1. Background information

a. Definition

Clinical syndrome of typical symptoms (e.g. breathlessness, fatigue) ± signs (e.g. oedema) due to structural or functional cardiac abnormality, resulting in reduced cardiac output and/or raised intracardiac pressures.

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b. Clinical classification (AKT high-yield)

By Ejection Fraction

• HFrEF (≤40%) – systolic dysfunction
• HFmrEF (41–49%)
• HFpEF (≥50%) – diastolic dysfunction

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By symptom severity (NYHA)

• I: No limitation
• II: Mild
• III: Marked
• IV: Symptoms at rest

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Acute vs Chronic

• Chronic HF (stable/progressive)
• Acute HF (e.g. pulmonary oedema – emergency)

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c. Aetiopathophysiology

Common causes

• Ischaemic heart disease (most common)
• Hypertension
• Valvular disease
• Cardiomyopathy
• Arrhythmias (e.g. AF)

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Pathophysiology (AKT concept)

• ↓ cardiac output → activation of:
  • RAAS
  • Sympathetic nervous system
• → vasoconstriction + fluid retention → worsens HF cycle

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2. Assessment

a. Clinical presentation

Symptoms

• Breathlessness (exertional → orthopnoea → PND)
• Fatigue
• Reduced exercise tolerance
• Ankle swelling

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Signs

• Elevated JVP
• Peripheral oedema
• Bibasal crackles
• Displaced apex beat
• S3 gallop

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AKT clues

• Orthopnoea = highly suggestive
• Rapid weight gain = fluid overload

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b. Relevant investigations (NICE pathway)

Initial test (AKT classic)

• NT-proBNP
  • <400 → HF unlikely
  • 400–2000 → echo within 6 weeks
  • 2000 → urgent echo within 2 weeks

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Confirmatory

• Echocardiogram → defines EF + cause

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Additional tests

• ECG
• CXR (cardiomegaly, pulmonary oedema)
• Bloods:
  • FBC (anaemia)
  • U&Es (renal function)
  • TFTs
  • LFTs

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3. Management (UK NICE CKS-based)

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a. Emergency care (Acute HF / Pulmonary oedema)

ABCDE approach

Immediate management

• Oxygen (if hypoxic)
• IV loop diuretic (e.g. furosemide)
• Nitrates (if hypertensive)
• Consider CPAP

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Key AKT point

• Morphine rarely used now (exam trap)

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b. Referral

NICE thresholds

• NT-proBNP >2000 → urgent specialist review (2 weeks)
• NT-proBNP 400–2000 → 6-week referral

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Refer if:

• Suspected HF (new diagnosis)
• Severe symptoms
• Diagnostic uncertainty
• Consider device therapy (ICD/CRT)

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c. Primary care management (chronic HF)

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1. Lifestyle + general measures

• Fluid/salt restriction
• Daily weights
• Vaccination (flu, pneumococcal)
• Exercise (cardiac rehab)

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2. Pharmacological management (HFrEF – AKT core)

First-line backbone:

• ACE inhibitor (or ARB)
• Beta-blocker

→ Add if ongoing symptoms:

• MRA (spironolactone)

→ Now guideline expansion:

• SGLT2 inhibitor (e.g. dapagliflozin)

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Step-up options

• ARNI (sacubitril/valsartan)
• Ivabradine (if sinus tachycardia)
• Digoxin (symptom control)

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HFpEF

• No mortality benefit drugs
• Treat comorbidities (HTN, AF, fluid overload)

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3. Monitoring (AKT practical)

• U&Es after starting ACEi/MRA
• Weight + symptoms regularly
• Review functional status

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4. Devices / specialist care

• ICD → prevent sudden cardiac death
• CRT → dyssynchrony

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AKT Exam Pearls

• NT-proBNP = first-line test in primary care
• Echo confirms diagnosis
• ACEi + beta-blocker = cornerstone
• Add MRA + SGLT2 inhibitor early
• HF = high mortality → treat aggressively
• Always consider ischaemic cause