Heart failure is a clinical syndrome characterised by symptoms of shortness of breath, effort intolerance and fluid retention. These symptoms are caused by abnormalities in heart function. It is also commonly called 'congestive cardiac failure' or 'congestive heart failure'. 

Heart failure with reduced ejection fraction (HFrEF) refers to a subset of heart failure, where the 'ejection fraction', or contraction strength of the heart muscles is reduced to less than 40% (normal ejection fraction is around 55 – 65%). Reduction of cardiac 'ejection fraction' can be seen on echocardiogram (heart ultrasound) or on cardiovascular magnetic resonance imaging (MRI).

Common causes of HFrEF include:

• Coronary artery disease
• Acute myocardial infarction ('heart attack')
• Electrical rhythm disturbances in the heart
• Cardiomyopathies (heart muscle disease)
• Previous viral infection of the heart muscles
• Previous cancer treatment using cardiotoxic agents
• Alcohol and other substance abuse
  

• Shortness of breath (on exertion or during rest)
• Decreasing effort tolerance
• Difficulty in breathing when lying flat
• Waking up breathless at night
• Chronic fatigue
• Swelling of ankles/ legs/ abdomen
• Unexplained fainting spells
  

HFrEF is a clinical syndrome diagnosed through integrating various medical data and information, including:

• Patient symptoms
• Typical symptoms of shortness of breath on exertion, inability to sleep lying flat, worsening fatigue etc
• Clinical examination
• Signs of fluid retention (leg swelling, abdominal swelling, fluid sound in lungs)
• Detect possible underlying cause of heart failure (heart murmur, irregular pulse)
• Cardiac pumping function (assessment of peripheral perfusion)
• Blood tests
• Red blood cell counts, kidney/ liver function, thyroid hormone level
• NT-proBNP: hormone produced by the heart, which is markedly elevated in heart failure
• Electrocardiogram ('ECG')
• Electrical tracing of the heart, looking for heart rhythm abnormalities, as well as signs of underlying structural heart abnormalities
• Chest radiograph
• X-ray examination, looking for abnormal heart enlargement/ abnormal fluid collection in the lungs
• Specialised cardiac imaging
• Echocardiogram: Ultrasound examination which allows doctors to evaluate important morphological features of the heart, including the ejection fraction
• Cardiovascular magnetic resonance imaging ('Cardiac MRI'): Specialised scan looking specifically at the heart muscles, to look for underlying heart muscle abnormalities
• Invasive investigations
• Coronary angiogram: look for blockages in the heart blood vessels from atherosclerotic plaques
• Right heart study: assess pressures in the heart chambers, as well as the blood delivery effectiveness of the heart
  

Acute decompensation

When a patient is admitted to the hospital for severe shortness of breath and fluid retention, the treatment will be targeted at reversing the episode of decompensation and getting the patient back to his/ her baseline functioning.

Treatment of acute decompensation may include:

• Oxygen supplementation if necessary
• Medications to remove excess fluid ('diuretics')
• Adjustment of home heart failure therapy
• Education/ counseling to prevent repeat episodes of decompensation
• Medications to improve heart pumping function ('inotropes') in severe cases
  

Chronic management

HFrEF is a chronic condition that requires long term treatment and follow up. The Heart Failure Programme at NUHCS provides a multi-disciplinary approach to the chronic management of HFrEF, which will include:

Lifestyle modifications

• Smoking/ alcohol cessation
• Fluid and salt restriction
• Regular monitoring of body weight/ blood pressure
• Exercise as recommended by the heart failure team
• Cardiac rehabilitation programme enrollment

Medical therapy

• Initiating patients on the evidence-based '4 pillars' of HFrEF therapy whenever possible, is important to reduce the symptom burden of patients with HFrEF. These medications also can prevent premature death in patients with HFrEF. These 4 classes of medications include
1. Angiotensin receptor-neprilysin inhibitor (ARN-i)/ angiotensin conveting enzyme inhibitors (ACE-i)/ angiotensin receptor blockers (ARB)
2. Beta-adrenergic blockers
3. Mineralocorticoid antagonists
4. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors
• Medications to improve patients' symptoms and reduce the risk of hospitalisation
1. Diuretics ('water retention tablets')
2. Heart rate reducing agent (I_f channel blocker)
3. Vasodilators
4. Digoxin

Procedures

• Restore blood flow to the heart muscles via coronary angioplasty ('stenting') or coronary artery bypass graft surgery

• Implantable electronic devices (defibrillators/ pacemakers) in patients who qualify

Advanced heart failure management

• Evaluation for patients with persistent symptoms for consideration of mechanical circulatory support ('mechanical heart pumps') or heart transplantation

Suitable patients will be followed up in the specialised Heart Failure Clinic, a multi-disciplinary clinic aimed at providing holistic management of heart failure, to improve the long-term outcome for our patients.