1. Heart Failure (Acute & Chronic) -

1. Heart Failure (Acute and Chronic)

📄 Definition

Heart failure (HF) is a clinical syndrome caused by structural/functional cardiac abnormality → impaired ventricular filling or ejection → inadequate cardiac output and/or raised intracardiac pressures.

Acute HF: rapid onset/worsening of symptoms (often pulmonary oedema).
Chronic HF: persistent symptoms, usually stable with periods of decompensation.

Pathophysiology

↓ Cardiac output → ↑ Renin-Angiotensin-Aldosterone System (RAAS) and Sympathetic Nervous System (SNS) → fluid retention, vasoconstriction, remodelling
HFrEF = systolic failure
HFpEF = diastolic dysfunction

🛡️ Classification

Category	Description	Notes
By LVEF	– HFrEF: reduced EF ≤40% – HFmrEF: mildly reduced EF 41–49% – HFpEF: preserved EF ≥50%	NICE/ESC use echo EF cut-offs
By presentation	Acute vs chronic	Acute = pulmonary oedema, cardiogenic shock
By sidedness	Left vs right vs biventricular	Right HF often secondary to left HF or lung disease (cor pulmonale)

Risk Factors

Mnemonic: DAMN HEART

Diabetes
Age
Myocardial infarction
NSAIDs/nephrotoxins
Hypertension
Ethanol
Arrhythmias
Renal dysfunction
Thyroid disease

🤒 Clinical Features (Mnemonic: FAILURE)

Fatigue, reduced exercise tolerance
Anxiety, nocturia
Increased JVP
Lung crackles, orthopnoea, PND (paroxysmal nocturnal dyspnoea)
Unsure pulse (AF common)
Rales (basal crackles), peripheral oedema
Exertional breathlessness

Acute HF: severe breathlessness, orthopnoea, pink frothy sputum, tachycardia, clammy peripheries.

🎯 EXAM ANCHOR – SIDEDNESS

Left-sided HF → pulmonary congestion
- Bilateral basal crackles
- Orthopnoea / Paroxysmal Nocturnal Dyspnea

Right-sided HF → systemic venous congestion
- Raised JVP
- Peripheral oedema

📌 PARA commonly asks:

Which clinical sign is most associated with left-sided heart failure?

🚩 Red Flags / Admit if

Pulmonary oedema, hypoxia, hypotension.
Cardiogenic shock (SBP <90, poor perfusion).
Rapidly rising creatinine/oliguria.
New arrhythmia or ACS trigger.

🎯 EXAM ANCHOR – ADMISSION

Pulmonary oedema
Cardiogenic shock
Hypotension or hypoxia

📌 PARA often frames these as:

“Which patient requires urgent admission?”

🔬 Investigations (Stepwise PARA Focus)

Step	Test	Findings / Notes
1️⃣ Initial	BNP/NT-proBNP	High level supports HF; normal makes HF unlikely. BNP >400 pg/mL → 2-week echo; >2000 pg/mL → 2-day echo.
	FBC, U&E, LFTs, TFTs, glucose, lipids	Look for anaemia, renal dysfunction, thyroid, DM, risk factors.
	CXR	Cardiomegaly, pulmonary oedema, Kerley B lines.
2️⃣ Diagnostic	Echocardiography	Essential to confirm LV function and classify (HFrEF, HFpEF).
3️⃣ Additional	ECG (arrhythmias, ischaemia), troponin (exclude ACS), iron studies (HF can be worsened by iron deficiency).

🎯 EXAM ANCHOR – BNP

Normal BNP → heart failure very unlikely
High BNP triggers urgent echo

📌 PARA commonly asks:

Which test is most useful to rule out heart failure?

🎯 EXAM ANCHOR – DIAGNOSIS

Echocardiogram = diagnostic gold standard
Required to classify HFrEF vs HFpEF

📌 PARA commonly asks:

Which investigation confirms the diagnosis of heart failure?

CXR FINDINGS

Mnemonic: ABCDE

Alveolar oedema (bat-wing)
Basal effusions
Cardiomegaly
Dilated upper lobe veins
Effusions (interlobar)

Severity – NYHA Classification

Class	Description
I	No limitation
II	Mild limitation
III	Marked limitation
IV	Symptoms at rest

📋 Management

A) Acute Heart Failure (NICE / ESC)

Step	Treatment	Notes
1️⃣ Immediate	Sit upright, high-flow O₂ if hypoxic, monitor (SpO₂, ECG, BP).	Avoid O₂ if sats normal.
2️⃣ Loop diuretics	IV furosemide (40–80 mg).	First-line for pulmonary oedema.
3️⃣ Vasodilators	IV nitrates if SBP >100 mmHg.	Avoid if hypotensive/severe AS.
4️⃣ Inotropes	Dobutamine/NA if cardiogenic shock.	Specialist/ICU setting.
5️⃣ Treat cause	ACS, arrhythmia, infection, PE, non-adherence.

🎯 EXAM ANCHOR – ACUTE HF

First-line drug in pulmonary oedema = IV loop diuretic
Treat the trigger (ACS, arrhythmia, infection)

📌 PARA commonly asks:

First-line treatment in acute pulmonary oedema?

B) Chronic Heart Failure (HFrEF – reduced EF ≤40%)

Stepwise ladder (NICE NG106 2026):

1️⃣ The goal is Rapid Sequence Initiation: all four pillars should be started within 4–6 weeks of diagnosis.

Pillar	Medication	2026 NICE Guidance
1	ACEi or ARNI	Ramipril (ACEi) is traditional, but Sacubitril/Valsartan (ARNI) is now recommended if symptoms persist on ACEi or can be started de novo in hospital.
2	Beta-Blocker	Bisoprolol or Carvedilol. Start low but do not wait for “target dose” before adding other pillars.
3	MRA	Spironolactone or Eplerenone. Introduced early (Pillar 3) to reduce mortality and remodeling.
4	SGLT2i	Dapagliflozin or Empagliflozin. Now a first-line “Big Four” drug for all HFrEF, regardless of diabetes status.

The “5th Pillar”: Iron Deficiency

Screening: Check Ferritin and TSAT for all HF patients at diagnosis and at every 6-month review.
Treatment: If Ferritin <100 µg/L (or 100–299 if TSAT <20%), offer IV Iron (e.g., Ferric Derisomaltose).
Note: Oral iron is generally ineffective in heart failure due to poor absorption; IV is the standard for reducing hospitalizations.

C) HFpEF (Preserved Ejection Fraction ≥50%)

The “no treatment” era is over. Management is now proactive.

First-Line Therapy: SGLT2 inhibitors (Dapagliflozin or Empagliflozin) are now the only drugs proven to reduce CV death and hospitalizations in HFpEF.
Second-Line (Consider): MRAs (Spironolactone) are now recommended by NICE to be considered for symptom control and reducing admission risk.
Congestion: Use loop diuretics (Furosemide) as needed for fluid status.
Aggressive Comorbidity Management:
- BP Control: Aim for <130/80 mmHg.
- AF: High priority for rate/rhythm control (stiff hearts rely on the “atrial kick”).
- Weight: Weight loss is a formal therapeutic goal to improve exercise tolerance.

🩺 3. Monitoring & Titration (The 2026 Checklist)

Because multiple drugs affecting the RAAS and kidneys are started quickly, monitoring is more frequent:

Frequency: Monitor U&Es (Potassium/Creatinine) every 1–2 weeks during initiation/titration, then 6-monthly when stable.
Acceptable Shifts:
- Creatinine: A rise of up to 30% is acceptable (do not stop the drug unless >50%).
- Potassium: Aim to keep $<5.5$ mmol/L. If it hits 6.0 mmol/L, stop the MRA/ACEi and review.
The “36-Hour Rule”: If switching from an ACEi to an ARNI, you must wait 36 hours between the last ACEi dose and the first ARNI dose to prevent life-threatening angioedema.

Quick Summary Table for Exams

If the patient has…	The “Best Next Step” is…
New Diagnosis	Start ACEi/ARNI + Beta-blocker (+ SGLT2i/MRA ASAP).
Symptoms on ACEi	Switch to ARNI (Wait 36 hours!).
Persistent Congestion	Increase Loop Diuretic (Furosemide).
Fatigue + Low Ferritin	IV Iron (Not oral).
HFrEF + HR >75bpm + Sinus Rhythm	Consider Ivabradine.

🩺 Monitoring

Weight (target: <2kg/week loss)
Monitor U&Es on ACEi/MRA
Echo every 1–2 years
Digoxin monitoring if used
Annual flu + 1-off pneumococcal vaccine

Complications

🧠 Mnemonic: CHAD

Cardiogenic shock
Hypokalaemia / hyponatraemia
Arrhythmias
Death (sudden cardiac)

🔎 Key PARA Exam Traps

💡 BNP normal → HF very unlikely.
💡 Echo = diagnostic gold standard.
💡 SGLT2 inhibitors are now standard therapy for HFrEF.
💡 Loop diuretics improve symptoms but NOT survival.
💡 Always look for & treat reversible causes (ACS, valve disease, thyroid, arrhythmias, anaemia).

📅Last updated in line with:

NICE NG106 (2025/26 Update): Reflecting Rapid Sequence Initiation for the Four Pillars.
NICE TA902 & TA929 (2023/24): Formally mandating SGLT2 inhibitors (Dapagliflozin/Empagliflozin) for HFpEF and HFmrEF.
ESC HF Guidelines (2023 Focused Update): Regarding the management of acute decompensation and iron deficiency.
UK Kidney Association (2024): Guidelines on potassium and creatinine tolerance during RAAS-inhibitor initiation.
PARA/MLA-aligned: Reviewed February 2026 for the current exam cycle.

🔒 PASSMAP Assurance: All content is peer-reviewed, NICE-compliant, and optimized for the GMC Medical Licensing Assessment (MLA) and PA National Exam (PARA).

Educational platform. Not medical advice.