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Heart Failure

NICE guidelines [CG187] Acute heart failure: diagnosis and management. Last updated: Nov 2021. NICE guidelines [NG106] Chronic heart failure: diagnosis and management Published: Sep 2018.

Background Information

Heart failure is a condition in which the heart does not pump enough blood to meet all the demands of the body. It is caused by a dysfunction of the heart due to muscle damage (either systolic or diastolic dysfunction), valvular dysfunction, arrythmias or other causes.

Classification by time course:
  • Acute HF is a life-threatening condition characterised by a sudden onset in people without any known cardiac dysfunction, or as acute decompensation of chronic HF
  • Chronic HF is a progressive condition characterised by the gradual deterioration of symptoms over time
 
Classification by ejection fraction:
  • HFrEF (HF with reduced ejection fraction):  LVEF of ≤40%
  • HFmrEF (HF with mildly reduced ejection fraction): LVEF between 41-49%
  • HFpEF (HF with preserved ejection fraction): LVEF of ≥50%
  • High-output HF: higher than normal CO but still insufficient to meet the demands of the body

Clinical features of chronic heart failure can be classified into left- and right-sided.
 

Symptoms from pulmonary congestion: (increasing in severity)
  • Exertional dyspnoea
  • Paroxysmal nocturnal dyspnoea
  • Orthopnoea
  • Dyspnoea at rest

Symptoms from ↓ cardiac output:
  • ↓ Exercise tolerance
  • Fatigue

On examination:
  • Bi-basal fine crepitations on auscultation
  • Cardiomegaly → displaced apex beat
  • Peripheral hypoperfusion → ↑ CRT, cold extremities, pallor

Symptoms from fluid retention and ↑ CVP
  • Peripheral oedema
  • Ascites → abdominal distention
  • Hepatic congestion → RUQ pain and jaundice  
  • GI congestion → nausea, loss of appetite

On examination:
  • JVP distention
  • Congestive hepatomegaly
  • Hepatojugular reflex

  • Tachycardia and various arrhythmia
  • Gallop rhythms can give clues towards underlying cause:
    • S3 heart sound- dilated cardiomyopathy, high-output states
    • S4 heart sound- hypertensive heart disease, HOCM / HCM
  • Pulsus alternans
 

Main differentiating factors that suggest acute heart failure over chronic failure:

  • Rapid onset of symptoms (often over hours to days)
  • Sudden and severe symptoms
  • Results from a trigger (e.g. myocardial infarction, arrhythmia, infection)
  • Pulmonary congestion predominant
 

NB there is significant overlap in symptoms as there might be chronic heart failure features present, left side

The NYHA classification is classify the severity of chronic heart failure and guide management:
 
NYHA Class Description
I No limitation of physical activity. Ordinary physical activity does not cause symptoms.
II Comfortable at rest. Ordinary physical activity causes symptoms.
III Comfortable at rest. Less than ordinary physical activity cause symptoms.
IV Unable to carry out any physical activity without symptoms +/- symptoms at rest.
 

Acute Heart Failure Guidelines

1st line investigation: BNP or NT-proBNP

Heart failure is unlikely if:
  • BNP < 100 ng/L
  • NT-proBNP < 300 ng/L

Confirmatory test: TTETrans-thoracic echocardiogram

 

Although not mentioned in the guidelines, if acute heart failure is suspected clinically, a bed side chest X-ray is likely to the first test to be done to confirm heart failure and exclude other cardiopulmonary causes.

1st line in all patients:  IV loop diuretic

Add-on therapy:
  • IV nitrates if there is:
    • Concomitant myocardial ischaemia
    • Severe hypertension
    • Aortic or mitral regurgitation
 
  • If cardiogenic shock → consider inotropes or vasopressors
 
Ventilatory support:
  • CPAP can be used in severe cardiogenic pulmonary oedema
  • Invasive ventilation

 

Initial management of acute heart failure is IV loop diuretic

Start / continue if already taking, the following drugs during hospital admission after stabilisation:
  • ACE-I / ARB
  • Beta blocker (unless HR <50bpm / 2nd degree HB / 3rd degree HB / shock)
  • Aldosterone antagonist (e.g. spironolactone)

Chronic Heart Failure Guidelines

  • 1st line investigation: NT-pro-BNP
  • Confirmatory test: TTETrans-thoracic echocardiogram

Subsequent investigations depend on NT-pro-BNP level:
 
NT-pro-BNP level Next step
>2000 ng/L Refer to specialist and TTE Trans-thoracic echocardiogramwithin 2 weeks
400-2000 ng/L Refer to specialist and TTETrans-thoracic echocardiogram within 6 weeks
<400 ng/L Heart failure less likely, consider alternative diagnosis

Factors that can affect interpretation of NT-pro-BNP
  • Click here to view causes of falsely ↓ NT-pro-BNP level 
  • Click here to view causes of falsely ↑ NT-pro-BNP level 

The following applies to all types of heart failure:
  • Offer cardiac rehabilitation
  • Avoid potassium-containing salt substitutes
  • If patient has excess salt and/or fluid consumption → advise reducing intake (but do not routinely advise patients to restrict sodium or fluid intake)
  • Annual influenza vaccination + one-off pneumococcal vaccination

Step 1 - all patients should receive:
  • Loop diuretics only if there is any features of congestion and fluid retention (e.g. dyspnoea, limb oedema)
  • ACE inhibitors (alternative: ARBAngiotensin receptor blocker)
  • Beta blocker

Step 2 (add the following to step 1 medications):
  • Mineralocorticoid receptor antagonist (e.g. spironolacton)
  • SGLT-2 inhibitor (dapagliflozin or empagliflozin)
 
Step 3 (specialist treatment):
  • Ivabradine, recommended if all the following are met:
    • NYHA 2-4
    • Sinus rhythm >75 bpm
    • LVEF <35%
  • Sacubitril valsartan, recommended if all the following are met:
    • NYHA 2-4
    • LVEF <35%
  • Hydralazine + nitrate, especially if Afro-Caribbean origin + NYHA 3-4 + ↓ LVEF
  • Digoxin – useful if concomitant atrial fibrillation
 
 

All recommends drugs are prognostic (i.e. reduces mortality in HFrEF), with the exception of loop diuretics and digoxin.

All patients should receive:
  • Loop diuretics only if there is any features of congestion and fluid retention (e.g. dyspnoea, limb oedema)
  • SGLT-2 inhibitor (dapagliflozin or empagliflozin)

 

Note other drugs used in HFrEF have no benefit in HfpEF / HfmrEF. 

The only prognostic drug in HFpEF and HFmrEF is SGLT-2 inhibitors.

The recommendations regarding use of ICDImplantable cardioverter defibrillator and CRTCardiac resynchronisation therapy in heart failure by NICE is complicated and overwhelming. One might benefit from learning the ESC class I recommendations:
  • CRTCardiac resynchronisation therapy – ESC class I recommendation:
    • NYHA class II-IV, AND
    • LVEFLeft ventricular ejection fraction ≤35%, AND
    • QRS ≥150 ms with LBBBLeft bundle branch block
 
  • ICDImplantable cardioverter defibrillator
    • ESC class I recommendation: NYHA class II-IV + LVEFLeft ventricular ejection fraction ≤35% due to myocardial infarction, despite 3 months of optimised medical therapy
    • ESC class I recommendation for secondary prevention:
      • Survivor of cardiac arrest due to VTVentricular tachycardia / VFVentricular fibrillation, that is not due to transient or reversible cause (e.g. acute MI and electrolyte disturbances)
      • Patients with sustained VTVentricular tachycardia and structural heart disease

Other:
  • Coronary revascularisation – do not routinely offer in HFrEF and concurrent coronary artery disease
  • Cardiac transplantation – consider in severe refractory symptoms or refractory cardiogenic shock

Original guidelines

Author: Noah Thomaidis
Reviewer:
Last edited: 28/07/25