Heart failure (HFrEF, HFpEF)

Quick Overview

Heart failure (HF) affects >900,000 UK adults with 5-year mortality ~50%. HFrEF (reduced ejection fraction, LVEF ≤40%) and HFpEF (preserved ejection fraction, LVEF ≥50%) require distinct management strategies. NICE NG106 emphasizes BNP-guided diagnosis and quadruple therapy for HFrEF.

Core Facts & Concepts

Diagnostic Criteria

• BNP thresholds (NICE NG106):
  • BNP >400 pg/mL or NT-proBNP >2000 pg/mL → urgent echo within 2 weeks
  • BNP 100-400 pg/mL or NT-proBNP 400-2000 pg/mL → routine echo within 6 weeks
  • Previous MI → refer regardless of BNP
• Classification by LVEF:
  • HFrEF: LVEF ≤40%
  • HFmrEF (mildly reduced): LVEF 41-49%
  • HFpEF: LVEF ≥50%

HFrEF Pharmacological Pillars (NICE NG106 quadruple therapy):

⭐ Clinical Pearl: Start all 4 pillars within 4-6 weeks; don't wait for sequential titration to max doses.

Diuretic Management

• Loop diuretics (furosemide 40-240mg OD) for symptom relief only-no mortality benefit
• Adjust dose based on daily weights and fluid status
• IV if oral absorption poor (bowel oedema)

Problem-Solving Approach

Step-by-Step HF Diagnosis

1. Clinical suspicion: Breathlessness, orthopnoea, ankle oedema, fatigue
2. Order BNP/NT-proBNP: Elevated in >95% of HF cases
3. Transthoracic echo: Assess LVEF, valves, wall motion
4. ECG + CXR: Identify arrhythmias, cardiomegaly, pulmonary oedema
5. Bloods: FBC, U&E, TFTs, HbA1c, lipids (exclude reversible causes)

HFrEF Medication Initiation Algorithm

1. Start ACEi + beta-blocker simultaneously at low doses
2. Add MRA if NYHA II-IV persists (K⁺ <5.0 mmol/L, eGFR >30)
3. Switch ACEi to ARNI after 4 weeks if symptomatic
4. Add SGLT2i immediately (regardless of diabetes status)
5. Titrate each drug to target/max tolerated dose every 2-4 weeks

🚩 Red Flags for Specialist Referral

• NYHA III-IV despite optimal medical therapy
• Symptomatic hypotension preventing up-titration
• Refractory fluid overload
• Consider device therapy: ICD if LVEF ≤35%, CRT if QRS ≥130ms

Analysis Framework

HFrEF vs HFpEF Key Differences

⚠️ Warning: HFpEF lacks robust evidence-focus on treating comorbidities (HTN, AF, obesity) and symptom control with diuretics.

Drug Monitoring Essentials

• ACEi/ARNI: Check U&E at 1-2 weeks; accept Cr rise <30%, K⁺ <5.5 mmol/L
• MRA: Stop if K⁺ >5.5 mmol/L or eGFR <30 mL/min
• SGLT2i: Monitor for genital infections, DKA (rare)

Visual Aid

NYHA Functional Classification

Key Points Summary

✓ Diagnosis: BNP >400 pg/mL (or NT-proBNP >2000) + echo showing LVEF ≤40% confirms HFrEF

✓ HFrEF quadruple therapy: ARNI (or ACEi) + beta-blocker + MRA + SGLT2i-start all within 4-6 weeks for maximum mortality benefit (50-60% reduction)

✓ Diuretics: For symptom relief only; no mortality benefit. Titrate loop diuretics to euvolaemia

✓ HFpEF management: Limited evidence-SGLT2i (dapagliflozin 10mg OD) only proven therapy. Focus on BP control and treating comorbidities

✓ Device therapy: ICD if LVEF ≤35% post-MI or dilated cardiomyopathy; CRT if QRS ≥130ms with LBBB

✓ Monitoring: Accept Cr rise <30% and K⁺ <5.5 mmol/L when initiating RAAS inhibitors-don't stop prematurely

✓ Common pitfall: Sequential drug titration delays benefit-initiate all 4 pillars early, then up-titrate simultaneously