The prevalence of symptomatic heart failure in Europe is thought to be between 0.4% and 2.0% with the mean age being 74 years. Where the underlying problem cannot be rectified the prognosis is poor with 50% of people dead within 4 years. In patients with severe heart failure 50% will die within 1 year [1].

Acute versus chronic

Heart failure may be acute with a low cardiac output resulting in hypotension with poor organ perfusion and/or pulmonary oedema. It may also be chronic with output insufficient to provide the optimal needs of metabolizing tissues resulting in decreased tissue performance. The patient may complain of lethargy or reduced exercise tolerance.

Systolic versus diastolic

Severe heart failure is usually due to poor myocardial contractility. However the myocardium may inadequately relax resulting in reduced stretch of myocardial filaments and decreased cardiac output. This is termed diastolic heart failure and often occurs with systolic failure but may exist with the presence of a normal ejection fraction.

Aetiology

The commonest cause of heart failure in the Western world is myocardial ischaemia from coronary artery diseases. However potentially treatable and reversible aetiologies should be considered.

Cardiac

• Valvular dysfunction

• Arrhythmias

• Hypertension

• Pericardial disease.

Non-cardiac

• High-output states; anaemia, pregnancy and thyrotoxicosis

• Vitamin deficiencies

• Alcohol

• Autoimmune diseases

• Infections

• Drug toxicity (e.g. calcium channel blockers, beta blockers).