Makindo Medical Notes

💡 Key Point: Heart failure (HF) is a clinical syndrome of symptoms/signs due to structural or functional cardiac abnormality → impaired ventricular filling or ejection. ⚡ It is a major cause of morbidity and mortality, but effective guideline-based therapy can improve survival and quality of life.

📖 About Heart Failure

• Acute HF: Rapid onset or worsening of symptoms (e.g. pulmonary oedema, cardiogenic shock). Often needs urgent hospital management.
• Chronic HF: Long-standing, stable or progressively worsening symptoms, usually managed in the community with optimisation of guideline-directed therapy.

💡 Key Point: Heart failure can be predominantly left-sided (pulmonary congestion due to LV dysfunction) or right-sided (systemic venous congestion due to RV dysfunction). Often both sides eventually fail, but early recognition of the dominant pattern helps with diagnosis and management.

🧬 Pathophysiology

• HFrEF: LV systolic dysfunction (EF <40%) → impaired contractility → ↓ stroke volume.
• HFmrEF: Mid-range EF (40–49%), overlapping features.
• HFpEF: EF ≥50% → diastolic dysfunction, stiff LV, impaired filling despite normal contractility.
• Neurohormonal activation (RAAS, SNS, ADH) → fluid retention, vasoconstriction, cardiac remodelling.

📖 Types

• Left Heart Failure: Failure of the LV to pump blood forward → ↑ left atrial pressure → pulmonary venous congestion → pulmonary oedema and breathlessness.
• Right Heart Failure: Failure of the RV to pump into pulmonary circulation → ↑ systemic venous pressure → peripheral oedema, ascites, hepatomegaly.
• Most cases of R-sided failure are secondary to L-sided failure, but isolated RV failure can occur (e.g. cor pulmonale, RV infarct, pulmonary hypertension).

🩺 Clinical Features

• Breathlessness (exertional → orthopnoea → PND → rest dyspnoea).
• Fatigue, reduced exercise tolerance.
• Peripheral oedema, ascites, hepatomegaly.
• Signs: elevated JVP, displaced apex, third heart sound (S3 gallop), pulmonary crepitations, ankle oedema.
• Acute HF: Pulmonary oedema, hypoxia, pink frothy sputum, tachycardia, cool peripheries.

🔎 Diagnosis

• Clinical syndrome: Symptoms + signs suggestive of HF.
• BNP/NT-proBNP: Sensitive test; normal level rules out HF. High levels prompt urgent echocardiography.
• ECG: AF, LVH, Q waves, conduction delay → may support HF diagnosis.
• Echocardiography: Gold standard → assesses EF, chamber size, wall motion, valves.
• CXR: Cardiomegaly, pulmonary venous congestion, Kerley B lines, pleural effusion.
• Bloods: FBC, U&E, LFT, TFT, glucose, lipids; troponin if ACS suspected.

📊 Classification of HF

🚑 Acute HF – Management (ABCDE)

• 🫁 Oxygen: If hypoxic, titrate to SpO₂ > 94%.
• 💊 IV diuretics: Furosemide 40–80 mg IV bolus (higher in chronic users).
• 🪑 Sit upright to improve ventilation.
• 💊 Nitrates: If hypertensive and not hypotensive, GTN infusion reduces preload/afterload.
• ⚡ Inotropes/vasopressors: Dobutamine, noradrenaline in cardiogenic shock.
• 💉 Consider CPAP/NIV if severe pulmonary oedema.
• 🚨 Identify and treat precipitant: ACS, arrhythmia, infection, PE, poor compliance.

💊 Chronic HF – Guideline-Directed Therapy (HFrEF)

• Stepwise drug therapy:
  • ACEi (or ARB if intolerant) + beta-blocker (bisoprolol, carvedilol, nebivolol) ➝ titrate to max tolerated.
  • Add MRA (spironolactone/eplerenone) if still symptomatic.
  • SGLT2 inhibitors (dapagliflozin, empagliflozin) – now class I recommendation (ESC 2021).
  • ARNI (sacubitril/valsartan) in place of ACEi if EF remains <35% and symptomatic.
  • Other: Ivabradine (if sinus rhythm HR ≥75 despite max beta-blocker), hydralazine/nitrates (esp. Afro-Caribbean patients), digoxin (AF, symptoms).
• Devices:
  • CRT (cardiac resynchronisation) – EF ≤35%, broad QRS.
  • ICD – for secondary prevention (post-VF/VT) or primary prevention in selected HFrEF.
• Advanced: LVAD, transplant in refractory cases.

💊 Chronic HF – HFpEF

• No disease-modifying therapy proven.
• Focus on treating comorbidities: HTN, AF, IHD, obesity, diabetes.
• Diuretics for symptom control (congestion relief).
• SGLT2 inhibitors show emerging benefit (EMPEROR-Preserved trial).

⚡ Complications

• Arrhythmias (AF, VT/VF).
• Thromboembolism (esp. in AF).
• Progressive renal dysfunction.
• Sudden cardiac death.

📚 Prognosis

• 5-year mortality for HFrEF ≈ 50% (worse than many cancers).
• Timely initiation of guideline therapies improves both survival and quality of life.
• HFpEF prognosis is comparable but with fewer therapeutic options.

📝 Teaching Pearls

🔍 BNP normal virtually excludes HF (high negative predictive value). 💡 Always distinguish HFpEF vs HFrEF → management pathways differ. ⚠️ In acute pulmonary oedema: sit up, O₂, IV furosemide, GTN (if BP allows), treat trigger.

📚 References

• ESC Heart Failure Guidelines 2021
• NICE NG106: Chronic Heart Failure (2018, updated 2022)
• Ponikowski P et al, Eur Heart J 2021