Congestive Heart Failure

Exam Cram

• Congestive Heart Failure: heart fails to pump the blood around the body, resulting in fluid overload (from increased back pressure)

• Presentation: progressive shortness of breath, leg swelling; o/e bilateral pitting oedema, bibasal crackles; raised BNP

• Diagnosis: reduced ejection fraction on ECHO for HFrEF; HFpEF is clinical

• Management: diuretics e.g. furosemide

Outline

Background 

• Congestive heart failure describes the heart's inability to pump blood through the body

• This results in congestion, using the traffic jam analogy with blood being cars and blood vessels the roads, movement through the heart is too slow, causing back pressure into the venous system

• Heart failure is classified into failure to contract (systolic) and eject blood (HFrEF) or failure to relax (diasytolic) and fill with blood, prior to ejecting the blood (HFpEF)

Assessment

Presentation

• Progressive shortness of breath, reduced exercise tolerance and bilateral leg swelling

• Requiring pillows to sleep at night (upright)- paroxysmal nocturnal dyspnoea (PND)

• Background: elderly with known ischaemic heart disease; non compliance to duiretics

Examination

• Bilateral leg swelling

• Bi-basal coarse crackles

• Tachypnoea, hypoxia +- hypotension, tachycardic

Investigations

• Raised BNP

• CXR: pulmonary congestion

• ECHO: reduced left ventricular function (ejection fraction)

Diagnosis 

• Classification:

  • HFpEF- Heart Failure with preserved ejection fraction

  • HFrEF- Heart Failure with reduced ejection fraction

• Diagnostic criteria:

  • HFrEF: reduced ejection fraction on ECHO

  • HFpEF: clinical diagnosis- based on clinically overload and signs of diasystolic dysfunction on ECHO

• Differentials: 

  • Acute onset shortness of breath: pneumonia, pneumothorax, myocardial infarction, pulmonary embolus

  • Insidious onset shortness of breath: chronic lung disease e.g. COPD/ pulmonary fibrosis, anaemia, malignancy

  • Insidious onset bilateral leg swelling: liver cirrhosis, nephrotic syndrome

Management

Acute

• Diuresis: furosemide

Chronic

Goal of care is to slow gradual deterioation in cardiac function:

• Low dose ace inhibitor

• Low dose betablocker

Decompensated Heart Failure Admission Cycle

Admission

Presentation: causes of decompensation

• Poor compliance with diuretics

• Infection: chest, urine, bowels

• Worsening heart failure control +- ischaemic event

Investigations

• Baseline bloods: FBC, urea and electrolytes, LFTs

  • Common: AKI, hyponatraemia

• ECG- LVH

• CXR- pulmonary congestion

• BNP- raised, e.g. > 2000

• Septic screen: viral PCR, CRP, blood/ urine cultures

• Consider- VBG ?T2RF, troponin ?ischaemic event

Management (ward optimisation):

• Furosemide IV 20mg - 40mg & assess response

• Fluid balance: consider urine catheter

• Fluid restriction 1.5L

• Daily EUCs

• Daily weights 

• Symptom control: morphine 2mg QID prn PO 

• Escalation status, VTE prophylaxis, capacity,

Escalation (CCU/ HDU/ ICU):

Indications: 

1. T2RF (hypercapnia)

2. Increase work of breathing & tiring

Interventions: 

1. • BiPAP: reduces LV afterload

   • GTN infusion

   • Furosemide infusion/ bumetanide

De-escalation to End of life care

• Patient wishes & concerns- capacity & consent

• High symptom burden

• Frailty, multiple previous exacerbations

Inpatient Management

• Daily fluid review

• Daily Na+ and K+

• Daily weight

• Review input/ output

Deterioration on the ward

1. • Differentials: MI, PE, CAP, pneumothorax

   • Investigations: 

     1. Baseline bloods, consider troponin / d-dimer

     2. CXR, CTPA

     3. ECG +- repeat ECHO

   • Consider escalation of care & de-escalation to End of Life

Discharge planning

These can require long admissions, unfortunately. 

• IV furosemide to PO

• Cardiology follow up

• Heart failure nurse specialist follow up

• Education on fluid and salt restrictions

Long Term Management of Congestive Heart Disease

Diagnosis

Diagnostic criteria: 

• Heart Failure with reduced ejection fraction (HFrEF): ECHO- ejection fraction < 35% (European Guidelines)

• Heart Failure with preserved ejection fraction (HFpEF):  clinical signs of heart failure with ejection fraction > 35%

  • • • • • • Sob, reduced exercise tolerance

            • Leg swelling, bibasal crackles

            • Raised BNP, CXR showing cardiomegaly and pulmonary fluid overload

HFpEF is naturally a harder diagnosis to make and is often undiagnosed as a result. 

Chronic Management

HFrEF

1. ACE inhibitor, statin, betablocker, furosemide

ARB if ACEi not tolerated

2. Spirolactone if K+ < 4.5

Eplerenone if gynecomastia

3. Sacubitril/ valsartan (stop monotherapy ACEi/ARB)

4. Other interventions

   • Ivabradine: max dose of betablocker & HR > 75

   • Hydralazine + nitrate

   • SGLT-2 inhibitors

5. Cardio re-synchronisation therapy

6. End of Life Care: morphine

HFpEF

1. Furosemide

2. Empagliflozin

Cardio Reg Notes

Explaining ejection fraction and HFpEF

The function of the heart to pump blood around the body, blood in volume. 

Ejection fraction measures the percentage of blood filling into the heart as being pumped out. In HFpEF, the heart doesn't fill properly therefore it only pumps out a small amount of blood, however the volume of blood pumped out / total blood filled (ejection fraction) is preserved. 

Therefore the ejection fraction is not always a great metric of cardiac function. 

Furosemide conversions

Furosemide 40mg PO = 

• Furosemide 20mg IV

• Bumetanide 1mg 

Furosemide 80mg PO TDS = furosemide 24hr infusion: 10mg/hr

Long Term Management

Ivabradine can cause new AF and should be stopped if this occurs. 

Indications for Cardio Resynchronisation Therapy (CRT)

Need 3/3

1. QRS > 120, 

2. Class II NYHA CHF 

3. LBBB

? Bifasicular block (e.g. RBBB + left axis deviation)

In patients with LBBB & QRS 100-120m ICD preferred.

References and Resources

Page updated in 2025.