Acute heart failure (AHF) is a leading cause of hospitalisation in developed nations, responsible for 67,000 admissions a year in the UK alone, an incidence which is set to increase with an ageing population.1 The prognosis remains poor: in-hospital mortality ranges from 4–11 % and in those patients surviving to discharge 50 % will be re-admitted and one-third will die within 12 months.2–6 These poor outcomes indicate room for improvement in the standard of care. There may be several reasons why this is so and the failure to make an accurate and timely diagnosis may be an important contributor. There is no single diagnostic test, the symptoms and signs may be non-specific and may be further compounded by features of co-morbidity, meaning a high index of clinical suspicion is essential.7,8 These difficulties are set against a backdrop of concern amongst the profession about the declining status of the utility of bedside assessment in modern medicine.9,10 Failure to recognise suspected HF may delay major investigations, instigation of appropriate initial management and access to specialist input; all of which influence clinical outcome in the short and long term.1 Delayed diagnosis at presentation may result in patients being inappropriately transferred to non-specialist wards, resulting in longer stays, increased re-admission and poorer outcomes.11 Indeed, the wide variation in current management and service provision taken together with a lack of new treatment developments over the last 25 years has led to AHF being termed the ‘Cinderella’ of cardiology.11
It is of no surprise therefore that contemporary practice guidelines all highlight the importance of early recognition of HF in a patient presenting acutely to allow prompt access to those treatments and services with proven survival benefit.12–14 This short review focuses on the clinical signs and radiographic changes present in AHF and discusses their relative utility in the assessment and diagnosis of these patients alongside the most up to date evidence.