Cardiovascular













Chronic Heart Failure with Reduced Ejection Fraction (HFrEF)

Definition:

Chronic heart failure with reduced ejection fraction (HFrEF) is a type of heart failure where the heart muscle is weakened and cannot pump blood effectively. The ejection fraction (EF) is ≤ 40%.

Etiology:

  • IHD: Ischemic heart disease (most common)
  • HTN: Hypertension
  • DCM: Dilated cardiomyopathy
  • VHD: Valvular heart disease
  • Myocarditis: Inflammation of the heart muscle
  • Toxic: Alcohol, drugs (e.g., chemotherapy)
  • Metabolic: Diabetes, thyroid disorders

Pathophysiology:

  • Reduced Contractility: Decreased ability of the heart to contract
  • Increased Afterload: Resistance against which the heart must pump
  • Neurohormonal Activation: Compensatory mechanisms (e.g., RAAS, sympathetic nervous system) worsen the condition

Clinical Features:

Symptoms:

  • Dyspnea: Shortness of breath, especially on exertion
  • Orthopnea: Difficulty breathing when lying flat
  • PND: Paroxysmal nocturnal dyspnea
  • Fatigue: Persistent tiredness
  • Edema: Swelling in legs, ankles, and feet

Signs:

  • S3 Gallop: Third heart sound
  • Elevated JVP: Jugular venous pressure
  • Hepatomegaly: Enlarged liver
  • Ascites: Fluid accumulation in the abdomen
  • Pulmonary Rales: Crackles heard on lung auscultation

Diagnostic Investigations:

  • BNP/NT-proBNP: Biomarkers elevated in heart failure
  • Echocardiography: Gold standard for assessing ejection fraction
  • ECG: May show ischemia, hypertrophy, arrhythmias
  • CXR: Chest X-ray to assess heart size and pulmonary congestion
  • Lab Tests: CBC, electrolytes, renal function, LFTs, thyroid function

Management:

Mnemonic: "ABCDD"

  1. A - ACE Inhibitors / ARBs: First-line treatment; Reduces mortality and morbidity
  2. B - Beta-blockers: Improves survival; Reduces hospitalization
  3. C - CRT (Cardiac Resynchronization Therapy): For patients with wide QRS complex; Improves symptoms and reduces mortality
  4. D - Diuretics:
    • Spironolactone (MRA): Mineralocorticoid receptor antagonist; may improve survival
    • Loop Diuretics: For symptom control; reduces fluid overload
  5. D - Digoxin: Improves symptoms; Reduces hospitalizations (does not reduce mortality)

Additional Management:

  • Lifestyle Modifications: Sodium restriction; Fluid restriction; Regular physical activity; Smoking cessation; Alcohol limitation
  • Patient Education: Importance of medication adherence; Recognizing symptoms of worsening HF; Daily weight monitoring
  • Advanced Therapies: IV Inotropes: For severe, refractory cases; LVAD: Left ventricular assist device for end-stage HF; Transplant: Heart transplantation in eligible patients

Complications:

  • Arrhythmias: Atrial fibrillation, ventricular tachycardia
  • Thromboembolism: Increased risk of blood clots
  • Renal Dysfunction: Due to reduced cardiac output
  • Hepatic Congestion: Due to right-sided heart failure
  • Cachexia: Severe weight loss and muscle wasting

Prognosis:

Depends on the underlying cause, severity, and response to treatment. Regular follow-up and monitoring are essential.

Summary:

HFrEF is a chronic condition with significant morbidity and mortality. Early diagnosis and comprehensive management are crucial for improving outcomes. Focus on guideline-directed medical therapy and lifestyle modifications.