Heart failure (HF) is a clinical syndrome where the heart is unable to pump sufficient blood to meet the metabolic needs of body tissues despite adequate venous return. It results in impaired perfusion and/or systemic or pulmonary congestion.
Causes of Heart Failure
Heart failure may arise from structural, functional, or systemic abnormalities that compromise cardiac performance.
Common causes include:
- Hypertension (chronic pressure overload)
- Ischemic heart disease (e.g., myocardial infarction)
- Valvular heart diseases (e.g., aortic stenosis, mitral regurgitation)
- Dilated or restrictive cardiomyopathies
- Arrhythmias (e.g., atrial fibrillation)
- Congenital heart defects
- High-output states (e.g., anemia, thyrotoxicosis, AV fistula)
- Pulmonary thromboembolism (leading to RV failure)
Clinical Features of Heart Failure
General signs and symptoms:
- Tachycardia
- Gallop rhythm (S3 or S4)
- Raised Jugular Venous Pressure (JVP)
- Dependent (pitting) edema
- Tender hepatomegaly
- Orthopnea and paroxysmal nocturnal dyspnea
- Fatigue, weakness
- Exercise intolerance
- Basal lung crackles (crepitations)
- Cyanosis (in severe cases)
Precipitating Factors for Decompensation
Heart failure may worsen due to acute triggers. Identifying and correcting them is essential.
Precipitants include:
- Poor adherence to medications or diet
- Increased metabolic demand (e.g., anemia, pregnancy, fever)
- Myocardial ischemia or infarction
- Uncontrolled hypertension
- Tachyarrhythmias or bradyarrhythmias
- Pulmonary embolism
- Infection (e.g., pneumonia, infective endocarditis)
- Excessive fluid or salt intake
- Use of negative inotropic drugs (e.g., non-dihydropyridine calcium channel blockers)
Diagnostic Investigations
Initial work-up includes:
- Chest X-ray: Cardiomegaly, pulmonary venous congestion, interstitial edema
- ECG: Assess rhythm, ischemia, LV hypertrophy
- Echocardiography: Most important for assessing EF, chamber size, wall motion, and valves
- Full blood count: Rule out anemia, infection
- Urea and electrolytes: Assess renal function, sodium, potassium
- BNP or NT-proBNP: Elevated in HF, helps confirm diagnosis
- Thyroid function tests: Especially in new-onset or refractory HF
General Management of Heart Failure
- Rest: Limit physical activity during acute decompensation; semi-Fowler’s position for dyspnea
- Oxygen therapy: For hypoxic patients
- Daily weight monitoring
- Fluid and sodium restriction: <2 L/day fluids, <2 g/day sodium
- Monitor urine output: Especially in hospitalized or oliguric patients
Pharmacological Management
1. Diuretics (for symptomatic fluid overload):
- Furosemide (Frusemide): 20–160 mg PO/IV daily; titrate based on response
- Monitor electrolytes and volume status
2. Digoxin:
- Maintenance: 0.125–0.25 mg PO daily (used in HFrEF with atrial fibrillation)
- Loading (optional): 0.25–0.5 mg PO Q6h up to 1–1.5 mg total over 24 hours
3. Potassium supplements:
- Use with loop diuretics unless contraindicated
- Dietary sources: bananas, oranges, spinach
4. Anticoagulation:
- Heparin 2,500–5,000 IU SC BD for immobile patients or those at thromboembolic risk
5. ACE Inhibitors (for HFrEF):
- Captopril: Start 6.25 mg TDS, titrate to 25–50 mg TDS
- Enalapril: Start 2.5 mg BD, titrate to 10–20 mg BD
- Reduce afterload and improve survival
6. Beta-blockers (e.g., bisoprolol, carvedilol):
- Initiate when stable, start low and titrate
- Avoid in acute decompensated HF
7. Treat underlying cause:
- Control hypertension
- Revascularization in ischemic heart disease
- Manage arrhythmias
- Treat infections or anemia
Note: SGLT2 inhibitors and ARNI (e.g., sacubitril/valsartan) are now part of guideline-directed therapy in HFrEF but may not be widely available in all settings.
