HEART FAILURE (HF)

A clinical syndrome that develops when the heart is unable to deliver blood and oxygen at the rate needed by the tissues, in spite of normal or increased filling pressures. Usually the left ventricle is enlarged and ventricular contraction is poor. The most common cause of HF in the UK is CHD (HF often occurs in survivors of acute MI), and about one-third of cases result from hypertensive heart disease. Others include cardiomyopathy, valve disease, arrhythmias and atrial fibrillation. HF carries a risk of sudden death, and evidence suggests that quality of life is worse than in most other common medical conditions. However, effective treatments for heart failure have been identified that control symptoms, improve quality of life and slow disease progression.

Presentation

• Shortness of breath/exhaustion, often at rest or with little exertion.
• Oedema: bilateral ankle oedema, generally worse at night/better in the morning; may advance to abdomen as HF worsens.
• Paroxysmal nocturnal dyspnoea: acute dyspnoea that wakes patient from sleep.
• Orthopnoea: dyspnoea on lying flat, which is relieved by sitting up (patients with HF often sleep with several pillows to reduce symptom).
• Bloating/nausea.
• Irregular pulse.
• Nocturnal polyuria: because of increased perfusion while supine.

Disease marker Circulating BNP (B-type natriuetic peptide) rises in proportion to disease severity. Measure N-terminal pro-B-type natriuretic peptide (NT-proBNP) in people with suspected heart failure. Very high levels of NT-proBNP are associated with a poor prognosis; refer people with suspected heart failure and an NT-proBNP level above 2,000 ng/l urgently. An NT-proBNP level below 400 ng/l makes a diagnosis of heart failure less likely. 

Diagnosis Diagnosis depends upon a combination of a good history, clinical observation, physical examination and test results. See below for NICE recommendations on the diagnosis of heart failure.

Download NICE guidance

Annual review

Patients with HF should be reviewed annually, with recent blood test results, urine test and blood pressure reading

• Assess symptoms/disease progression (see Appendix for NYHA classification).
• Review medication: side-effects, assess effectiveness of additions or alterations, and adherence; document by Read codes if contraindications or side-effects prevent use of recommended medications; re-issue prescription as appropriate
• Offer seasonal vaccination(s)
• Monitor/discuss lifestyle issues: smoking, BMI, daily physical activity, adequate rest, alcohol consumption, and dietary alteration necessary, e.g. in advanced heart failure restrict salt and fluid intake.
• Discuss concerns or worries. Consider sexual activity in relation to breathlessness, including in men erectile dysfunction as a result of condition or medication.
• Write management plan, if appropriate, to include symptom recognition (e.g. weight gain, worsening dyspnoea) and self management.
• Discuss fitness to drive in relation to latest Driver and Vehicle Licensing Authority DVLA regulations (See https://www.gov.uk/government/publications/at-a-glance)
• Assess presence of depression or suspected depression.
• Discuss role of local HF service, including specialist counsellor.
• Discuss support for patient and family.