The failing heart creates a huge health care problem. It is common and becomes more so with age. Recognising our aging population, it is understandable that the prevalence of heart failure is increasing¹ in the UK and is the most common diagnostic related group at hospital discharge. It is the primary or secondary diagnosis in about 1% of the population and consumes a similar proportion of the country’s gross domestic product every year. So how do we recognise this monster? The 2005 American College of Cardiology/American Heart Association (ACC/AHA) guideline update for the diagnosis and management of chronic heart failure in the adult² defines heart failure as: “a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood”.

CLASSIFICATION OF HEART FAILURE

It is a progressive disorder and to capture this the ACC/AHA has proposed a new approach to the classification of heart failure² (table 1).

Although this classification implies a progressive clinical picture for heart failure, it has an unpredictable course. It is difficult to characterise and especially so in its early stages. This probably follows from there being no diagnostic test for heart failure because it is “largely a clinical diagnosis that is based on a careful history and physical examination”.² When symptoms present they are predominantly fatigue, breathlessness and limited exercise tolerance. Fluid accumulation is apparent on the right side as dependent oedema and on the left as pulmonary oedema. The condition is fickle and patients describe variation in symptoms. Thus sequential clinical assessment finds patients moving up and down the New York Heart Association (NYHA) functional classification (table 2).