Chronic Heart Failure (CHF)

🔍 When to Suspect

Breathlessness (on exertion, orthopnoea, PND), fatigue, and ankle swelling, particularly in patients with a history of 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. The core symptoms are 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; a history of heavy alcohol intake, cardiotoxic chemotherapy (for example anthracyclines or trastuzumab), or a family history of cardiomyopathy or sudden cardiac death raises suspicion further. The key primary-care skills are twofold: 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
HFrEF – reduced	≤ 40%	The phenotype that responds to the four pillars of prognostic therapy
HFmrEF – mildly reduced	41–49%	Increasingly managed with the same four-pillar approach as HFrEF
HFpEF – preserved	≥ 50%	Treat with an SGLT2 inhibitor and an MRA, plus aggressive comorbidity control

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

Source: NICE NG106 · NICE QS9

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