Cardiac failure

Overview

•Left-sided: dyspnoea on exertion, orthopnoea, paroxysmal nocturnal dyspnoea, bibasal crackles, S3

•Right-sided: peripheral pitting oedema, raised JVP, hepatomegaly

•Orthopnoea/PND - fluid redistributes from dependent tissues to pulmonary circulation when recumbent

Investigations

🥇 First-line

•BNP (>100 pg/mL) or NT-proBNP (>400 pg/mL) - elevated due to ventricular wall stress; normal result makes heart failure unlikely

•ECG - rarely normal; look for LVH, AF, LBBB, prior MI

•Chest X-ray - cardiothoracic ratio >0.5 on PA film = cardiomegaly; assess pulmonary congestion

🏆 Gold standard

•Echocardiogram (transthoracic) - measures ejection fraction, identifies structural cause, assesses diastolic function

•Bloods: FBC, U&Es/eGFR (baseline before ACEi/diuretics), TFTs, LFTs, glucose/HbA1c

🧠

CXR findings - ABCDE: Alveolar oedema (bat-wing shadowing), B Kerley B lines, Cardiomegaly (CTR >0.5), Diversion of upper lobe vessels (earliest sign), Effusions (pleural - typically bilateral, right > left)

Management

🚨

Admit any patient with suspected new heart failure AND: SBP >180/120 mmHg, acute pulmonary oedema, new confusion, chest pain, or suspected AKI. Do not delay for outpatient echocardiogram - specialist inpatient assessment is required first.

•Acute decompensation - immediate: sit upright, high-flow O2 targeting SpO2 94-98%, cardiac monitoring

🥇 First-line

•IV furosemide 40-80 mg - reduces preload rapidly by venodilation (within minutes) before diuresis begins

•CPAP (NIV) - reduces work of breathing, improves oxygenation, reduces preload and afterload; start early in severe pulmonary oedema

🥈 Second-line

•IV glyceryl trinitrate (GTN) infusion - venodilator; reduces preload; use cautiously if SBP <90 mmHg; particularly helpful if hypertension is the precipitant

•IV morphine - no longer routinely recommended; associated with worse outcomes in observational data

•Chronic HFrEF - four pillars (mortality benefit):

•ACE inhibitor (e.g. ramipril) - blocks RAAS; reduces afterload and remodelling; if ACEi-intolerant (cough), use ARB (e.g. candesartan)

•Beta-blocker (e.g. bisoprolol, carvedilol, nebivolol) - do NOT start during acute decompensation

•MRA (e.g. spironolactone, eplerenone) - monitor potassium closely (hyperkalaemia risk with ACEi/ARB)

•SGLT2 inhibitor (dapagliflozin or empagliflozin) - reduces hospitalisation and CV death regardless of diabetic status (NICE 2023)

•Second-line chronic: sacubitril/valsartan (ARNI) - replaces ACEi if symptomatic despite optimised ACEi + beta-blocker + MRA; allow 36-hour washout when switching from ACEi

•Second-line chronic: ivabradine - sinus rhythm, HR ≥75 bpm, LVEF ≤35% despite optimal beta-blocker

🥉 Third-line

•Vasopressors/inotropes (e.g. noradrenaline, dobutamine) - cardiogenic shock; escalation to critical care

•CRT - if LBBB with QRS ≥130 ms and LVEF ≤35% on optimal medical therapy

•ICD - if LVEF ≤35% despite 3 months of optimal medical therapy; primary prevention of sudden cardiac death

🎯

Loop diuretics (e.g. furosemide) improve symptoms and quality of life in chronic heart failure but do NOT reduce mortality.