Heart Failure and Cardiomyopathies: Acute and Chronic Management, Devices and Self-Care Support
Pathophysiology and assessment
Heart failure is a syndrome of congestion or low perfusion due to impaired filling or ejection. HFrEF has reduced ejection fraction; HFpEF has preserved ejection fraction with diastolic dysfunction. Preload, afterload, and contractility determine stroke volume. Assess dyspnea, orthopnea, JVD, crackles, edema, weight, urine output, mental status, and cool extremities. Acute decompensation often presents with congestion; cardiogenic shock presents with hypoperfusion.
Management
Acute care includes oxygen if hypoxemic, diuretics for congestion, vasodilators for hypertensive pulmonary edema, and inotropes for low output. Guideline-directed therapy for HFrEF includes ARNI/ACEi/ARB, evidence-based beta blocker, MRA, and SGLT2 inhibitor. Devices: ICD for sudden death prevention; CRT for dyssynchrony. Self-care: daily weights, symptom action plan, sodium and fluid guidance, medication adherence, and vaccination.
Traps
Not every dyspneic patient needs fluid; assess for congestion versus low output. Do not start a beta blocker during acute decompensation. NSAIDs worsen fluid retention. Monitor potassium and renal function after MRA or ARNI. Device deactivation is an ethical discussion, not an automatic decision.
Worked example
A patient gains 2 kg in three days with increasing orthopnea and leg swelling. This exceeds the usual 1 kg/day or 2–2.5 kg/week threshold; advise same-day contact and diuretic adjustment per plan.