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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

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

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)

Acute pulmonary oedema…

Acute pulmonary oedema management is covered here!

Try some questions

What are the chest radiograph (CXR) findings in heart failure?

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What does a giant V wave in the JVP suggest?

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What is cardiac output dependent on?

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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

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