Heart failure is a serious clinical syndrome characterized by a range of symptoms and signs due to decreased cardiac function. Typical symptoms include shortness of breath, fatigue, and ankle swelling, and common clinical findings include increased jugular venous pressure (JVP) and pulmonary congestion.

According to both NICE and European Society of Cardiology (ESC) guidelines, in addition to the clinical picture, cardiac structural and/or functional conditions that cause increased intracardiac pressure and/or inadequate cardiac output at rest There must be evidence of abnormality. and/or effort.

Heart failure can be classified according to left ventricular (LV) ejection fraction (EF). EF represents the percentage of blood in the LV that is ejected after each systole. This classification is important because it affects management. Echocardiography is an important, readily available and cost-effective test for establishing the diagnosis.

epidemiology

Heart failure (HF) is considered an epidemic, accounting for 5% of NHS emergency admissions.

The average age at diagnosis is approximately 77 years, with a higher incidence in males, likely due to the earlier onset of CAD. The overall prevalence of HF is 1-2%, but is much higher in older age groups. Prevalence increases from 1 in 35 people aged 65 to 74 years to 1 in 7 people aged 85 years and older. The prevalence is likely to continue to increase due to the aging of the population and increasing obesity rates.

The most common etiologies include CAD, cardiomyopathy, and hypertension. Valve disease accounts for approximately 10% of cases, but this proportion is likely to increase as degenerative aortic stenosis becomes more common.

diagnosis

Diagnosis begins by identifying signs and symptoms that may suggest heart failure, especially in patients with known risk factors such as CAD, hypertension, and diabetes. Symptoms include shortness of breath when exercising or lying down, fatigue, swelling of the legs, and weakness. Typical signs include peripheral and pulmonary congestion, elevated JVP, and third heart sound. An important screening test is NT-proBNP, which has a high negative predictive value, but high values ​​require further testing with echocardiography. If severely elevated (>2000 ng/liter), evaluation should be carried out within 2 weeks. Clinical evaluation should also include 12-lead ECG, FBC, and biochemistry to rule out atrial fibrillation, anemia, diabetes, and hyperthyroidism. CXR and spirometry can also help identify chronic lung diseases such as COPD, which is a very common comorbidity in heart failure.

Echocardiography not only confirms or refutes the diagnosis of heart failure, but also points to possible etiologies such as CAD, dilated cardiomyopathy, and valvular heart disease. All new diagnoses should be considered for expert review to determine future management plans and further investigations. For patients with heart failure secondary to valvular disease, MDT should be considered promptly before valvular intervention is likely to occur. The most common valve pathology in the UK is aortic stenosis, and transcatheter aortic valve implantation (TAVI) is an option even for patients with comorbidities that make them unsuitable for surgery.

HFrEF refers to patients with LVEF below 40% and HFmrEF between 41 and 49%. Approximately 50% of HF patients have a preserved LVEF of more than 50%, so-called HFpEF. In HFpEF, cardiac contractility is relatively preserved, but filling is impaired by increased left ventricular stiffness.

Comorbidities in heart failure, as heart failure is often the culmination of chronic disease processes such as IHD, hypertension, and valvular heart disease, and its treatment may induce comorbidities such as gout, erectile dysfunction, and AKI. is almost inevitable. Obesity, atrial fibrillation, and obstructive sleep apnea are particularly common comorbidities in HFpEF that must be identified and appropriately managed.

process

All patients with heart failure should receive counseling and advice regarding smoking cessation, alcohol moderation, salt restriction, and exercise. HFrEF (previously known as left ventricular systolic dysfunction) [LVSD]) If left untreated, the prognosis is worse than most cancers.² But the best possible treatments, many of which can and probably should be provided in primary care, can at least double survival rates.³

Patients with HFrEF should now consider a four-pronged treatment according to the latest ESC guidelines: beta-blockers plus ACE inhibitors/ARBs/ARNIs, MRAs and SGLT2i (dapagliflozin or empagliflozin) doses. Optimize. Both dapagliflozin and empagliflozin have the advantage of not requiring titration and NICE recommends that they can be started with specialist advice. Flexibly administered loop diuretics should be used to reduce fluid congestion.

According to the ESC, the same treatment pillars should be considered for patients with HFmrEF, although it should be noted that the evidence of benefit is less convincing in this cohort.

In patients with HFpEF, SGLT2is is the only specifically approved treatment with proven benefit, and the 2023 update of the ESC guidelines gives a class 1A recommendation for the use of SGLT2is in HFpEF. In fact, SGLT2 currently has a Class 1A recommendation across the entire HF spectrum.

Patients with significantly reduced LVEF (≤35%) are at particularly high risk of sudden cardiac death from ventricular arrhythmias, and these patients should be treated with implantable cardioverters, which have proven mortality benefits in this cohort. The use of an intravenous device (ICD) should be considered. In addition to LVEF ≤35%, patients who demonstrate significant widening of her QRS complex on ECG, especially in cases of left bundle branch block (LBBB), consider evaluation for biventricular pacing or cardiac resynchronization therapy (CRT) need to do it. Also the amount of life.

Management of comorbidities

Management of heart failure requires consideration of comorbidities to optimize outcomes. For patients who remain dyspneic despite optimal treatment, the possibility that HFrEF coexists in patients with COPD, or vice versa, should always be considered. This is because the two chronic diseases commonly overlap due to common risk factors such as smoking.^Four

Undiagnosed and untreated COPD in patients with heart failure not only significantly worsens symptoms and quality of life, but can ultimately lead to right-sided heart failure secondary to pulmonary hypertension. Elevated JVP and peripheral edema are clues to this. Significant tricuspid regurgitation and elevated right ventricular systolic pressure on echocardiography suggest significant pulmonary hypertension.

Other pitfalls include inappropriate exclusion of beta-blocker therapy for HFrEF patients with COPD. Among patients coded as LVSD in primary care, 86% were on her ACE inhibitor or ARB, but only 86% were on both an ACE inhibitor/ARB and a beta blocker. He is only 65%.⁶ Beta-blocker exception reporting rates vary by more than four times between regions of England.⁶ If you are concerned about using beta-blockers, which are the most prognostically beneficial treatment for patients with HFrEF, in patients with obstructive airway disease, spirometry to rule out significant reversibility should provide reassurance. COPD exacerbations should be managed without high-dose oral steroid therapy if possible to avoid exacerbation of fluid retention due to heart failure.

Recent Cochrane reviews⁷ Exercise was confirmed to be an excellent treatment for heart failure, demonstrating a 60% reduction in the relative risk of hospitalization for rehabilitation with exercise. All heart failure patients should be encouraged to be active, as no such program is offered in the UK. Erectile dysfunction is a common comorbidity of HF, and unless patients are receiving nitrate therapy, phosphodiesterase inhibitors should be provided as needed to promote an active lifestyle.

prognosis