Heart Failure

Heart failure (HF) is a condition in which the heart is unable to provide adequate cardiac output to supply the organs and the body. This condition may occur in the setting of diastolic or systolic dysfunction.

Diastolic dysfunction

is referred to as HFpEF (Heart Failure with Preserved Ejection Fraction).
In HFpEF, the ejection fraction (EF) is preserved (>50 %), but ventricular filling during diastole is reduced, resulting in decreased cardiac output.

Systolic dysfunction

In systolic dysfunction, EF is reduced (<50 %).
According to EF, systolic heart failure is classified into:

HFmrEF (EF 41–49 %) – Heart Failure with mildly reduced Ejection Fraction
HFrEF (EF <40 %) – Heart Failure with reduced Ejection Fraction

Illustration depicting heart failure as a major comorbidity of atrial fibrillation with an ECG recording of the arrhythmia.

Heart Failure
Definition Heart failure (HF) is a condition in which the heart is unable to provide adequate cardiac output to supply the organs and the body. This condition may occur in the setting of diastolic or systolic dysfunction.
Symptoms Unexplained weakness Dyspnoea Fatigue Weight gain (due to fluid retention) Lower limb oedema
Diagnosis Laboratory: NT-proBNP or BNP Echocardiography Ejection fraction (EF) HFA-PEFF algorithm – used for the diagnosis of diastolic dysfunction

HFA-PEFF is an acronym that precisely designates the diagnostic algorithm for HFpEF and stands for:

HFA – Heart Failure Association

A specialist branch of the European Society of Cardiology that developed the HFA-PEFF diagnostic algorithm for HFpEF.

P – Pre-test assessment

Initial clinical evaluation of a patient with dyspnoea to identify suspicion of HFpEF.

E – Echocardiography

Echocardiographic assessment of functional and morphological signs of diastolic dysfunction.

F – Functional testing

Additional functional testing (particularly stress echocardiography) in case of an inconclusive score.

F – Final aetiology

Final determination of the cause of HFpEF as a basis for targeted therapy.

HFA-PEFF algorithm – diagnosis of HFpEF (Heart Failure with preserved Ejection Fraction)
Criteria	Major	Minor
Functional	septal e′ <7 cm/s or lateral e′ <10 cm/s or Average E/e′ ≥15 or TR velocity >2.8 m/s (PASP >35 mmHg)	Average E/e′ 9–14 or GLS <16 %
Morphological	LAVI >34 ml/m² or LVMI ≥149/122 g/m² (m/w) and RWT >0.42	LAVI 29–34 ml/m² or LVMI ≥115/95 g/m² (m/w) or RWT >0.42 or LV wall thickness ≥12 mm
Sinus rhythm	NT-proBNP >220 pg/ml or BNP >80 pg/ml	NT-proBNP 125–220 pg/ml or BNP 35–80 pg/ml
Atrial fibrillation	NT-proBNP >660 pg/ml or BNP >240 pg/ml	NT-proBNP 365–660 pg/ml or BNP 105–240 pg/ml
Interpretation of results (HFA-PEFF) – scoring
Major criterion = 2 points Minor criterion = 1 point (maximum 2 points in each domain)
Interpretation of results (HFA-PEFF) – conclusion
0–1 point: HFpEF unlikely 2–4 points: HFpEF possible –> perform stress echocardiography, invasive haemodynamic assessment 5–6 points: HFpEF

TR – tricuspid regurgitation, PASP – pulmonary artery systolic pressure, LAVI – left atrial volume index, RWT – relative wall thickness, (m/w) – men / women, GLS – global longitudinal strain, LVMI – left ventricular mass index, LV – left ventricle

In HF, regardless of type, blood stasis (congestion) develops in the venous circulation “upstream” of the heart. The terms “heart failure” and “congestive heart failure” are synonymous.

Atrial fibrillation (AF) causes heart failure, but conversely, heart failure also promotes AF.

37% of patients with newly diagnosed AF also have HF.

During AF, there is dyssynchrony between atrial systole and ventricular systole. Haemodynamic overload of the heart occurs, cardiac output decreases, and heart failure develops.

57% of patients with newly diagnosed HF also have AF.

Chronic HF causes haemodynamic overload of the heart, including the left atrium, which undergoes remodelling, leading to AF.

An episode of AF is the most common cause of acute heart failure requiring emergency transport and hospitalization.

Combination of HF and AF

Increases the risk of thromboembolism (including stroke) twofold, regardless of anticoagulation therapy
Increases mortality by 25%

Heart Failure and Atrial Fibrillation	Class
Adequate treatment of heart failure reduces the incidence and improves the clinical course of AF and reduces the risk of cardiovascular disease.	I
In all patients with heart failure (regardless of ejection fraction), SGLT2 inhibitors and diuretics (if signs of congestion are present) are recommended as part of treatment.	I