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Heart Failure Hub

Heart failure is a clinical syndrome where the heart cannot meet the body's needs or can only do so with elevated filling pressures. This module covers recognition, workup, management, and patient communication.

Cardiology APPsPA/NP StudentsNursesMAsMedical StudentsClinic Staff

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🫀Heart Failure

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Pre-Test — Heart Failure

~2 min

Answer a few quick questions before starting to measure your learning gain.

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Overview

Learning Objectives

1.Recognize common heart failure symptoms
2.Distinguish stable symptoms from possible decompensation
3.Ask focused history questions
4.Understand basic workup
5.Review core medication classes
6.Know when to escalate care
7.Communicate daily weights, sodium restriction, fluid restriction, and medication adherence

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Choose Your View

Same topic, different depth. Jump to the view that matches your role.

🩺APP / NP / PA

Pathophysiology, differential, GDMT, and disposition decisions.

Scope: Clinical reasoning, diagnostics, and management. Not procedural or raw-imaging training.

💉Nurse

Triage, escalation criteria, and patient education reinforcement.

Scope: Triage and workflow support. Does not replace institutional protocols or provider direction.

🏥MA / Nurse Tech

Rooming, vitals, red flags, and what to report immediately.

Scope: Safe data collection and escalation. Not independent triage or clinical decision-making.

🎓Student

Start with the lesson and cheat sheet, then test yourself with the quiz.

Scope: Introductory learning, to be used under supervision.

📄Patient Education 🗣️Spanish / Communication 🩺Sim Case 🧠Quiz

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APP Lesson: Heart Failure Foundations

Audience: New cardiology APPs, PA/NP students, and clinicians new to cardiology.

What is Heart Failure?

›Heart failure is not one single disease but a syndrome caused by structural or functional cardiac abnormalities leading to symptoms and signs from congestion and/or low output.
›The heart may fail to pump enough blood forward (systolic dysfunction), fail to relax and fill normally (diastolic dysfunction), or both. The result is that the body's oxygen demands are not met, or they are only met at the cost of elevated filling pressures that cause fluid to back up into the lungs, legs, and abdomen.

Common Categories

›HFrEF (Heart Failure with Reduced Ejection Fraction): EF < 40%. Impaired systolic pump function. Most evidence-based therapies target this group.
›HFmrEF (Heart Failure with Mildly Reduced EF): EF 41–49%. A middle-ground category with evolving evidence.
›HFpEF (Heart Failure with Preserved EF): EF ≥ 50%. The heart pumps well but doesn't relax normally. Very common, especially in older patients with hypertension, obesity, and diabetes.
›Right-sided heart failure: Can occur in isolation (e.g., pulmonary hypertension) or alongside left-sided failure. Presents with elevated JVP, peripheral edema, hepatomegaly.
›Acute decompensated heart failure (ADHF): Worsening HF requiring urgent evaluation and intensified therapy.
›Chronic stable heart failure: Well-compensated HF managed with guideline-directed medical therapy and close monitoring.

Key Symptoms to Ask About

›Dyspnea on exertion — How far can they walk? What limits them?
›Orthopnea — Shortness of breath lying flat. How many pillows do they use?
›Paroxysmal nocturnal dyspnea (PND) — Waking from sleep gasping or short of breath
›Leg swelling — New, worsening, symmetric or asymmetric
›Rapid weight gain — Gain of 2–3 lb/day or 5 lb/week suggests fluid retention
›Fatigue and reduced exercise tolerance
›Abdominal bloating or discomfort (from ascites or hepatic congestion)
›Chest pain — Rule out ischemia as a precipitant
›Palpitations — Arrhythmia may be the driver or result of decompensation
›Syncope or near-syncope — Suggests low output or arrhythmia
›Medication adherence — Missed diuretics are a very common trigger
›Diuretic response — Are they urinating after their diuretic?
›Sodium and fluid intake — Dietary indiscretion is a common trigger

Key Physical Exam Findings

›Weight — Compare to previous visits or known dry weight
›Blood pressure — Hypertension can precipitate decompensation; hypotension suggests low output
›Heart rate — Tachycardia may indicate compensation for low output or a primary arrhythmia
›Oxygen saturation — Resting hypoxia is a red flag
›Jugular venous distension (JVD) — Elevated JVP suggests volume overload
›Lung exam — Crackles (rales) suggest pulmonary congestion. Distinguish from rhonchi (low-pitched, clears with cough) and wheezing (high-pitched, expiratory).
›Lower extremity edema — Grade and note if pitting, how far it extends
›Murmurs — Valve disease may be the cause or contributor. Common in HF: mitral regurgitation (holosystolic, apex), tricuspid regurgitation (LLSB, louder with inspiration), aortic stenosis (harsh systolic, RUSB).🔊 Hear MR
›S3 gallop — "Ken-tuc-ky" cadence, low-pitched, heard at apex with bell. When present in an adult, highly associated with elevated filling pressures and volume overload.
›Cool extremities or poor perfusion signs — Suggest reduced cardiac output
›Abdominal distension — Ascites, hepatomegaly from right heart failure

Initial Workup

›EKG — Look for ischemia, arrhythmia, prior MI, conduction disease, LVH
›Chest X-ray — Evaluate for pulmonary vascular congestion, pleural effusions, and cardiomegaly when worsening dyspnea or congestion is suspected
›BNP or NT-proBNP — Helpful when the diagnosis or severity is unclear; elevated in most ADHF
›BMP/CMP — Assess renal function and electrolytes before and after diuretic changes
›CBC — Rule out anemia as a contributing factor; evaluate for infection
›Troponin — Order if chest pain, ischemic symptoms, or acute presentation
›Echocardiogram — If EF unknown, significant clinical change, or prior imaging is outdated
›Ischemic evaluation — Consider stress testing or cath referral depending on presentation and history

CXR Examples

Basic Treatment Concepts

›Loop diuretics (e.g., furosemide, torsemide, bumetanide) — Primary treatment for congestion. Dose may need to be IV in decompensation.
›Guideline-directed medical therapy (GDMT) for HFrEF — ACEi/ARB/ARNI, beta-blockers, MRAs, and SGLT2 inhibitors when appropriate
›SGLT2 inhibitors — Proven mortality and hospitalization benefit in both HFrEF and HFpEF; important for most HF patients without contraindication
›Monitor renal function and potassium — Especially after diuretic or RAAS medication changes
›Blood pressure control — Uncontrolled hypertension is a major driver of HF decompensation
›Address contributing conditions — Ischemia, arrhythmias, valve disease, sleep apnea, obesity, diabetes, medication adherence
›Educate patients — Daily weights, sodium restriction (<2g/day), fluid restriction when appropriate, and clear instructions on when to call

Red Flags / When to Escalate

›Resting hypoxia (SpO2 < 90–92%)
›Severe dyspnea at rest or with minimal exertion
›Chest pain concerning for ACS
›Syncope or presyncope
›Hypotension
›Rapid weight gain (e.g., 8+ lb) with worsening symptoms
›Poor urine output despite diuretic therapy
›Confusion or altered mental status
›Cool, clammy appearance suggesting poor perfusion
›New significant arrhythmia
›Worsening renal function or severe electrolyte abnormality
›Failure of outpatient diuresis
›Any concern for cardiogenic shock

Common Beginner Mistakes

›Treating leg swelling as isolated edema without asking about orthopnea, PND, or weight gain
›Forgetting to check renal function and potassium before and after diuretic changes
›Not asking about missed diuretic doses — one of the most common decompensation triggers
›Assuming all dyspnea is pulmonary without considering a cardiac cause
›Ignoring blood pressure as a driver of decompensation
›Not reviewing the most recent echocardiogram before clinical decisions
›Not escalating patients with hypoxia or instability for higher-level care
›Overexplaining complex plans to patients without engaging a certified interpreter when language discordance exists

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Nurse Triage Checklist

Help nurses gather useful information before escalating to the APP or physician.

Symptoms

Shortness of breath at rest?
Shortness of breath with activity?
Worse lying flat?
Waking up short of breath?
New or worse leg swelling?
Chest pain?
Palpitations?
Dizziness or syncope?
Cough or fever?
Reduced urination?

Measurements

Current weight
Baseline / dry weight if known
Weight gain in 1 day
Weight gain in 1 week
Blood pressure
Heart rate
Oxygen saturation if available
Temperature if sick symptoms present

Medications

Taking diuretic as prescribed?
Any missed doses?
Recent medication changes?
NSAID use (ibuprofen, naproxen)?
Increased salt intake?
Increased fluid intake?

⚠️ Escalate Urgently / ER Consideration

Severe shortness of breath
Chest pain
Syncope or fainting
Oxygen saturation low or worsening
Confusion or altered mental status
Blue lips or fingertips
Very low blood pressure
Rapidly worsening symptoms
Poor urine output
Patient sounds unstable on the phone

Information to Send Provider

Current symptoms and onset
Current vitals
Weight trend (today vs. baseline)
Current diuretic dose
Missed doses
Last labs if available
Last known EF if available
Patient pharmacy
Callback number

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Clinical Cheat Sheet

Ask

•When did shortness of breath start?
•Worse with exertion?
•Worse lying flat?
•How many pillows?
•Waking up gasping?
•Leg swelling?
•Weight gain? How much?
•Missed diuretic?
•Increased sodium or fluid intake?
•Chest pain?
•Palpitations?
•Syncope or near-syncope?
•Urine output?

Check

•Vitals (BP, HR, RR, SpO2, Temp)
•Weight trend vs. dry weight
•Oxygen saturation at rest
•Exam for volume overload (JVD, crackles, edema)
•EKG
•BMP/CMP
•BNP or NT-proBNP
•CBC when appropriate
•Chest X-ray when appropriate
•Echo history / prior EF

Think

•Stable chronic HF
•Acute decompensated HF
•Ischemia / ACS
•Atrial fibrillation or arrhythmia
•Valve disease
•Renal dysfunction
•Pulmonary cause
•Medication nonadherence
•Dietary indiscretion

Act

•Escalate unstable or hypoxic patients
•Intensify diuresis if appropriate and safe
•Monitor renal function and potassium
•Review GDMT and optimize
•Educate on daily weights and sodium/fluid plan
•Arrange follow-up based on severity
•Use certified interpreter for diagnosis, treatment, medication changes, and discharge instructions

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Patient Education Handout

What is Heart Failure?

Heart failure means your heart is not pumping or relaxing normally. This can cause fluid to build up in your lungs, legs, or belly.
Heart failure can be managed. Following your care plan, taking your medicines, and watching your symptoms can help you stay out of the hospital.

Daily Weights

Weigh yourself every morning.
Use the same scale every time.
Weigh after using the bathroom and before eating.
Write down your weight each day.
Call your clinic if you gain 2–3 pounds in one day or 5 pounds in one week — unless your clinic gave you different instructions.

Symptoms to Report

More shortness of breath than usual
Trouble lying flat to sleep
Waking up short of breath at night
More swelling in legs, ankles, or belly
Rapid weight gain
More fatigue or weakness
Dizziness or fainting
Less urination than usual
Chest pain or pressure

Salt (Sodium)

Too much salt can make your body hold extra fluid and make heart failure worse.
Common high-salt foods to limit: fast food, canned soup, chips, processed meats, frozen meals, and restaurant food.
Try to follow your clinic's sodium instructions. Many heart failure patients are advised to stay under 2,000 mg of sodium per day.

Fluids

Some patients may need a fluid limit. Follow your clinic's instructions.
Fluids include: water, coffee, tea, soda, juice, milk, soup, ice chips, popsicles, and gelatin (Jell-O).
Ask your care team if you have a daily fluid limit.

Your Medicines

Take your medicines every day as prescribed.
Do not stop your water pill (diuretic) unless your care team tells you to.
Call your clinic if you cannot keep your medicines down.
Call before taking ibuprofen, naproxen, or other anti-inflammatory medicines — these can make heart failure worse.

When to Seek Urgent Help

Call emergency services or go to the ER for:
•Severe shortness of breath
•Chest pain or pressure
•Fainting
•Confusion
•Blue lips or fingertips
•Severe weakness
•Symptoms that are quickly getting worse

This handout is for education only and does not replace medical advice from your healthcare team.

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Sim Patient Case

Cardiology ClinicInteractive

Patient

[EN] 68-year-old Spanish-speaking male with HFrEF, hypertension, and diabetes. [ES] Hombre de 68 años, hispanohablante, con insuficiencia cardíaca con fracción de eyección reducida (ICFEr), hipertensión y diabetes.

Chief Complaint

[EN] "I can't breathe when I lie flat and my legs are so swollen I can't put my shoes on." [ES] "No puedo respirar cuando me acuesto y mis piernas están tan hinchadas que no puedo ponerme los zapatos."

Vitals

162/88 mmHg

96 bpm

22 breaths/min

SpO2

91%

Temp

98.4°F

Weight

Up 8 lb from last visit

Goal

[EN] Interview the patient in Spanish, understand his responses, choose appropriate workup, identify the likely diagnosis, select safe next steps, and recognize when a certified interpreter is required. [ES] Entreviste al paciente en español, comprenda sus respuestas, elija el estudio apropiado, identifique el diagnóstico probable, seleccione los próximos pasos seguros y reconozca cuándo se requiere un intérprete certificado.

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Knowledge Check Quiz

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Spanish / Communication Phrases

Interpreter Notice: These phrases are for basic communication and rapport only. Use a certified medical interpreter for diagnosis, treatment decisions, medication changes, consent, discharge instructions, and all complex clinical conversations.

Are you short of breath?

¿Le falta el aire?

Is it worse when you lie down?

¿Le falta más el aire cuando se acuesta?

How many pillows do you use to sleep?

¿Cuántas almohadas usa para dormir?

Do your legs swell?

¿Se le hinchan las piernas?

Have you gained weight?

¿Ha subido de peso?

Did you take your water pill?

¿Tomó su pastilla de agua?

Did you miss any doses?

¿Se le olvidó tomar alguna dosis?

Do you have chest pain?

¿Tiene dolor en el pecho?

Please weigh yourself every morning.

Por favor, pésese cada mañana.

We need an interpreter to explain the plan clearly.

Necesitamos un intérprete para explicar el plan claramente.

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Clinical Sounds & Visual Findings

Advanced reference — auscultation and imaging findings for learners who want to go deeper.

Press ▶ Play to hear the sound directly. No page navigation needed.

S3 — Third Heart Sound (Gallop)Key HF finding

"Ken-tuc-ky" cadence. Low-pitched, heard at apex with bell. Suggests volume overload and elevated filling pressures — one of the most specific findings for heart failure.

University of Washington Dept. of Medicine

Mitral RegurgitationCommon in HFrEF

Holosystolic blowing murmur at apex, often radiating to axilla. Very common as the mitral annulus dilates in HFrEF.

University of Washington Dept. of Medicine

Tricuspid RegurgitationRight-sided HF

Holosystolic at left lower sternal border, louder with inspiration (Carvallo's sign). Common in right-sided HF and pulmonary hypertension.

🔊Listen ↗

Aortic StenosisHF precipitant

Diamond-shaped harsh systolic murmur at right upper sternal border, radiates to carotids. Can cause or worsen heart failure.

University of Washington Dept. of Medicine

Normal Heart Sounds (S1 + S2)Normal reference

Reference: lub-dub. S1 = mitral and tricuspid valve closure. S2 = aortic and pulmonic valve closure.

University of Washington Dept. of Medicine

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Disclaimer: This content is for educational purposes only. It is not medical advice, does not replace clinical judgment, and is not a substitute for institutional protocols or certified medical interpreters. No patient health information (PHI) should be entered into this application.