Establishing the diagnosis
Symptoms and signs are unreliable on their own. Two tests carry the weight:
- BNP or NT-proBNP — most useful for its negative predictive value. A normal level in an untreated breathless patient makes heart failure unlikely. Raised in AF, renal failure, PE, sepsis and age; lowered by obesity
- Echocardiography — establishes the ejection fraction, and therefore which of the two diseases you are treating
Split on ejection fraction: HFrEF at ≤ 40% has disease-modifying therapy; HFpEF at ≥ 50% does not, beyond diuretics, comorbidity control and SGLT2 inhibitors.
The four pillars of HFrEF
All four reduce mortality. Start them all, at low dose, and titrate — the modern approach is early combination rather than sequential maximisation of one class:
- ARNI (sacubitril–valsartan) in preference to an ACE inhibitor, or an ACE inhibitor/ARB if ARNI is not available. Requires a 36-hour washout from an ACE inhibitor to avoid angioedema
- Beta-blocker — only bisoprolol, carvedilol or metoprolol succinate have the evidence. Start when euvolaemic, never during decompensation
- Mineralocorticoid receptor antagonist — spironolactone or eplerenone; monitor potassium and creatinine
- SGLT2 inhibitor — dapagliflozin or empagliflozin, with or without diabetes
Loop diuretics relieve congestion and do not change mortality. Titrate to symptoms and weight.
Drugs to stop or avoid
- NSAIDs — sodium retention and renal impairment
- Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) — negatively inotropic
- Thiazolidinediones — fluid retention
- Most antiarrhythmics other than amiodarone
Devices
- ICD for ejection fraction ≤ 35% despite ≥ 3 months of optimal therapy, with a reasonable life expectancy
- CRT additionally for QRS ≥ 150 ms, especially with LBBB morphology
Acute decompensation
The picture divides usefully into wet/dry and warm/cold:
- Wet and warm (most common): IV loop diuretic, nitrates if hypertensive, non-invasive ventilation for pulmonary oedema
- Wet and cold: low output — inotropes, and consider mechanical support
- Look for the trigger every time: ischaemia, arrhythmia (especially new AF), infection, non-adherence, NSAIDs, anaemia, thyroid disease, pulmonary embolism
What to check when it is not improving
New heart failure needs a cause: ischaemic disease (the commonest), valvular disease, hypertension, alcohol, thyroid, iron overload, amyloid, peripartum, chemotherapy (anthracyclines, trastuzumab), tachycardia-induced. Iron deficiency — ferritin < 100, or < 300 with saturation < 20% — is worth correcting intravenously; it improves symptoms independent of anaemia.