Heart Failure

Heart failure, a complex clinical syndrome, results from any structural or functional impairment of ventricular filling or ejection of blood. It’s a serious condition requiring timely diagnosis and management.

Causes

  • Coronary Artery Disease: Leading cause, due to past myocardial infarction or ischemic heart disease.
  • Hypertension: Chronic high blood pressure leading to left ventricular hypertrophy and dysfunction.
  • Cardiomyopathies: Including dilated, hypertrophic, or restrictive types.
  • Valvular Heart Disease: Such as aortic stenosis or mitral regurgitation.
  • Arrhythmias: Especially atrial fibrillation.
  • Congenital Heart Disease: In younger patients.
  • Infections: Myocarditis due to viral or other infectious agents.
  • Alcohol and Drugs: Including chronic alcohol abuse and certain chemotherapeutic agents.
  • Endocrine Disorders: Like diabetes and thyroid diseases.

Types – HFrEF and HFpEF

  • Heart Failure with Reduced Ejection Fraction (HFrEF)
    • Also known as systolic heart failure.
    • The heart’s ability to contract is impaired, leading to a reduced ejection fraction (EF <40%).
    • Often due to ischemic heart disease, dilated cardiomyopathy, or myocardial infarction.
    • HFrEF is typically treated with ACE inhibitors or ARBs, ARNI, beta-blockers, SGLT2, aldosterone antagonists, diuretics and possibly device therapy.
    • Treatment improves longevity
  • Heart Failure with Preserved Ejection Fraction (HFpEF)
    • Also known as diastolic heart failure.
    • The heart muscle is stiff and cannot relax properly, leading to poor filling but normal ejection fraction (EF ≥50%).
    • Common in older adults, hypertension, obesity, and diabetes.
    • HFpEF management focuses on controlling comorbid conditions (like hypertension), diuretics for fluid overload, and lifestyle modifications.
    • No treatments are proven to improve longenvity

Diagnosis

  • Clinical Assessment: Symptoms like dyspnea, fatigue, reduced exercise tolerance, and signs like peripheral edema, jugular venous distension, and pulmonary crackles.
  • Echocardiogram: Key diagnostic tool to assess ejection fraction, heart structure, and function.
  • Electrocardiogram (ECG): To identify arrhythmias, previous myocardial infarction, or hypertrophy.
  • Chest X-Ray: To detect pulmonary congestion, cardiomegaly.
  • Laboratory Tests:
    • Natriuretic Peptides: BNP or NT-proBNP levels aid in diagnosis and assessing the severity.
    • FBC, electrolytes, liver function

Differential Diagnosis

  • Chronic Obstructive Pulmonary Disease (COPD): Overlapping symptoms like dyspnea and cough.
  • Liver Cirrhosis: Can cause fluid retention, leading to peripheral edema.
  • Renal Failure: Can mimic heart failure with fluid overload.
  • Anemia or Thyroid Disorders: Can cause fatigue and dyspnea.
  • Pulmonary Embolism: Acute dyspnea, often with a history of thromboembolism.

Management

  • Lifestyle Modifications: Low-salt diet, fluid restriction, weight management, and smoking cessation.
  • Pharmacotherapy:
    • ACE Inhibitors or ARBs: First-line therapy to reduce afterload.
    • Beta-Blockers: To reduce myocardial oxygen demand and improve survival.
    • Diuretics: For fluid overload.
    • Aldosterone Antagonists: Especially in severe heart failure.
    • SGLT2: Recently shown to improve survival
    • Digoxin: Used in certain cases, particularly for rate control in atrial fibrillation.
    • Example Drugs:
      • ACE: Ramipril 2.5 mg oral OD
      • ARB: Irbesartan 75mg oral OD
      • ARNI: (ARB+Neprilysin Inhibitor)  Sacubitril+Valsartan 24/26mg oral BD
      • Beta Blocker: Carvedilol 3.125-25mg oral BD
      • MRA: Spironolactone 25-50mg oral OD
      • SGLT2: Dapagliflozin 10mg oral OD
      • Other Drugs
        • Loop Diuretics – Furosemide 20-40mg oral OD-BD
        • Ivabradine 2.5-5mg oral BD
        • Digoxin 62.5-250ug oral OD
  • Device Therapy: Like implantable cardioverter-defibrillators (ICDs) or biventricular pacemakers for patients with reduced ejection fraction and arrhythmia risk.
  • Management of Comorbid Conditions: Like hypertension, diabetes, and ischemic heart disease.
  • Advanced Therapies: Cardiac transplantation or mechanical circulatory support in end-stage heart failure.
  • Patient Education: On recognizing symptom exacerbation and medication adherence.

Monitoring and Follow-Up

  • Regular monitoring of renal function, electrolytes, and symptoms.
  • Adjusting medications based on clinical status and side effects.
  • Education on heart failure management and when to seek urgent care.

Referral

  • Referral to a cardiologist is recommended for specialized management.
  • Consideration for heart failure programs or multidisciplinary teams for comprehensive care.

Conclusion

Heart failure management involves a combination of lifestyle modifications, medical therapy, monitoring, and, in some cases, advanced interventions. Early diagnosis and individualized treatment are crucial to improve symptoms, quality of life, and survival. Regular follow-up and patient education are key components of managing this chronic condition.

New York Heart Association Classification

The New York Heart Association (NYHA) classification is a commonly used system to describe the severity of heart failure based on the patient’s symptoms and how those symptoms affect their physical activity.  It categorizes patients into four classes based on their limitations during physical activity; the symptoms; and their impact on the individual’s comfort, ability to exercise, and daily activities.

  1. Class I: Patients with no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath), or anginal pain.
  2. Class II: Patients with slight, mild limitation of physical activity. They are comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
  3. Class III: Patients with marked limitation of physical activity. They are comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
  4. Class IV: Patients with an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

The NYHA classification is a subjective assessment and primarily focuses on how the patient’s condition affects their lifestyle and physical capabilities. Despite its subjective nature, it has been a useful tool for clinicians to assess the severity of heart failure, guide treatment decisions, and evaluate prognosis.