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ReferenceAll Years (1st-Final)All UniversitiesCongestive Heart Failure

Congestive Heart Failure: Notes, PPT and PYQs for MBBS

Congestive heart failure (CHF) is a clinical syndrome in which the heart cannot pump enough blood to meet the body's metabolic needs, or can do so only at raised filling pressures, leading to congestion of the lungs and systemic veins. It is examined in Physiology in 1st Year, Pathology and Pharmacology in 2nd Year, and General Medicine in Final Year.

SME-reviewed. Updated 2026.
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Quick Summary: What You Need to Know for University Exams

  • Heart failure is classified by ejection fraction: reduced (HFrEF), mildly reduced (HFmrEF) and preserved (HFpEF).
  • Coronary artery disease and hypertension are the commonest causes; rheumatic heart disease remains important in India.
  • Left heart failure causes pulmonary congestion; right heart failure causes systemic venous congestion.
  • The NYHA classification grades symptoms from class I to IV.
  • Echocardiography is the key investigation; natriuretic peptides (BNP, NT-proBNP) support the diagnosis.
  • HFrEF is treated with four drug pillars: ACE inhibitor/ARB/ARNI, beta-blocker, mineralocorticoid antagonist and SGLT2 inhibitor.
  • Loop diuretics relieve congestion but do not improve survival.

Heart Failure Across MBBS Subjects

MBBS Year

1st Year

Subject

Physiology

What Is Usually Asked

Cardiac output, Frank-Starling law, regulation of the heart

MBBS Year

2nd Year

Subject

Pathology

What Is Usually Asked

Pathophysiology, chronic venous congestion of lung and liver, cardiac hypertrophy

MBBS Year

2nd Year

Subject

Pharmacology

What Is Usually Asked

Drugs for heart failure, digoxin, diuretics

MBBS Year

Final Year

Subject

General Medicine

What Is Usually Asked

Causes, clinical features, investigations, management, acute pulmonary oedema

Definition and Classification

Definition: Heart failure is a clinical syndrome with symptoms and signs caused by a structural or functional cardiac abnormality, supported by raised natriuretic peptide levels or objective evidence of pulmonary or systemic congestion.

Classification

Basis

Ejection fraction

Types

HFrEF (40% or less); HFmrEF (41 to 49%); HFpEF (50% or more)

Basis

Side mainly affected

Types

Left-sided; right-sided; biventricular (congestive)

Basis

Onset

Types

Acute; chronic; acute decompensation of chronic heart failure

Basis

Cardiac output

Types

Low-output; high-output

Basis

Function

Types

Systolic dysfunction; diastolic dysfunction

NYHA Functional Classification

Class

I

Symptoms

No limitation of ordinary physical activity

Class

II

Symptoms

Slight limitation; ordinary activity causes symptoms

Class

III

Symptoms

Marked limitation; less than ordinary activity causes symptoms

Class

IV

Symptoms

Symptoms at rest; any activity increases discomfort

Aetiology (Causes)

Category

Myocardial damage

Examples

Coronary artery disease and myocardial infarction, cardiomyopathies, myocarditis

Category

Pressure overload

Examples

Hypertension, aortic stenosis

Category

Volume overload

Examples

Mitral and aortic regurgitation

Category

Valvular disease

Examples

Rheumatic heart disease

Category

Arrhythmias

Examples

Atrial fibrillation, persistent tachyarrhythmias, complete heart block

Category

Pericardial disease

Examples

Constrictive pericarditis, cardiac tamponade

Category

Right heart failure

Examples

Secondary to left heart failure (most common), cor pulmonale, pulmonary hypertension

Category

High-output failure

Examples

Severe anaemia, thyrotoxicosis, arteriovenous fistula, beriberi, Paget's disease of bone

Precipitating Factors of Acute Decompensation

  1. Infection, especially respiratory infection
  2. Arrhythmia, particularly new atrial fibrillation
  3. Non-adherence to drugs or salt restriction
  4. Acute myocardial infarction or ischaemia
  5. Uncontrolled hypertension
  6. Anaemia
  7. Drugs such as NSAIDs and some calcium channel blockers
  8. Pregnancy and thyrotoxicosis

Pathophysiology

Flowchart

  1. Cardiac injury or overload reduces cardiac output
  2. Baroreceptors sense low effective circulating volume
  3. Sympathetic nervous system activation increases heart rate and contractility and causes vasoconstriction
  4. Renin-angiotensin-aldosterone system activation causes sodium and water retention and vasoconstriction
  5. Antidiuretic hormone release causes further water retention
  6. These responses initially support output but later increase preload and afterload
  7. Myocardial remodelling (hypertrophy, dilatation, fibrosis) worsens function
  8. Rising filling pressures produce pulmonary and systemic congestion

Natriuretic peptides (ANP and BNP) are released in response to stretch and partly counter these effects. Modern drug treatment works by blocking the harmful neurohormonal pathways.

(Examiner may ask you to draw the neurohormonal activation flowchart.)

Frank-Starling Mechanism

Within limits, increased stretch of cardiac fibres (higher end-diastolic volume) increases the force of contraction. In failing hearts, the curve is flattened, so extra filling produces congestion rather than more output.

Pathology of Chronic Venous Congestion

Organ

Lung (left heart failure)

Findings

Congested alveolar capillaries, alveolar oedema, haemosiderin-laden macrophages ("heart failure cells"), brown induration in chronic cases

Organ

Liver (right heart failure)

Findings

Centrilobular congestion and necrosis giving a "nutmeg liver" appearance; cardiac sclerosis in long-standing cases

Organ

Heart

Findings

Hypertrophy (concentric in pressure overload, eccentric in volume overload) and dilatation

Clinical Features

Left Versus Right Heart Failure

Left Heart Failure (Pulmonary Congestion)

Breathlessness on exertion

Right Heart Failure (Systemic Congestion)

Raised jugular venous pressure

Left Heart Failure (Pulmonary Congestion)

Orthopnoea

Right Heart Failure (Systemic Congestion)

Tender hepatomegaly

Left Heart Failure (Pulmonary Congestion)

Paroxysmal nocturnal dyspnoea

Right Heart Failure (Systemic Congestion)

Dependent pitting oedema

Left Heart Failure (Pulmonary Congestion)

Cough with frothy sputum in pulmonary oedema

Right Heart Failure (Systemic Congestion)

Ascites and pleural effusion

Left Heart Failure (Pulmonary Congestion)

Basal crackles

Right Heart Failure (Systemic Congestion)

Positive hepatojugular reflux

Left Heart Failure (Pulmonary Congestion)

Third heart sound (gallop rhythm)

Right Heart Failure (Systemic Congestion)

Anorexia and abdominal discomfort from gut congestion

Left Heart Failure (Pulmonary Congestion)

Pulsus alternans in severe disease

Right Heart Failure (Systemic Congestion)

-

General features: Fatigue, reduced exercise tolerance, weight gain from fluid retention, cool peripheries and cardiac cachexia in advanced disease.

Framingham Criteria (Clinical Diagnosis)

Heart failure is diagnosed with two major criteria, or one major and two minor criteria.

Major Criteria

Paroxysmal nocturnal dyspnoea

Minor Criteria

Bilateral ankle oedema

Major Criteria

Neck vein distension

Minor Criteria

Nocturnal cough

Major Criteria

Crackles

Minor Criteria

Breathlessness on ordinary exertion

Major Criteria

Cardiomegaly on X-ray

Minor Criteria

Hepatomegaly

Major Criteria

Acute pulmonary oedema

Minor Criteria

Pleural effusion

Major Criteria

Third heart sound gallop

Minor Criteria

Reduced vital capacity

Major Criteria

Raised central venous pressure

Minor Criteria

Tachycardia

Major Criteria

Hepatojugular reflux

Minor Criteria

-

Major Criteria

Weight loss in response to treatment

Minor Criteria

-


Diagnosis

Investigation

Echocardiography

Purpose or Findings

Key test: ejection fraction, chamber size, wall motion, valve disease, pericardial disease

Investigation

BNP or NT-proBNP

Purpose or Findings

Raised in heart failure; a normal level makes heart failure unlikely

Investigation

ECG

Purpose or Findings

Ischaemia, previous infarction, hypertrophy, arrhythmias such as atrial fibrillation

Investigation

Chest X-ray

Purpose or Findings

Cardiomegaly (cardiothoracic ratio above 0.5), upper lobe venous diversion, Kerley B lines, "bat-wing" perihilar shadowing, pleural effusion

Investigation

Blood tests

Purpose or Findings

Complete blood count (anaemia), renal function, electrolytes, liver function, thyroid function, glucose, lipids

Investigation

Coronary angiography

Purpose or Findings

When ischaemic heart disease is suspected

Management

General Measures

  1. Treat the underlying cause and precipitating factors
  2. Salt restriction and, in advanced disease, fluid restriction
  3. Daily weight monitoring to detect fluid retention
  4. Regular physical activity or cardiac rehabilitation when stable
  5. Vaccination against influenza and pneumococcus
  6. Avoid drugs that worsen heart failure, such as NSAIDs

Drug Treatment of HFrEF: Four Pillars

Drug Class

ACE inhibitors, ARBs or ARNI

Examples

Enalapril, ramipril; losartan; sacubitril-valsartan

Key Points

Reduce mortality; monitor potassium and renal function

Drug Class

Beta-blockers

Examples

Carvedilol, bisoprolol, metoprolol succinate

Key Points

Reduce mortality; start low and increase slowly when stable

Drug Class

Mineralocorticoid receptor antagonists

Examples

Spironolactone, eplerenone

Key Points

Reduce mortality; risk of hyperkalaemia; gynaecomastia with spironolactone

Drug Class

SGLT2 inhibitors

Examples

Dapagliflozin, empagliflozin

Key Points

Reduce hospitalisation and death, in patients with or without diabetes

Other Drugs and Devices

Treatment

Loop diuretics (furosemide)

Role

Relieve congestion and oedema; no survival benefit

Treatment

Digoxin

Role

Symptom control and rate control in atrial fibrillation; narrow therapeutic index

Treatment

Ivabradine

Role

Selected patients in sinus rhythm with a high heart rate

Treatment

Hydralazine with isosorbide dinitrate

Role

Selected patients, such as those unable to take ACE inhibitors or ARBs

Treatment

Implantable cardioverter-defibrillator

Role

Prevention of sudden cardiac death in selected patients

Treatment

Cardiac resynchronisation therapy

Role

Selected patients with a wide QRS complex

Treatment

Heart transplantation

Role

End-stage heart failure

Acute Pulmonary Oedema (MBBS Level)

  1. Sit the patient upright
  2. Give oxygen if saturation is low; non-invasive ventilation if needed
  3. Intravenous loop diuretic
  4. Nitrates if blood pressure allows
  5. Identify and treat the cause, such as MI, arrhythmia or hypertensive crisis

Complications

  • Arrhythmias, including atrial fibrillation and ventricular arrhythmias
  • Sudden cardiac death
  • Thromboembolism, including stroke
  • Cardiorenal syndrome and electrolyte disturbances
  • Congestive hepatopathy
  • Cardiac cachexia
  • Recurrent hospitalisation

Prognosis

Heart failure carries a high risk of hospitalisation and death, especially in advanced NYHA classes. Guideline-directed drug therapy, device therapy where indicated and treatment of the underlying cause substantially improve symptoms and survival.


Quick Viva Questions

Q: What are heart failure cells? A: Haemosiderin-laden macrophages in the alveoli, seen in chronic left heart failure.

Q: What is the commonest cause of right heart failure? A: Left heart failure.

Q: Why does orthopnoea occur? A: Lying flat increases venous return to the heart and lungs, worsening pulmonary congestion.

Q: What are Kerley B lines? A: Short horizontal lines at the lung bases on chest X-ray, indicating interstitial oedema.

Q: How does digoxin act? A: It inhibits the Na+/K+ ATPase, increasing intracellular calcium and contractility; hypokalaemia increases its toxicity.


How Congestive Heart Failure Appears in MBBS University Exams

Typical question styles (not attributed to specific papers or years):

  1. "Define heart failure. Discuss the aetiology, clinical features and management of congestive cardiac failure." (Long essay, General Medicine)
  2. "Classify drugs used in congestive heart failure. Write a note on digoxin." (Long essay, Pharmacology)
  3. "Write a short note on the pathophysiology of heart failure." (Short note, Pathology or Medicine)
  4. "Write a short note on chronic venous congestion of the liver." (Short note, Pathology)
  5. "Discuss the management of acute pulmonary oedema." (Short note, Medicine)

Frequently Asked Questions

What is the difference between left and right heart failure?

Left heart failure causes pulmonary congestion with breathlessness, orthopnoea and crackles. Right heart failure causes systemic venous congestion with raised JVP, hepatomegaly and dependent oedema. The most common cause of right heart failure is left heart failure.

Which drugs reduce mortality in heart failure with reduced ejection fraction?

ACE inhibitors, ARBs or sacubitril-valsartan; evidence-based beta-blockers; mineralocorticoid receptor antagonists; and SGLT2 inhibitors. Loop diuretics relieve symptoms but do not reduce mortality.

Can I download the congestive heart failure PPT for my presentation?

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