Overview
Heart failure is a clinical syndrome in which the heart is unable to provide adequate cardiac output for the body's metabolic needs or can do so only at elevated filling pressures.
Patients may present with symptoms and signs of pulmonary or systemic congestion, reduced exercise tolerance, or impaired tissue perfusion.
Heart failure is a clinical syndrome rather than a single disease, and the underlying cause should always be identified.
Classification
Heart failure may be classified according to ventricular function, time course, and clinical presentation.
Reduced ejection fraction, mildly reduced ejection fraction, and preserved ejection fraction represent different phenotypes that may require different therapeutic approaches.
The ejection fraction helps characterize heart failure but should always be interpreted alongside the patient's clinical findings.
Clinical Features
Common symptoms include exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, and reduced exercise tolerance.
Examination may demonstrate elevated jugular venous pressure, peripheral edema, pulmonary crackles, hepatomegaly, and displaced apex beat depending on the underlying disease.
Orthopnea and paroxysmal nocturnal dyspnea are particularly important clues to clinically significant cardiac congestion.
Investigation
Investigation aims to confirm the syndrome, determine its severity, identify the cause, and detect potentially reversible contributors.
Assessment may include ECG, chest imaging, natriuretic peptides, blood tests, and echocardiography.
Echocardiography provides important information about ventricular structure, systolic function, valvular disease, and other structural abnormalities.
Investigations should answer two questions: what is causing the heart failure, and how severely is cardiac function impaired?
Management
Management depends on the underlying cause, ventricular phenotype, degree of congestion, haemodynamic stability, and comorbidities.
Treatment may include pharmacological therapy, management of contributing disease, lifestyle measures, device therapy, and selected procedural or surgical interventions.
Acute decompensation requires assessment of congestion and perfusion with urgent treatment of reversible precipitants.
In acute heart failure, clinical stabilization and treatment of the precipitating cause take priority over long-term disease modification.
Clinical Pearls
When approaching suspected heart failure, think in three steps: Is the patient congested? Is perfusion adequate? What caused the syndrome?
Heart failure is a syndrome, not an isolated diagnosis. Always search for the structural, ischemic, valvular, rhythm-related, or systemic cause.
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