syndrome.
• Arrhythmia, especially atrial fibrillation.
• Infection, especially pneumonia.
• Poor medication adherence.
• Excess salt or fluid intake.
• Uncontrolled hypertension.
• Renal impairment.
• Anaemia.
• Pulmonary embolism.
• Thyrotoxicosis.
• NSAIDs or other medications causing fluid retention.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about their symptoms.
• Gain consent.
• Check whether the patient is currently very breathless, has chest pain, feels faint or appears acutely unwell.
• If acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask what brought the patient in today.
• Clarify the main symptom: breathlessness, leg swelling, fatigue, reduced exercise tolerance, cough or weight gain.
• Ask when the symptoms started.
• Ask whether symptoms were sudden or gradual.
• Ask whether symptoms are worsening, improving or stable.
• Ask whether this is a first episode or known heart failure.
• Ask about previous hospital admissions with heart failure.

Breathlessness history

• Ask about breathlessness on exertion.
• Ask how far the patient can walk on flat ground.
• Ask how many flights of stairs they can climb.
• Compare current exercise tolerance with previous baseline.
• Ask whether breathlessness occurs at rest.
• Ask whether symptoms limit activities of daily living.
• Ask whether the patient can speak in full sentences.

Orthopnoea and paroxysmal nocturnal dyspnoea

• Ask whether breathlessness is worse when lying flat.
• Ask how many pillows the patient uses at night.
• Ask whether they sleep sitting upright.
• Ask whether they wake up suddenly at night gasping for breath.
• Orthopnoea and paroxysmal nocturnal dyspnoea strongly support heart failure.

Fluid overload symptoms

• Ankle or leg swelling.
• Abdominal swelling.
• Rapid weight gain.
• Reduced urine output.
• Nocturia.
• Tight shoes or clothes.
• Facial swelling.
• Reduced appetite or early satiety from hepatic congestion or ascites.

Symptoms suggesting low cardiac output

• Fatigue.
• Weakness.
• Dizziness.
• Presyncope or syncope.
• Confusion.
• Cold peripheries.
• Reduced exercise tolerance.

Associated cardiac symptoms

• Chest pain or pressure.
• Palpitations.
• Syncope.
• Known murmur.
• Previous myocardial infarction.
• Previous angioplasty, stent or CABG.
• History of atrial fibrillation.
• History of valvular heart disease.

Respiratory symptoms

• Cough, especially nocturnal cough.
• Frothy sputum in acute pulmonary oedema.
• Wheeze, which may occur in cardiac asthma.
• Fever or productive cough suggesting pneumonia.
• Haemoptysis.
• Pleuritic chest pain suggesting PE or pneumonia.

Past medical history

• Known heart failure and previous ejection fraction if known.
• Ischaemic heart disease.
• Previous myocardial infarction.
• Hypertension.
• Valvular heart disease.
• Atrial fibrillation or other arrhythmia.
• Diabetes mellitus.
• Chronic kidney disease.
• Stroke or TIA.
• COPD or chronic lung disease.
• Thyroid disease.
• Anaemia.
• Cardiomyopathy.
• Previous chemotherapy or radiotherapy.

Drug history and allergies

• Current regular medications.
• Diuretics such as furosemide or bumetanide.
• ACE inhibitors, ARBs or ARNI.
• Beta-blockers.
• Mineralocorticoid receptor antagonists such as spironolactone or eplerenone.
• SGLT2 inhibitors such as dapagliflozin or empagliflozin.
• Anticoagulants if atrial fibrillation is present.
• Anti-anginal medications.
• Ask about adherence to medication.
• Ask about recent missed diuretics.
• Ask about NSAID use, which may worsen fluid retention.
• Ask about recent medication changes.
• Document allergies and reaction.

Family history

• Family history of cardiomyopathy.
• Family history of sudden cardiac death.
• Premature ischaemic heart disease.
• Inherited cardiac conditions.
• Hypertension or diabetes in family members.

Social history

• Smoking history.
• Alcohol intake, including heavy alcohol use.
• Recreational drug use, especially cocaine or amphetamines.
• Diet, salt intake and fluid intake.
• Functional baseline and exercise tolerance.
• Occupation.
• Living situation.
• Support at home.
• Ability to manage medications.
• Recent falls or frailty.
• Impact on daily activities and quality of life.

Heart failure self-management history

• Ask whether the patient monitors daily weight.
• Ask whether they know what to do if weight increases rapidly.
• Ask about salt restriction advice.
• Ask about fluid restriction if previously advised.
• Ask about heart failure clinic follow-up.
• Ask whether they have had cardiac rehabilitation.
• Ask about vaccination status if relevant.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the symptoms.
• Ask what they are most worried about.
• Ask what they were hoping would happen today.
• Acknowledge anxiety about breathlessness and explain that symptoms will be assessed carefully.

Red flags

• Severe breathlessness at rest.
• Unable to speak in full sentences.
• Pink frothy sputum.
• Chest pain suggestive of ACS.
• Syncope or presyncope.
• Palpitations with haemodynamic symptoms.
• Hypotension or shock.
• Confusion or reduced consciousness.
• Cyanosis.
• Rapidly worsening oedema or weight gain.
• New murmur.
• Features of infection or sepsis.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would examine them, check observations, perform ECG, request blood tests including natriuretic peptide where appropriate, and arrange echocardiography.

3. Physical Examination

The examination should assess severity, congestion, perfusion, underlying cause and complications. If the patient is acutely breathless, start with an ABCDE assessment.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient is comfortable to proceed.
• Position the patient at 45 degrees.
• Ensure adequate exposure of the chest and legs while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment: is the patient unstable?

• Look from the end of the bed: is the patient comfortable, breathless, pale, sweaty, cyanosed or confused?
• Assess whether the patient can speak in full sentences.
• Look for use of accessory muscles.
• Look for oxygen therapy, cardiac monitor, IV lines, urinary catheter, GTN infusion or diuretic infusion.
• If the patient is acutely unwell, state that you would perform ABCDE assessment and call for senior help.

ABCDE assessment if acutely unwell

• Airway: check if the patient can speak and whether the airway is patent.
• Breathing: assess respiratory rate, oxygen saturation, work of breathing, chest expansion and auscultate for crackles or wheeze.
• Circulation: assess pulse, blood pressure, capillary refill, peripheral temperature, ECG monitoring and obtain IV access.
• Disability: assess consciousness level and capillary blood glucose.
• Exposure: check temperature, inspect for oedema, rashes, infection and signs of DVT while maintaining dignity.

Vital signs

• Respiratory rate.
• Oxygen saturation.
• Heart rate.
• Pulse rhythm.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Pain score if chest pain is present.
• Daily weight if monitoring fluid status.
• Fluid balance and urine output if inpatient or acutely unwell.

Hands

• Inspect for peripheral cyanosis.
• Assess capillary refill time.
• Look for cool peripheries suggesting poor perfusion.
• Look for clubbing, which may suggest infective endocarditis or chronic lung disease.
• Look for splinter haemorrhages suggesting infective endocarditis.
• Look for nicotine staining.
• Check for palmar pallor suggesting anaemia.
• Look for tremor suggesting thyrotoxicosis or medication effect.

Pulse

• Assess radial pulse rate.
• Assess rhythm: regular or irregular.
• An irregularly irregular pulse suggests atrial fibrillation.
• Assess pulse volume.
• Tachycardia may suggest decompensation, infection, anaemia, thyrotoxicosis or arrhythmia.
• Bradycardia may suggest conduction disease or medication effect.
• Check radio-radial delay if vascular disease is suspected.

Blood pressure

• Measure blood pressure accurately.
• Hypertension may be a cause or precipitant of heart failure.
• Hypotension suggests severe decompensation, cardiogenic shock or medication effect.
• Narrow pulse pressure may suggest low cardiac output.
• Postural blood pressure may be useful if dizziness or over-diuresis is suspected.

Face and eyes

• Look for conjunctival pallor suggesting anaemia.
• Look for central cyanosis.
• Look for xanthelasma and corneal arcus suggesting hyperlipidaemia.
• Look for signs of distress or exhaustion.
• Look for thyroid eye signs if thyrotoxicosis is suspected.

Neck

• Assess jugular venous pressure at 45 degrees.
• Raised JVP suggests elevated right atrial pressure and fluid overload.
• Assess hepatojugular reflux if appropriate.
• Inspect for prominent V waves if tricuspid regurgitation is suspected.
• Assess carotid pulse if relevant.
• Auscultate for carotid bruits if vascular disease is suspected.
• Inspect and palpate thyroid if thyrotoxicosis is suspected.

Precordial inspection

• Inspect the chest for previous sternotomy scar.
• Look for pacemaker or ICD.
• Look for thoracotomy scars.
• Look for visible pulsations.
• Look for chest wall deformity.
• Assess respiratory distress while inspecting the chest.

Palpation of the chest

• Palpate the apex beat.
• A displaced apex beat may suggest cardiomegaly.
• A diffuse or forceful apex may suggest ventricular enlargement.
• Palpate for a left parasternal heave suggesting right ventricular hypertrophy.
• Palpate for thrills over valve areas.
• Assess for tenderness if chest pain is present.

Auscultation of the heart

• Auscultate the aortic area.
• Auscultate the pulmonary area.
• Auscultate the tricuspid area.
• Auscultate the mitral area.
• Identify first and second heart sounds.
• Listen for a third heart sound, which may suggest heart failure.
• Listen for a fourth heart sound if relevant.
• Listen for murmurs suggesting valvular disease.
• Listen for mitral regurgitation, aortic stenosis or tricuspid regurgitation.
• Assess rhythm during auscultation.

Lung examination

• Inspect respiratory rate and work of breathing.
• Assess chest expansion.
• Percuss lung bases if pleural effusion is suspected.
• Auscultate lung bases for fine inspiratory crackles suggesting pulmonary oedema.
• Listen for widespread crackles in severe pulmonary oedema.
• Listen for wheeze, which may occur in cardiac asthma.
• Reduced breath sounds and dullness at the bases may suggest pleural effusion.

Peripheral oedema and fluid status

• Inspect both ankles and legs for swelling.
• Press over the shin or ankle to assess pitting oedema.
• Assess whether oedema is unilateral or bilateral.
• Bilateral pitting oedema supports fluid overload but may have other causes.
• Look for sacral oedema if the patient is bedbound.
• Assess peripheral temperature.
• Check for signs of dehydration or over-diuresis if relevant.

Abdominal examination

• Inspect for abdominal distension.
• Palpate for hepatomegaly, which may occur in right-sided heart failure.
• Assess for hepatic tenderness from congestion.
• Assess for ascites.
• Look for pulsatile liver if tricuspid regurgitation is suspected.
• Consider abdominal aortic aneurysm if clinically relevant.

Signs of underlying cause

• Murmur of aortic stenosis or mitral regurgitation suggesting valvular disease.
• Irregularly irregular pulse suggesting atrial fibrillation.
• Evidence of previous MI or CABG scars suggesting ischaemic heart disease.
• Features of thyrotoxicosis such as tremor, warm hands and thyroid signs.
• Anaemia signs such as pallor and tachycardia.
• Infection signs such as fever, crackles or productive cough.

Specific findings to mention in heart failure OSCE

• Raised JVP.
• Displaced apex beat.
• Third heart sound.
• Bibasal crackles.
• Peripheral pitting oedema.
• Hepatomegaly.
• Ascites.
• Pleural effusion.
• Cool peripheries and hypotension in severe low-output failure.
• A normal chest examination does not exclude early or compensated heart failure.

To complete the examination

To complete my examination, I would review observations, assess fluid balance and daily weight, perform a 12-lead ECG, request blood tests including renal function and natriuretic peptide where appropriate, obtain a chest X-ray, and arrange echocardiography to assess ejection fraction, valves and structural heart disease. I would escalate urgently if there are features of acute pulmonary oedema, cardiogenic shock, hypoxia, chest pain or serious arrhythmia.

4. Differential Diagnosis

Cardiac causes of breathlessness and oedema

• Heart failure with reduced ejection fraction.
• Heart failure with preserved ejection fraction.
• Acute coronary syndrome.
• Atrial fibrillation or other arrhythmia.
• Valvular heart disease.
• Cardiomyopathy.
• Pericardial effusion or tamponade.
• Pulmonary hypertension and right heart failure.

Respiratory causes

• COPD exacerbation.
• Asthma.
• Pneumonia.
• Pulmonary embolism.
• Pleural effusion.
• Interstitial lung disease.

Other causes of oedema

• Chronic kidney disease.
• Nephrotic syndrome.
• Liver cirrhosis.
• Venous insufficiency.
• Medication-related oedema, such as calcium channel blockers or NSAIDs.
• Hypoalbuminaemia.
• Lymphoedema.
• Deep vein thrombosis if unilateral.

Other causes of fatigue and breathlessness

• Anaemia.
• Thyrotoxicosis.
• Obesity or deconditioning.
• Anxiety.
• Sepsis.
• Metabolic acidosis.

5. Investigations

Bedside tests

• Full observations.
• Oxygen saturation.
• 12-lead ECG.
• Continuous cardiac monitoring if unstable or arrhythmia suspected.
• Capillary blood glucose if unwell or diabetic.
• Urine dip for proteinuria or renal disease.
• Daily weight if monitoring fluid status.
• Fluid balance chart if inpatient.

Blood tests

• Full blood count to assess anaemia or infection.
• Urea and electrolytes to assess renal function and guide diuretic therapy.
• Liver function tests, which may be abnormal in hepatic congestion.
• CRP if infection is suspected.
• Thyroid function tests if arrhythmia or thyrotoxicosis is suspected.
• HbA1c and lipid profile for cardiovascular risk assessment.
• Troponin if ACS is suspected.
• BNP or NT-proBNP when diagnosis is uncertain and according to local pathway.
• Iron studies if anaemia or iron deficiency is suspected.

Imaging and cardiac investigations

• Chest X-ray to assess pulmonary oedema, cardiomegaly, pleural effusion or pneumonia.
• Echocardiogram to assess ejection fraction, valve disease, chamber size and structural abnormalities.
• Coronary angiography or CT coronary angiography if ischaemic heart disease is suspected.
• Cardiac MRI if cardiomyopathy, myocarditis or infiltrative disease is suspected.
• Ambulatory ECG monitoring if intermittent arrhythmia is suspected.

Chest X-ray findings in heart failure

• Cardiomegaly.
• Upper lobe venous diversion.
• Interstitial oedema.
• Kerley B lines.
• Perihilar shadowing or bat-wing oedema.
• Pleural effusions.
• Alveolar oedema in severe pulmonary oedema.

ECG findings to look for

• Atrial fibrillation.
• Previous myocardial infarction.
• Left ventricular hypertrophy.
• Bundle branch block.
• Ischaemic changes.
• Tachyarrhythmia or bradyarrhythmia.
• Conduction disease.

Important investigation points

• Echocardiography is central to confirming type and cause of heart failure.
• Natriuretic peptide supports diagnosis but must be interpreted in clinical context.
• Renal function and potassium must be monitored when using diuretics, ACE inhibitors, ARBs, ARNIs or mineralocorticoid receptor antagonists.
• Normal chest X-ray does not completely exclude heart failure.
• Search for reversible precipitants such as ACS, arrhythmia, infection, anaemia and thyroid disease.

6. Management

Management depends on whether the patient has acute decompensated heart failure or chronic stable heart failure. In an OSCE, always start with severity, oxygenation, haemodynamic status and escalation before discussing long-term disease-modifying therapy.

Immediate approach if acutely unwell

1. Assess ABCDE.
2. Call for senior help if severe breathlessness, hypoxia, pulmonary oedema, hypotension, chest pain or confusion is present.
3. Sit the patient upright.
4. Give oxygen if hypoxaemic according to local oxygen target protocol.
5. Attach cardiac monitoring.
6. Obtain IV access and take bloods.
7. Perform urgent 12-lead ECG.
8. Request chest X-ray.
9. Treat the precipitating cause.

Acute pulmonary oedema management

• Sit the patient upright.
• Give oxygen if hypoxaemic.
• Consider non-invasive ventilation if severe respiratory distress or hypoxaemia persists, according to local protocol.
• Give IV loop diuretic such as furosemide according to local protocol.
• Consider nitrates if hypertensive and not contraindicated, according to local protocol.
• Monitor urine output, blood pressure, oxygen saturation, renal function and electrolytes.
• Escalate to high-dependency or intensive care if severe or not responding.

Identify and treat precipitants

• Acute coronary syndrome.
• Arrhythmia, especially atrial fibrillation.
• Infection.
• Uncontrolled hypertension.
• Medication non-adherence.
• Excess salt or fluid intake.
• Renal impairment.
• Anaemia.
• Pulmonary embolism.
• Thyroid disease.
• NSAID use or other fluid-retaining medications.

Chronic heart failure management

• Confirm diagnosis and type using echocardiography.
• Optimize disease-modifying therapy according to heart failure type and local guideline.
• For heart failure with reduced ejection fraction, treatment commonly includes ACE inhibitor, ARB or ARNI; evidence-based beta-blocker; mineralocorticoid receptor antagonist; and SGLT2 inhibitor where appropriate.
• Use loop diuretics for symptom relief from congestion.
• Manage blood pressure, diabetes, lipids and other cardiovascular risk factors.
• Treat atrial fibrillation and consider anticoagulation where indicated.
• Consider device therapy such as ICD or CRT in selected patients according to specialist criteria.
• Refer to heart failure specialist team or clinic.

Lifestyle and self-care advice

• Daily weight monitoring if advised.
• Seek medical advice if rapid weight gain or worsening oedema occurs.
• Reduce salt intake.
• Fluid restriction only if advised by the clinical team.
• Smoking cessation.
• Limit alcohol, especially if alcohol-related cardiomyopathy is suspected.
• Regular appropriate physical activity and cardiac rehabilitation.
• Vaccination advice where appropriate.
• Medication adherence.
• Avoid NSAIDs unless advised by a doctor.

Follow-up and monitoring

• Monitor renal function and electrolytes after medication changes.
• Monitor symptoms, weight, blood pressure and pulse.
• Review medication tolerance and adherence.
• Assess for depression, frailty and social support needs.
• Arrange follow-up with heart failure nurse, cardiology or primary care.
• Provide clear safety-net advice.

Palliative and advanced care considerations

• Discuss prognosis sensitively in advanced heart failure.
• Assess symptom burden and quality of life.
• Consider palliative care involvement for refractory symptoms or repeated admissions.
• Discuss advanced care planning when appropriate.
• Review device deactivation issues sensitively if ICD present and end-of-life care is being considered.

7. Examiner Questions

1. What is heart failure?
2. What are the common causes of heart failure?
3. What symptoms suggest heart failure?
4. What are orthopnoea and paroxysmal nocturnal dyspnoea?
5. What signs would you expect in heart failure?
6. What are the causes of acute decompensation?
7. What investigations would you request?
8. What is the role of BNP or NT-proBNP?
9. Why is echocardiography important?
10. What chest X-ray findings suggest heart failure?
11. How would you manage acute pulmonary oedema?
12. What are the main drug classes used in HFrEF?
13. Why must renal function and potassium be monitored?
14. What lifestyle advice would you give?
15. When would you refer to cardiology or heart failure clinic?

Suggested short answers

8. OSCE Pearls

• Always ask about orthopnoea and paroxysmal nocturnal dyspnoea.
• Ask how many pillows the patient sleeps with.
• Ask about exercise tolerance compared with baseline.
• Ask about ankle swelling, weight gain and nocturia.
• Ask about medication adherence and missed diuretics.
• Ask about precipitants: ACS, arrhythmia, infection, hypertension and NSAID use.
• Look for raised JVP, displaced apex beat, S3, bibasal crackles and peripheral oedema.
• Acute pulmonary oedema is an emergency.
• Atrial fibrillation is both a cause and consequence of heart failure.
• Echocardiography is key to diagnosis and classification.
• Monitor renal function and potassium when starting or adjusting heart failure medications.
• Do not forget lifestyle advice and safety-netting.
• Mention heart failure specialist nurse or cardiology follow-up.

9. Example Presentation to Examiner

10. References

• NICE NG106: Chronic heart failure in adults: diagnosis and management.
• NICE CG187: Acute heart failure: diagnosis and management.
• ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
• 2023 Focused Update of the ESC heart failure guidelines.
• Local cardiology and acute medical protocols.