Heart Failure Summary

Definition

  • Syndrome from cardiac structural/functional impairment
  • Acute HF: Rapid onset requiring urgent treatment
  • Chronic HF: Long-term management required

Key Symptoms

  • Breathlessness (exertional, orthopnea, PND)
  • Fluid retention (edema, weight gain)
  • Fatigue and reduced exercise tolerance
  • Cough with frothy sputum

Key Signs

  • Elevated JVP
  • Displaced apex beat
  • Basal crepitations
  • Peripheral edema
  • S3/S4 gallop

Diagnostic Tests

  • BNP/NT-proBNP: Rule out HF if normal
  • ECG: Assess rhythm and ischemia
  • Echocardiogram: Assess LVEF and structure
  • CXR: Cardiomegaly, pulmonary congestion

Acute Management

  • IV diuretics: For fluid overload
  • Vasodilators: For hypertensive AHF
  • Inotropes: For cardiogenic shock
  • Oxygen/NIV: For respiratory distress

Long-term Therapy (HFrEF)

  • Beta-blockers
  • ACEi/ARB/ARNI
  • MRAs
  • SGLT2 inhibitors

Common Causes

  • Coronary artery disease (most common)
  • Hypertension
  • Cardiomyopathies
  • Valvular heart disease

Heart Failure

A complex clinical syndrome resulting from structural or functional impairment of ventricular filling or ejection of blood

Definition

Heart failure is defined clinically as a syndrome in which patients have symptoms and signs resulting from an abnormality of cardiac structure and/or function.

Acute heart failure refers to rapid onset or worsening of symptoms and/or signs of heart failure, requiring urgent evaluation and treatment.

Causes of Heart Failure

Myocardial Disease

  • Coronary artery disease (most common)
  • Hypertension
  • Cardiomyopathies:
    • Familial
    • Infective
    • Immune-mediated
    • Toxic (alcohol, cocaine)
    • Peripartum
    • Infiltrative (sarcoidosis, amyloidosis)

Structural/Mechanical

  • Valvular heart disease (e.g., aortic stenosis)
  • Pericardial disease:
    • Constrictive pericarditis
    • Pericardial effusion
  • Congenital heart disease

High Output States

  • Anemia
  • Thyrotoxicosis
  • Pheochromocytoma
  • Sepsis
  • AV shunts
  • Thiamine (B1) deficiency

Other Causes

  • Arrhythmias (e.g., atrial fibrillation)
  • Volume overload (CKD, nephrotic syndrome)
  • Obesity
  • Drugs (NSAIDs, beta-blockers, CCBs)

Clinical Features

Symptoms

  • Breathlessness (exertional, orthopnea, PND)
  • Cough (sometimes with frothy sputum)
  • Fluid retention (edema, ascites, weight gain)
  • Fatigue and reduced exercise tolerance
  • Lightheadedness or syncope

Signs

  • Tachycardia, irregular pulse
  • Displaced apex beat, S3/S4 gallop
  • Elevated JVP
  • Hepatomegaly
  • Basal crepitations, pleural effusions
  • Peripheral edema

Differential Diagnosis

Respiratory Causes

  • COPD
  • Asthma
  • Pulmonary embolism
  • Lung cancer

Edema Causes

  • Venous insufficiency
  • Nephrotic syndrome
  • Hypoalbuminemia
  • Drug-induced

Other Conditions

  • Severe anemia
  • Thyroid disease
  • Renal artery stenosis
  • Anxiety disorders

Investigations

Initial Workup

BNP/NT-proBNP

  • BNP <100 ng/L or NT-proBNP <300 ng/L rules out HF
  • Levels correlate with severity

ECG

  • Assess rhythm, ischemia, strain patterns
  • Look for arrhythmias

Chest X-ray

  • Cardiomegaly (CTR >50%)
  • Pulmonary venous congestion
  • Kerley B lines
  • Pleural effusions

Additional Tests

Test Purpose
Echocardiogram Assess LVEF, wall motion, valves, pericardium
Blood tests Renal/liver/thyroid function, FBC, troponin
Coronary angiography If ischemic etiology suspected
CMR For tissue characterization (fibrosis, infiltration)

Management of Acute Heart Failure

Initial management focuses on stabilizing the patient, relieving symptoms, and identifying/treating precipitating factors.

Pharmacological Treatment

Medication Indication Notes
IV Diuretics All patients with fluid overload Furosemide 40-80mg IV, monitor renal function
Vasodilators Hypertensive AHF Nitrates, nitroprusside (caution with SBP <110)
Inotropes Cardiogenic shock Dobutamine, milrinone - use in ICU setting

Non-Pharmacological Treatment

Oxygen & Ventilation
  • Oxygen if SpO₂ <90% (avoid unnecessary oxygen)
  • NIV (CPAP/BiPAP) for pulmonary edema with respiratory distress
  • Intubation for respiratory failure or decreased consciousness

Stabilization Phase

  1. Initiate GDMT (beta-blockers, ACEi/ARB/ARNI, MRA) once stable
  2. Monitor fluid status (daily weights, strict I/O)
  3. Address precipitating factors (infection, ischemia, arrhythmias)
  4. Plan discharge with close follow-up

Long-Term Management

Pharmacotherapy (HFrEF)

  • Beta-blockers: Bisoprolol, carvedilol, metoprolol
  • RAAS inhibitors: ACEi/ARB/ARNI
  • MRAs: Spironolactone, eplerenone
  • SGLT2 inhibitors: Empagliflozin, dapagliflozin

Device Therapy

  • ICD for primary/secondary prevention
  • CRT for QRS >150ms + LBBB
  • LVAD for advanced HF

Lifestyle Modifications

  • Salt restriction (<2g/day)
  • Fluid restriction (1.5-2L/day if hyponatremic)
  • Daily weight monitoring
  • Regular physical activity