Chronic Heart Failure (CHF)

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Chronic heart failure\: syndrome with reduced cardiac output due to impaired cardiac contraction; symptoms\: shortness
of breath, fatigue, ankle swelling.
Prevalence\: 1-2%, increases to 10% in those over 70.
Pathophysiology\: Stroke volume requires adequate preload, myocardial contractility and decreased afterload. CO = HR x
SV. Cardiac output can be reduced by\:
decreased heart rate
decreased preload
decreased contractility
increased afterload
Causes\: coronary heart disease, atrial
diseases (hypothyroidism, hyperthyroidism, diabetes), medications (calcium antagonists, anti-arrhythmics, cytotoxic
medication, beta blockers), and high-output states (pregnancy, anaemia, sepsis).
Symptoms\: dyspnoea on exertion, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, nocturnal cough, pre-
syncope/syncope, reduced appetite.
Clinical examination\: Tachycardia, hypotension, narrow pulse pressure, raised JVP, displaced apex beat, right ventricular
heave, gallop rhythm, murmurs and pedal and ankle oedema.
Investigations\: ECG, urinalysis, FBC, U&Es, LFTs, troponin, lipids/HbA1c, TFTs, NT-proBNP, echocardiography, chest X-ray,
cardiac MRI.
NT-proBNP levels\:
>2000 ng/L - refer urgently for specialist assessment and TTE within 2 weeks
400-2000 ng/L - refer routinely for specialist assessment and TTE within 6 weeks
\<400 ng/L - heart failure unlikely
Management\:
morbidities, vaccinations, medication review, monitoring functional capacity and renal function.
Pharmacological treatment\: diuretics, ACE inhibitors, beta-blockers, ARBs, MRAs, SGLT2 inhibitors, ivabradine, ARNI.
Complications\: arrhythmias, depression, loss of muscle mass, sudden cardiac death; poor prognosis with ~50% dying
within
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A comprehensive topic overview

Introduction

Chronic heart failure (CHF) is a clinical syndrome involving reduced cardiac output because of impaired cardiac
contraction. Typical clinical symptoms of CHF include shortness of breath, fatigue and ankle swelling.
1
CHF prevalence is 1-2%, rising to 10% in over 70-year-olds.
4
For more information on the acute presentation of heart failure, see the Geeky Medics guide to acute heart failure.Aetiology
Pathophysiology
Stroke volume requires\:
adequate preload
optimal myocardial contractility (Frank-Starling mechanism)
decreased afterload
As a result, cardiac output (CO) can be reduced by any of the following factors (potentially causing CHF)\:
decreased heart rate
decreased preload
decreased contractility
increased afterload
Cardiac output (CO) = Heart rate (HR) x Stroke volume (SV)
Causes of heart failure
The most common causes of heart failure in the UK are coronary heart disease (myocardial infarction), atrial
valvular heart disease and hypertension.
Other causes of heart failure include\:
Endocrine disease\: hypothyroidism, hyperthyroidism, diabetes, adrenal insuCushing's syndrome
Medications\: calcium antagonists, anti-arrhythmics, cytotoxic medication, beta-blockers.
High-output cardiac failure occurs in states where demand exceeds normal cardiac output such as pregnancy, anaemia
and sepsis.
HIGH-VIS
The acronym HIGH-VIS is useful to remember some of the causes of CHF\:
Hypertension (common cause)
Infection/immune\: viral (e.g. HIV), bacterial (e.g. sepsis), autoimmune (e.g. lupus, rheumatoid arthritis)
Genetic\: hypertrophic obstructive cardiomyopathy (HOCM), dilated cardiomyopathy (DCM)
Heart attack\: ischaemic heart disease (common cause)
Volume overload\: renal failure, nephrotic syndrome, hepatic failure
In
Structural\: valvular heart disease, septal defects

Clinical features

History
Patients with CHF often present with symptoms that have gradually worsened over months to years.
Typical symptoms of CHF include\:
Dyspnoea on exertion
Fatigue limiting exercise tolerance
Orthopnoea\: the patient may be using several pillows to reduce this symptom.
Paroxysmal nocturnal dyspnoea (PND)\: attacks of severe shortness of breath in the night that are relieved by sitting up
(pathognomonic for CHF).
Nocturnal cough with or without the characteristic 'pink frothy sputum'
.
Pre-syncope/syncopeReduced appetite
Other important areas to cover in the history include\:
Past medical history\: hypertension, coronary artery disease and valvular heart disease (common causes of CHF)
Medication history\: several medications can cause or worsen CHF including calcium antagonists, antiarrhythmics,
cytotoxic medication and beta-blockers (in the acute phase, but long term provide prognostic bene
Family history\: specicardiomyopathy (e.g. HOCM) or coronary artery
disease.
Social history\: risk factors for CHF include smoking, excess alcohol intake and recreational drug use.
Clinical examination
Clinical cardiovascular examination may include\:
Tachycardia at rest
Hypotension
Narrow pulse pressure
Raised jugular venous pressure
Displaced apex beat (due to left ventricular dilatation)
Right ventricular heave
Gallop rhythm on auscultation (pathognomic for CHF)
Murmurs associated with valvular heart disease (e.g. an ejection systolic murmur in aortic stenosis)
Pedal and ankle oedema
Clinical respiratory examination may include\:
Tachypnoea
Bibasal end-inspiratory crackles and wheeze on auscultation of the lung
Reduced air entry on auscultation with stony dullness on percussion (pleural e
Clinical abdominal examination may include\:
Hepatomegaly
Ascites

Investigations

After a comprehensive history and clinical examination have been performed, the following investigations are
recommended by NICE.
2
Bedside investigations
Relevant bedside investigations include\:
ECG\: should be performed on all patients with suspected heart failure. An ECG may identify evidence of previous
myocardial infarction (e.g.
'Q' waves) or arrhythmias (AV block or atrial
unlikely.
1
Urinalysis\: may show glycosuria (diabetes) or proteinuria (renal disease)
ECG
ECG
Tachycardia
Atrial
Left-axis deviation (due to left ventricular hypertrophy)
P wave abnormalities (e.g. P.mitrale/P.pulmonale due to atrial enlargement)
Prolonged PR interval (due to AV block)Wide QRS complexes (due to ventricular dyssynchrony)
Laboratory investigations
Relevant laboratory investigations include\:
FBC\: anaemia
U&Es\: renal failure, electrolyte abnormalities due to
LFTs\: hepatic congestion
Troponin\: if considering recent myocardial infarction
Lipids/HbA1c\: ischaemic risk pro
TFTs\: hyperthyroidism/hypothyroidism
Cardiomyopathy screen (see below)
N-terminal pro-B-type natriuretic peptide (see below)
Cardiomyopathy screen
Screening for cardiomyopathy includes the following blood tests\:
Serum iron and copper studies (to rule out haemochromatosis and Wilson's disease)
Rheumatoid factor, ANCA/ANA, ENA, dsDNA (to rule out autoimmune disease)
Serum ACE (to rule out sarcoidosis)
Serum-free light chains (to rule out amyloidosis)
NT-proBNP
N-terminal pro-B-type natriuretic peptide (NT-proBNP) should be measured in all patients presenting with symptoms
and clinical signs of heart failure to inform the type and urgency of further investigations such as echocardiography\:
NT-proBNP level >2000 ng/L - refer urgently for specialist assessment and transthoracic echocardiography within 2
weeks
NT-proBNP level 400-2000ng/L - refer routinely for specialist assessment and transthoracic echocardiography within 6
weeks
NT-proBNP level \<400 ng/L - heart failure unlikely
Other conditions in which NT-proBNP may be raised include\:
Left ventricular hypertrophy
Tachycardia
Liver cirrhosis
Diabetes
Acute or chronic renal disease
Imaging
Echocardiography
All patients with suspected chronic heart failure should undergo transthoracic echocardiography, with the urgency
determined by their NT-proBNP level as discussed above.
Chest X-ray
Typical chest X-ray
Alveolar oedema (perihilar/bat-wing opaci
Kerley B lines (interstitial oedema)
Cardiomegaly (cardiothoracic ratio >50%)
Dilated upper lobe vessels
E
Cardiac MRI
Cardiac MRI is the gold standard investigation for assessing ventricular mass, volume and wall motion. It can also be
used with contrast to identify in
infarction). It is typically used when echocardiography has provided inadequate views.
5Figure 1. Typical CXR signs associated with heart failure.
4

Classi

Structural classi
Chronic heart failure can be classi
LVEF is the percentage of blood that enters the left ventricle in diastole that is subsequently pumped out in systole.
LVEF is usually measured using transthoracic echocardiography, however, MRI, nuclear medicine scans and
transoesophageal echocardiography can also be used.
1,2
Symptomatic/functional classi
The New York Heart Association's (NYHA) classi
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Class I\: no symptoms during ordinary physical activity
Class II\: slight limitation of physical activity by symptoms
Class III\: less than ordinary activity leads to symptoms
Class IV\: inability to carry out any activity without symptoms

Management

The focus of CHF management is to improve cardiac function and quality of life, prevent hospitalisation and reduce
mortality.
General management
Lifestyle management
Lifestyle management strategies include\:
Fluid and salt restriction
Regular exercise
Smoking cessation
Reduced alcohol intake
VaccinationAll patients with CHF should be o
Medication review
A medication review should be performed to identify medications which may be harmful in the context of heart failure
such as\:
Calcium channel blockers (e.g. verapamil, diltiazem)
Tricyclic antidepressants
Lithium
NSAIDs and COX-2 inhibitors
Corticosteroids
QT-prolonging medications
Monitoring
All patients with chronic heart failure require monitoring of\:
Functional capacity,
Renal function
The frequency of monitoring depends on the patient's clinical condition.
Management of co-morbidities
Coronary artery disease
If heart failure is caused by coronary artery disease, statins and aspirin may be prescribed as secondary prevention.
Atrial
Oral anticoagulation is recommended for patients with heart failure and atrial
due to the high risk of stroke.
Pharmacological management
Pharmacological treatment aims to increase cardiac output ­ by optimising preload and contractility whilst decreasing
afterload.
The medications below target the pathological sympathetic response and renin-angiotensin-aldosterone system (RAAS)
activation that occurs in CHF.
Diuretics
Diuretics should be prescribed to relieve symptoms of
Diuretics (e.g. furosemide) work by increasing sodium excretion via diuresis, ultimately reducing cardiac afterload.
Doses should be titrated according to clinical response and renal function should be closely monitored.
ACE inhibitors
contraindicated.
All patients with CHF and a reduced ejection fraction (≤40%) should be commenced on an ACE inhibitor unless
ACE inhibitors have been shown to improve ventricular function and reduce mortality.
U&Es should be checked prior to starting treatment and then after 1-2 weeks of treatment.
Contraindications include a history of angioedema, bilateral renal artery stenosis, hyperkalaemia (>5 mmol/L), severe renal
impairment (serum creatinine >220 μmol/L) and severe aortic stenosis.
Beta-blockers
Beta-blockers (e.g. bisoprolol) should be prescribed for all patients with symptomatic heart failure and reduced LVEF
(≤40%) unless contraindicated.
Beta-blockers decrease heart rate, myocardial oxygen demand and RAAS activation.
Blood pressure and heart rate need to be monitored carefully when adjusting doses.
Contraindications include asthma, 2nd or 3rd degree AV block, sick sinus syndrome and sinus bradycardia.
Angiotensin-II receptor antagonists (ARBs)If a patient is unable to tolerate an ACE inhibitor (usually due to persistent cough) an ARB (e.g. candesartan) should be
prescribed as an alternative.
Patients must have normal serum potassium and adequate renal function to commence an ARB.
Mineralocorticoid/aldosterone receptor antagonists (MRAs)
A low-dose aldosterone antagonist (e.g. spironolactone or eplerenone) should also be prescribed if a patient continues to
have symptoms of heart failure despite diuretics, ACE inhibitors and beta-blockers.
MRAs antagonise aldosterone, increasing sodium excretion via diuresis, ultimately decreasing cardiac afterload.
Sodium-glucose cotransporter-2 (SGLT2) inhibitors
SGLT2 inhibitors (e.g. dapagli
has been shown to reduce the risk of cardiovascular events and hospital admission. This bene
patient's glycaemic control.
5
Specialist pharmacological treatments
Ivabradine
Ivabradine inhibits the sinoatrial node, slowing the heart rate of patients in sinus rhythm, increasing stroke volume whilst
preserving myocardial contractility.
It has been shown to reduce cardiovascular death or hospitalisation for heart failure by 18%.
ARNI (angiotensin receptor and neprilysin inhibitor)
ARNI's increase BNP levels by inhibiting the neprilysin enzyme which breaks down BNP.
Higher BNP causes natriuresis/diuresis, therefore decreasing cardiac afterload.
Figure 2. NICE visual summary of pharmacological management of CHF.
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Other management options
If heart failure is caused or worsened by other conditions, these should be managed appropriately\:
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Revascularisation (e.g. coronary artery bypass grafting)
Valve surgery (e.g. aortic valve replacement)
Implantable cardiac de (ICD)\: inserted if EF \<30% for prevention of fatal arrhythmias
Cardiac resynchronisation therapy + de
synchronise left and right ventricular contraction to improve EF
Cardiac transplantation is rare and strict criteria must be met for consideration.Complications
Complications of CHF include\:
Arrhythmias\: atrial
Depression and impaired quality of life
Loss of muscle mass
Sudden cardiac death
Prognosis is poor overall, with approximately 50% of people with heart failure dying within
7

References

European Society of Cardiology. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure\:
The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology
(ESC). Published in 2016. Available from [LINK].
Chronic heart failure in adults - diagnosis and management; NICE Guidance (Sept 2018). Available from\: [LINK]
Penn Medicine. Heart Failure Classi
Mikael Häggström. Public domain. Available from\: [LINK]
NICE. DapagliLINK]
NICE. Visual summary of chronic heart failure management. All rights reserved. Subject to notice of rights.
Dr Colin Tidy. Patient.info. Heart failure. Published November 2018. Available from\: [LINK]

Reviewer

Dr Steven Sutcli
Consultant Cardiologist

Related notes

Acute Coronary Syndrome (ACS)
Acute Heart Failure
Atrial Fibrillation (AF)
Atrioventricular Block
Brugada Syndrome

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Contents

Introduction
Aetiology
Clinical features
InvestigationsSource\: geekymedics.com