Terminology

Watch ▶Heart failure: Pathology review

Term	Description
1️⃣ Heart Failure (HF)	🔷 A complex clinical syndrome with structural or functional impairment of ventricular filling and/or ejection of blood.
2️⃣ Congestive Heart Failure (CHF)	🔷 HF with signs and/or symptoms of fluid overload, such as peripheral edema or jugular venous distention.
3️⃣ Left Heart Failure (LHF)	🔷 HF due to structural or functional impairment of the left heart circulatory system, causing tissue hypoperfusion and/or increased pulmonary capillary pressure.
4️⃣ Right Heart Failure (RHF)	🔷 HF due to structural or functional impairment of the right heart circulatory system, leading to impaired pulmonary circulation or elevated venous pressures.
5️⃣ Biventricular Heart Failure	🔷 HF affecting both the left and right ventricles, leading to symptoms of both RHF and LHF.
🔷 One-sided HF often progresses to biventricular HF.
6️⃣ Chronic Compensated HF	🔷 HF with stable symptoms.
7️⃣ Acute Decompensated HF (ADHF)	🔷 AHF due to decompensation of preexisting disease and/or cardiomyopathy (most common).
8️⃣ Systolic Dysfunction	🔷 Reduced ventricular contractility, resulting in ventricular enlargement and decreased ejection fraction.
9️⃣ Diastolic Dysfunction	🔷 Reduced ventricular compliance with elevated filling pressures, abnormal relaxation, and increased ventricular stiffness.

Heart Failure

Watch ▶Congestive heart failure: Clinical sciences

General

Clinical syndrome of Dyspnea resulting from cardiomyopathy that impairs ventricular filling or ejection.
HF is very common cause of hospitalization

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Subtypes

Subtype	Definition	Causes
HFpEF	Ejection Fraction > 50%	🔷 Diastolic dysfunction; associated with

  🔸 HTN [1# cause]
  🔸 Obesity
  🔸 DM
  🔸 Aging

Etiology

<aside> 💡 The three major causes of HF are

CAD (most common)
Hypertension
Diabetes mellitus → Patients typically have multiple risk factors that contribute to the development of HF </aside>

Clinical Presentation

Right-Sided Heart Failure
- Peripheral edema, JVD elevation, hepatomegaly.
- Jugular venous distention
- Hepatojugular reflux
Left-Sided Heart Failure
- Pulmonary edema, orthopnea, paroxysmal nocturnal dyspnea.
Physical Exam
- S3, displaced PMI, pulmonary rales & crackles, jugular venous distension.
  
  <aside> 💡 S3 is an important clue to HFrEF (LV Volume Overload)
  - S4 is a sign of HFpEF </aside>

Extra Details

Peripheral edema

Diagnosis

Mainly clinical diagnosis, supported with
- BNP
  - Indicated in all patients
  - High sensitivity, high negative predictive value (low BNP excludes heart failure).
  <aside> 💡
  
  BNP level can be falsely low in patients with heart failure and obesity because BNP undergoes increased clearance by fat cells.
  
  </aside>
- TTE (Transthoracic Echocardiogram)
  - To Confirm (initial imaging test)
  - Evaluates systolic ejection fraction and diastolic function
- CXR
  - Pulmonary Interstitial & Alveolar edema
  - Kerley B lines (perpendicular streaks to pleura; due to fluid retention in lungs)
  - Pleural effusion (can be unilateral or bilateral)
  - Cardiomegaly
    - Cardiothoracic ratio > 0.5
- Coronary Angiogram
  - Assesses for underlying CAD in new HF presentation.
- Right Heart Catheterization
  - ↑ PCWP (left-sided HF)
  - ↑ RA pressure, RVEDP (right-sided HF).

Classification

New York Heart Association (NYHA) Classification

Classes	Symptoms

Class I	Asymptomatic

🔷 No limitations in physical activity 🔷 No symptoms of HF | | Class II | Symptoms with moderate exertion

🔷 Mild symptoms and slight limitations during ordinary physical activity 🔷 No symptoms at rest | | Class III | Symptoms with activities of daily living

🔷 Marked limitations in physical activity 🔷 Less-than-ordinary activity causes symptoms. 🔷 Comfortable only at rest | | Class IV | Symptoms at rest

🔷 Severe limitations 🔷 Symptoms during any form of physical activity 🔷 Symptoms at rest |

Lifestyle modifications

Aerobic exercise
- Brisk walking for ≥ 150 minutes/week
Weight loss
Nutrition and fluid management
- Encourage healthy eating patterns, e.g., DASH diet, Mediterranean diet.
- Avoid excessive dietary sodium intake to reduce the risk of congestion (< 2g/day salt).
Fluid restriction does not reduce hospitalization or mortality rates in patients with HF.
Smoking cessation, avoidance of alcohol and recreational drug use

<aside> 💡 Nonpharmacological interventions are associated with better patient outcomes ( ↓ Hospitalizations and all-cause and cardiovascular mortality)

</aside>

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