Heart Failure (HFrEF, HFpEF)
Causes
Common to all HF types: CAD, HTN, valvular heart disease, COPD
HFrEF
DCM:
Ischaemic (most common), viral (e.g., Coxsackie B, HIV), toxic (e.g., alcohol)
Non-ischaemic causes: HTN, rheumatic heart disease, and idiopathic forms (≥2/3 of cases)
Other associated conditions: IHD, COPD, or uncontrolled HTN
HFpEF
HCM: Genetic predisposition (e.g., HOCM)
Restrictive cardiomyopathy: Caused by HTN, amyloidosis, sarcoidosis, haemochromatosis, and certain cancers
Most common cause: CAD with increased myocardial oxygen demand
Precipitants
Cardiac: MI, arrhythmias, uncontrolled HTN
Non-cardiac: PE, pneumonia, anaemia, kidney failure, noncompliance with medications, or alcohol misuse
History
Fatigue
Paroxysmal nocturnal dyspnoea (PND), orthopnoea
SOBOE
Examination
General Findings
Elevated JVP with possible V waves in tricuspid regurgitation
Third heart sound (specific for HF)
Laterally displaced apex beat (suggestive of ventricular dilation)
Pulmonary crackles and peripheral oedema
RHF-specific Findings
Elevated JVP with giant V waves (tricuspid regurgitation)
Parasternal heave (right ventricular hypertrophy)
Hepatomegaly, ascites, and peripheral oedema
Investigations
FBC, UEC, LFTs
ECG, CXR, echo, and BNP (to assess severity if diagnosis is uncertain)
Notes:
Avoid NSAIDs, steroids, and TCAs, as they can worsen HF by fluid retention or reducing eGFR
Symptom-focused management (e.g., diuretics for congestion) should accompany diagnostic work-up
Echo and BNP are essential for confirmation if no alternative causes are identified
NYHA Classes
Class I: No symptoms, no limitation of physical activity
Class II: Mild symptoms, slight limitation during ordinary activity
Class III: Moderate symptoms, marked limitation during less-than-ordinary activity, but comfortable at rest
Class IV: Severe symptoms, inability to perform any physical activity without discomfort, symptoms at rest
HFrEF - Symptoms +/- signs of HF and EF <50%
Pharmacological Management
Initiate as soon as possible after diagnosis:
ARNI (sacubitril/valsartan): First-line if tolerated (preferred over ACEI/ARB)
ACEI or ARB: Use if ARNI is not available or tolerated
HF-specific BBs (e.g. Bisoprolol, carvedilol, metoprolol succinate)
Mineralocorticoid receptor antagonists (MRAs): E.g., spironolactone, eplerenone
SGLT2 inhibitors: E.g., dapagliflozin, empagliflozin (regardless of diabetes status)
Titrate renin-angiotensin system inhibitors (ACEI/ARB/ARNI) and BB every 2–4 weeks to target or maximum tolerated doses
Up-titrate MRAs 4–8 weeks after initiation if required
Loop diuretics (e.g., frusemide) for symptom (e.g., congestion, peripheral oedema).
Note: Defer BB initiation until patients are euvolaemic (to avoid worsening congestion)
HFpEF - Symptoms +/- signs of HF and and EF >50% + objective evidence of structural heart disease (LVH, LAH) or diastolic dysfunction with high filling pressure
Pharmacological Management
Focus: Treat contributing conditions like HTN and fluid overload
Mainstay therapy: Diuretics for symptom relief and volume control
Consider low-dose MRA: Reduces HF hospitalisations
Non-Pharmacological Management
Stress echo: Consider for first diagnosis to assess structural changes
Lifestyle modifications:
Cease smoking and alcohol
Salt restriction: <6g/day
Fluid restriction: 1.5L/day (if symptomatic) or 2L/day (if asymptomatic)**
Daily weighing for fluid monitoring**
Regular exercise: 150 min/week of moderate-intensity activity
Weight loss: 5–10% if overweight/obese
Limit caffeine to 1–2 cups/day (avoid diuresis)
Referral to a dietitian for a low-calorie, heart-healthy diet
Avoid triggers: Over-the-counter NSAIDs due to fluid retention risks
Notes
Repeat echo every 3–6 months for disease progression monitoring
Up-titrate BBs only if HR >50 bpm and no signs of congestion
Avoid MRAs if serum potassium >5mmol/L
Use ARBs only if ACEIs are not tolerated
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