Heart Failure: Clinical Framework for Junior Doctors

A comprehensive guide for JMOs on diagnosing and managing heart failure, including aetiology, pathophysiology, investigations, and the 4 pillars of treatment.

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CASE-BASED APPROACH · JMO LEVEL

Heart Failure

A Clinical Framework for Junior Doctors

📋 PRESENTING CASE

• 72M | SOB × 3 days, orthopnoea, PND

• Bilateral leg swelling

• PMHx: Hypertension, Ischaemic Heart Disease

What are your top differentials?

Heart Failure | JMO Teaching Session | 2026

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SLIDE 2 · DIFFERENTIALS

Acute Dyspnoea + Oedema

🔴 CARDIAC

• Heart Failure (acute decompensation)

• ACS → causing HF

• Arrhythmia (AF with RVR)

🟠 RESPIRATORY

• Pneumonia

• COPD exacerbation

• Pulmonary Embolism

🟡 OTHER

• Renal failure (fluid overload)

• Liver disease (ascites, oedema)

• Hypoalbuminaemia

💡 Clue toward HF: Orthopnoea + PND + bilateral oedema → classic constellation

Heart Failure | JMO Teaching Session | 2026

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SLIDE 3 · AETIOLOGY

Causes of Heart Failure

🔴 ISCHAEMIC

Most Common Cause

• CAD / prior MI → myocardial damage

🟠 PRESSURE OVERLOAD

• Hypertension

• Aortic stenosis

🟡 VOLUME OVERLOAD

• Mitral regurgitation

• Aortic regurgitation

🟣 MYOCARDIAL DISEASE

• Dilated cardiomyopathy

• Hypertrophic cardiomyopathy

• Myocarditis

🔵 OTHER CAUSES

• Arrhythmias (AF, VT)

• Alcohol / cardiotoxic drugs

• Thyroid disease (hypo/hyper)

Heart Failure | JMO Teaching Session | 2026

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SLIDE 4 · PATHOPHYSIOLOGY & FEATURES

Pathophysiology + Clinical Features

⚙️ PATHOPHYSIOLOGY

↓ Cardiac Output

↓

↑ RAAS Activation

↓

Fluid Retention

↓

↑ Preload & Afterload

↓

Further ↓ in cardiac output (vicious cycle)

Compensatory → eventually maladaptive

😮‍💨 SYMPTOMS

• Dyspnoea on exertion

• Orthopnoea (↑ pillows)

• Paroxysmal nocturnal dyspnoea (PND)

• Fatigue / reduced exercise tolerance

• Ankle swelling

• Abdominal bloating (RHF)

🩺 SIGNS

• Raised JVP

• Bibasal crackles

• Peripheral / pitting oedema

• S3 gallop (ventricular filling)

• Displaced apex beat

• Hepatomegaly (RHF)

• Ascites (severe)

💡 Think: Fluid overload (congestion) + Poor perfusion (low output) — both can coexist

Heart Failure | JMO Teaching Session | 2026

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SLIDE 5 · INVESTIGATIONS

Investigations – What You Actually Do

📋 BEDSIDE

• Vital signs (HR, BP, SpO2, RR)

• ECG → ischaemia, AF, LVH, LBBB

• Fluid balance chart

• Daily weight

🩸 BLOODS

• BNP / NT-proBNP ↑↑ (key marker)

• UEC → renal function, K+

• LFTs → hepatic congestion

• Troponin → rule out ACS trigger

• FBC → anaemia as trigger

• TFTs → thyroid cause

• BSL → diabetic cardiomyopathy

🖼️ IMAGING

• CXR → pulmonary oedema, cardiomegaly, Kerley B lines, pleural effusions

• Echocardiogram ⭐ GOLD STANDARD

• Echo: EF → HFrEF (<40%) vs HFpEF (≥50%)

• Echo: valve function + wall motion

🌟 Echo = Gold Standard for Diagnosis | ⚠️ Normal BNP makes HF diagnosis unlikely

Heart Failure | JMO Teaching Session | 2026

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SLIDE 6 · MANAGEMENT

Management – Acute & Chronic

🔴 ACUTE DECOMPENSATED HF (Ward)

Immediate Actions

• Sit upright (reduces preload)

• Oxygen if SpO2 <94%

• IV access + monitoring

Medications

⭐ IV Frusemide ⭐ (key — titrate to urine output)

• GTN infusion if hypertensive

• Consider CPAP/BiPAP if respiratory distress

Monitor

• Urine output hourly

• Daily weight

• Electrolytes (K+, Cr)

• Fluid balance

🟢 CHRONIC HF – 4 PILLARS (HFrEF)

1️⃣ ACEi / ARNI (e.g. Ramipril / Sacubitril-Valsartan) — reduces afterload, mortality benefit

2️⃣ Beta-blocker (e.g. Carvedilol, Bisoprolol) — reduces HR, remodelling

3️⃣ MRA (e.g. Spironolactone) — anti-aldosterone, reduces fluid

4️⃣ SGLT2 Inhibitor (e.g. Empagliflozin, Dapagliflozin) — newest, strong mortality benefit

⚕️ Non-Pharmacological

• Fluid restriction (1.5L/day)

• Influenza + pneumococcal vaccination

• Salt restriction

• Cardiac rehabilitation

• Daily weights at home

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SLIDE 7 · TRIGGERS & COMPLICATIONS

Triggers, Complications & Red Flags

🔥 TRIGGERS

• Infection / Sepsis

• Acute Coronary Syndrome

• Arrhythmia (AF with RVR)

• Medication non-compliance

• Uncontrolled hypertension

• Renal failure

• Anaemia

• NSAIDs / CCBs

⚠️ COMPLICATIONS

• Acute pulmonary oedema

• Cardiogenic shock

• AF / VT / VF

• Cardiorenal syndrome

• Hepatic congestion

• DVT / Pulmonary Embolism

• Depression & poor QoL

🚩 RED FLAGS

(Escalate Now)

• SBP < 90 mmHg

• Rising creatinine

• Urine output < 0.5 mL/kg/hr

• Persistent hypoxia

• Altered consciousness

• New arrhythmia

📞 Call Senior / ICU Early

💡 Finding and fixing the trigger is what prevents the next admission

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SLIDE 8 · CASE RESOLUTION

Back to Our Patient

📋 CASE RECAP

72M | SOB × 3 days | Orthopnoea, PND | Bilateral oedema | PMHx: HTN, IHD

✅ LIKELY DIAGNOSIS

• Acute Decompensated Heart Failure

• Most likely ISCHAEMIC cause (IHD background)

• Possible trigger: ? Infection, ? ACS, ? Non-compliance

📝 YOUR PLAN

Sit up + O₂ if hypoxic

IV Frusemide (40–80mg) stat

ECG → rule out ACS trigger

Bloods: Troponin, BNP, UEC, FBC

CXR → confirm pulmonary oedema

Echo → confirm HF, assess EF

Identify + treat the trigger

Monitor: UO, weight, electrolytes

Refer Cardiology

💡 Treat the fluid — but always ask: WHY did they decompensate?

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SLIDE 9 · TAKE HOME

Key Take-Home Points

🩺

Think Heart Failure in ANY patient with SOB + bilateral oedema

⚡

Always rule out an ACS trigger — troponin + ECG in every patient

🔬

Echo is the gold standard — confirms diagnosis and guides management

💧

Treat fluid overload early — IV frusemide and monitor response

🔍

Identify and fix the trigger — this prevents the next admission

"In heart failure, treating the fluid is important — but finding and fixing the trigger is what prevents the next admission."

— The clinical principle to carry through your career

Heart Failure | JMO Teaching Session | 2026

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Heart Failure: Clinical Framework for Junior Doctors

A comprehensive guide for JMOs on diagnosing and managing heart failure, including aetiology, pathophysiology, investigations, and the 4 pillars of treatment.

CASE-BASED APPROACH · JMO LEVEL

Heart Failure

A Clinical Framework for Junior Doctors

PRESENTING CASE

72M | SOB × 3 days, orthopnoea, PND

Bilateral leg swelling

Hypertension, Ischaemic Heart Disease

What are your top differentials?

Heart Failure | JMO Teaching Session | 2026

SLIDE 2 · DIFFERENTIALS

Acute Dyspnoea + Oedema

🔴 CARDIAC

Heart Failure (acute decompensation)

ACS → causing HF

Arrhythmia (AF with RVR)

🟠 RESPIRATORY

Pneumonia

COPD exacerbation

Pulmonary Embolism

🟡 OTHER

Renal failure (fluid overload)

Liver disease (ascites, oedema)

Hypoalbuminaemia

💡 Clue toward HF: Orthopnoea + PND + bilateral oedema → classic constellation

Heart Failure | JMO Teaching Session | 2026

SLIDE 3 · AETIOLOGY

Causes of Heart Failure

ISCHAEMIC

Most Common Cause

CAD / prior MI → myocardial damage

PRESSURE OVERLOAD

Hypertension

Aortic stenosis

VOLUME OVERLOAD

Mitral regurgitation

Aortic regurgitation

MYOCARDIAL DISEASE

Dilated cardiomyopathy

Hypertrophic cardiomyopathy

Myocarditis

OTHER CAUSES

Arrhythmias (AF, VT)

Alcohol / cardiotoxic drugs

Thyroid disease (hypo/hyper)

Heart Failure | JMO Teaching Session | 2026

SLIDE 4 · PATHOPHYSIOLOGY & FEATURES

Pathophysiology + Clinical Features

⚙️ PATHOPHYSIOLOGY

↓ Cardiac Output

↑ RAAS Activation

Fluid Retention

↑ Preload & Afterload

Further ↓ in cardiac output (vicious cycle)

Compensatory → eventually maladaptive

😮‍💨 SYMPTOMS

Dyspnoea on exertion

Orthopnoea (↑ pillows)

Paroxysmal nocturnal dyspnoea (PND)

Fatigue / reduced exercise tolerance

Ankle swelling

Abdominal bloating (RHF)

🩺 SIGNS

Raised JVP

Bibasal crackles

Peripheral / pitting oedema

S3 gallop (ventricular filling)

Displaced apex beat

Hepatomegaly (RHF)

Ascites (severe)

💡 Think: Fluid overload (congestion) + Poor perfusion (low output) — both can coexist

Heart Failure | JMO Teaching Session | 2026

SLIDE 5 · INVESTIGATIONS

Investigations – What You Actually Do

📋 BEDSIDE

Vital signs (HR, BP, SpO2, RR)

ECG → ischaemia, AF, LVH, LBBB

Fluid balance chart

Daily weight

🩸 BLOODS

BNP / NT-proBNP ↑↑ (key marker)

UEC → renal function, K+

LFTs → hepatic congestion

Troponin → rule out ACS trigger

FBC → anaemia as trigger

TFTs → thyroid cause

BSL → diabetic cardiomyopathy

🖼️ IMAGING

CXR → pulmonary oedema, cardiomegaly, Kerley B lines, pleural effusions

Echocardiogram ⭐ GOLD STANDARD

Echo: EF → HFrEF (<40%) vs HFpEF (≥50%)

Echo: valve function + wall motion

🌟 Echo = Gold Standard for Diagnosis | ⚠️ Normal BNP makes HF diagnosis unlikely

Heart Failure | JMO Teaching Session | 2026

SLIDE 6 · MANAGEMENT

Management – Acute & Chronic

🔴 ACUTE DECOMPENSATED HF (Ward)

Immediate Actions

Sit upright (reduces preload)

Oxygen if SpO2 <94%

IV access + monitoring

Medications

IV Frusemide ⭐ (key — titrate to urine output)

GTN infusion if hypertensive

Consider CPAP/BiPAP if respiratory distress

Monitor

Urine output hourly

Daily weight

Electrolytes (K+, Cr)

Fluid balance

🟢 CHRONIC HF – 4 PILLARS (HFrEF)

1️⃣ ACEi / ARNI (e.g. Ramipril / Sacubitril-Valsartan) — reduces afterload, mortality benefit

2️⃣ Beta-blocker (e.g. Carvedilol, Bisoprolol) — reduces HR, remodelling

3️⃣ MRA (e.g. Spironolactone) — anti-aldosterone, reduces fluid

4️⃣ SGLT2 Inhibitor (e.g. Empagliflozin, Dapagliflozin) — newest, strong mortality benefit

⚕️ Non-Pharmacological

Fluid restriction (1.5L/day)

Salt restriction

Daily weights at home

Influenza + pneumococcal vaccination

Cardiac rehabilitation

Heart Failure | JMO Teaching Session | 2026

SLIDE 7 · TRIGGERS & COMPLICATIONS

Triggers, Complications & Red Flags

TRIGGERS

Infection / Sepsis

Acute Coronary Syndrome

Arrhythmia (AF with RVR)

Medication non-compliance

Uncontrolled hypertension

Renal failure

Anaemia

NSAIDs / CCBs

COMPLICATIONS

Acute pulmonary oedema

Cardiogenic shock

AF / VT / VF

Cardiorenal syndrome

Hepatic congestion

DVT / Pulmonary Embolism

Depression & poor QoL

RED FLAGS

(Escalate Now)

SBP < 90 mmHg

Rising creatinine

Urine output < 0.5 mL/kg/hr

Persistent hypoxia

Altered consciousness

New arrhythmia

Call Senior / ICU Early

Finding and fixing the trigger is what prevents the next admission

Heart Failure | JMO Teaching Session | 2026

SLIDE 8 · CASE RESOLUTION

Back to Our Patient

CASE RECAP

72M | SOB × 3 days | Orthopnoea, PND | Bilateral oedema | PMHx: HTN, IHD

LIKELY DIAGNOSIS

Acute Decompensated Heart Failure

Most likely ISCHAEMIC cause (IHD background)

Possible trigger: ? Infection, ? ACS, ? Non-compliance

YOUR PLAN

Sit up + O₂ if hypoxic

IV Frusemide (40–80mg) stat

ECG → rule out ACS trigger

Bloods: Troponin, BNP, UEC, FBC

CXR → confirm pulmonary oedema

Echo → confirm HF, assess EF

Identify + treat the trigger

Monitor: UO, weight, electrolytes

Refer Cardiology

Treat the fluid — but always ask: WHY did they decompensate?

Heart Failure | JMO Teaching Session | 2026

SLIDE 9 · TAKE HOME

Key Take-Home Points

🩺

Think Heart Failure in ANY patient with SOB + bilateral oedema

⚡

Always rule out an ACS trigger — troponin + ECG in every patient

🔬

Echo is the gold standard — confirms diagnosis and guides management

💧

Treat fluid overload early — IV frusemide and monitor response

🔍

Identify and fix the trigger — this prevents the next admission

In heart failure, treating the fluid is important — but finding and fixing the trigger is what prevents the next admission.

— The clinical principle to carry through your career

Heart Failure | JMO Teaching Session | 2026

heart-failure
medical-education
junior-doctor-teaching
cardiology
hfref-management
clinical-framework

Heart Failure

A Clinical Framework for Junior Doctors

📋 PRESENTING CASE

Acute Dyspnoea + Oedema

🔴 CARDIAC

🟠 RESPIRATORY

🟡 OTHER

Causes of Heart Failure

🔴 ISCHAEMIC

🟠 PRESSURE OVERLOAD

🟡 VOLUME OVERLOAD

🟣 MYOCARDIAL DISEASE

🔵 OTHER CAUSES

Pathophysiology + Clinical Features

⚙️ PATHOPHYSIOLOGY

😮‍💨 SYMPTOMS

🩺 SIGNS

Investigations – What You Actually Do

Management – Acute & Chronic

Triggers, Complications & Red Flags

Back to Our Patient

Key Take-Home Points

DESIGNER-MADE PRESENTATION, GENERATED FROM YOUR PROMPT

Heart Failure: Clinical Framework for Junior Doctors

DESIGNER-MADE
PRESENTATION,
GENERATED FROM
YOUR PROMPT