Chronic Heart Failure (CHF)

🔍 When to Suspect

Breathlessness (on exertion, orthopnoea, paroxysmal nocturnal dyspnoea [PND]), fatigue, and ankle swelling, particularly in patients with a history of ischaemic heart disease (IHD) or hypertension

From the full topic in The Ocean Library: Chronic Heart Failure (CHF)

🧭 When to suspect

Suspect chronic heart failure in anyone with the cardinal triad captured by the BEAT-HF prompt – breathless, exhausted, ankle swelling? Time for a simple blood test.

• Core symptoms: breathlessness (on exertion or lying flat – orthopnoea), fatigue and peripheral oedema.

• Some patients describe waking suddenly at night gasping for breath (paroxysmal nocturnal dyspnoea).

The diagnosis is more likely against a background of ischaemic heart disease, hypertension, atrial fibrillation or diabetes. Suspicion is raised further by:

• A history of heavy alcohol intake

• Cardiotoxic chemotherapy (for example anthracyclines or trastuzumab)

• A family history of cardiomyopathy or sudden cardiac death

Use NT-proBNP as the gateway to diagnosis, and classify by ejection fraction, because the type of heart failure determines which drugs prolong life.

Type	Left ventricular ejection fraction (LVEF)	Note
Heart failure with reduced ejection fraction (HFrEF) – reduced	< 50%	• Responds to the four pillars of prognostic therapy • Now includes 41–49%, previously called mildly reduced (HFmrEF)
Heart failure with preserved ejection fraction (HFpEF) – preserved	≥ 50%	Treat with an SGLT2 inhibitor and an mineralocorticoid receptor antagonist (MRA), plus aggressive comorbidity control

Echocardiography is needed to assign the type: NT-proBNP does not differentiate between reduced and preserved ejection fraction.

• The 2026 European Society of Cardiology (ESC) guideline uses two types (reduced below 50%, preserved 50% or more) and retired the mildly reduced type (HFmrEF, 41–49%).

• It also stages heart failure from A to D: A at risk, B structural heart disease without symptoms, C symptomatic heart failure, D advanced heart failure.

• NICE funding decisions still set their own left ventricular ejection fraction (LVEF) criteria, e.g. finerenone needs LVEF ≥ 40% (TA1182), so check them when prescribing.

Source: NICE NG106 · NICE QS9 · ESC 2026

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