Heart Failure Made Simple: Early Signs, NYHA Classification & Treatment Algorithm

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--- # ✅ **1. Definition** **Heart Failure (HF)** = A **clinical syndrome** where the heart cannot pump adequately to meet metabolic needs or can do so only with increased filling pressures. Types: * **HFrEF** – LVEF < 40% * **HFmrEF** – LVEF 40–49% * **HFpEF** – LVEF ≥ 50% with diastolic dysfunction --- # ✅ **2. Pathophysiology (Simple & High-yield)** 1. **Myocardial injury** → ↓ Contractility or stiff ventricle 2. → ↓ Cardiac Output → ↑ SNS, RAAS, ADH 3. → Vasoconstriction + Na/H₂O retention → ↑ Preload & Afterload 4. → Ventricular remodeling (dilation/hypertrophy) → worsening HF 5. **Pulmonary congestion** (left HF) / **systemic congestion** (right HF) --- # ✅ **3. Causes / Triggers** ### **Left-sided HF** * Ischemic heart disease / MI * Hypertension * Dilated / hypertrophic cardiomyopathy * Valvular lesions (MR, AS) * Arrhythmias ### **Right-sided HF** * Left HF (most common) * COPD, pulmonary hypertension, PE * RV infarction * Congenital heart disease ### **Common Acute Triggers** * Infection * Anemia * Arrhythmias (AF) * Excess salt/water * Uncontrolled hypertension * Medication non-adherence * Drugs: NSAIDs, steroids, verapamil/diltiazem in HFrEF --- # ✅ **4. Early Signs & Symptoms (Simple Screening)** ### **Earliest Symptoms** * **Exertional breathlessness** * **Fatigue / reduced exercise capacity** * **Orthopnea** (needs extra pillows) * **Paroxysmal nocturnal dyspnea (PND)** ### **Later Symptoms** * Bilateral pedal edema * Abdominal distension, ascites * Nocturia * Palpitations * Cough with frothy sputum ### **Signs** * Tachycardia * S3 gallop * Elevated JVP * Basal crepitations * Hepatomegaly * Cool extremities (low output HF) --- # ✅ **5. NYHA Classification (Very Exam-Friendly)** | **Class** | **Symptoms** | | --------- | ------------------------------------------------------------------------ | | **I** | No limitation of physical activity. Ordinary activity → **no symptoms**. | | **II** | Mild limitation. Ordinary activity → **fatigue, dyspnea, palpitations**. | | **III** | Marked limitation. Less than ordinary activity → symptoms. | | **IV** | Symptoms **at rest**; unable to carry out physical activity. | --- # ✅ **6. Investigations & Diagnosis** ### **Essential** * **Echocardiography (gold standard)** → EF, chamber size, valves * **BNP / NT-proBNP elevated** * **ECG** → LVH, MI, arrhythmias * **Chest X-ray** → cardiomegaly, pulmonary edema, Kerley B lines ### **Blood tests** * CBC (anemia), LFT, KFT, TSH * Serum electrolytes * Troponins in acute settings --- # ✅ **7. Differential Diagnoses** * COPD / asthma exacerbation * Pneumonia * Pulmonary embolism * Nephrotic syndrome * Cirrhosis with ascites * Renal failure --- # ✅ **8. Treatment Algorithm (Stepwise, Simple)** ### **A. Acute Decompensated HF (ADHF)** – “LMNOP” * **L**asix (Furosemide) * **M**orphine (rarely used now; caution) * **N**itrates * **O**xygen * **P**osition upright Add: Non-invasive ventilation if needed, treat the trigger. --- # **B. Chronic HFrEF – Golden 4 Pillars (All must be started)** ### **1. ARNI / ACEI / ARB** * ↓ Mortality, ↓ hospitalization * Preferred: **Sacubitril + Valsartan (ARNI)** ### **2. Beta-blockers** * **Metoprolol succinate**, **Bisoprolol**, **Carvedilol** * Start low, titrate every 2 weeks ### **3. Mineralocorticoid Antagonist** * **Spironolactone** / **Eplerenone** * ↓ Mortality ### **4. SGLT2 Inhibitor** * **Dapagliflozin** / **Empagliflozin** * Works in diabetic & non-diabetic HF --- ### **Other Add-ons** * **Diuretics** (symptom relief) * **Ivabradine** (if HR > 70 despite beta-blocker) * **Hydralazine + Nitrates** (African ancestry or ACEI intolerance) * **Digoxin** (AF + HF, reduces hospitalizations) --- ### **HFpEF Treatment** * Control BP * Diuretics for congestion * Treat AF, ischemia * SGLT2 inhibitors (proven benefit) --- # ✅ **9. Drug Details (Complete & High Yield)** --- ## **A. ARNI – Sacubitril/Valsartan** **Indication:** HFrEF **MOA:** * Sacubitril → neprilysin inhibitor → ↑ natriuretic peptides * Valsartan → ARB → blocks AT1 receptor **Dose:** Start 24/26 mg BID → target 97/103 mg BID **PK:** Hepatic metabolism; renal excretion **Common AEs:** Hypotension, hyperkalemia **Serious AEs:** Angioedema **Contra:** ACEI within 36 hrs, pregnancy **Interactions:** Avoid ACEI, K⁺-sparing drugs **Monitoring:** K⁺, creatinine, BP **Counselling:** Rise slowly; avoid salt substitutes --- ## **B. Beta-blocker – Metoprolol Succinate** **Indication:** HFrEF, post-MI **MOA:** β1 blockade → ↓ HR, ↓ arrhythmias **Dose:** Start 12.5–25 mg daily → up to 200 mg **AEs:** Bradycardia, fatigue **Contra:** Acute decompensated HF, heart block **Monitoring:** HR, BP **Counselling:** Don’t stop suddenly --- ## **C. Spironolactone** **Indication:** HFrEF **MOA:** Aldosterone antagonist **Dose:** 12.5–25 mg daily **AEs:** Hyperkalemia, gynecomastia **Contra:** K⁺ > 5.0, CrCl < 30 **Monitoring:** K⁺, creatinine **Counselling:** Avoid high-potassium foods --- ## **D. SGLT2 Inhibitors (Dapagliflozin)** **Indication:** HFrEF & HFpEF **MOA:** ↑ urinary glucose & sodium excretion → ↓ preload/afterload **Dose:** 10 mg daily **AEs:** UTI, genital infections, dehydration **Monitoring:** Renal function **Counselling:** Hydration, hygiene --- ## **E. Furosemide** **Indication:** Congestion **MOA:** Loop diuretic → natriuresis **Dose:** 20–80 mg/day, titrate **AEs:** Hypokalemia, ototoxicity **Monitoring:** K⁺, weight **Counselling:** Daily morning dose; monitor weight --- ## **F. Ivabradine** **Indication:** HR >70 despite β-blocker **MOA:** SA node “funny current” blocker **Dose:** 5 mg BID **AEs:** Luminous phenomena, bradycardia --- # ✅ **10. Monitoring Parameters** * BP, HR * Daily weights * Symptoms (NYHA class) * Serum K⁺, sodium * Creatinine * BNP trend * Echocardiography every 6–12 months --- # ✅ **11. Patient Counselling (Simple Points)** * Salt restriction: **<2 g/day** * Fluid restriction: **<1.5–2 L/day** if hyponatremic * Daily weight monitoring * Avoid NSAIDs * Vaccinations: influenza, pneumococcal * Regular exercise (cardiac rehab) ---