Index

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 soundSound from rapid ventricular filling- 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

1^st line investigation: BNP or NT-proBNP
Heart failure is unlikely if:

BNP < 100 ng/L
NT-proBNP < 300 ng/L

Confirmatory investigation: TTE

1^st 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 / 2^nd degree HB / 3^rd degree HB / shock)
Aldosterone antagonist (e.g. spironolactone)

Chronic Heart Failure Guidelines

1^st 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 retentionE.g. dyspnoea, limb oedema
ACE-I or ARB
BB

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

Original guidelines

NICE guidelines on Acute heart failure: diagnosis and management
NICE guidelines on Chronic heart failure in adults: diagnosis and management
HFpEF/HFmEF treatment with SGLT2-inhibitor (dapagliflozin):

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Heart Failure (acute and chronic)

Background Information

Acute Heart Failure Guidelines

Chronic Heart Failure Guidelines

Original guidelines

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Heart Failure (acute and chronic)

Background Information

Definitions and Classifications

Clinical features

Left-sided heart failure

Right-sided heart failure

Non-specific cardiac findings

Symptomatic severity- NYHA (The New York Heart Association)

Acute Heart Failure Guidelines

Investigations and Diagnosis

Initial Management

Management after stabilisation

Chronic Heart Failure Guidelines

Investigations and Diagnosis

Management

Lifestyle/Conservative Management-all types of heart failure

Pharmacological Management- depends on type of heart failure

HFrEF

HFpEF/HFmrEF

Interventional Management

Original guidelines

References