Summary of findings
Present from the periphery to the heart, then say what the findings mean: the lesion, its cause, and its consequence.
I examined the cardiovascular system of a woman in her thirties. The pulse is 100 per minute, regular and of small volume, with no radio-femoral delay; all peripheral pulses are present. Blood pressure is 110/70 mmHg. The JVP is raised 5 cm above the sternal angle. The apex is displaced to the sixth intercostal space in the anterior axillary line and is diffuse. There is a pansystolic murmur at the apex, grade 3, radiating to the axilla and louder with the patient on her left side, and a third heart sound. There are fine crackles at both bases, tender hepatomegaly and pitting ankle oedema. These are the signs of mitral regurgitation with biventricular heart failure, probably rheumatic.
For every murmur state its timing, site, radiation, grade, and how manoeuvres change it.
Differential diagnoses
Causes of heart failure to offer in our setting
- Hypertensive heart disease
- Rheumatic valve disease
- Dilated cardiomyopathy, including peripartum cardiomyopathy
- Ischaemic heart disease
- Endomyocardial fibrosis
- Hypertrophic and restrictive cardiomyopathy
- Pericardial effusion or constriction
What tips a stable heart into failure
- Arrhythmia, especially atrial fibrillation
- Infection, including infective endocarditis
- Anaemia
- Stopping medicines, or too much salt and fluid
- Uncontrolled blood pressure
- Pregnancy, thyrotoxicosis
- NSAIDs and other fluid-retaining drugs
Investigations
- ECG: rhythm, chamber enlargement (LVH with strain, left atrial enlargement), ischaemia or old infarction, bundle branch block
- Chest X-ray: cardiomegaly, upper lobe diversion, Kerley B lines, alveolar oedema, effusions
- Echocardiography: the key test — chamber sizes, wall thickness, ejection fraction, regional wall motion, valve structure and gradients, pulmonary pressure, pericardium, thrombus
- Natriuretic peptides: in the clinic, heart failure is likely when NT-proBNP is 125 pg/mL or more under 50 years, 250 or more at 50–75 years, or 500 or more over 75 years; arrange echocardiography, within 2 weeks if it is above 2000 pg/mL. Levels read lower in obesity and in people of African ancestry, and higher with kidney disease and atrial fibrillation
- Blood and urine: full blood count, urea, electrolytes and creatinine with eGFR, urine albumin–creatinine ratio, liver function, thyroid function, HbA1c, lipids, and iron status (ferritin and transferrin saturation); troponin if ischaemia is suspected; three sets of blood cultures if endocarditis is possible
Treatment
- Relieve congestion with a loop diuretic
- Start the foundational drugs together and build up the doses: an SGLT2 inhibitor and a mineralocorticoid receptor antagonist at any ejection fraction, plus a beta-blocker and an ACE inhibitor or sacubitril/valsartan when it is below 50% — see Heart failure treatment at a glance
- Treat the cause and the precipitant
- Salt restriction, daily weights, stopping alcohol and smoking, graded exercise once stable
- Devices and surgery where indicated: valve repair or replacement, revascularisation, resynchronisation, defibrillators
Examiner questions
References
- Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, et al., eds. Harrison's Principles of Internal Medicine. 22nd ed. New York: McGraw Hill; 2025.