Heart Failure (HF)

Types

•    HFrEF (Reduced EF)

o    EF <40%

o    Systolic dysfunction (impaired contraction)

o    Common causes: ischaemic heart disease, dilated cardiomyopathy, myocarditis

•    HFpEF (Preserved EF)

o    EF >50%

o    Diastolic dysfunction (impaired relaxation)

o    Causes: HTN, LVH, ageing, restrictive cardiomyopathy

Diagnosis

•    Clinical: dyspnoea, orthopnoea, PND, peripheral oedema

•    NT-proBNP: elevated → echo for confirmation

•    CXR: pulmonary oedema (Kerley B lines, upper lobe diversion, pleural effusions)

Management

•    Symptom relief: loop diuretics (e.g., furosemide)

•    Prognostic treatments (HFrEF)

o    ACE inhibitors / ARBs

o    Beta-blockers (bisoprolol, carvedilol, nebivolol)

o    Mineralocorticoid receptor antagonists (MRAs; e.g., spironolactone, eplerenone)

o    SGLT2 inhibitors (e.g., dapagliflozin)

o    Sacubitril/valsartan (ARNI) if symptomatic on ACEI/ARB

•    Devices:

o    CRT (if QRS >120 ms, LBBB, symptomatic)

o    ICD (EF ≤35%, high arrhythmic risk)

•    HFpEF: manage BP, diuretics for symptoms; no mortality-proven therapy

Hypertrophic Cardiomyopathy (HCM)

Features

•    Autosomal dominant (mutations in sarcomere proteins)

•    LVOT obstruction

•    Syncope, exertional dyspnoea, sudden cardiac death risk (young athletes)

Murmur

•    Harsh ejection systolic murmur

•    Increases with Valsalva, standing (↓ preload)

•    Decreases with squatting (↑ preload)

Echo

•    Asymmetric septal hypertrophy (septum thicker than free wall)

Management

•    Beta-blockers or verapamil (reduce obstruction)

•    Avoid dehydration and vasodilators

•    ICD for high-risk cases (e.g., family history, syncope, severe hypertrophy)

Dilated Cardiomyopathy (DCM)

Features

•    Systolic dysfunction → low EF

•    Global dilatation of all chambers

•    Causes:

o    Idiopathic (most common)

o    Alcohol, viral myocarditis, peripartum, doxorubicin, genetic

Management

•    Standard HF treatment

•    Alcohol cessation if relevant

•    Consider transplant in end-stage

Restrictive Cardiomyopathy

Features

•    Stiff ventricles → impaired diastolic filling, preserved systolic function

•    Causes:

o    Amyloidosis (AL type most common in UK)

o    Haemochromatosis

o    Sarcoidosis

o    Fabry disease

Signs

•    Right heart failure signs predominate

•    Bi-atrial enlargement on echo

Myocarditis

Causes

•    Viral (e.g., Coxsackie B), post-infectious, autoimmune

Presentation

•    Mimics ACS: chest pain, troponin rise

•    May cause sudden death or progress to DCM

Diagnosis

•    MRI: myocardial oedema

•    Endomyocardial biopsy (definitive, but rarely done)

Takotsubo Cardiomyopathy

Features

•    Stress-induced ("broken heart syndrome")

•    Post-menopausal women, emotional/physical stress

•    ECG & troponin mimic MI

Echo

•    Apical ballooning (hyperkinesis of base, akinesis of apex)

Prognosis

•    Reversible, usually recovers in weeks

Atrial Myxoma

Features

•    Most common primary cardiac tumour

•    Left atrium, attached to fossa ovalis

•    Mimics mitral stenosis (diastolic murmur, "tumour plop")

Other signs

•    Constitutional: fever, weight loss

•    Embolic phenomena: stroke, systemic emboli

Cardiac Transplantation

Indications

•    End-stage heart failure refractory to maximal medical/device therapy

•    Contraindications: severe pulmonary hypertension, systemic illness, ongoing infection

Extra Revision Pearls

•    HFrEF clue → all mortality-reducing therapies only proven in reduced EF

•    HCM clue → sudden death in young, murmur ↑ with Valsalva

•    DCM clue → global dilatation, alcohol link

•    Restrictive clue → diastolic HF, amyloid classic cause, low voltage ECG + thick walls = amyloid

•    Myocarditis clue → young, viral prodrome, mimic MI but normal coronaries

•    Takotsubo clue → post-stress, apical ballooning, recovers

•    Atrial myxoma clue → fever, emboli, mitral stenosis murmur, tumour plop