Heart Failure (acute and chronic)

Reference: Acute heart failure: diagnosis and management NICE guidelines [CG187] Published: 08 October 2014 Chronic heart failure: diagnosis and management NICE guidelines [NG106] Published: 12 September 2018

Background Information

  • Heart failure (HF) is a condition in which the heart does not pump enough blood to meet all the demands of the body. It is caused by a dysfunction of the heart due to muscle damage (either systolic or diastolic dysfunction), valvular dysfunction, arrythmias or other causes.
Classification by time course:
  • Acute HF is a life-threatening condition characterised by a sudden onset in people without any known cardiac dysfunction, or as acute decompensation of chronic HF
  • Chronic HF is a progressive condition characterised by the gradual deterioration of symptoms over time
Classification by ejection fraction:
  • HFrEF (HF with reduced ejection fraction):  LVEF of ≤40%
  • HFmrEF (HF with mildly reduced ejection fraction): LVEF between 41-49%
  • HFpEF (HF with preserved ejection fraction): LVEF of ≥50%
  • High-output HF: higher than normal CO but still insufficient to meet the demands of the body

Clinical features of chronic heart failure can be classified into left- and right-sided.

Symptoms from pulmonary congestion: (increasing in severity)
  • Exertional dyspnoea
  • Paroxysmal nocturnal dyspnoea
  • Orthopnoea
  • Dyspnoea at rest
Symptoms from ↓ cardiac output:
  • ↓ Exercise tolerance
  • Fatigue
On examination:
  • Bi-basal fine crepitations on auscultation
  • Cardiomegaly → displaced apex beat
  • Peripheral hypoperfusion → ↑ CRT, cold extremities, pallor

Symptoms from fluid retention and ↑ CVP
  • Peripheral oedema
  • Ascites → abdominal distention
  • Hepatic congestion → RUQ pain and jaundice  
  • GI congestion → nausea, loss of appetite
On examination:
  • JVP distention
  • Congestive hepatomegaly
  • Hepatojugular reflex

  • Tachycardia and various arrhythmia
  • Gallop rhythms can give clues towards underlying cause:
    • S3 heart sound- dilated cardiomyopathy, high-output states
    • S4 heart sound- hypertensive heart disease, HOCM / HCM
  • Pulsus alternans

Main differentiating factors that suggest acute heart failure over chronic failure:

  • Rapid onset of symptoms (often over hours to days)
  • Sudden and severe symptoms
  • Results from a trigger (e.g. myocardial infarction, arrhythmia, infection)
  • Pulmonary congestion predominant

NB there is significant overlap in symptoms as there might be chronic heart failure features present, left side

The NYHA classification is mainly used in chronic HF to assess and guide management
NYHA Class Description
I No limitation of physical activity. Ordinary physical activity does not cause symptoms.
II Comfortable at rest. Ordinary physical activity causes symptoms.
III Comfortable at rest. Less than ordinary physical activity cause symptoms.
IV Unable to carry out any physical activity without symptoms +/- symptoms at rest.

 

Acute Heart Failure Guidelines

1st line investigation: BNP or NT-proBNP
Heart failure is unlikely if:
  • BNP < 100 ng/L
  • NT-proBNP < 300 ng/L
Confirmatory investigation: TTE
 

  • 1st line in all patients:  IV loop diuretic
Add-on therapy: (these should not be offered routinely to all patients):
  • IV nitrates should only be given if:
    • Concomitant myocardial ischaemia
    • Severe hypertension
    • Aortic or mitral regurgitation
  • If cardiogenic shock → consider inotropes or vasopressors
Non-pharmacological options:
  • CPAP can be used in severe cardiogenic pulmonary oedema
  • Invasive ventilation

Initial management of acute heart failure = IV loop diuretic

Start / continue if already taking, the following drugs during hospital admission after stabilisation:
  • ACE-I / ARB
  • Beta blocker (unless HR <50bpm / 2nd degree HB / 3rd degree HB / shock)
  • Aldosterone antagonist (e.g. spironolactone)

Chronic Heart Failure Guidelines

  • 1st line investigation: NT-pro-BNP
  • Confirmation test: TTE (transthoracic echocardiography)
Subsequent investigations depend on NT-pro-BNP level:
NT-pro-BNP level Next step
>2000 ng/L Refer to specialist and TTE within 2 weeks
400-2000 ng/L Refer to specialist and TTE within 6 weeks
<400 ng/L Heart failure less likely, consider alternative diagnosis

Factors that can affect interpretation of NT-pro-BNP
  • Click here to view causes of falsely ↓ NT-pro-BNP level 
  • Click here to view causes of falsely ↑ NT-pro-BNP level 

  • Offer cardiac rehabilitation
  • Avoid potassium-containing salt substitutes
  • If patient has excess salt and/or fluid consumption → advise reducing intake (but do not routinely advise patients to restrict sodium or fluid intake)
  • Annual influenza vaccination + one-off pneumococcal vaccination

List of abbreviations in this section:
ACE-I Angiotensin converting enzyme inhibitor
ARB Angiotensin receptor blocker
BB Beta blocker
MRA Mineralocorticoid receptor antagonist
SGLT-2-I Sodium-glucose co-transporter 2 inhibitor

All patients should receive:
  • Loop diuretics if there is any congestive symptoms and fluid retention
  • ACE-I or ARB 
  • BB
Click here to view how to monitor patients on ACE-I 
  • Step 2 medications:
    • MRA
    • SGLT-2-I (dapagliflozin or empagliflozin)
  • Step 3 mediations: (specialist treatment)
    • Ivabradine, recommended if all the following are met:
      • NYHA 2-4
      • Sinus rhythm >75 bpm
      • LVEF <35%
    • Sacubitril valsartan, recommended if all the following are met:
      • NYHA 2-4
      • LVEF <35%

Only drugs that are not prognostic, i.e. reduce mortality in HFrEF is loop diuretics and digoxin.

    • Hydralazine + nitrate, especially if Afro-Caribbean origin + NYHA 3-4 + ↓ LVEF
    • Digoxin – useful if concomitant atrial fibrillation

All patients should receive:
  • Loop diuretics if there is any congestive symptoms and fluid retention
  • SGLT-2-I (dapagliflozin or empagliflozin)
Note other drugs used in HfrEF have no benefit in HfpEF / HfmrEF

The recommendations regarding use of ICD and CRT in heart failure by NICE is complicated and overwhelming. One might benefit from learning the ESC class I recommendations:
  • CRT – ESC class I recommendation:
    • NYHA class II-IV, AND
    • LVEF ≤35%, AND
    • QRS ≥150 ms with LBBB
  • ICD
    • ESC class I recommendation: NYHA class II-IV + LVEF ≤35% due to myocardial infarction, despite 3 months of optimised medical therapy
    • ESC class I recommendation for secondary prevention:
      • Survivor of cardiac arrest due to VT / VF, that is not due to transient or reversible cause (e.g. acute MI and electrolyte disturbances)
      • Patients with sustained VT and structural heart disease
Other:
  • Coronary revascularisation – do not routinely offer in HFrEF and concurrent coronary artery disease
  • Cardiac transplantation – consider in severe refractory symptoms or refractory cardiogenic shock
Author: Noah Thomaidis
Editor: Adams Lau
Reviewer: