HEART FAILURE

 1. DEFINITION

A. ESC DEFINITION (ESC 2021/2023 Guidelines):

Heart failure is a clinical syndrome characterized by symptoms (e.g., breathlessness, ankle swelling, fatigue) and signs (e.g., elevated jugular venous pressure, pulmonary crackles, peripheral edema) 

caused by a structural and/or functional cardiac abnormality, resulting in reduced cardiac output and/or elevated intracardiac pressures at rest or during stress.

 B. ACC/AHA DEFINITION(2022 Guidelines):

“Heart failure is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.”

 2. CLASSIFICATION 

 A. Based on Ejection Fraction (ESC 2023)

Type

EF

Key Features

HFrEF

≤40%

Systolic dysfunction

HFmrEF

41–49%

Intermediate

HFpEF

≥50%

Diastolic dysfunction

HFimpEF

Improved EF

Prior HFrEF now EF >40%


 B. Based on Clinical Course

  • Acute HF (AHF) → sudden onset/worsening
  • Chronic HF → long-standing
  • Acute decompensated HF (ADHF) → ICU scenario


 C. Hemodynamic 

Profile

Warm/Cold

Wet/Dry

I

Warm + Dry

Stable

II

Warm + Wet

Pulmonary congestion

III

Cold + Dry

Hypoperfusion

IV

Cold + Wet

Cardiogenic shock

 3. ETIOLOGY

 Ischemic

  • CAD → most common cause worldwide

 Non-ischemic

  • Hypertension
  • Valvular heart disease
  • Cardiomyopathy:
    • Dilated
    • Hypertrophic
    • Restrictive

 Others

  • Arrhythmias (AF)
  • Infections (myocarditis)
  • Toxins (alcohol, chemo)
  • Endocrine:
    • Thyroid disease
    • Diabetes

 4. PATHOPHYSIOLOGY 

 Initial insult → ↓ Cardiac Output

 Compensatory Mechanisms:

1. Neurohormonal Activation

  • RAAS activation

Triggered by:

  • ↓ Renal perfusion

Angiotensin II

  • Vasoconstriction → ↑ afterload
  • Myocardial fibrosis

 Aldosterone

  • Na⁺ + water retention → ↑ preload
  • Fibrosis + remodeling


  • Sympathetic activation
  • ADH release

 Short-term benefit, long-term harm

2. Ventricular Remodeling

  • Dilatation
  • Hypertrophy
  • Fibrosis

3. Hemodynamic Changes

  • ↑ Preload → congestion
  • ↑ Afterload → ↓ output


 5. CLINICAL FEATURES

 1. SYMPTOMS 

Symptom

Mechanism (Pathophysiology)

Dyspnea (Exertional)

↑ Pulmonary capillary pressure → interstitial ,edema,Earliest symptom

Orthopnea

↑ venous return in supine → ↑ pulmonary congestion

Paroxysmal Nocturnal Dyspnea (PND)

Fluid redistribution at night + ↓ adrenergic tone

Fatigue / Weakness

↓ Cardiac output → ↓ muscle perfusion

Reduced exercise tolerance

Inadequate CO rise during exertion

Palpitations

Arrhythmias due to remodeling

Chest discomfort

Myocardial ischemia

Nocturia

Improved renal perfusion in supine position

Cough (dry)

Pulmonary congestion

Pink frothy sputum

Alveolar edema

Abdominal distension

Hepatic congestion + ascites, seen in Right HF

Loss of appetite / nausea

Gut edema, seen in Right HF

Weight gain

Fluid retention

Weight loss (cachexia)

Chronic inflammation, seen in Advanced HF

 2. SIGNS 

Sign

Mechanism

Tachycardia

SNS activation

Hypotension

Low cardiac output

Raised JVP

↑ Right atrial pressure

Peripheral edema

↑ venous pressure + RAAS

Pulmonary crackles (rales)

Alveolar fluid

S3 gallop

Rapid LV filling in dilated ventricle

S4 gallop

Stiff ventricle

Cardiomegaly

Ventricular dilation

Hepatomegaly

Venous congestion

Ascites

Portal hypertension

Cool extremities

Vasoconstriction

Cyanosis

Hypoxia

Cheyne–Stokes breathing

Central apnea due to low CO

Oliguria

↓ Renal perfusion


 3. LEFT vs RIGHT HEART FAILURE 

Feature

Left HF

Right HF

Main issue

Pulmonary congestion

Systemic congestion

Dyspnea

Prominent

Less

Orthopnea/PND

Common

Rare

Crackles

Present

Absent

Edema

Mild/late

Prominent

JVP

Normal/↑ late

↑ early

Hepatomegaly

No

Yes

 4. ACUTE vs CHRONIC HF FEATURES

Feature

Acute HF

Chronic HF

Onset

Sudden

Gradual

Dyspnea

Severe

Progressive

Edema

May be absent

Common

Pulmonary edema

Common

Occasional

Weight changes

Rapid gain

Long-term gain/loss

 6. DIAGNOSIS

HEART FAILURE — DIAGNOSTIC CRITERIA

According to the European Society of Cardiology (ESC 2021/2023):

 Diagnosis of HF requires ALL 3 components:

1. Symptoms ± Signs of HF

  • Symptoms:
    • Dyspnea, orthopnea, PND
    • Fatigue, reduced exercise tolerance
  • Signs:
    • Raised JVP
    • Pulmonary crackles
    • Peripheral edema


 2. Objective Evidence of Cardiac Dysfunction (MANDATORY)

  • Reduced EF (HFrEF)
  • Structural heart disease:
    • LV hypertrophy
    • LA enlargement
  • Diastolic dysfunction

➡️ Best test: Echocardiography

 3. Elevated Natriuretic Peptides (SUPPORTIVE)

  • BNP or NT-proBNP elevated

Non-acute setting:

  • BNP >35 pg/mL
  • NT-proBNP >125 pg/mL


Acute setting:

  • BNP >100 pg/mL
  • NT-proBNP >300 pg/mL


Suspected HF → BNP → Echo → Confirm HF

2. UNIVERSAL DEFINITION OF HF (2021 CONSENSUS)

From global consensus (ACC/ESC/HFSA):

HF is diagnosed when there are:

  • Symptoms ± signs
  • AND structural/functional cardiac abnormality
  • AND evidence of:
    • Elevated natriuretic peptides
      OR
    • Objective evidence of congestion (imaging/hemodynamics)

3. HFpEF-SPECIFIC CRITERIA 

 Important because EF is normal

Requires ALL:

  1. Symptoms ± signs of HF
  2. LVEF ≥50%
  3. Elevated BNP
  4. Evidence of:
    • Structural heart disease (LA enlargement / LVH)
      OR
    • Diastolic dysfunction

 Scoring Systems 

  • HFA-PEFF score (ESC)
  • H2FPEF score

 4. FRAMINGHAM CRITERIA 

2 Major OR 1 Major + 2 Minor

 Major Criteria

  • PND
  • Neck vein distension
  • Pulmonary edema
  • Cardiomegaly
  • S3 gallop
  • Acute pulmonary edema

 Minor Criteria

  • Ankle edema
  • Dyspnea on exertion
  • Hepatomegaly
  • Pleural effusion
  • Tachycardia


  7. MANAGEMENT 

NON-PHARMACOLOGICAL MANAGEMENT

Lifestyle

  • Salt restriction (<5 g/day)
  • Fluid restriction (if hyponatremia)-1.5–2 L/day
  • Weight monitoring->2–3 kg gain in 3 days → fluid retention
  • Exercise (cardiac rehab)


Vaccination

  • Influenza
  • Pneumococcal

 A. CHRONIC HFrEF MANAGEMENT (ESC/ACC 2023–24)

“FOUR PILLARS” (START EARLY)

Drug Class

Example

ARNI / ACEi / ARB(RAAS blockade)

Sacubitril–valsartan

Beta-blocker( sympathetic activity)

Metoprolol, Carvedilol

MRA(↓ aldosterone)

Spironolactone

SGLT2 inhibitor(metabolic + renal + HF benefit)

Dapagliflozin

New guideline approach: Rapid initiation of all 4 within weeks

  • Start low → up-titrate
  • Add all 4 early unless contraindicated

Drug (Examples)

Starting Dose → Target Dose (Titration)

Contraindications / Cautions

Sacubitril/Valsartan-= (Preferred RAAS blockade)

Start: 24/26 mg BD (or 49/51 mg BD if stable) → Target: 97/103 mg BD 

-Double dose every 2–4 weeks

History of angioedema 

 Concomitant ACEi (36 hr washout needed) 

 SBP <100 mmHg 

 Severe renal failure

Hyperkalemia,

Enalapril / Ramipril

Enalapril: 2.5 mg BD → 10–20 mg BD 

– Increase every 1–2 weeks

Pregnancy 

 Bilateral renal artery stenosis 

 Angioedema history 

 K⁺ >5.5

Carvedilol / Bisoprolol / Metoprolol succinate

Carvedilol: 3.125 mg BD → 25–50 mg BD 

Bisoprolol: 1.25 mg OD → 10 mg OD 

– Double every 2 weeks

Acute decompensated HF 

 Severe bradycardia / AV block 

 Cardiogenic shock 

 Asthma/COPD

Spironolactone / Eplerenone

Start: 12.5–25 mg OD → Target: 25–50 mg OD 

– Adjust after 4 weeks

K⁺ >5.0 mmol/L 

 eGFR <30 ml/min 

 Severe renal failure

Dapagliflozin / Empagliflozin

Fixed dose: 10 mg OD 

– No titration needed

 Type 1 DM 

 DKA 

 eGFR <20–25 ml/min (agent dependent)


 ADD-ON THERAPIES (WHEN INDICATED)

 1. IVABRADINE

Indication

  • Sinus rhythm
  • HR ≥70 bpm
  • On max tolerated beta-blocker


 2. HYDRALAZINE + NITRATE

Indications

  • ACEi intolerance
  • African ethnicity (strong evidence in ACC)


3. VERICIGUAT

  • Soluble guanylate cyclase stimulator
  • For high-risk worsening HF


 4. DIGOXIN

  • Symptom relief
  • ↓ hospitalization (NO mortality benefit)


 5. OMECAMTIV MECARBIL

  • Cardiac myosin activator
  • Select patients with low EF


 6. DIURETICS (SYMPTOM CONTROL ONLY)

  • Loop diuretics (Furosemide, Torsemide)

 Important:

  • Improve congestion
  • No mortality benefit


 7. DEVICE THERAPY

 1. ICD (Implantable Cardioverter Defibrillator)

Indication

  • LVEF ≤35%
  • Life expectancy >1 year

Prevents sudden cardiac death


 2. CRT (Cardiac Resynchronization Therapy)

Indications

  • LVEF ≤35%
  • QRS ≥130 ms
  • LBBB pattern

 Improves survival + EF


 8. ADVANCED THERAPIES

 1. LVAD (Left Ventricular Assist Device)

  • Bridge to transplant
  • Destination therapy


 2. HEART TRANSPLANT

  • End-stage HF
  • Refractory symptoms

 MONITORING & FOLLOW-UP

Parameter

Frequency

Renal function

After starting RAAS/MRA

Potassium

Regular

BP

Every visit

Weight

Daily

Echo

3–6 months