Doctors Revision

Cardiovascular System

Heart Failure

A clinical syndrome where the heart cannot pump sufficient blood to meet the body's metabolic needs, or can only do so at elevated filling pressures. Can be acute or chronic, left-sided, right-sided, or biventricular.

Also known as: HF, Congestive Heart Failure, CCF, Cardiac Failure

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Referral and warning signs

When to refer

Refer to cardiologist/specialist (H/RR) for: New diagnosis of HF for etiological workup (esp. Echo). Acute decompensation requiring hospitalisation. Refractory symptoms despite optimal medical therapy. Consideration for advanced therapies (devices, transplant). Significant arrhythmias. Severe valvular disease.

Red flags

  • Acute onset severe dyspnoea, orthopnea, frothy sputum (Pulmonary Oedema)
  • Chest pain (possible ACS)
  • Syncope or pre-syncope
  • Signs of cardiogenic shock (hypotension, cool peripheries, altered mental status)
  • Significant worsening of renal function or hyperkalaemia
  • Symptomatic bradycardia or ventricular arrhythmias

Signs and symptoms

  • Dyspnoea (shortness of breath): On exertion (early), at rest, orthopnea (worse lying flat), paroxysmal nocturnal dyspnoea (PND - waking breathless at night).
  • Fatigue, exercise intolerance, weakness.
  • Fluid retention: Peripheral oedema (ankles, legs, sacrum), weight gain, ascites, pleural effusion.
  • Cough (often worse at night, may be productive of frothy sputum - see Pulmonary Oedema).
  • Wheezing ('cardiac asthma').
  • Palpitations, tachycardia.
  • Raised Jugular Venous Pressure (JVP).
  • Cardiomegaly (enlarged heart - displaced apex beat).
  • Third heart sound (S3 gallop).
  • Basal lung crepitations (crackles).
  • Hepatomegaly (enlarged, tender liver).
  • Infants/Young Children: Respiratory distress (tachypnea, recessions), feeding difficulties, poor weight gain, sweating, tachycardia, hepatomegaly.

Risk factors

  • Hypertension (leading cause)
  • Ischaemic Heart Disease / Myocardial Infarction
  • Valvular Heart Disease (Rheumatic Heart Disease, degenerative)
  • Cardiomyopathy (dilated, hypertrophic, restrictive)
  • Myocarditis (viral, other)
  • Arrhythmias (prolonged tachycardia, atrial fibrillation)
  • Congenital Heart Disease
  • Severe Anaemia
  • Thyroid Disease (hyper- or hypothyroidism)
  • Chronic Kidney Disease
  • Diabetes Mellitus
  • Obesity
  • Excessive alcohol consumption
  • Certain medications (e.g., some chemotherapy, NSAIDs)

Diagnosis

Clinical assessment

Diagnosis based on characteristic symptoms (dyspnoea, fatigue, fluid retention) and signs (raised JVP, oedema, S3 gallop, crepitations, hepatomegaly). Framingham criteria can aid diagnosis. Differentiate from other causes of dyspnoea (lung disease - COPD, asthma, pneumonia, PE) and oedema (renal disease, liver disease, venous insufficiency, malnutrition).

Investigations

  • Chest X-ray: Cardiomegaly, pulmonary venous congestion (upper lobe diversion), interstitial oedema (Kerley B lines), pleural effusions.
  • ECG: May show underlying cause (MI, LVH, arrhythmia) or non-specific changes.
  • Echocardiogram: Key investigation. Assesses cardiac structure, chamber size, wall thickness, valve function, ejection fraction (EF), diastolic function. Helps determine cause and severity.
  • Blood tests: CBC (anaemia), Urea & Electrolytes (renal function, electrolyte imbalance due to diuretics), LFTs (liver congestion), Thyroid function tests, BNP/NT-proBNP (elevated levels support HF diagnosis, useful for prognosis/monitoring).
  • Urinalysis (rule out nephrotic syndrome).

Diagnostic criteria

Clinical diagnosis based on symptoms and signs, supported by investigations like Chest X-ray and especially Echocardiography.

Management

Non-pharmacological management

  • Lifestyle Modification: Salt restriction (<2g/day), Fluid restriction (1-1.5 L/day in severe HF), Weight monitoring (daily), Smoking cessation, Limit alcohol intake, Regular moderate exercise (as tolerated).
  • Patient Education: Understanding HF, symptom monitoring, medication adherence, diet/fluid restrictions.
  • Acute Decompensation: Bed rest with head elevated, oxygen therapy (if hypoxic), manage precipitating factors.
  • Chronic Management: Address underlying cause, manage co-morbidities.
  • Vaccinations: Influenza and pneumococcal vaccinations recommended.

Pharmacological treatment

  • Diuretics (for fluid overload/congestion):
  • - Loop diuretics: Furosemide 20-80mg daily (oral or IV in acute setting), titrate dose to achieve euvolemia. Higher doses may be needed. Child: 1mg/kg daily or BID (max 8mg/kg/day).
  • - Thiazide diuretics (e.g., Hydrochlorothiazide): Less potent, may be added in resistant oedema (specialist).
  • ACE Inhibitors (ACEi) or Angiotensin Receptor Blockers (ARBs) (Cornerstone for HFrEF - HF with reduced EF):
  • - Start low, titrate up as tolerated. Examples: Enalapril 2.5mg OD -> target 10-20mg BID; Lisinopril 5mg OD -> target 20-40mg OD; Captopril 6.25mg TID -> target 50mg TID. ARBs (Losartan, Valsartan) if ACEi intolerant (cough).
  • - Child: Enalapril 0.1-1mg/kg/day; Captopril 0.1-0.3mg/kg Q8-12H.
  • - Monitor BP, renal function, potassium.
  • Beta-Blockers (BB) (Cornerstone for HFrEF, introduce when stable):
  • - Start very low dose, titrate slowly (every 2-4 weeks) as tolerated. Proven benefit: Carvedilol, Bisoprolol, Metoprolol Succinate (long-acting).
  • - Examples: Carvedilol 3.125mg BID -> target 25mg BID; Bisoprolol 1.25mg OD -> target 10mg OD.
  • - Child: Carvedilol 0.05mg/kg BID -> max 0.35mg/kg BID.
  • - Monitor HR, BP, signs of worsening HF during titration.
  • Mineralocorticoid Receptor Antagonists (MRAs) (for symptomatic HFrEF despite ACEi/BB):
  • - Spironolactone 25-50mg OD OR Eplerenone.
  • - Child: Spironolactone 1.5-3mg/kg/day.
  • - Monitor potassium and renal function.
  • Digoxin (for rate control in AF with HF, or persistent symptoms in HFrEF despite optimal therapy):
  • - Dose 125-250 mcg OD (lower in elderly/renal impairment).
  • - Child: Loading (rarely used), Maintenance 10-15 mcg/kg/day.
  • - Monitor for toxicity (nausea, vomiting, vision changes, arrhythmias).
  • Other therapies (Specialist): Ivabradine, ARNI (Sacubitril/Valsartan), SGLT2 inhibitors, Hydralazine/Nitrates (in specific populations).

Monitoring

  • Monitor symptoms, functional status, weight, volume status (JVP, oedema, lung sounds).
  • Monitor BP, heart rate.
  • Monitor electrolytes (esp. potassium) and renal function regularly, especially after initiating/titrating ACEi/ARB/MRA/diuretics.
  • Periodic ECG, Echocardiogram.
  • Monitor for digoxin toxicity if applicable.

Complications

  • Acute decompensation / Pulmonary oedema
  • Arrhythmias (Atrial Fibrillation, Ventricular Tachycardia)
  • Thromboembolism (Stroke, PE, DVT)
  • Cardiorenal syndrome (worsening renal function)
  • Cachexia (severe weight loss)
  • Sudden cardiac death
  • Liver dysfunction (congestive hepatopathy)
  • Depression

Prevention

  • Control of risk factors: Hypertension, diabetes, dyslipidemia.
  • Treatment of underlying causes: Ischaemic heart disease, valvular disease.
  • Lifestyle modification: Healthy diet, exercise, smoking cessation, limit alcohol.
  • Adherence to prescribed medications.

Patient education

  • Explain heart failure, its chronic nature, and goals of management.
  • Educate on medications: purpose, dose, potential side effects, importance of adherence.
  • Teach symptom monitoring: daily weight checks, recognizing worsening dyspnoea/oedema, when to seek help.
  • Dietary advice: Sodium restriction, fluid restriction (if advised).
  • Activity recommendations: Encourage regular exercise within limits.
  • Importance of vaccinations (flu, pneumococcus).
  • Smoking cessation and alcohol limitation.

Uganda-specific notes

Hypertension and Rheumatic Heart Disease are major causes. Access to echocardiography and specialist care is limited. Focus on clinical diagnosis, managing fluid overload (Furosemide), and initiating ACE inhibitors where possible. Beta-blockers and MRAs may be less available or harder to monitor.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 4, Section 4.1.3

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