Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Determining the etiology and severity of heart failure or cardiomyopathy

Wilson S Colucci, MD
Section Editor
Stephen S Gottlieb, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Heart failure (HF) is a common clinical syndrome caused by a variety of cardiac diseases [1]. Evaluation of the etiology and severity of HF is discussed here. Initial evaluation of suspected HF and the management and prognosis of HF are discussed separately. (See "Evaluation of the patient with suspected heart failure" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Prognosis of heart failure".)

Evaluation of patients with HF should also include evaluation for concurrent conditions as appropriate, such as sleep-disordered breathing. (See "Sleep-disordered breathing in heart failure".)


Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiovascular disorder causing systemic perfusion inadequate to meet the body’s metabolic demands without excessively increasing left ventricular filling pressures [2]. It is characterized by specific symptoms, such as dyspnea and fatigue, and signs, such as fluid retention. There are many ways to assess cardiac function. However, there is no diagnostic test for HF, since it is largely a clinical diagnosis that is based upon a careful history and physical examination. (See "Evaluation of the patient with suspected heart failure".)

Classification of HF severity — The history, including assessment of New York Heart Association (NYHA) functional class, and physical examination in conjunction with the diagnostic tests reviewed below should both establish the primary cause of the HF and provide a reasonable estimate of its severity.

The classification system that is most commonly used to quantify the degree of functional limitation imposed by HF is one first developed by the NYHA. This system assigns patients to one of four functional classes, depending on the degree of effort needed to elicit symptoms (table 1):


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Feb 16, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 1993; 22:6A.
  2. Tan LB, Williams SG, Tan DK, Cohen-Solal A. So many definitions of heart failure: are they all universally valid? A critical appraisal. Expert Rev Cardiovasc Ther 2010; 8:217.
  3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 62:e147.
  4. Luk A, Metawee M, Ahn E, et al. Do clinical diagnoses correlate with pathological diagnoses in cardiac transplant patients? The importance of endomyocardial biopsy. Can J Cardiol 2009; 25:e48.
  5. Roberts WC, Roberts CC, Ko JM, et al. Morphologic features of the recipient heart in patients having cardiac transplantation and analysis of the congruence or incongruence between the clinical and morphologic diagnoses. Medicine (Baltimore) 2014; 93:211.
  6. He J, Ogden LG, Bazzano LA, et al. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001; 161:996.
  7. Baldasseroni S, Opasich C, Gorini M, et al. Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure. Am Heart J 2002; 143:398.
  8. Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342:1077.
  9. Caruana L, Petrie MC, Davie AP, McMurray JJ. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from "diastolic heart failure" or from misdiagnosis? A prospective descriptive study. BMJ 2000; 321:215.
  10. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
  11. McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
  12. Drazner MH, Hamilton MA, Fonarow G, et al. Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure. J Heart Lung Transplant 1999; 18:1126.
  13. Erbel R, Schweizer P, Krebs W, et al. Sensitivity and specificity of two-dimensional echocardiography in detection of impaired left ventricular function. Eur Heart J 1984; 5:477.
  14. Yamaguchi S, Tsuiki K, Hayasaka M, Yasui S. Segmental wall motion abnormalities in dilated cardiomyopathy: hemodynamic characteristics and comparison with thallium-201 myocardial scintigraphy. Am Heart J 1987; 113:1123.
  15. Vigna C, Russo A, De Rito V, et al. Regional wall motion analysis by dobutamine stess echocardiography to distinguish between ischemic and nonischemic dilated cardiomyopathy. Am Heart J 1996; 131:537.
  16. Dokainish H, Zoghbi WA, Lakkis NM, et al. Optimal noninvasive assessment of left ventricular filling pressures: a comparison of tissue Doppler echocardiography and B-type natriuretic peptide in patients with pulmonary artery catheters. Circulation 2004; 109:2432.
  17. Mullens W, Borowski AG, Curtin RJ, et al. Tissue Doppler imaging in the estimation of intracardiac filling pressure in decompensated patients with advanced systolic heart failure. Circulation 2009; 119:62.
  18. Diwan A, McCulloch M, Lawrie GM, et al. Doppler estimation of left ventricular filling pressures in patients with mitral valve disease. Circulation 2005; 111:3281.
  19. Giannuzzi P, Temporelli PL, Bosimini E, et al. Independent and incremental prognostic value of Doppler-derived mitral deceleration time of early filling in both symptomatic and asymptomatic patients with left ventricular dysfunction. J Am Coll Cardiol 1996; 28:383.
  20. Gola A, Pozzoli M, Capomolla S, et al. Comparison of Doppler echocardiography with thermodilution for assessing cardiac output in advanced congestive heart failure. Am J Cardiol 1996; 78:708.
  21. Naqvi TZ, Goel RK, Forrester JS, Siegel RJ. Myocardial contractile reserve on dobutamine echocardiography predicts late spontaneous improvement in cardiac function in patients with recent onset idiopathic dilated cardiomyopathy. J Am Coll Cardiol 1999; 34:1537.
  22. Naqvi TZ, Goel RK, Forrester JS, et al. Usefulness of left ventricular mass in predicting recovery of left ventricular systolic function in patients with symptomatic idiopathic dilated cardiomyopathy. Am J Cardiol 2000; 85:624.
  23. Allman KC, Shaw LJ, Hachamovitch R, Udelson JE. Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: a meta-analysis. J Am Coll Cardiol 2002; 39:1151.
  24. Bart BA, Shaw LK, McCants CB Jr, et al. Clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy. J Am Coll Cardiol 1997; 30:1002.
  25. Repetto A, Dal Bello B, Pasotti M, et al. Coronary atherosclerosis in end-stage idiopathic dilated cardiomyopathy: an innocent bystander? Eur Heart J 2005; 26:1519.
  26. Frustaci A, Chimenti C, Maseri A. Global biventricular dysfunction in patients with asymptomatic coronary artery disease may be caused by myocarditis. Circulation 1999; 99:1295.
  27. Hershberger RE, Lindenfeld J, Mestroni L, et al. Genetic evaluation of cardiomyopathy--a Heart Failure Society of America practice guideline. J Card Fail 2009; 15:83.
  28. Burkett EL, Hershberger RE. Clinical and genetic issues in familial dilated cardiomyopathy. J Am Coll Cardiol 2005; 45:969.
  29. Mahon NG, Murphy RT, MacRae CA, et al. Echocardiographic evaluation in asymptomatic relatives of patients with dilated cardiomyopathy reveals preclinical disease. Ann Intern Med 2005; 143:108.
  30. Crispell KA, Hanson EL, Coates K, et al. Periodic rescreening is indicated for family members at risk of developing familial dilated cardiomyopathy. J Am Coll Cardiol 2002; 39:1503.
  31. Hershberger RE, Cowan J, Morales A, Siegfried JD. Progress with genetic cardiomyopathies: screening, counseling, and testing in dilated, hypertrophic, and arrhythmogenic right ventricular dysplasia/cardiomyopathy. Circ Heart Fail 2009; 2:253.