Heart failure is a critical cardiovascular condition in which the heart fails to pump blood adequately to meet the body’s metabolic demands. It is broadly classified into systolic (forward) failure and diastolic (filling) failure, with further subtypes including right-sided and left-sided heart failure.
Types of Heart Failure
1. Systolic Heart Failure (Forward Failure)
Systolic failure occurs when the heart is unable to effectively pump blood out, often due to a weakened or dilated myocardium. Causes include:
- Myocardial infarction (dead heart tissue)
- Valve regurgitation (leaky valves)
- Weak cardiac muscles (from alcohol, drugs, or hypertension)
2. Diastolic Heart Failure (Filling Failure)
In diastolic failure, the heart cannot fill properly due to stiff or thickened walls. Common causes include:
- Hypertrophic cardiomyopathy
- Constrictive pericarditis
- Restrictive cardiomyopathy
Right-Sided vs Left-Sided Heart Failure
Right-Sided Heart Failure: Signs
Occurs when the right heart fails to pump blood to the lungs, leading to systemic venous congestion. Signs include:
- Peripheral edema (leg swelling)
- Ascites
- Jugular venous distension (JVD)
- Hepatosplenomegaly
- GI symptoms like nausea and bloating
Left-Sided Heart Failure: Symptoms
Occurs when the left heart cannot pump blood to the body, causing pulmonary congestion. Symptoms include:
- Dyspnea (shortness of breath)
- Orthopnea
- Paroxysmal nocturnal dyspnea (PND)
- Cough with blood-tinged sputum
- Cold extremities and weak pulse
Key Investigations
- Echocardiography – Assesses ejection fraction (EF), wall motion, and valve integrity
- EF < 55% → Systolic heart failure
- EF > 55% → Diastolic heart failure
- Chest X-Ray – May show curly B lines, indicative of pulmonary edema
- ECG – Detects arrhythmias, ischemia, or hypertrophy
- BNP (Brain Natriuretic Peptide) – Elevated in decompensated heart failure
NYHA Classification and Management
Heart failure is classified into 4 classes based on severity (NYHA):
| Class | Symptoms | Treatment |
|---|---|---|
| I | No symptoms during ordinary activity | ACE inhibitors, Beta-blockers |
| II | Mild limitation, symptoms with exertion | Add loop diuretics (e.g. furosemide) |
| III | Marked limitation, symptoms during minimal activity | Add spironolactone or hydralazine–isosorbide dinitrate |
| IV | Symptoms at rest | Add inotropes (digoxin, dobutamine), consider palliative care |
⚠️ Inotropes like digoxin improve contractility but may increase mortality by overworking a failing heart.
Sudden Death Prevention
Patients with EF < 35% are at high risk of fatal arrhythmias. An Implantable Cardioverter Defibrillator (ICD) is recommended to detect and terminate these arrhythmias.
Lifestyle Modifications
- Sodium intake < 2g/day
- Fluid restriction < 2L/day
- Control blood pressure and glucose levels
- Avoid alcohol and NSAIDs
Mortality-Reducing Medications
- ACE inhibitors
- Beta-blockers (bisoprolol, carvedilol, metoprolol)
- Spironolactone
Summary
Heart failure can severely impair quality of life and carries a high mortality risk if untreated. Early diagnosis, accurate classification, evidence-based medications, and device therapy like ICDs can dramatically improve outcomes. A combination of clinical judgment, imaging, and lab workup is essential in guiding management.
