Heart failure - chronic
Exam Tips
- In OSCEs, classify by EF (HFrEF/HFmrEF/HFpEF) and by NYHA functional class; examiners reward this structured framing.
- Orthopnoea and paroxysmal nocturnal dyspnoea are high-yield symptom discriminators from many non-cardiac causes of breathlessness.
- Raised JVP plus bilateral pitting oedema plus bibasal crackles strongly supports congestive HF but always consider mixed cardio-respiratory pathology.
- Loop diuretics improve symptoms rapidly but do not replace prognostic HFrEF therapy (ACEi/ARNI, beta-blocker, MRA, SGLT2 inhibitor).
- Always state safety monitoring: U&E/creatinine and potassium after starting or uptitrating RAAS blockers, MRAs, and diuretics.
- If a patient needs unexpectedly high diuretic doses, think poor adherence, renal dysfunction, excess salt/fluid intake, drug triggers (for example NSAIDs), or alternative diagnosis.
Definition
Chronic heart failure is a long-term clinical syndrome in which structural and/or functional cardiac abnormality causes raised intracardiac filling pressures and/or reduced cardiac output, leading to typical symptoms (for example breathlessness, fatigue, ankle swelling) and signs (for example elevated JVP, crackles, peripheral oedema). It is classified by left ventricular ejection fraction into HFrEF (<=40%), HFmrEF (41-49%), and HFpEF (>=50% with supportive structural/functional abnormalities or raised natriuretic peptides).
Pathophysiology
Most chronic heart failure begins with myocardial injury or loading stress (commonly ischaemic heart disease or long-standing hypertension), causing reduced stroke volume and/or impaired ventricular relaxation. Compensatory neurohormonal activation (sympathetic nervous system, renin-angiotensin-aldosterone system, vasopressin) initially preserves perfusion but chronically drives vasoconstriction, sodium-water retention, adverse ventricular remodelling, fibrosis, arrhythmogenicity, and worsening pump efficiency. In HFrEF, impaired contractility predominates; in HFpEF, diastolic stiffness and abnormal filling predominate with preserved EF but elevated filling pressures, especially during exertion. See Figure: ventricular remodelling and Frank-Starling shift in standard cardiology textbook heart-failure chapters.
Risk Factors
- Coronary artery disease and previous myocardial infarction
- Hypertension
- Atrial fibrillation and other tachyarrhythmias
- Diabetes mellitus
- Valvular heart disease (for example aortic stenosis)
- Cardiomyopathies (familial, infective, immune-mediated, toxin-related)
- Alcohol and cocaine use
- Infiltrative disease (amyloidosis, sarcoidosis, haemochromatosis)
- Chronic kidney disease, nephrotic syndrome, volume overload states
- High-output states (anaemia, thyrotoxicosis, sepsis, AV shunts, thiamine deficiency)
- Family history of heart failure or sudden cardiac death at young age
- Obesity
Clinical Features
Symptoms
- Exertional breathlessness progressing to breathlessness at rest
- Orthopnoea
- Paroxysmal nocturnal dyspnoea and nocturnal cough
- Ankle swelling, abdominal bloating/distension, rapid weight gain from fluid retention
- Fatigue, reduced exercise tolerance, prolonged recovery after activity
- Light-headedness or syncope
Signs
- Tachycardia (often >100 bpm) and possible irregular pulse (for example AF)
- Raised jugular venous pressure
- Bibasal inspiratory crackles and possible pleural effusions
- Peripheral pitting oedema (legs/sacrum), ascites, hepatomegaly
- Laterally displaced apex beat
- Third heart sound (S3 gallop), possible fourth sound, murmurs indicating valvular disease
- Tachypnoea
- Blood pressure may be high early, low systolic pressure in advanced disease
Investigations
Management
Lifestyle Modifications
- Education and self-management: daily weight tracking, early reporting of rapid weight gain/oedema/breathlessness
- Salt and fluid advice individualized to congestion status; avoid excess alcohol
- Smoking cessation and supervised exercise/cardiac rehabilitation when stable
- Vaccination (influenza, pneumococcal) and comorbidity optimization
- Medication review: stop/reduce drugs that worsen HF where possible (for example NSAIDs)
- Advance care planning in progressive disease
Pharmacological Treatment
Loop diuretics for congestion relief
- Furosemide 20-40 mg once daily (oral, titrate to symptoms)
- Bumetanide 0.5-1 mg once daily
- Torasemide 5-10 mg once daily
Symptomatic benefit (not mortality-modifying). If escalating beyond usual starting doses, reassess adherence/alternative diagnoses and seek specialist advice. Monitor U&E/creatinine for hypokalaemia, hyponatraemia, dehydration, AKI, postural hypotension.
RAAS inhibition (HFrEF disease-modifying)
- Ramipril 1.25-2.5 mg once daily, titrate to max tolerated (often up to 10 mg once daily)
- Candesartan 4-8 mg once daily if ACE inhibitor not tolerated, titrate upward
- Sacubitril/valsartan 24/26 mg twice daily (specialist initiation/switch from ACE inhibitor with 36-hour washout)
Reduces mortality/hospitalization in HFrEF. Contraindications/warnings: pregnancy, bilateral renal artery stenosis, previous ACEi-related angioedema (for ACEi/ARNI), significant hyperkalaemia; monitor renal function and potassium after initiation and each dose increase.
Evidence-based beta-blockers (HFrEF disease-modifying)
- Bisoprolol 1.25 mg once daily, up-titrate gradually to 10 mg once daily if tolerated
- Carvedilol 3.125 mg twice daily, up-titrate (commonly to 25 mg twice daily; higher in heavier patients)
- Nebivolol 1.25 mg once daily in selected patients (for example older adults), titrate as tolerated
Start when clinically stable and euvolaemic. Avoid abrupt withdrawal. Use caution with bradycardia, AV block, hypotension, and severe uncontrolled asthma.
Mineralocorticoid receptor antagonists (HFrEF disease-modifying)
- Spironolactone 25 mg once daily (may increase to 50 mg once daily if appropriate)
- Eplerenone 25 mg once daily, increase to 50 mg once daily
Improves survival in HFrEF. Contraindications/warnings: hyperkalaemia, significant renal impairment; monitor potassium and creatinine closely. Spironolactone may cause gynaecomastia.
SGLT2 inhibitors (HFrEF disease-modifying; benefit also across wider HF phenotypes)
- Dapagliflozin 10 mg once daily
- Empagliflozin 10 mg once daily
Reduces HF hospitalization and cardiovascular death. Check renal function and volume status. Warn about genital infections and sick-day rules; rare ketoacidosis risk (including euglycaemic DKA).
Rate/rhythm and adjunctive therapy (selected patients)
- Ivabradine 5 mg twice daily (sinus rhythm, elevated resting heart rate despite maximal beta-blocker, specialist use)
- Digoxin 62.5-250 micrograms once daily (especially with AF/rate control needs, dose by renal function)
Specialist-guided selection. Digoxin has narrow therapeutic index; toxicity risk rises with renal impairment and hypokalaemia.
Surgical / Interventional
- Cardiac resynchronization therapy (CRT) for eligible symptomatic patients with dyssynchrony (for example broad QRS/LBBB)
- Implantable cardioverter-defibrillator (ICD) for primary/secondary prevention of sudden cardiac death in selected HFrEF
- Valve intervention (surgical or transcatheter) when significant valvular disease drives symptoms
- Coronary revascularization where ischaemia/viability assessment supports benefit
- Advanced therapies in end-stage disease: LV assist device or heart transplantation (specialist centres)
Complications
- Atrial fibrillation (common and increases with HF severity)
- Ventricular arrhythmias and sudden cardiac death
- Progressive renal dysfunction and acute kidney injury
- Electrolyte disturbance (for example hypokalaemia/hyperkalaemia) related to disease and treatment
- Anaemia and iron deficiency worsening exercise tolerance
- Cardiac cachexia (>=6% unintentional weight loss over 6-12 months)
- Depression and reduced quality of life
- Recurrent decompensation requiring hospitalization
- Sexual dysfunction
Prognosis
Chronic heart failure has a variable but often progressive course with stable periods punctuated by acute decompensation. Population data suggest roughly half of patients die within 5 years of diagnosis; prognosis worsens with older age, lower EF, ischaemic aetiology, NYHA class III-IV symptoms, hypotension/tachycardia, renal dysfunction, diabetes, COPD, AF, and recurrent admissions.
Sources & References
🏥BMJ Best Practice(1)
💊BNF Drug References(6)
- Carvedilol[management.pharmacological]
- Chlortalidone[management.pharmacological]
- Empagliflozin[management.pharmacological]
- Ivabradine[contraindications]
- Ivabradine[management.pharmacological]
- Losartan potassium[management.pharmacological]
✅NICE Guidelines(1)
- Heart failure - chronic[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 245)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 245)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 244, 245)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 241)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 477, 478)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 304, 305)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 281)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 539)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 287)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 539)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 281)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 287)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 287)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 197)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 868, 869)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 169)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 149)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 150, 151)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 275)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 854)[context]