Heart Failure: Types, Diagnosis and Treatment

Heart failure is a clinical syndrome in which the heart cannot pump enough blood to meet the body's needs, or can only do so at high filling pressures. It is a common cause of hospital admission, especially in older adults, and modern treatment has greatly improved survival.

Classification

Heart failure is classified by the left ventricular ejection fraction (LVEF) on echocardiography:

• HFrEF (reduced ejection fraction): LVEF 40% or less.
• HFmrEF (mildly reduced): LVEF 41–49%.
• HFpEF (preserved): LVEF 50% or more, with evidence of raised filling pressures or structural heart disease.

Symptom severity is described by the NYHA classes I–IV, from no limitation of physical activity (I) to symptoms at rest (IV).

Causes

• Ischaemic heart disease — the most common cause in many countries.
• Hypertension.
• Valvular heart disease, including rheumatic heart disease.
• Cardiomyopathies.
• Arrhythmias such as atrial fibrillation.
• Alcohol and some chemotherapy drugs.
• Thyroid disease.
• Severe anaemia.

Clinical features

• Symptoms:
  • breathlessness on exertion
  • orthopnoea (breathlessness lying flat)
  • paroxysmal nocturnal dyspnoea
  • fatigue
  • ankle swelling
• Signs:
  • raised jugular venous pressure
  • bibasal crackles
  • third heart sound (S3)
  • displaced apex beat
  • pitting oedema
  • tachycardia
  • hepatomegaly and ascites in right-sided failure

Investigations

• Natriuretic peptides (BNP or NT-proBNP): a normal level makes heart failure unlikely.
• Echocardiography: confirms the diagnosis and the type.
• ECG: ischaemia, arrhythmia, left ventricular hypertrophy.
• Chest X-ray: cardiomegaly, upper lobe diversion, Kerley B lines, pleural effusions, alveolar oedema.
• Blood tests: full blood count, kidney function and electrolytes, liver and thyroid function, glucose and lipids.

Management of chronic HFrEF

Current European and American guidelines describe four groups of disease-modifying medicines, started and increased carefully:

• ACE inhibitor, ARB or ARNI (sacubitril–valsartan).
• Beta-blocker licensed for heart failure (for example bisoprolol or carvedilol).
• Mineralocorticoid receptor antagonist (for example spironolactone).
• SGLT2 inhibitor (dapagliflozin or empagliflozin).

Loop diuretics (for example furosemide) relieve congestion but do not improve survival. Selected patients benefit from devices: an implantable cardioverter-defibrillator (ICD) or cardiac resynchronisation therapy (CRT). Other measures include fluid and salt advice, daily weights, vaccination, exercise rehabilitation and treating the cause.

Acute heart failure

Acute pulmonary oedema presents with severe breathlessness, crackles and low oxygen saturation. Management includes sitting the patient up, oxygen if hypoxic, IV loop diuretics, and treating the trigger (for example ischaemia, arrhythmia, infection or poor adherence). Non-invasive ventilation may be needed. Seek senior help early.

Exam pearls

• The commonest cause of right heart failure is left heart failure.
• Chest X-ray signs mnemonic "ABCDE": Alveolar oedema, Kerley B lines, Cardiomegaly, Diversion of upper lobe vessels, pleural Effusions.
• Do not stop beta-blockers in stable heart failure without a reason.
• Check potassium and kidney function after starting or increasing ACE inhibitors, ARBs, ARNI or MRAs.

For more detail, see the cardiovascular chapter of our Medicine Companion.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. What LVEF defines heart failure with reduced ejection fraction (HFrEF)?

   1. 50% or more
   2. Less than 60%
   3. 41–49%
   4. Less than 20% only
   5. 40% or less
   Show answer

   Answer: E. 40% or less
   HFrEF: LVEF ≤40%; HFmrEF 41–49%; HFpEF ≥50%.

2. Which blood test makes heart failure unlikely when normal?

   1. Troponin
   2. D-dimer
   3. Creatine kinase
   4. BNP or NT-proBNP
   5. CRP
   Show answer

   Answer: D. BNP or NT-proBNP
   Natriuretic peptides have a high negative predictive value; a normal level makes heart failure unlikely.

3. Which medicine relieves congestion but does not improve survival in HFrEF?

   1. Sacubitril–valsartan
   2. Spironolactone
   3. Furosemide
   4. Bisoprolol
   5. Dapagliflozin
   Show answer

   Answer: C. Furosemide
   Loop diuretics relieve symptoms of fluid overload. The other four are disease-modifying therapies.

4. Breathlessness when lying flat is called:

   1. Orthopnoea
   2. Tachypnoea
   3. Platypnoea
   4. Trepopnoea
   5. Paroxysmal nocturnal dyspnoea
   Show answer

   Answer: A. Orthopnoea
   Orthopnoea is breathlessness lying flat; PND is waking up breathless at night.

5. Which chest X-ray finding is typical of heart failure?

   1. Free air under the diaphragm
   2. Unilateral hyperlucency
   3. Kerley B lines and upper lobe diversion
   4. Apical cavitation
   5. Bilateral hilar lymphadenopathy
   Show answer

   Answer: C. Kerley B lines and upper lobe diversion
   ABCDE: Alveolar oedema, Kerley B lines, Cardiomegaly, upper lobe Diversion, Effusions.

More articles in Cardiology

• Hypertension (High Blood Pressure): Diagnosis and ManagementHigh blood pressure explained: diagnostic thresholds, primary and secondary causes, assessment, first-line drugs, hypertensive emergency and exam pearls.
• Acute Coronary Syndrome (Heart Attack): STEMI, NSTEMI and Unstable AnginaRecognise and manage a heart attack: types of ACS, ECG and troponin, reperfusion, secondary prevention and complications after myocardial infarction.
• Atrial Fibrillation: Stroke Prevention, Rate and Rhythm ControlTypes of AF, causes, ECG findings, anticoagulation decisions, rate versus rhythm control and when to cardiovert, for exams and the wards.
• Rheumatic Fever and Rheumatic Heart Disease: Jones Criteria and ProphylaxisRevised Jones criteria, management of acute rheumatic fever, benzathine penicillin secondary prophylaxis and the valve disease it causes.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.