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.
