Heart Failure

HF-rEF & HF-pEF

• Heart failure with reduced ejection fraction (HF-rEF) = systolic heart failure -> EF<40% -> It is from impaired contractility 

• Heart failure with preserved ejection fraction (HF-pEF) = diastolic heart failure. Diagnosis

Three domains: 1. Functional, 2. Morphological, & 3. Biomarkers

HF-pEF is from impaired cardiac relaxation due to ventricular stiffness, resulting in poor cardiac filling and elevated diastolic pressure -> results in fluid overload (like right ventricular failure). It’s a clinical + structural + functional + biomarker diagnosis. You cannot diagnose HFpEF without HF symptoms/signs. Typical:

Exertional dyspnoea

Orthopnoea / PND

Exercise intolerance

Peripheral oedema

Recurrent “pulmonary oedema with normal EF”

If asymptomatic → no HFpEF, no matter what the echo shows. Preserved EF (mandatory), Structural heart disease (Left atrial enlargement), + diastolic dysfunction on echo, elevated biomarkers (ProBNP; also be cautious: It can be normal in obesity. Elevated in AF even without HF) - To make diagnosis

BNP

B-type Natriuretic Peptide (BNP) => Natriuresis + diuresis + Vasodilation + RAAS & sympathetic inhibition => Diagnose heart failure in dyspnoea (>400). BNP reflects wall stress, not EF. BNP rises with:

• Sepsis (myocardial depression + cytokines)

• Renal failure (reduced clearance)

• Pulmonary HTN / PE

• AF, elderly

BNP good for rule-out, mediocre for rule-in. Low BNP rules out HF. High BNP means myocardial stress — not automatically HF. Always correlate with clinical picture + bedside echo.

BNP

B-type Natriuretic Peptide (BNP) => Natriuresis + diuresis + Vasodilation + RAAS & sympathetic inhibition => Diagnose heart failure in dyspnoea (>400). BNP reflects wall stress, not EF. BNP rises with:

• Sepsis (myocardial depression + cytokines)

• Renal failure (reduced clearance)

• Pulmonary HTN / PE

• AF, elderly

BNP good for rule-out, mediocre for rule-in. Low BNP rules out HF. High BNP means myocardial stress — not automatically HF. Always correlate with clinical picture + bedside echo.

Questions:

1. This patient has symptomatic HFrEF (exertional dyspnoea, EF 35%) and is already on an ACE inhibitor. The next disease-modifying therapy with prognostic benefit is beta-blocker such as Bisoprolol/Carvedilol

2. Disease-modifying therapy will be optimised once the patient is euvolemic

3. Advanced HFrEF, now symptoms at rest (NYHA IV), Clear fluid overload, already on 3 core drugs: ACE-I (ramipril),B Βlocker (bisoprolol), Loop diuretic (furosemide). Which drug next? (Not “more diuresis” or “BP control” or Not rhythm drugs.) => Spironolactone (next disease-modifying agent.RALES trial).

Counteracts aldosterone-mediated myocardial fibrosis & remodelling: 

When ACE-I + beta-blocker aren’t enough in HFrEF → add an MRA.