Cardiovascular

Chronic Heart Failure

Heart failure is a clinical syndrome in which a structural or functional cardiac abnormality raises filling pressures, lowers cardiac output, or both. Ejection fraction then chooses the treatment; it does not make the diagnosis.

In a nutshell

Heart failure is symptoms plus an objective cardiac abnormality; N-terminal pro-B-type natriuretic peptide (NT-proBNP) sets the referral urgency and echocardiography names the phenotype. In heart failure with reduced ejection fraction (HFrEF) give all four disease-modifying classes, and use furosemide only for congestion.

Classic presentation

An older person with ischaemic or hypertensive heart disease has months of worsening exertional breathlessness and orthopnoea, with a raised JVP, bibasal crackles and pitting ankle oedema.

Key points

NT-proBNP above 2,000 nanograms per litre means specialist assessment and echocardiography within 2 weeks; 400 to 2,000 within 6 weeks; below 400 untreated makes heart failure unlikely.
HFrEF is left ventricular ejection fraction (LVEF) 40% or less; mildly reduced (HFmrEF) is 41% to 49%; preserved (HFpEF) is 50% or more plus structural evidence.
New York Heart Association (NYHA) class: I no limitation, II slight, III marked, IV symptoms at rest. Class drives device, driving and prognosis decisions.
Diuretic resistance means escalating beyond the previous dose ceiling, or near the maximum daily dose, without more diuresis. It is the trigger to consider ultrafiltration.
Level 2 care means detailed observation or support for one failing organ system, and is the minimum setting for intravenous nitrates, inotropes or vasopressors.
Obesity, African or African-Caribbean background and most heart-failure drugs lower NT-proBNP; renal, liver and lung disease, sepsis and diabetes raise it without heart failure.

First-line investigation

NT-proBNP first in suspected chronic heart failure, because the value sets how fast the patient needs specialist assessment; the echocardiogram then confirms the phenotype and looks for a correctable cause.

Management

Acute decompensation and pulmonary oedema

Sit upright, ABCDE, monitored bed, ECG, chest X-ray and bloods. Oxygen to 94 to 98%, or 88 to 92% via a controlled 24% or 28% concentration if at risk of hypercapnia.^2,4
Furosemide 20 to 50 mg IV, then 20 mg steps every 2 hours if needed, maximum 1.5 g daily. Above 50 mg by infusion only. Already on a diuretic: exceed the admission dose.^2,5
Cardiogenic pulmonary oedema with severe dyspnoea and acidaemia: start non-invasive ventilation without delay. Otherwise it is not routine. Consider invasive ventilation for respiratory failure, reduced consciousness or exhaustion.²
Do not routinely offer opiates, nitrates, inotropes, vasopressors, ultrafiltration or pulmonary artery catheterisation; never sodium nitroprusside. Get specialist heart-failure team input within 24 hours of admission.^2,3
Hypotension with cool peripheries, oliguria or confusion is cardiogenic shock: inotropes or vasopressors only if potentially reversible, in a cardiac care unit, HDU or level 2 care.²
Continue an established beta-blocker unless heart rate is below 50 beats per minute, there is second or third degree AV block, or shock. Restart once stable, 48 hours before discharge.²

The four classes in HFrEF, with doses

Angiotensin-converting enzyme (ACE) inhibitor: ramipril 1.25 mg once daily, increased every 1 to 2 weeks as tolerated to 10 mg daily in 1 to 2 divided doses.^1,8
Beta-blocker: bisoprolol 1.25 mg once daily each morning for a week, then 2.5, 3.75, 5, 7.5 and 10 mg once daily, each step only if tolerated.^1,9
Mineralocorticoid receptor antagonist (MRA): spironolactone 25 mg once daily, adjusted according to response to 50 mg once daily. Eplerenone is the alternative when spironolactone is not tolerated.^1,10
Sodium-glucose cotransporter-2 (SGLT2) inhibitor: dapagliflozin or empagliflozin 10 mg once daily, started on heart-failure specialist advice, for everyone with HFrEF and not only for diabetes.^{1,11,12,13,14}
No fixed order: begin early combination at a pace set by symptoms, blood pressure, frailty and renal function. Do not maximise one drug before adding the next.¹
HFmrEF: consider the same four classes. HFpEF: consider an MRA and an SGLT2 inhibitor only, plus a diuretic for congestion and treatment of every contributing condition.^1,19,20

Congestion, monitoring and drug safety

Chronic congestion: furosemide 40 mg orally each morning, then maintenance 20 to 40 mg daily, or 80 to 120 mg daily if resistant. Chart daily weights and titrate to the lowest effective dose.^1,5
Renal function and electrolytes before an ACE inhibitor, ARNI, ARB or MRA. Repeat 1 to 2 weeks after starting and after each increment, then every 3 to 6 months.¹
Creatinine rise above 50% or potassium above 5.5 mmol per litre: follow local guidelines, not automatic discontinuation. Blood pressure before and after each increment; 12-lead ECG before any beta-blocker.¹
Spironolactone plus an ACE inhibitor or ARB has caused fatal hyperkalaemia. Use the lowest effective doses, check potassium and creatinine 1 week after starting and after each increase.^6,10
Hospitalised for major surgery or acute serious illness: interrupt the SGLT2 inhibitor, monitor blood rather than urine ketones, and restart only when ketones are normal and the patient is stable.^18,11
eGFR 45 mL/minute/1.73 m² or less: lower starting doses and smaller increments. Below 30: the specialist team should consider liaising with a renal physician.¹

When four classes are not enough

Symptoms on maximum tolerated doses: switch the ACE inhibitor to sacubitril with valsartan 100 mg twice daily, or 50 mg twice daily if systolic pressure is 100 to 110 mmHg. Specialist-initiated.^1,15,16
Allow at least 36 hours after the last ACE inhibitor dose. Never combine an angiotensin receptor-neprilysin inhibitor (ARNI) with an ACE inhibitor or ARB. Angioedema rules the ARNI out permanently.^1,16
ACE-inhibitor angioedema can start years in, usually without urticaria, and does not respond to adrenaline. Stop the drug immediately, never restart, and secure the airway.¹⁷
Specialist add-ons: ivabradine 5 mg twice daily if in sinus rhythm, digoxin 62.5 to 125 micrograms once daily, or hydralazine with a nitrate. Avoid verapamil and diltiazem.^1,21,22
Iron deficiency: haemoglobin below 150 g per litre with transferrin saturation below 20% or ferritin below 100 nanograms per mL warrants intravenous iron. Still investigate other causes of anaemia.¹
Refer for device assessment after ventricular tachycardia or fibrillation arrest, and when LVEF is 35% or less. The specialist chooses between ICD, CRT-P and CRT-D.^24,1
Severe refractory symptoms or refractory cardiogenic shock: discuss transplantation and mechanical circulatory support with an advanced heart-failure centre early, not once the patient is failing.^1,2

Discharge, follow-up and driving

Specialist heart-failure team review within 2 weeks of discharge. Newly diagnosed: an extended first consultation and a second consultation within 2 weeks if possible.^2,1
Monitor at least every 6 months when stable, but over days to every 2 weeks after any change in condition or medication. Provide daily weights and written deterioration advice.¹
Annual influenza vaccination; pneumococcal vaccination is only required once. Offer exercise-based cardiac rehabilitation after a suitability assessment. Do not routinely restrict salt or fluid, and avoid potassium-containing salt substitutes.¹
Coexisting atrial fibrillation: score stroke risk with CHA2DS2-VASc and bleeding risk with ORBIT, anticoagulate accordingly, and never use aspirin alone for stroke prevention.²³
Group 1 drivers notify the DVLA only if symptoms affect safe driving, distract them or occur at rest. Group 2 drivers must always notify and stop driving.^25,26
Palliative care is triggered by need, not by a prognostic score. Review whether a defibrillator should remain active every 6 months and whenever the goals of care change.¹

Exam traps

The acute rule-out thresholds (BNP under 100 ng/litre, NT-proBNP under 300 ng/litre) are not the chronic referral thresholds of 400 and 2,000 nanograms per litre.
'Do not routinely' is not 'do not'. Non-invasive ventilation is indicated without delay in cardiogenic pulmonary oedema with severe dyspnoea and acidaemia.
'Four pillars' does not mean four prescriptions on day one, and does not mean a slow one-drug ladder either. NICE removed the fixed sequence in 2025.
An SGLT2 inhibitor belongs in the HFrEF regimen for everyone, not only in diabetes, and an ARNI replaces the ACE inhibitor rather than adding to it.
Continue an established beta-blocker in acute heart failure unless heart rate is below 50 beats per minute, there is second or third degree AV block, or shock.
Creatinine rising by more than 50%, or potassium above 5.5 mmol per litre, means follow local guidelines. The reflex answer of automatically stopping the drug is wrong.
ACE-inhibitor angioedema can begin after years of uneventful use and will not respond to adrenaline. Stop the drug and never restart it.
LVEF 50% or more does not by itself diagnose HFpEF: symptoms plus objective structural or functional evidence are required.
Do not routinely restrict salt or fluid, and do not revascularise simply because HFrEF and coronary artery disease coexist.

Illustrations

Neurohormonal vicious cycleFlow diagram of reduced cardiac output activating sympathetic and renin-angiotensin-aldosterone pathways, increasing afterload, congestion and remodelling, with disease-modifying drug classes mapped to their targets.PassFinals · original

Pulmonary oedema in heart failure on chest X-raySitting anteroposterior chest radiograph showing cardiomegaly, bilateral perihilar and basal pulmonary oedema and small pleural effusions in decompensated heart failure.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Echocardiogram in reduced ejection fractionEchocardiographic still illustrating a dilated left ventricle with reduced systolic function; ejection fraction is one component of the full heart-failure assessment.Kalumet, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.