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

Causes

Clinical features of heart failure

	Reduced perfusion	Pulmonary 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 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

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