Heart failure

Heart failure is a clinical syndrome characterised by the symptoms and signs that occur due to a reduced cardiac output and/or increased filling pressures.

Types

Heart failure with reduced ejection fraction – ‘systolic heart failure’

• Reduction in contractility of ventricles
• Usually divided into LVF or RVF

  • LVF is more common
  • The most common cause of RVF is LVF, but RVF can also occur independently due to pulmonary hypertension or right-sided valve disease

• Causes below

Heart failure with preserved ejection fraction (HFpEF) – ‘diastolic heart failure’

• Reduction in compliance of ventricles (i.e. stiff ventricles)
• Usually related to old age/chronic hypertension

Causes

Clinical features of heart failure

Peripheral oedema

Peripheral cyanosis

Central cyanosis

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Investigations

To confirm diagnosis 

• Serum B-type natriuretic peptide
• Chest X-ray
• Echocardiography: diagnostic test and may help determine cause

To determine cause

• Bloods: FBC, U&Es, TFTs, LFTs, ferritin, transferrin saturation, lipid profile, HbA1C, vasculitic/rheumatological screen, viral serologies (e.g. HIV)
• ECG: look for ischaemia, arrhythmias, small complexes (amyloid/pericardial effusion)
• Angiogram or functional imaging: if suspect ischaemic heart disease
• Cardiac MRI: if poor echo windows, suspected infiltrative cause, or unclear cause

Chronic heart failure management

• Treat cause where possible
• Diuretic (e.g. furosemide, bumetanide) if fluid overloaded
• Drugs with prognostic benefit for heart failure with reduced ejection function
  • ACE inhibitor or angiotensin receptor-neprilysin inhibitor (e.g. sacubitril/valsartan)
  • β-blocker (e.g. bisoprolol)
  • Aldosterone antagonist (e.g. eplerenone)
  • SGLT2 inhibitor (e.g. dapagliflozin, empagliflozin)
• Non-pharmacological treatments
  • Exercise rehabilitation
  • Devices
    • Cardiac resynchronisation therapy device considered if QRS significantly prolonged
    • Implantable cardioverter defibrillator considered if risk of ventricular arrhythmias
    • Left ventricular assist device considered in end-stage heart failure
  • Heart transplant considered in end-stage heart failure
• Control specific causes/associated conditions (e.g. hypertension, AF, obesity, diabetes, myocardial ischaemia) and SGLT2 inhibitor for heart failure with preserved ejection function

Reference: European Society of Cardiology ‘Guidelines for the diagnosis and treatment of acute and chronic heart failure’ 2021 (update 2023)

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Picture references

Peripheral cyanosis: 2011 James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license (https://creativecommons.org/licenses/by-sa/3.0/deed.en). Sourced from: https://commons.wikimedia.org/wiki/File:Cynosis.JPG

Pitting oedema: James Heilman, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license (https://creativecommons.org/licenses/by-sa/3.0/deed.en). Sourced from: https://en.m.wikipedia.org/wiki/File:Combinpedal.jpg