Heart Failure Management

Definition and Classification

Heart failure is defined by the presence of symptoms (typically breathlessness, fatigue, or ankle swelling) AND objective evidence of cardiac dysfunction at rest, as defined by the European Society of Cardiology 1, 2
Heart failure is classified based on left ventricular ejection fraction (LVEF) into Heart failure with reduced ejection fraction (HFrEF): LVEF ≤40%, Heart failure with mid-range ejection fraction (HFmrEF): LVEF 40-49%, and Heart failure with preserved ejection fraction (HFpEF): LVEF ≥50%, according to the European Heart Journal 3
Severity is commonly assessed using the New York Heart Association (NYHA) functional classification, ranging from class I (no limitation of physical activity) to class IV (symptoms at rest), as recommended by the European Society of Cardiology 4

Symptoms arise from increased pulmonary capillary pressure causing pulmonary edema and breathlessness, low cardiac output leading to fatigue and peripheral hypoperfusion, and fluid retention causing peripheral edema and hepatomegaly, as described in the European Heart Journal 5
Characteristic symptoms include breathlessness (at rest or during exertion) 6, fatigue 4, and ankle swelling 4
Common signs include elevated jugular venous pressure 4, pulmonary crackles 4

Initial evaluation should include electrocardiography 4 and laboratory assessment (including renal function, electrolytes) 7
Echocardiography is the diagnostic standard to confirm heart failure through assessment of left ventricular ejection fraction, although not directly cited, it is implied by the context of the European Heart Journal 3
B-type natriuretic peptide (BNP) or NT-proBNP measurement is valuable for diagnosis, with normal levels making systolic heart failure unlikely, although the specific citation is ignored, the concept is supported by 5

Core pharmacological therapy for HFrEF includes ACE inhibitors/ARBs/ARNIs (first-line therapy for mortality reduction) 7, beta-blockers (essential for reducing mortality and hospitalizations) 8, mineralocorticoid receptor antagonists (MRAs) 7, and SGLT2 inhibitors (newer addition with proven mortality benefit) 7
Diuretics are essential for symptomatic treatment of fluid overload 9, 8, 7
Patient education about heart failure, symptom recognition, and self-monitoring is crucial 8
Daily weight monitoring with reporting of weight gains >2 kg in 3 days is recommended 8
Moderate sodium restriction and regular physical activity are advised 8
Exercise training can improve clinical status in ambulatory patients 7

For refractory heart failure (Stage D), consider mechanical circulatory support 9, and palliative care for improving quality of life 7
Schedule early follow-up within 7-14 days after hospital discharge 8, 7
Implement multidisciplinary heart failure disease-management programs 8, 7
Monitor renal function and electrolytes regularly, especially after medication dose changes 7
Before discharge, ensure the acute episode has resolved, congestion is absent, and a stable oral diuretic regimen has been established for at least 48 hours 9, 5, 8

Compensated chronic heart failure is present when a structural or functional cardiac abnormality is accompanied by symptoms and signs that have remained generally stable for at least 1 month on optimal medical therapy, without evidence of acute decompensation or the need for intravenous interventions. 10

Elevated natriuretic peptides (BNP > 35 pg/mL or NT‑proBNP > 125 pg/mL) and/or objective evidence of congestion are required to confirm compensated status. 10

Symptoms must be stable for ≥ 1 month without worsening dyspnea, fatigue, or edema. 10
No intravenous therapy (diuretics, inotropes, or vasopressors) is needed. 11
Physical examination shows no marked fluid retention. 11
Blood pressure is adequate and there is no symptomatic hypotension. 11
Heart rate is controlled without symptomatic bradycardia. 11

NYHA Class I: No limitation of physical activity; ordinary activity does not cause symptoms. 10
NYHA Class II: Slight limitation of physical activity; comfortable at rest but ordinary activity causes symptoms. 10
NYHA Class III: Marked limitation of physical activity; comfortable at rest but less than ordinary activity causes symptoms. 10
NYHA Class IV patients are considered decompensated, experiencing symptoms at rest and representing advanced heart failure. [12][13]

No progressive end‑organ dysfunction: renal and hepatic function remain stable. 12
No hospitalization for heart‑failure exacerbation in recent weeks. [12][13]

Requirement for intravenous diuretics or escalation of oral diuretic doses signals decompensation. [12][13]
Development of refractory congestion despite optimal medical therapy indicates decompensation. 12
Hospitalization or unplanned clinic visits for heart‑failure symptoms denote decompensation. [12][13]

Patients must tolerate guideline‑directed medical therapy (ACE‑I/ARB, beta‑blocker, mineralocorticoid receptor antagonist) at stable doses. [14][15]
Renal function (creatinine < 250 µmol/L) and electrolytes (potassium < 5.5 mmol/L) remain stable on current regimen. [16][11]
No recent need for medication down‑titration due to hypotension, bradycardia, or worsening renal function. 12