How to manage congestive heart failure

Congestive heart failure (CHF) is a complex clinical syndrome in which the heart is unable to pump sufficient blood to meet the body’s metabolic demands. Typically, it represents the end stage of various cardiovascular conditions. Because of this, CHF is associated with high morbidity and mortality worldwide.

Classification and prevention

The common method of classifying CHF is using the New York Heart Association Functional Classification (NYHA). It categorises patients from Class I (no symptoms) to Class IV (symptoms at rest).

Another widely used system is the ACC/AHA Heart Failure Stages, ranging from Stage A (at risk) to Stage D (advanced disease).

Additionally, CHF can be divided (based on cardiac function) into:

• Heart failure with reduced ejection fraction (HFrEF), and
• Heart failure with preserved ejection fraction (HFpEF)

Prevention strategies focus on controlling risk factors such as:

• Hypertension,
• Diabetes,
• Obesity, and
• Coronary artery disease

When it comes to prevention, lifestyle modifications such as smoking cessation, regular physical activity, reduced salt intake, and weight management are essential. Early treatment of conditions like hypertension and coronary artery disease reduces the risk of progression to CHF significantly.

Diagnosis and investigations

CHF is diagnosed based on the following clinical symptoms:

• Dyspnoea,
• Fatigue, and
• Fluid retention

Physical findings, like peripheral oedema and pulmonary crackles, are vital too. Key investigations include:

• Echocardiography to assess cardiac structure and function (particularly ejection fraction)
• Blood tests measuring biomarkers like B-type Natriuretic Peptide (BNP) or NT-proBNP (invaluable for diagnosis and prognosis)
• Additional tests such as chest X-ray, electrocardiogram (ECG), and cardiac MRI may help identify underlying causes and complications.

CHF causes

CHF results from a variety of conditions that impair the heart’s ability to pump effectively.

The most common causes include:

• Ischemic heart disease,
• Long-standing hypertension, and
• Cardiomyopathies

Other contributors include valvular heart disease, arrhythmias, infections (such as myocarditis), and metabolic disorders.

Lifestyle factors and aging also play significant roles in disease development.

Management and prognosis of acute heart failure

Acute heart failure is a medical emergency. It is characterised by a rapid onset or worsening of symptoms. Management focuses on:

• Stabilising the patient,
• Relieving symptoms, and
• Addressing underlying causes

Initial treatment often includes oxygen therapy, diuretics to reduce fluid overload, and vasodilators to improve cardiac output. In severe cases, inotropic agents or mechanical circulatory support may be required.

Long-term management involves pharmacological therapy such as ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and newer agents like SGLT2 inhibitors.

Selected patients may benefit from device therapy, including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronisation therapy (CRT).

Prognosis depends on disease severity, underlying aetiology, and response to treatment, but despite advances in therapy, CHF remains a progressive condition.

End-of-life care is an essential component of management in advanced stages. The focus is on symptom relief, quality of life, and patient-centred decision-making. Palliative care should ensure comfort and dignity by addressing both physical and psychosocial needs.

Congestive heart failure is a multifaceted condition. It calls for early identification, comprehensive management, and preventive strategies to improve outcomes and reduce healthcare burden.

- Dr Rosmy De Barros

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References

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2. Stamp, K. D., Prasun, M. A., McCoy, T. P., & Rathman, L. (2025). Utility of the New York Heart Association Functional Classification Compared to Other Measures: A Systematic Review. Health Sciences Review, 100241.
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5. Gupta, A. K., Tomasoni, D., Sidhu, K., Metra, M., & Ezekowitz, J. A. (2021). Evidence-Based Management of Acute Heart Failure. The Canadian journal of cardiology, 37(4), 621–631. https://doi.org/10.1016/j.cjca.2021.01.002