Table of Contents Types Causes Clinical features of heart failure Investigations To confirm diagnosis To determine causeChronic heart failure management Try some questions 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 Reduced perfusionPulmonary congestion (LVF)Systemic congestion (RVF)Symptoms•Fatigue•Exercise intolerance •SOB on exertion, orthopnoea•Paroxysmal nocturnal dyspnoea •White/pink frothy sputum •Cardiac wheeze•Peripheral oedema•Weight gain•Bloating and reduced appetite Signs•Cyanosis•Tachypnoea/ tachycardia•Cool extremities•Oliguria•Pulmonary oedema (fine basal creps)•Pleural effusions•S3/ventricular gallop•Hypotension (in advanced heart failure)•Raised JVP•Peripheral oedema (pedal, sacral, scrotal)•Hepatomegaly•Ascites Peripheral oedemaPeripheral cyanosisCentral cyanosis 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 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! Try some questions What are the chest radiograph findings in heart failure? Oops! This section is restricted to members. What does a giant V wave in the JVP suggest? Oops! This section is restricted to members. What is cardiac output dependent on? Oops! This section is restricted to members. What is Kussmaul’s sign? Oops! This section is restricted to members.