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.


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


Clinical features of heart failure

Reduced perfusionPulmonary congestion (LVF)Systemic congestion (RVF)
•Exercise intolerance  
•SOB on exertion, orthopnoea
•Paroxysmal nocturnal dyspnoea 
•White/pink frothy sputum      
•Cardiac wheeze
•Peripheral oedema
•Weight gain
•Bloating and reduced appetite 
•Tachypnoea/ tachycardia
•Cool extremities
•Pulmonary oedema (fine basal creps)
•Pleural effusions
•S3/ventricular gallop
•Hypotension (in advanced heart failure)
•Raised JVP
•Peripheral oedema (pedal, sacral, scrotal)


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 blocker or angiotensin receptor-neprilysin inhibitor (e.g. sacubitril/valsartan)
    • β-blocker (e.g. bisoprolol)
    • Aldosterone antagonist (e.g. spironolactone, 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: end-stage heart failure
    • Heart transplant: end-stage heart failure
  • Control specific causes/associated conditions (e.g. hypertension, AF, obesity, diabetes, myocardial ischaemia) 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

Acute pulmonary oedema…

Acute pulmonary oedema management is covered here!

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