5 Heart Failure

Recognizing heart failure

Heart failure is a clinical syndrome in which the heart cannot fill or pump effectively enough to meet the body’s needs. Common findings include shortness of breath, fatigue, crackles, swelling, orthopnea, and sudden weight gain. These symptoms may reflect pulmonary or systemic fluid congestion.

Orthopnea is shortness of breath when lying flat. Paroxysmal nocturnal dyspnea is breathlessness that awakens a person from sleep; both can occur with pulmonary congestion. Assessment also considers activity tolerance, swelling, and changes in breathing.

Identifying worsening congestion

Changes in weight and swelling can signal worsening fluid retention. A sudden gain, such as $3\text{ lb}$ ($1.4\text{ kg}$) in $24$ hours, is more concerning for fluid accumulation than a small decrease such as $0.2\text{ lb}$ ($0.1\text{ kg}$) over a week. Common guidance includes reporting a gain of about $2\text{–}3\text{ lb}$ in a day or $5\text{ lb}$ in a week, but patients should follow the threshold in their own care plan.

Increasing weight together with increasing ankle swelling may indicate worsening congestion. Patients should contact their healthcare team promptly and follow their individualized action plan. Severe shortness of breath at rest or other emergency warning signs require urgent evaluation.

Responding to acute breathing changes

When a hospitalized patient develops severe shortness of breath at rest and oxygen saturation is falling, the priority is to position the patient upright, assess respiratory status, and urgently escalate care. Upright positioning can ease breathing while urgent care is arranged. Walking to improve endurance or delaying action is not appropriate in this situation.

Using and monitoring diuretics

A loop diuretic such as furosemide helps the body remove excess fluid and can reduce congestion. Diuretics relieve symptoms but do not cure heart failure, and their use does not eliminate the need for monitoring.

During loop diuretic therapy, monitor blood pressure and symptoms of dizziness, intake and output as appropriate to the care plan, kidney function, electrolytes, and daily weight trends. Monitoring helps assess the response and potential adverse effects, including blood pressure, fluid-balance, kidney-function, and electrolyte changes. The specific monitoring plan depends on the patient and treatment.

Medication use and HFrEF treatment

Patients should take heart failure medications as prescribed and should not stop them or change a dose without consulting a healthcare professional. They should tell their care team about over-the-counter medicines and supplements and ask before making medication changes. Feeling better is not a reason to stop medication without checking with the care team.

For eligible patients with HFrEF, guideline-directed medical therapy may include an ARNI, ACE inhibitor, or ARB; an evidence-based beta blocker; a mineralocorticoid receptor antagonist; and an SGLT2 inhibitor. Medication selection and dosing are individualized. Diuretics may also be used to manage fluid retention, but they are not the only medications used to treat HFrEF.

Daily routines and individualized guidance

For consistent daily weights at home, weigh at the same time each morning, after urinating and before breakfast, using the same scale. Record the weights and bring the log to appointments so changes can be reviewed.

Sodium and fluid recommendations should be individualized. Patients should follow the guidance provided by their healthcare team rather than assume that everyone needs the same strict fluid limit. Treatment plans, including sodium and fluid guidance, are tailored to the patient.