Heart failure is a complex clinical syndrome resulting from a structural and/or functional abnormality of the heart causing elevated intracardiac pressures and/or insufficient cardiac output. This presents with symptoms such as breathlessness, ankle swelling and fatigue. When a physical examination is performed by medical professionals, signs of heart failure including elevated jugular venous pressure, pulmonary crackles and peripheral oedema may be present.

​By Dr Alex Tan, Associate Consultant, Department of Cardiology

If there are clinical features of heart failure as highlighted above, further investigations should be pursued. A resting electrocardiogram, biomarkers such as NT-proBNP and chest X-Ray can be ordered. Specialists consultation and further imaging (eg. echocardiogram) should be considered.

Epidemiology of Heart Failure

The reported prevalence of heart failure is 1 to 2% of adult population, though this is likely underestimated. The prevalence of heart failure also increases with age from 1% in those aged 55 years and below to more than 10% in those aged 70 years or over. With an ageing population, the prevalence of heart failure will likely increase in the future.

Southeast Asian patients tend to present with heart failure at a younger age than those in the Western population (54 years versus 75 years)1. Furthermore, they tend to have a more severe condition requiring intensive care, longer length of stay, and a higher hospital mortality rate. Amongst various ethnic groups, the hospitalisation rates are shown to be higher in Malays and Indians (35% higher) than Chinese. Mortality is also 3.5 times higher in Malay population as compared to Indians and Chinese.

Latest Guidelines on Heart Failure

In recent years, there have been new guidelines2 for heart failure from both the European Society of Cardiology (2021) (ESC 2021) and American Heart Association/ American College of Cardiology (2022) (AHA/ACC/HFSA 2022). Heart failure can be classified into the following three groups according to ejection fraction:

  1. Heart Failure with reduced ejection fraction (HFrEF): LVEF ≤ 40%

  2. Heart Failure with mildly reduced ejection fraction (HFmrEF): LVEF 41-49%

  3. Heart Failure with preserved ejection fraction (HpEF): LVEF ≥ 50%

Left ventricular ejection fraction (LVEF) is a measurement of how much blood is pumped out of the heart per cardiac cycle. The assessment of heart function can be performed using a transthoracic echocardiogram or cardiac magnetic resonance imaging. This classification based on LVEF will help guide management and treatment strategies. Patients with HFrEF have higher risk of mortality than patients with HFpEF.

Apart from diagnosing and classifying heart failure, one should also consider the underlying cause of heart failure which needs to be treated to. This can range from coronary artery disease, hypertensive heart disease, valvular heart disease, abnormal heart rhythms, etc.

Medical therapy for heart failure has evolved leaps and bounds over the decades. Gone are the days of just isosorbide dintrate/hydralazine, ACE-inhibitors and digoxin. With the latest guidelines from ESC 2021 and AHA/ACC/HFSA 2022 for the management of HFrEF, there are four groups of medications that are strongly recommended. Angiotensin-receptor-neprilysin inhibitor (ARNI), Betablockers, Mineralocorticoid receptor antagonist (MRA) and Sodium-Glucose Cotransporter-2 Inhibitors (SGLT2i). The goal of treatment in patients with HFrEF is to initiate them on these four pillars of therapy early and concurrently, but bearing in mind that each patient is different and hence the initiation, up-titration and combination of these medications may vary.

Credits: Alosahealth.org

With appropriate management and medical therapy, patients with HFrEF may see an improvement in their LVEF over time. This group of patients can be classified as HF with improved EF (HFimpEF) where previous LVEF was ≤ 40% and a follow up measurement of LVEF >40%. It is important to recognise this group of patients and continue their guideline-directed medical therapy and not stop medications as it may increase the risk of heart failure relapse.

Previously, HFpEF was a recognised entity with limited treatment options with the aim of treating comorbidities such as hypertension, diabetes as well as managing fluid status. This was until the recent ground-breaking trial involving the SGLT2i Empagliflozin, in the EMPEROR-Preserved study3. Empagliflozin was shown to reduce the combined risk of cardiovascular death or hospitalisation for heart failure in patients with heart failure and LVEF >40%. This is now recommended for use in patients with HFmrEF and HFpEF. 

Heart failure is associated with a chronic inflammatory state which can lead to iron deficiency. The role of intravenous iron (Ferric carboxymaltose) has also been shown to improve symptoms and reduce heart failure hospitalisation in patients with iron deficiency and heart failure.

Additionally, regardless of the type of heart failure and LVEF, it is important to manage the fluid balance in patients. This is achieved through a combination of fluid intake restriction, a low-salt diet and the use of diuretics.

Apart from optimal medical therapy, there are adjuncts and devices which can be considered in HFrEF management. The role of an implantable cardioverter defibrillator (ICD) should be considered in patients with LVEF <35% to reduce the risk of sudden cardiac death due to the risk of life threatening arrhythmias.

Multi-disciplinary Approach

At NHCS, heart failure management is undertaken by a multi-disciplinary team comprises heart failure cardiologists, trained heart failure nurses, palliative supportive care specialists, pharmacists, physiotherapists, dietitians, transplant coordinators and medical social workers who work hand in hand to care for our patients.

In advanced heart failure, heart transplantation or mechanical heart pumps such as the Left Ventricular Assist Device (LVAD) can be considered as a permanent or destination therapy, and recommended in selected patients who are repeatedly hospitalised despite being on optimal medical therapy.

The aim of treatment is to alleviate symptoms, reduce frequency of hospitalisation, reduce mortality, and improve quality of life. However, the trajectory of heart failure is complex, as it is typically characterised by intermittent deterioration with subsequent stabilisation, and the condition may worsen in an unpredictable pattern of decline resulting in risk of sudden death.

Advance care planning is important for patients with heart failure to make plans about their future health care, especially when they are not in a position to make or communicate their healthcare choices. Shared decision-making among patients, their families, and the medical team in establishing the goals of care should be initiated early.

Credits: Beattie, J.M., Riley, J.P. (2018). Palliative Care in Heart Failure

As heart failure is becoming increasingly common in the world and in Singapore, early recognition and diagnosis and referral for specialist management is important. The availability of improved medication treatment options may help in the managing of symptoms and reduction in hospitalisation and mortality rates.

1. Lam CSP. Heart failure in Southeast Asia: facts and numbers. ESC Heart Fail. 2015 Jun;2(2):46-49. doi: 10.1002/ehf2.12036. PMID: 28834655; PMCID: PMC6410537

2. McDonagh TA, et al; ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-3726. doi:10.1093/eurheartj/ehab368. Erratum in: Eur Heart J. 2021 Oct 14;: PMID: 34447992. Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Card Fail. 2022 May;28(5):e1-e167. doi: 10.1016/j.cardfail.2022.02.010. Epub 2022 Apr 1. PMID: 35378257

3. Anker SD, et al.; EMPEROR-Preserved Trial Investigators. Empagliflozin in Heart Failure with a Preserved Ejection Fraction. N Engl J Med. 2021 Oct 14;385(16):1451-1461. doi: 10.1056/NEJMoa2107038. Epub 2021 Aug 27. PMID: 34449189

This article is from Murmurs Issue 42 (January – April 2022). Click here to read other articles or issues.