10 CHF (chronic heart failure) facts
We will now go through 10 facts about CHF (chronic heart failure).
Key Points
- Chronic heart failure (CHF) is a progressive condition where the heart is unable to pump blood effectively to meet the body’s needs. The commonest cause is ischaemic heart disease (IHD)
- It can be classified as heart failure with reduced ejection fraction (HFrEF), or heart failure with preserved ejection fraction (HFpEF)
- Symptoms include peripheral and pulmonary oedema (i.e. fluid retention) which present as shortness of breath, fatigue, and leg swelling
- Diagnosis is primarily clinical, supported by investigations such as echocardiography, blood tests (e.g., BNP/NT-proBNP), and ECG
- Management involves lifestyle modifications, pharmacotherapy (ACE inhibitors, beta-blockers, diuretics), and sometimes device therapy or surgery.
1. Definition
- Chronic heart failure (CHF) – or congestive cardiac/heart failure – is a clinical syndrome characterised by the heart’s inability to pump sufficient blood to meet the body’s metabolic demands.
- It can result from structural or functional abnormalities of the heart and leads to symptoms such as dyspnea, fatigue, and fluid retention.
- CHF can be classified based on left ventricular ejection fraction (LVEF):
- HFrEF: LVEF ≤ 40%
- HFpEF: LVEF ≥ 50%.
2. Epidemiology
- Prevalence: Approximately 1-2% of adults in the UK have heart failure, with the prevalence increasing with age (up to 10% in those over 70 years).
- Incidence: Around 200,000 new cases are diagnosed annually in the UK.
- Gender: Men are more likely to develop HFrEF, while HFpEF is more common in older women.
3. Risk Factors
- Age: Risk increases significantly with age.
- Hypertension: A major contributor to HFpEF.
- Ischaemic Heart Diseases (IHD): The most common cause of HFrEF.
- Diabetes Mellitus: Increases risk through mechanisms like diabetic cardiomyopathy.
- Obesity: Associated with HFpEF.
- Smoking: Contributes to IHD and other heart conditions.
- Previous Myocardial Infarction (MI): Can lead to impaired cardiac function.
- Chronic Kidney Disease (CKD): Linked to fluid overload and hypertension.
4. Causes
Common Causes of HFrEF
- Ischaemic Heart Disease: Ischaemic heart disease leading to myocardial damage.
- Hypertension: Leads to left ventricular hypertrophy and heart failure over time.
- Dilated Cardiomyopathy: Can be idiopathic, genetic, or secondary to toxins (e.g. alcohol, chemotherapy).
- Valvular Heart Disease: Conditions like aortic stenosis or mitral regurgitation.
- Congenital Heart Disease.
Common Causes of HFpEF
- Hypertension: Causes left ventricular hypertrophy, leading to diastolic dysfunction.
- Atrial Fibrillation: Loss of atrial contribution to ventricular filling.
- Aging: Structural and functional changes in the myocardium.
- Obesity and Diabetes: Contribute to metabolic syndrome and diastolic dysfunction.
5. Symptoms
- Shortness of breath: Particularly on exertion or lying flat (orthopnea). Nocturnal paroxysmal dyspnea (PND; waking up breathless) is also common.
- Cough: Can be frothy (+/- haemoptysis) in pulmonary oedema.
- Fatigue: Reduced exercise tolerance due to inadequate cardiac output.
- Peripheral Oedema: Swelling in the legs, ankles, and feet due to fluid retention.
- Chest Pain: May occur, particularly if underlying ischaemic heart disease is present.
- Palpitations: Due to arrhythmias such as atrial fibrillation.
- Weight Gain: Secondary to fluid retention.
6. Diagnosis
Clinical Assessment
- History: Inquire about SOB, fatigue, swelling, history of MI, hypertension, diabetes, and other comorbidities.
- Physical Examination: Look for signs such as raised jugular venous pressure (JVP), displaced apex beat, cardiac murmur(s) that indicate cause of CHF, bibasal lung crackles, hepatomegaly, and .peripheral/sacral oedema,
Investigation
- Blood Tests
- Natriuretic Peptides (BNP/NT-proBNP): Elevated levels suggest heart failure but can also be raised in other conditions like CKD. Useful for ruling out heart failure if levels are normal.
- Full Blood Count (FBC): To identify anaemia, which can exacerbate symptoms.
- Urea & Electrolytes: Assess for electrolyte disturbances and kidney function.
- Liver Function Tests (LFTs): To check for hepatic congestion.
- Thyroid Function Tests (TFTs): Hyperthyroidism or hypothyroidism can contribute to heart failure.
- Imaging
- Echocardiogram: Key investigation for assessing ejection fraction, wall motion abnormalities, valvular function, and ventricular hypertrophy.
- Chest x-ray: Can show cardiomegaly, pulmonary congestion, or pleural effusions.
- Electrocardiogram (ECG): To detect arrhythmias, ischaemia, or left ventricular hypertrophy.
Differential Diagnosis
- Chronic Obstructive Pulmonary Disease (COPD): Symptoms of breathlessness and wheezing can mimic heart failure.
- Pulmonary Embolism: Acute onset of dyspnea, chest pain, and hypoxia.
- Nephrotic Syndrome: Causes peripheral oedema, but without cardiac involvement. Pleural effusions occur bit not pulmonary oedema.
- Liver Cirrhosis: Can lead to ascites and peripheral oedema, but typically lacks cardiomegaly and pulmonary congestion.
- Chronic Kidney Disease: Patients may have a ‘cardiorenal syndrome’ duet o CHF and CKD, both due to atheroma (IHD and RVD).
7. Treatment
Lifestyle Modifications
- Smoking Cessation: Reduces cardiovascular risk.
- Diet: Low-sodium diet to manage fluid retention; maintain a healthy weight.
- Fluid restriction: Often neglected; can work well with diuretics.
- Exercise: Regular physical activity is recommended under supervision.
Pharmacological
- ACE Inhibitors (ACEIs) / Angiotensin II Receptor Blockers (ARBs): First-line therapy for HFrEF. They reduce mortality, improve symptoms, and slow disease progression.
- Beta-Blockers: Reduce heart rate, improve cardiac function, and reduce mortality. Examples include bisoprolol and carvedilol.
- Diuretics: For symptomatic relief of fluid retention. Loop diuretics (e.g. furosemide) are commonly used.
- Mineralocorticoid Receptor Antagonists (MRAs): Spironolactone or eplerenone can improve survival in HFrEF.
- SGLT2 Inhibitors: Newer class shown to benefit heart failure patients regardless of diabetes status (e.g. dapagliflozin).
- Ivabradine: For patients with HFrEF who are in sinus rhythm with a resting heart rate >70 bpm despite beta-blocker therapy.
Devices
- Implantable Cardioverter-Defibrillator (ICD): Indicated for patients at risk of sudden cardiac death.
- Cardiac Resynchronisation Therapy (CRT): For patients with ventricular dys-synchrony (e.g. left bundle branch block) and symptomatic heart failure despite optimal medical treatment.
Surgical
- Coronary Revascularisation: For ischaemic heart disease, coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) may be indicated.
- Valve Surgery: For patients with severe valvular heart disease contributing to heart failure.
- Heart Transplant: Reserved for end-stage heart failure when other treatments have failed.
8. Complications
- Acute Decompensated Heart Failure: Sudden worsening of symptoms, often requiring hospitalisation.
- Arrhythmias: Atrial fibrillation is common and can exacerbate symptoms.
- Renal Dysfunction: Heart failure can lead to reduced renal perfusion, worsening chronic kidney disease (cardiorenal syndrome).
- Thromboembolism: Increased risk of venous thromboembolism and stroke, especially in patients with atrial fibrillation.
- Cardiac Cachexia: Severe, unintentional weight loss due to advanced heart failure.
9. Prognosis
- Variable Outcomes: Prognosis depends on the severity, underlying cause, comorbidities, and response to treatment.
- Mortality: Approximately 80-90% of people live for one year, 50% for 5 years, and 30% for 10 years. I.e. the outlook is not as bad as the name sounds. Outcomes have improved with newer treatments.
- Frequent Hospital Admissions: Patients with chronic heart failure are at risk of repeated hospitalisations due to acute exacerbations.
10. Prevention
- Managing Risk Factors: Early treatment of hypertension, diabetes, and dyslipidemia to prevent the development of heart failure.
- Lifestyle Changes: Smoking cessation, regular exercise, and a heart-healthy diet.
- Monitoring and Regular Follow-up: Patients with known risk factors (e.g. post-MI, hypertension) should have regular check-ups and echocardiograms if indicated.
- Medication Adherence: Ensuring adherence to prescribed medication to manage underlying conditions and prevent progression.
Summary
We have described 10 facts about CHF (chronic heart failure). We hope it has been helpful.
Top Tip – Chronic Heart Failure
CHF (or CCF) is not a diagnosis. It is a syndrome with a cause. You need to find it.
