Congestive Cardiac Failure

Dr Swapnil Pawar June 22, 2021 510

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    Congestive Cardiac Failure
    Dr Swapnil Pawar

Congestive Cardiac Failure

Written by – Dr Andrew Lam

Pulmonary Congestion On Chest X-Ray

A – Alveolar Oedema. Due to increased hydrostatic pressure pushing fluid into alveoli. Identified by “bat-wing” appearance with opacification of perihilar areas

B – Kerley B Lines. Due to fluid overload resulting in interstitial oedema. Identified by linear opacifications extending to pleura

C – Cardiomegaly. Identified by a heat <50% of the thoracic diameter (on a P-A film) 

D – Dilated upper lobe vessels

E – Effusions. Small pleural effusions may be able to be identified by blunting of the costophrenic angles. 


New York Heart Association Classification


Class Symptoms
I Evidence of heart disease, but no symptoms with ordinary physical activity
II Symptoms with ordinary physical activity which slightly limits function
III Symptoms even with minimal exertion which severely limits physical activity
IV Cannot carry out any activity without discomfort, and might even be symptomatic at rest


Heart Failure with Reduced Ejection Fraction (HFREF)

Defined by heart failure with LV ejection fraction <40%

Causes include:

  • Ischaemic Heart Disease
  • Valvular Disease
  • Dilated Cardiomyopathy


Beta Blockers – reduces the risk of sudden death from arrhythmias and improves LV ejection fraction

ACE Inhibitors or ARB’s – prevents remodelling of the heart to decrease symptoms and mortality

Aldosterone Antagonists – reduce the rate of hospitalisation and also has a survival benefit

If symptoms persist despite optimal beta blocker and ACEI/ARB therapy, you can substitute the ACEI/ARB with an angiotensin receptor-neprilysin inhibitor (ARNI’s) 

Heart Failure with Preserved Ejection Fraction (HFPEF)

Defined by heart failure with LV ejection fraction <50%

Causes include: 

  • Hypertension
  • Hypertrophic Obstructive Cardiomyopathy (HOCM)
  • Infiltrative Disease (i.e. sarcoid, amyloid) 
  • Other causes of restrictive cardiomyopathy


Evidence for medical therapy in HFPEF is less robust than that for HFREF. However, beta blockers and ACEI’s/ARB’s may provide some benefit and are commonly used. 

Avoid diuretics and vasodilators as this may worsen the existing filling dysfunction of the heart. 


Colucci, W.S., Dunlay, S.M. Clinical manifestations and diagnosis of advanced heart failure. Retrieved 21st June 2021 from

Electronic Therapeutic Guidelines. Heart Failure. eTG Complete. Retrieved 21st June 2021 from

Rasuli, B. and Jones, J. Heart Failure (Summary). Radiopaedia. Retrieved 21st June 2021 from


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