QuestionSBA
QuestionChoice
There is no indication that this patient has an arrhythmia, angina or hypertension which are the indications for verapamil. In fact, you should avoid calcium channel blockers in heart failure as they are negatively inotropic so can further exacerbate heart failure by reducing cardiac function
31781
d
Verapamil
QuestionChoice
There are no indications for ibuprofen in this patient and, in fact, non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in heart failure
31782
e
Ibuprofen
QuestionChoice
Implantation of a cardiac resynchronisation therapy (CRT) device is indicated in patients with heart failure and a wide QRS complex on their ECG
31778
a
Implantation of a cardiac resynchronisation therapy (CRT) pacemaker device
QuestionChoice
There is no indication that this patient is she haemodynamically unstable and requires cardioversion
31779
b
Synchronised Direct current (DC) cardioversion
QuestionChoice
There is no indication that this patient has an arrhythmia which is what amiodarone is used to treat
31780
c
Amiodarone
QuestionComment
its not an arrthymia cox there is no tachycardia
60391
User
subscriber
Malignant Syndrome
QuestionComment
this is incorrect. peri arrest guidelines say if they have acute heart failure then its DC cardioversion
62217
User
subscriber
Sydney Sweeney
Concept
Chapter
# Summary

Heart failure (HF) is a clinical syndrome characterised by the heart's inability to pump enough blood to meet the body's needs. It is a common condition primarily affecting the elderly population. HF can be classified based on various factors, such as the type of dysfunction (systolic or diastolic), the onset (acute or chronic), and the severity of symptoms (NYHA classification). The clinical features of HF differ depending on whether it primarily affects the left or right ventricle, but broadly include fatigue, shortness of breath, and peripheral oedema. Diagnosis involves evaluating symptoms, NT-pro-BNP levels, and echocardiography. Management includes lifestyle modifications, medical therapy, and, in some severe cases, cardiac resynchronisation therapy. The prognosis for HF varies, but approximately 50% of those diagnosed are alive at 5 years.

# Definition 

Heart failure (HF), also known as congestive heart failure (CHF) and congestive cardiac failure (CCF), is defined as the failure of the heart to generate sufficient cardiac output to meet the metabolic demands of the body.

# Epidemiology 

* HF is common: the prevalence in the UK is estimated at 1-2%.

* HF primarily affects the elderly population: the average age of diagnosis is 75 years old. The incidence of HF has been increasing with the ageing population.

* In Europe and North America the most common causes are coronary artery disease, hypertension, and valvular disease.

* Although Chagas disease is a rare cause in Europe and North America, it is a significant cause of heart failure in Central/South America.

# Pathophysiology

The pathophysiology for HF is diverse and depends on the aetiology of the HF. 

# Classification 

HF can be classified in different ways. It can be classified as being low output vs. high output HF, predominantly systolic or diastolic dysfunction, whether the process has been acute or chronic, or by the severity of symptoms (and consideration for predominantly left or right ventricle features). 

## Low-output HF vs. High-output HF 

Low-output HF is much more common than high-output HF. Low-output HF occurs when cardiac output is reduced due to a primary problem with the heart and the heart is unable to meet the body's needs. Conversely, high-output HF refers to a heart that has a normal cardiac output, but there is an increase in peripheral metabolic demands that the heart is unable to meet. 

The common causes of low-output HF will be further discussed below. Common causes of high-output HF include: 

* Anaemia
* Arteriovenous malformation
* Paget's disease
* Pregnancy
* Thyrotoxicosis
* Thiamine deficiency (wet Beri-Beri)

These can be remembered with the AAPPTT mnemonic. 

## Systolic vs. Diastolic HF

Systolic dysfunction refers to an impairment of ventricular contraction. The ventricles are able to fill well, but the heart is unable to pump the blood sufficiently out of the ventricle due to impaired myocardial contraction during systole (reduced ejection fraction). Common causes include: ischaemic heart disease, dilated cardiomyopathy, myocarditis or infiltration (haemochromatosis or sarcoidosis). 

In comparison, diastolic dysfunction refers to the inability of the ventricles to relax and fill normally, hence the heart is still able to pump well but pumps out less blood per contraction due to reduced diastolic filling (preserved ejection fraction). Common causes include: uncontrolled chronic hypertension (significant left ventricular hypertrophy reduces filling of the left ventricle), hypertrophic cardiomyopathy, cardiac tamponade, and constrictive pericarditis. 

## Acute vs. Chronic HF 

HF can also be classified according to the time of onset. Acute HF occurs with new-onset HF symptoms (acute mitral regurgitation following an MI) or an acute deterioration in a patient with known, chronic HF. In comparison, chronic HF progresses more slowly and may take many years to develop. 

## Severity of Symptoms

**New York Heart Association (NYHA) Classification of HF**

The NYHA Classification system is used to classify HF through the severity of symptoms. It runs from Class I (no limitation) to Class IV (discomfort at rest). 

* Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitations or dyspnoea.
* Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitations and/or dyspnoea.
* Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary).
* Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.

# Symptoms and Signs

The clinical features of HF can be considered according to the ventricle most impacted. However, a common presenting complaint for all types of heart failure is **fatigue**. 


## Clinical features of left heart failure (LHF)

LHF, or left ventricular failure (LVF), causes pulmonary congestion (pressure builds up in the LHS of the heart and there is backpressure to the lungs) and systemic hypoperfusion.

### Symptoms 

* Shortness of breath on exertion
* Orthopnoea
* Paroxysmal nocturnal dyspnoea
* Nocturnal cough (± pink frothy sputum)
* **Fatigue**

### Signs 

* Tachypnoea
* Bibasal fine crackles on auscultation of the lungs
* Cyanosis
* Prolonged capillary refill time 
* Hypotension
* Less common signs: pulsus alternans (alternating strong and weak pulse), S3 gallop rhythm (produced by large amounts of blood striking compliant left ventricle), features of functional mitral regurgitation. 

## Clinical features of right heart failure 

Right heart failure causes venous congestion (pressure builds up behind the right heart) and pulmonary hypoperfusion (reduced right heart output).

### Symptoms 

* Ankle swelling 
* Weight gain 
* Abdominal swelling and discomfort 
* Anorexia and nausea 

### Signs

* Raised JVP
* Pitting peripheral oedema (ankle to thighs to sacrum)
* Tender smooth hepatomegaly
* Ascites
* Transudative pleural effusions (typically bilaterally)

*NB. Sometimes left-sided heart failure can lead to pulmonary congestion which in turn also pushes the right ventricle into failure. In these cases, signs and symptoms of both left and right-sided heart failure may be present. This is congestive cardiac failure.* 

# Differential Diagnoses

* **Chronic Obstructive Pulmonary Disease (COPD)** 
	* **Similarities**: both may present with dyspnoea (and significant respiratory distress) and fatigue. 
	* **Differences**: in heart failure, the shortness of breath is typically worse on lying flat (orthopnoea) and may be accompanied by paroxysmal nocturnal dyspnoea and peripheral oedema. Shortness of breath in COPD tends to be worse with exertion and is likely accompanied by other symptoms including chronic productive cough, wheeze and a significant smoking history. 

* **Acute Respiratory Distress Syndrome** 
	* **Similarities**: both may present with shortness of breath, tachypnoea and respiratory distress. Both lead to the accumulation of fluid in the lungs and impaired gaseous exchange leading to hypoxaemia. 
	* **Differences**: the underlying pathology between the two is different. Heart failure is a result of raised pressures in pulmonary capillaries, whereas ARDS is usually due to increased pressures in pulmonary capillaries secondary to a large insult (e.g. pneumonia, aspiration, or trauma). They can be distinguished by taking pulmonary capillary wedge pressures. 

* **Renal Failure** 
	* **Similarities**: fluid retention and peripheral overload. 
	* **Differences**: other signs and symptoms will allow distinction between HF and renal failure. In the latter, you may find uraemic symptoms(nausea, anorexia, uraemic flap) and potentially signs of renal replacement therapy. 

* **Liver Failure** 
	* **Similarities**: fluid retention and peripheral overload especially ascites. 
	* **Differences**: liver failure patients will present with other signs and symptoms including jaundice, hepatic encephalopathy and chronic liver disease signs (gynaecomastia, spider naevi, and excoriations). 


# Investigations

If a stable patient is presenting to the GP with suspected chronic heart failure, investigations should be carried out as per NICE guidelines. 

**1st line = NT-pro-BNP level**

NT-pro-BNP is released by the ventricles in response to myocardial stretch. It has a high negative predictive value.

Interpret NT-pro-BNP results as follows:  

* >2000ng/L (236pmol/L): refer urgently for specialist assessment and TTE <2 weeks. 
* 400-2000ng/L (47-236pmol/L): refer for specialist assessment and TTE <6 weeks. 
* If <400ng/L: diagnosis of heart failure is less likely. 

**Arrange a 12-lead ECG in all patients** 

ECG may be normal or hint at underlying aetiology (ischaemic changes or arrhythmias). 

**Transthoracic echocardiogram (TTE)**

An echocardiogram will confirm the presence and degree of ventricular dysfunction.

* Ventricular dysfunction is normally measured by the ejection fraction (EF). 
  * EF <40% = HF with reduced ejection fraction (HFrEF, systolic dysfunction). 
  * EF >40% but with raised BNP = HF with preserved ejection fraction (HFpEF, diastolic dysfunction).
  * EF 50-70% with normal BNP = normal. 

**Other Investigations:** 

* **Bloods**: U&E (renal function for medication and hyponatraemia), LFTS (deranged LFTs suggest hepatic congestion), TFTs (hyperthyroidism and high-output HF), glucose and lipid profile (modifiable CV risk factors)

* **CXR**: CXR findings in heart HF can be remembered by the ABCDEF mnemonic:
  * A: **Alveolar** oedema (with 'batwing' perihilar shadowing)
  * B: **Kerley B** lines (caused by interstitial oedema)
  * C: **Cardiomegaly** (cardiothoracic ratio >0.5)
  * D: upper lobe blood **diversion**
  * E: **Pleural effusions** (typically bilateral transudates)
  * F: **Fluid in the horizontal fissure**

[lightgallery]

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# Management

## Conservative management

* Weight loss if BMI >30. 
* Smoking cessation 
* Salt and fluid restriction - improves mortality
* Supervised exercise-based group rehabilitation programme for people with heart failure. 

Offer annual influenza and one-off pneumococcal vaccinations for patients diagnosed with heart failure. 

## Medical management

**Symptom management**: 

* For fluid overload, prescribe loop diuretics (e.g. furosemide or bumetanide). These do not affect overall mortality from heart failure. 


**Management which improves mortality**:
 
1st line = ACE-I and beta-blocker 

* Consider ARB if intolerant to ACE-I. 
* Consider hydralazine if intolerant to ACE-I/ARB. 

If symptoms persist and NYHA Class 3 or 4 consider adding:

* Aldosterone antagonists = spironolactone or eplerenone. 
* Hydralazine and a nitrate for Afro-Caribbean patients. 
* Ivabradine if in sinus rhythm and impaired EF. 
* Digoxin = useful in those with AF. This <u>worsens</u> mortality but improves morbidity.

NICE also advices seeking specialist guidance for prescribing **SGLT2 inhibitors** (dapagliflozin or empagliflozin). These should be given in symptomatic chronic heart failure with preserved or reduced ejection fraction, or as an add-on for patients already optimised with ACE-i/ARB/sacubitril-valsartan (i.e. combination), beta-blockers and aldosterone antagonists.

**BASH Mnemonic**

* BASH medications demonstrate a mortality benefit in patients with HFrEF = Beta-blockers, ACE-inhibitors/ARB, Spironolactone and Hydralazine. 
* There are no medications that improve mortality in diastolic heart failure. 

[lightgallery2]

# Surgical/Interventional management 

* Cardiac resynchronisation therapy
* Implantable cardiac defibrillators (ICDs) are indicated if the following criteria are fulfilled: 
    * QRS interval <120ms, high risk sudden cardiac death, NYHA class I-III
    * QRS interval 120-149ms without LBBB, NYHA class I-III
    * QRS interval 120-149ms with LBBB, NYHA class I

## Adverse effects of heart failure medications

The common side-effects for different heart failure medications are listed below

* **Beta blockers**: Bradycardia, hypotension, fatigue, dizziness
* **ACE inhibitors**: Hyperkalaemia, renal impairment, dry cough, lightheadedness, fatigue, GI disturbances, angioedema
* **Spironolactone**: Hyperkalaemia, renal impairment, gynaecomastia, breast tenderness/hair growth in women, changes in libido
* **Furosemide**: Hypotension, hyponatraemia/kalaemia,
* **Hydralazine/nitrates**: Headache, palpitations, flushing
* **Digoxin**: Dizziness, blurred vision, GI disturbances
* **SGLT-2 inhibitors:** Thrush, UTIs, DKA in patients with pre-existing diabetes

# Prognosis 

It is estimated that >50% of people diagnosed with HF will survive after 5 years. Approximately 35% will be alive in 10 years. 

# NICE Guidelines

[NICE Guidelines on Acute Heart Failure](https://www.nice.org.uk/guidance/cg187/chapter/1-Recommendations)

[NICE Guidelines on Chronic Heart Failure](https://cks.nice.org.uk/topics/heart-failure-chronic)

# References 

[2022 Stat Pearls Summary of Congestive Heart Failure](https://www.ncbi.nlm.nih.gov/books/NBK430873)
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Cardiac resynchronisation therapy (CRT) is beneficial for heart failure patients with wide QRS complexes to improve cardiac function and symptoms.
An 80 year old female is admitted to hospital with heart failure. Her ECG demonstrates sinus rhythm with wide QRS complexes of approximately 190ms. Her blood pressure is 130/85 mmHg, her heart rate is 78 bpm.

Which of the following is indicated in this patient?
a