Heart Failure, a clear clinical guide

This guide gives you a short and direct overview of heart failure. Use it for fast learning.

Definition

Heart failure is a syndrome where the heart fails to pump enough blood to meet the body’s needs. It results from structural or functional problems of the heart.

• Reduced ejection fraction, HFrEF
• Preserved ejection fraction, HFpEF

Pathophysiology

• Reduced cardiac output lowers tissue perfusion.
• Sympathetic and RAAS activation raises heart rate and promotes fluid retention.
• Increased preload worsens congestion.
• Chamber dilation or stiffening leads to remodeling.
• Myocyte loss and fibrosis impair contraction and relaxation.

Common causes

• Coronary artery disease
• Hypertension
• Valvular disease
• Cardiomyopathies
• Arrhythmias
• Drug induced injury such as anthracyclines

Signs and symptoms

Symptoms

• Breathlessness on exertion
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Fatigue
• Ankle swelling
• Reduced exercise tolerance

Signs

• Fast pulse
• Raised JVP
• Crackles at lung bases
• Hepatomegaly
• Pitting edema
• S3 gallop

Diagnosis

• History and focused physical exam
• ECG to assess rhythm and ischemia
• Echocardiography to check EF and structure
• BNP or NT pro BNP for confirmation
• Chest X ray for congestion
• Blood tests for kidney function, electrolytes, thyroid status, and anemia

Pharmacotherapy

Core drugs for HFrEF

• ACE inhibitors or ARBs reduce admissions and mortality.
• ARNI, sacubitril valsartan, for patients stable on ACE inhibitor or ARB.
• Beta blockers improve symptoms and survival.
• Mineralocorticoid antagonists reduce congestion and improve outcomes.
• SGLT2 inhibitors lower HF events in patients with or without diabetes.

Other drugs

• Loop diuretics relieve fluid overload.
• Ivabradine for patients in sinus rhythm with high heart rate despite beta blockers.
• Hydralazine with nitrates for selected patients or those intolerant to ACE inhibitors or ARBs.
• Digoxin for symptom relief in selected cases.

HFpEF management

• Control blood pressure.
• Give diuretics to treat fluid overload.
• Correct arrhythmias or ischemia.
• Use SGLT2 inhibitors for reduction in HF admissions.

Non pharmacological management

• Limit salt intake.
• Monitor weight daily and report rapid gain.
• Restrict fluid in advanced stages.
• Encourage physical activity within tolerance.
• Stop smoking and avoid alcohol excess.
• Give influenza and pneumococcal vaccines.
• Manage comorbidities including diabetes, hypertension, and sleep apnea.
• Educate on symptom recognition and follow up.

When to seek urgent care

• Worsening breathlessness
• Rapid weight gain
• Recurrent syncope
• Persistent edema
• Poor response to diuretics

Key points

• Heart failure is chronic with periodic acute worsening.
• Early diagnosis and regular follow up improve outcomes.
• Up titrate drug therapy to target doses when tolerated.
• Lifestyle measures lower admissions.