Congestive heart failure (CHF) is a chronic condition where the heart is unable to pump blood efficiently to meet the body’s needs. This leads to a build-up of fluid in the lungs, liver, abdomen, and lower limbs. CHF is a major cause of hospitalisation and reduced quality of life, particularly in older adults. Early diagnosis and proper management can significantly improve outcomes.
Causes
- Coronary artery disease (most common cause)
- Hypertension
- Cardiomyopathy (dilated, hypertrophic, or restrictive)
- Heart valve diseases (e.g., aortic stenosis, mitral regurgitation)
- Arrhythmias such as atrial fibrillation
- Congenital heart defects
- Myocarditis (inflammation of the heart muscle)
- Endocrine disorders like diabetes and thyroid disease
- Excessive alcohol intake, substance abuse (e.g., cocaine)
Pathophysiology
Heart failure occurs when there is an imbalance between the heart’s pumping ability and the body’s circulatory demands. This may happen due to weakened heart muscles (systolic failure) or stiffened heart muscles that cannot fill properly (diastolic failure). Compensatory mechanisms like activation of the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system initially maintain circulation but eventually lead to worsening heart function, fluid retention, and remodelling of heart tissue.
Signs and Symptoms
- Shortness of breath (dyspnoea) on exertion or at rest
- Orthopnoea (difficulty breathing while lying flat)
- Paroxysmal nocturnal dyspnoea (sudden breathlessness at night)
- Fatigue and weakness
- Swelling (oedema) in ankles, legs, abdomen
- Rapid or irregular heartbeat
- Persistent cough or wheezing, sometimes with pink frothy sputum
- Weight gain due to fluid retention
- Decreased ability to exercise
- Confusion or impaired thinking (especially in elderly patients)
Risk Factors
- Previous myocardial infarction
- High blood pressure (uncontrolled)
- Diabetes mellitus
- Obesity
- Smoking
- Family history of heart disease
- Sedentary lifestyle
- Excessive alcohol or drug use
- Advanced age
Investigation (Imaging or Labs)
History and physical examination for typical symptoms and signs
Blood tests:
- Full blood count (FBC), electrolytes, renal function, liver function tests
- B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP): elevated levels support diagnosis
- Electrocardiogram (ECG): may show ischaemia, arrhythmias, or previous infarction
- Chest X-ray: to assess heart size, pulmonary oedema, or pleural effusion
- Echocardiography: gold standard for assessing heart structure, ejection fraction (EF), and valve function
- Cardiac MRI: provides detailed imaging if echocardiogram is inconclusive
- Coronary angiography: if ischaemic heart disease is suspected
Management
1. Non-Pharmacological Management
- Lifestyle advice is crucial
- Salt restriction to reduce fluid overload
- Fluid intake monitoring in severe cases
- Regular physical activity (under supervision for stable patients)
- Weight monitoring daily to detect fluid retention early
- Smoking cessation
- Alcohol intake reduction or cessation
- Vaccinations against influenza and pneumococcus
2. Pharmacological Management
First-line medications:
- ACE inhibitors (or ARBs if intolerant) to reduce afterload and improve survival
- Beta-blockers (specifically bisoprolol, carvedilol, or nebivolol) to reduce heart rate and mortality
- Diuretics (e.g., furosemide) to control symptoms of fluid overload
Second-line and additional therapies:
- Mineralocorticoid receptor antagonists (e.g., spironolactone, eplerenone) for patients with ongoing symptoms
- Sacubitril/valsartan (an ARNI) for patients with persistent symptoms despite optimal ACE/ARB therapy
- Ivabradine for patients in sinus rhythm with high heart rates
- Digoxin, especially in patients with atrial fibrillation
- Anticoagulation if atrial fibrillation is present to prevent stroke
- Regular medication review and titration to target doses is essential
- SGLT2 inhibitors (such as empagliflozin, dapagliflozin, and canagliflozin) are medicines that make the kidneys excrete more glucose and sodium in the urine.
Surgical Management
- Cardiac resynchronisation therapy (CRT) for patients with heart failure and a wide QRS complex
- Implantable cardioverter-defibrillators (ICD) for primary or secondary prevention of sudden cardiac death
- Coronary artery bypass grafting (CABG) or angioplasty if ischaemic disease is contributing
- Valve repair or replacement surgery if valve disease is the cause
- Heart transplant in end-stage refractory heart failure
Complications
- Acute decompensated heart failure
- Life-threatening arrhythmias
- Thromboembolism (e.g., stroke, pulmonary embolism)
- Progressive renal failure
- Hepatic congestion leading to liver dysfunction
- Cachexia (severe weight loss)
- Depression and impaired quality of life
- Death if untreated
References
- National Institute for Health and Care Excellence (NICE) Chronic Heart Failure in Adults: Diagnosis and Management (NG106)
- British Society for Heart Failure Guidelines
- Royal College of Physicians Heart Failure Guidelines
- General Medical Council (GMC) Good Clinical Practice Guidance
- European Society of Cardiology Heart Failure Guidelines (adapted for UK practice)