Heart Failure

Heart Failure - The Failing Pump

• Heart Failure (HF): Heart can't meet metabolic demands or does so at ↑ filling pressures.

  • HFrEF (Heart Failure with reduced Ejection Fraction): EF < 40%
  • HFpEF (Heart Failure with preserved Ejection Fraction): EF ≥ 50%
  • HFmrEF (Heart Failure with mildly reduced Ejection Fraction): EF 40-49%

• Classifications:

  System	Stages Summary
  NYHA	I (Asymptomatic) - IV (Symptoms at rest)
  ACC/AHA	A (At Risk) - D (Refractory HF)

⭐ The most common cause of Right Heart Failure is Left Heart Failure.

Heart Failure - Why It Breaks

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Heart Failure - Spotting Trouble

• Symptoms: Dyspnea (DOE, orthopnea, PND), fatigue, edema, cough (frothy).

• Signs: Tachycardia, S3/S4, ↑JVP, edema, creps, hepatomegaly.

• 📌 Mnemonics:

  • Left HF (DOABLE): Dyspnea, Orthopnea, Awakening, Basal creps, Lung sounds-wheeze, Expectoration-frothy.
  • Right HF (CHAPS): Cor pulmonale, Hepatomegaly, Ascites, Peripheral edema, Splenomegaly.

• Diagnostic Tools:

  • ECG: LVH, prior MI, arrhythmias.
  • CXR: Cardiomegaly, pulm. congestion (Kerley B), effusion.
  • Echo (key): EF, wall motion, diastolic fx, valves.
  • Biomarkers: BNP > 100, NT-proBNP > 300 pg/mL (↑ if renal issues/elderly).

• Framingham criteria aid CHF diagnosis.

⭐ S3 gallop: highly specific for HF, especially with dyspnea.

Heart Failure - Mending Hearts

Non-pharm: Salt <2g/day, fluid <1.5-2L/day, lifestyle modifications. Pharm HFrEF (📌 'BASH' - 4 Pillars GDMT):

• ARNI (Sacubitril/Valsartan preferred) / ACEi / ARB
• Beta-blockers (Carvedilol, Metoprolol Succinate, Bisoprolol)
• MRA (Spironolactone, Eplerenone; monitor K+)
• SGLT2i (Dapagliflozin, Empagliflozin; regardless of diabetes) Diuretics (Loop) for symptomatic relief of congestion. HFpEF: Manage comorbidities (BP, etc.), diuretics for congestion, SGLT2i show benefit. Devices: ICD (primary/secondary SCD prevention); CRT (LVEF ≤35%, QRS ≥150ms LBBB, NYHA II-IV).

⭐ ARNIs (Sacubitril/Valsartan) have shown superiority over ACE inhibitors in reducing mortality and hospitalization in HFrEF.

Heart Failure - Code Blue Crisis

• Definition: Acute worsening of Heart Failure (HF) signs/symptoms requiring urgent therapy.
• Triggers: Non-compliance (diet/meds), ACS, arrhythmia (e.g., AF), infection, uncontrolled HTN, PE.
• Stevenson Profiles (Perfusion/Congestion) & Key Tx:
  • Warm & Wet: IV Diuretics, Vasodilators (if SBP >90-100 mmHg).
  • Cold & Wet: IV Diuretics + IV Inotropes/Vasopressors.
  • Cold & Dry: IV Fluids (cautiously), then IV Inotropes if no response.
• Key Meds: IV Loop Diuretics, IV Vasodilators, IV Inotropes. Oxygen, Non-Invasive Ventilation (NIV).
• 📌 LMNOP for acute pulmonary edema: Lasix, Morphine (less used), Nitrates, Oxygen, Position (upright).

⭐ The 'Cold and Wet' profile in Acute Decompensated Heart Failure (ADHF) carries the worst prognosis and often requires aggressive therapy including inotropes.

High‑Yield Points - ⚡ Biggest Takeaways

• Ischemic Heart Disease (IHD): most common cause of heart failure.
• NYHA Classification: key for symptom severity and guiding treatment.
• BNP/NT-proBNP: vital biomarkers for diagnosis, prognosis, and therapy response.
• HFrEF cornerstone drugs: ARNI/ACEi/ARB, Beta-blockers, MRAs, SGLT2is improve survival.
• Sacubitril/Valsartan (ARNI): superior mortality benefit vs ACEi/ARB in HFrEF.
• HFpEF: manage comorbidities (HTN, DM); diuretics for congestion relief.
• Acute Decompensated HF (ADHF): manage with LMNOP (Lasix, Morphine, Nitrates, Oxygen, Position) protocol.