GP · cardiovascular-health
Heart failure
Also known as Congestive cardiac failure · CCF · HFrEF · HFpEF
GP-fellowship guide to heart failure: EF-band definitions (HFrEF, HFmrEF, HFpEF), BNP rule-out thresholds and echo diagnosis, the four HFrEF pillars with quantified mortality benefits (ARNI/ACEI, evidence-based beta-blockers, MRA, SGLT2i), rapid titration per STRONG-HF, device criteria (ICD EF≤35, CRT), the HFpEF SGLT2i breakthrough (EMPEROR-Preserved, DELIVER), IV iron for iron deficiency, community decompensation triggers, monitoring and palliative overlap.
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Red flags
- Acute dyspnoea with orthopnoea, crackles and raised JVP is acute decompensation — nitrates and oxygen while arranging hospital transfer; do not start new oral therapy and send home
- Heart failure plus fever, new murmur or injection history — endocarditis until excluded
- Symptoms of low output (cold peripheries, confusion, oliguria) with worsening renal function on ACEI/MRA — cardiorenal shutdown needs same-day review
- Syncope in a patient with LVEF 35% or less — arrhythmic risk assessment before routine follow-up
Overview
Heart failure is a clinical syndrome — breathlessness, fatigue and fluid retention from structural or functional cardiac abnormality. It is classified by ejection fraction: HFrEF (EF ≤40%), HFmrEF (41–49%), and HFpEF (≥50%). The classification matters because disease-modifying drug evidence differs sharply between bands. [9]
Diagnosis rests on symptoms plus natriuretic peptides plus echocardiography. In the emergency department study of 1586 dyspnoeic patients, BNP at a cutoff of 100 pg/mL achieved 83.4% diagnostic accuracy, and levels below 50 pg/mL carried a 96% negative predictive value — making a low peptide one of medicine's better rule-outs.[9] Echo then establishes EF banding, structure and aetiology.
References12ShowHide
- [1]McMurray JJV, Packer M, Desai AS, et al. Angiotensin-neprilysin inhibition versus enalapril in heart failure N Engl J Med, 2014.PMID 25176015
- [2]McMurray JJV, Solomon SD, Inzucchi SE, et al. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction (DAPA-HF) N Engl J Med, 2019.PMID 31535829
- [3]Packer M, Anker SD, Butler J, et al. Cardiovascular and Renal Outcomes with Empagliflozin in Heart Failure (EMPEROR-Reduced) N Engl J Med, 2020.PMID 32865377
- [4]Anker SD, Butler J, Filippatos G, et al. Empagliflozin in Heart Failure with a Preserved Ejection Fraction (EMPEROR-Preserved) N Engl J Med, 2021.PMID 34449189
- [5]Solomon SD, McMurray JJV, Claggett B, et al. Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) N Engl J Med, 2022.PMID 36027570
- [6]Mebazaa A, Davison B, Chioncel O, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure: the STRONG-HF randomised trial Lancet, 2022.PMID 36356631
- [7]Anker SD, Comin Colet J, Filippatos G, et al. Ferric carboxymaltose in patients with heart failure and iron deficiency (FAIR-HF) N Engl J Med, 2009.PMID 19920054
- [8]Pitt B, Pfeffer MA, Assmann SF, et al. Spironolactone for heart failure with preserved ejection fraction (TOPCAT) N Engl J Med, 2014.PMID 24716680
- [9]Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure N Engl J Med, 2002.PMID 12124404
- [10]Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure (SCD-HeFT) N Engl J Med, 2005.PMID 15659722
- [11]Cleland JGF, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure (CARE-HF) N Engl J Med, 2005.PMID 15753115
- [12]MERIT-HF Study Group Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF) Lancet, 1999.PMID 10376614