Chronic Heart Failure

• An ejection fraction above 50% is considered normal
• Chronic heart failure refers to the clinical features of impaired heart function, specifically the function of the left ventricle to pump blood out of the heart and around the body
• Causes of chronic heart failure

  • Ischaemic heart disease
  • Valvular heart disease (commonly aortic stenosis)
  • Hypertension
  • Arrhythmias (commonly atrial fibrillation)
  • Cardiomyopathy
• The left atrium, pulmonary veins, and lungs experience an increased volume and pressure of blood, leading to pulmonary oedema
• Heart failure with preserved ejection fraction is when someone has the clinical features of heart failure but an ejection fraction greater than 50%
• Signs on examination of chronic heart failure

  • Tachycardia
  • Tachypnoea
  • Hypertension
  • Murmurs indicating valvular heart disease
  • 3rd heart sound
  • Bilateral basal crackles indicating pulmonary oedema
  • Raised jugular venous pressure (JVP)
• Heart failure with reduced ejection fraction is when the ejection fraction is less than 50%
• Impaired left ventricular function results in a chronic backlog of blood waiting to flow into and through the left side of the heart
• Ejection fraction

  The percentage of blood in the left ventricle squeezed out with each ventricular contraction
• Diastolic dysfunction

  An issue with the left ventricle filling with blood during diastole (the ventricle relaxing)
• Presentation of chronic heart failure

  • Breathlessness worsened by exertion
  • Cough producing frothy white/pink sputum
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Peripheral oedema
  • Fatigue
• Mechanisms explaining Paroxysmal Nocturnal Dyspnoea

  Fluid settling across a large surface area of the lungs while sleeping, causing breathlessness. Respiratory centre in the brain becomes less responsive during sleep, leading to reduced oxygen saturation. Less adrenaline circulating during sleep relaxes the myocardium, reducing cardiac output
• First-line medical treatment of chronic heart failure

  • ACE inhibitor (e.g., ramipril) titrated as high as tolerated
  • Beta blocker (e.g., bisoprolol) titrated as high as tolerated
  • Aldosterone antagonist when symptoms are not controlled with ACE inhibitor and beta blocker (e.g., spironolactone or eplerenone)
  • Loop diuretics (e.g., furosemide or bumetanide)
  • Angiotensin receptor blocker (ARB) (e.g., candesartan)
• Urgency of referral and specialist assessment

  Depends on the NT-proBNP result: 400 – 2000 ng/litre should have an echocardiogram within 6 weeks, above 2000 ng/litre should have an echocardiogram within 2 weeks
• Indications on auscultation


  • Murmurs indicating valvular heart disease
  • 3rd heart sound
  • Bilateral basal crackles indicating pulmonary oedema
  • Raised jugular venous pressure (JVP)
  • Peripheral oedema of the ankles, legs, and sacrum
  • Paroxysmal Nocturnal Dyspnoea (PND)
• New York Heart Association Classification

  • Class I: No limitation on activity
  • Class II: Comfortable at rest but symptomatic with ordinary activities
  • Class III: Comfortable at rest but symptomatic with any activity
  • Class IV: Symptomatic at rest
• Paroxysmal Nocturnal Dyspnoea (PND)

  Patients suddenly waking at night with a severe attack of shortness of breath, cough, and wheeze. They may feel suffocated, gasping for breath, and may want fresh air. Symptoms improve over several minutes
• Assessment for heart failure diagnosis

  • Clinical assessment (history and examination)
  • N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test
  • ECG
  • Echocardiogram
  • Bloods for anaemia, renal function, thyroid function, liver function, lipids, and diabetes
  • Chest x-ray and lung function tests
• Management principles

  • Refer to cardiology
  • Advise about the condition
  • Medical treatment
  • Procedural or surgical interventions
  • Specialist heart failure MDT input, such as heart failure specialist nurses, for advice and support
• Additional management

  • Flu, covid, and pneumococcal vaccines
  • Stop smoking
  • Optimise treatment of co-morbidities
  • Written care plan
  • Cardiac rehabilitation (a personalised exercise programme)
• A heart transplant may be considered in suitable patients with severe disease
• Medications for heart failure

  • Bisoprolol
  • Aldosterone antagonist (e.g., spironolactone or eplerenone)
  • Loop diuretics (e.g., furosemide or bumetanide)
  • Angiotensin receptor blocker (ARB) (e.g., candesartan)
  • SGLT2 inhibitor (e.g., dapagliflozin)
  • Sacubitril with valsartan (brand name Entresto)
  • Ivabradine
  • Hydralazine with a nitrate
  • Digoxin
• Patients should have their U&Es closely monitored whilst taking diuretics, ACE inhibitors, and aldosterone antagonists, as all three medications can cause electrolyte disturbances
• Implantable cardioverter defibrillators

  Continually monitor the heart and apply a defibrillator shock to cardiovert the patient back into sinus rhythm if they identify a shockable arrhythmia
• Cardiac resynchronisation therapy (CRT)

  May be used in severe heart failure, with an ejection fraction of less than 35%. Involves biventricular (triple chamber) pacemakers, with leads in the right atrium, right ventricle, and left ventricle. The objective is to synchronise the contractions in these chambers to optimise heart function
• Avoid ACE inhibitors in patients with valvular heart disease until initiated by a specialist
• It is particularly essential to closely monitor the renal function in patients taking ACE inhibitors and aldosterone antagonists. Both can cause hyperkalaemia (raised potassium), which is potentially fatal