Heart Failure History OSCE — Symptoms, NYHA Classification, and Precipitating Causes

Introduction

Heart failure history is a high-yield cardiology OSCE station that requires you to systematically elicit symptoms, classify severity, identify precipitants, and distinguish cardiac from respiratory breathlessness. Heart failure affects over 900,000 people in the UK and carries a worse 5-year prognosis than most common cancers.

The Cardinal Symptoms of Heart Failure

1. Dyspnoea on Exertion

• "Do you get short of breath?"
• "How far can you walk before you become breathless?"
• "Can you climb a flight of stairs without stopping?"
• Baseline: what could you previously do that you can no longer do?

2. Orthopnoea (Breathlessness Lying Flat)

• "Do you struggle to breathe when you lie flat?"
• "How many pillows do you sleep with? Have you needed more recently?"
• Caused by redistribution of peripheral fluid to the pulmonary circulation when supine
• Record number of pillows: 2-pillow, 3-pillow orthopnoea

3. Paroxysmal Nocturnal Dyspnoea (PND)

• "Do you wake at night feeling breathless or frightened?"
• "What helps? Do you need to open a window or sit upright?"
• Occurs 1-3 hours after falling asleep as fluid redistributes; patient wakes gasping, sits upright, and gradually improves over 20-30 minutes
• Highly specific for left ventricular failure

4. Peripheral Oedema

• "Have your ankles or legs been swollen?"
• "Is it worse at the end of the day? Does it reduce overnight?"
• "How far up the legs does the swelling reach?"
• Pitting bilateral ankle oedema + dyspnoea = heart failure until proven otherwise

5. Fatigue and Exercise Intolerance

• "Do you feel unusually tired?"
• Often disproportionate to activity level
• Caused by reduced cardiac output to skeletal muscle

NYHA Functional Classification

"Can I ask — are you comfortable just sitting here at rest? What about walking to the bathroom? What about getting dressed?"

Additional Symptoms

Identifying Precipitants

Ask about:

• Recent chest infection or other illness
• New palpitations (AF is the most common precipitant)
• Stopping medications (diuretics, beta-blockers, ACEi)
• Dietary indiscretion: excess salt, fluid bingeing
• Recent non-steroidal anti-inflammatory drug use (NSAIDs cause fluid retention and worsen HF)
• Recent cardiac event: MI, myocarditis

Past Cardiac History

• Previous MI, PCI, CABG — when? Ejection fraction known?
• Valvular disease: aortic stenosis, mitral regurgitation
• Hypertension (the most common underlying cause in the UK)
• Cardiomyopathy: ischaemic, dilated, hypertrophic, peripartum
• Previous echocardiogram results

Differentiating Cardiac from Respiratory Breathlessness

"How do you use the NYHA classification in a heart failure history?"

Ask about specific functional limits: Class I patients have no limitation with ordinary activity. Class II have slight limitation with moderate exertion (e.g. climbing two flights of stairs). Class III have marked limitation with minimal exertion (e.g. walking from the bedroom to the bathroom). Class IV have symptoms at rest. This classification guides prognosis communication, referral decisions, and treatment escalation.

"What is paroxysmal nocturnal dyspnoea and what causes it?"

PND is sudden breathlessness that wakes the patient from sleep, typically 1-3 hours after lying down. It occurs when fluid from dependent oedema redistributes to the pulmonary circulation in the supine position, causing acute pulmonary congestion. The patient wakes gasping, sits upright or opens a window, and gradually improves over 20-30 minutes. PND is highly specific for left ventricular failure.

"What are the common precipitants of acute decompensated heart failure?"

The PIRATES mnemonic: Pulmonary embolism, Infection (pneumonia is most common), Rhythm disturbance (new atrial fibrillation is the most frequent precipitant), Anaemia, Thyrotoxicosis, Endocarditis or medication non-compliance, Salt and fluid excess. NSAIDs are a commonly overlooked pharmacological precipitant — they cause sodium and water retention and directly worsen cardiac function.

"How do you differentiate cardiac from respiratory breathlessness in the history?"

Cardiac breathlessness (heart failure) is characterised by orthopnoea, PND, bilateral ankle oedema, and relief on sitting upright. Respiratory breathlessness (COPD, asthma) is characterised by prominent wheeze, productive cough, response to bronchodilators, and typically a significant smoking history. Cardiac wheeze (cardiac asthma) can mimic respiratory disease — the presence of orthopnoea and PND is the key discriminating feature.

Related guides: How to Take a Cardiology History OSCE | Cardiovascular Examination OSCE | Chest Pain History OSCE