Heart Failure and Valvular Disease

Medicine — Heart Failure and Valvular Disease, NMC MBBS licence examination syllabus (Nepal Medical Council).

Heart failure and valvular disease

Work out where the blood is backing up, and the examination findings write themselves.

Heart failure is a syndrome, not a diagnosis — it means the heart cannot deliver enough output for the body's needs at normal filling pressures. Almost everything you find on examination follows from one question: where is the blood backing up? Behind a failing left ventricle it backs into the lungs, giving breathlessness, orthopnoea and crackles. Behind a failing right ventricle it backs into the systemic veins, giving a raised jugular venous pressure, oedema and a large liver.

Valvular disease sits alongside it for a specific reason in this setting. In Nepal and comparable countries, rheumatic heart disease remains a significant cause of valve damage and of heart failure in young adults — and unlike most cardiac disease, it is preventable at the point of a childhood sore throat.

🩺 Where this lives: Rheumatic heart disease is a disease of poverty, and it is almost entirely preventable. A streptococcal sore throat that is never treated leads to rheumatic fever; repeated attacks damage the valves cumulatively; and twenty years later a young adult presents with breathlessness and atrial fibrillation from mitral stenosis, needing surgery that may not be available or affordable. Every link in that chain is interruptible, and the cheapest interruption is at the beginning. This is why treating sore throats appropriately and maintaining secondary prophylaxis are not trivial primary care tasks.

💡 A note on numbers. This chapter gives no doses, no ejection fraction cut-offs and no prophylaxis regimens. Ejection fraction boundaries have been revised and differ between guidelines; heart failure drug doses are titrated; rheumatic prophylaxis follows the national programme. Drug classes are named because the class is the examinable point. Beta-blockers are covered in the Autonomic Pharmacology chapter and the renin-angiotensin blockers and diuretics in the Cardiovascular Drugs chapter.

Left and right

Two points follow from this. First, the commonest cause of right heart failure is left heart failure — the raised pressure transmits backwards through the lungs — which is why most patients have features of both. Second, and diagnostically useful: right heart failure without left heart failure should send you to the lungs. Cor pulmonale from chronic lung disease, pulmonary embolism and pulmonary hypertension all load the right ventricle directly.

Reduced and preserved ejection fraction

WHY THE DISTINCTION MATTERS SO MUCH REDUCED EJECTION FRACTION — the ventricle cannot CONTRACT Causes: ischaemic heart disease, cardiomyopathy, valve disease, uncontrolled hypertension, alcohol. PRESERVED EJECTION FRACTION — the ventricle cannot RELAX A stiff ventricle that squeezes normally but fills poorly. Associated with hypertension, age, diabetes and obesity. YOU CANNOT DISTINGUISH THEM AT THE BEDSIDE. Both present with breathlessness, orthopnoea and oedema. ECHOCARDIOGRAPHY is what separates them, which is why it is the key investigation in any new heart failure. AND THE REASON IT MATTERS: DIURETICS relieve congestion and symptoms in both. But the drug classes shown to improve SURVIVAL are established principally in REDUCED ejection fraction. So a patient given only a diuretic feels better while their prognosis is unchanged. Symptom relief and prognostic treatment are two different jobs, and the second one is the one that gets forgotten. DRUG CLASSES WITH PROGNOSTIC BENEFIT in reduced ejection fraction include ACE inhibitors (or ARBs), beta-blockers and aldosterone antagonists — with newer classes added in current guidance. Doses are titrated upward slowly against blood pressure, renal function and potassium. BETA-BLOCKERS IN HEART FAILURE look paradoxical — blocking a struggling heart — and are covered in the beta-blocker chapter. The principle is that they are started LOW and SLOW, and NOT during acute decompensation.

Acute pulmonary oedema

💡 Exam angle: after the immediate measures — sit the patient up, oxygen, intravenous diuretic — the question that earns marks is "why now?". A patient with chronic stable heart failure who suddenly decompensates has usually been tipped over by something: myocardial infarction, a new arrhythmia (commonly atrial fibrillation), infection, missed medication, a salt load, anaemia, or a newly started NSAID. Treating the oedema without finding the precipitant means it recurs.

Rheumatic heart disease

The clinical shape of rheumatic disease is worth holding as a timeline. A streptococcal throat infection is followed, weeks later, by acute rheumatic fever — fever, a migratory arthritis of large joints, carditis, and sometimes chorea. That episode may settle completely. But each attack damages the valves a little more, and decades later the person presents with the consequences: most often mitral disease, then aortic. Prevention works at two points — treating the sore throat prevents the first attack, and long-term secondary prophylaxis prevents the recurrences that cause cumulative damage.

The murmurs

READING A MURMUR SYSTEMATICALLY ASK FOUR THINGS: TIMING Systolic or diastolic? SITE Where is it loudest? RADIATION Where does it travel? PULSE What does the pulse feel like? AORTIC STENOSIS Ejection systolic, loudest at the aortic area, radiating to the CAROTIDS. SLOW-RISING pulse, NARROW pulse pressure. The triad that means urgent referral is SYNCOPE, ANGINA and HEART FAILURE — symptoms mark a sharp change in prognosis. MITRAL REGURGITATION PANSYSTOLIC at the apex, radiating to the AXILLA. MITRAL STENOSIS Mid-DIASTOLIC rumble at the apex, loud first heart sound. Classically RHEUMATIC. Atrial fibrillation is common, and brings a stroke risk requiring anticoagulation — see the cardiovascular drugs chapter. AORTIC REGURGITATION Early DIASTOLIC, heard best leaning forward in expiration. COLLAPSING pulse, WIDE pulse pressure. A MEMORY HOOK: the two systolic murmurs radiate (carotids for aortic stenosis, axilla for mitral regurgitation); the two diastolic murmurs need a manoeuvre to hear well. ANY new murmur with FEVER raises INFECTIVE ENDOCARDITIS — take blood cultures before antibiotics.

Clinical reasoning: four presentations

🔍 Case 1 — feeling better, no better off

PresentationA 68-year-old with new heart failure and a reduced ejection fraction on echocardiography is discharged on a diuretic alone. He feels much improved at review, and no further changes are made.

What is missingPrognostic treatment.

ReasoningDiuretics relieve congestion but do not alter survival. The classes with prognostic benefit in reduced ejection fraction — ACE inhibitor or ARB, beta-blocker, aldosterone antagonist — have not been started.

AnswerIntroduce prognostic therapy per national guidance, titrated slowly with monitoring of blood pressure, renal function and potassium. Symptom relief is not the same as treatment.

🔍 Case 2 — swollen ankles and clear lungs

PresentationA 62-year-old with long-standing COPD has ankle oedema and a raised jugular venous pressure. His chest is not congested and he has no orthopnoea. He is treated with a diuretic for "heart failure" without further assessment.

Key clueRight-sided signs without left-sided ones.

ReasoningIsolated right heart failure points away from the left ventricle and towards the lungs. Chronic lung disease loading the right ventricle is cor pulmonale.

AnswerAssess the lungs and the right heart, optimise treatment of the underlying lung disease and oxygenation, and consider other causes of right-sided loading such as pulmonary embolism.

🔍 Case 3 — a young woman with breathlessness and AF

PresentationA 30-year-old presents with progressive exertional breathlessness. She is in atrial fibrillation, and there is a mid-diastolic rumble at the apex with a loud first heart sound. She recalls painful swollen joints and a long fever as a child.

DiagnosisMitral stenosis from rheumatic heart disease.

ReasoningThe murmur, the age, the atrial fibrillation and the childhood illness fit a rheumatic aetiology presenting decades after the acute attack. Mitral stenosis is the classic rheumatic lesion.

AnswerEchocardiography and cardiology referral. Anticoagulate for atrial fibrillation per guidance — the stroke risk here is substantial — and address secondary prophylaxis per the national programme.

🔍 Case 4 — decompensation with a reason

PresentationA patient with stable chronic heart failure presents with acute pulmonary oedema. He is sat up, given oxygen and an intravenous diuretic, improves, and is discharged the next day with no further investigation.

The unanswered questionWhy did it happen now?

ReasoningStable heart failure does not usually decompensate without a precipitant — myocardial infarction, new atrial fibrillation, infection, missed medication, a salt load, anaemia or a new NSAID are the usual candidates.

AnswerInvestigate for the precipitant before discharge, including an ECG and consideration of ischaemia and arrhythmia. Treating the oedema alone guarantees a readmission.

Commonly confused

Confusion	The distinction	Why it matters
Left vs right failure	Backs into the lungs versus the body	The findings follow the backlog.
Right failure vs lung disease	Isolated right signs point to the lungs	Cor pulmonale needs different treatment.
Reduced vs preserved ejection fraction	Cannot contract versus cannot relax	Only echocardiography separates them.
Symptom relief vs prognostic benefit	Diuretics do the first, not the second	Patients feel better with unchanged survival.
Treating oedema vs finding the precipitant	Ask "why now?"	Otherwise it recurs.
Aortic stenosis vs mitral regurgitation	Radiates to carotids versus axilla	Both are systolic — radiation separates them.
Mitral stenosis vs regurgitation	Mid-diastolic rumble versus pansystolic	Stenosis is the classic rheumatic lesion.
Asymptomatic vs symptomatic aortic stenosis	Syncope, angina or heart failure	Symptoms mark a sharp prognostic change.

Rapid revision

MUST-KNOW FACTS 1. Heart failure is a SYNDROME, not a diagnosis. 2. The findings follow WHERE THE BLOOD BACKS UP. 3. LEFT failure backs into the LUNGS. 4. Left: exertional breathlessness, ORTHOPNOEA, PND, basal crackles, third heart sound. 5. RIGHT failure backs into the BODY. 6. Right: RAISED JVP, ankle and sacral OEDEMA, tender liver, ascites. 7. The commonest cause of right heart failure is LEFT heart failure. 8. Isolated RIGHT failure — look at the LUNGS (cor pulmonale, PE). 9. REDUCED ejection fraction: the ventricle cannot CONTRACT. 10. PRESERVED ejection fraction: the ventricle cannot RELAX. 11. You CANNOT distinguish them at the bedside. 12. ECHOCARDIOGRAPHY is the key investigation in new heart failure. 13. DIURETICS relieve symptoms in both types. 14. PROGNOSTIC drugs are established mainly in REDUCED ejection fraction. 15. Classes: ACE inhibitor or ARB, BETA-BLOCKER, aldosterone antagonist. 16. Titrate slowly, monitoring BP, renal function and POTASSIUM. 17. Beta-blockers are started LOW and SLOW, NOT in acute decompensation. 18. ACUTE PULMONARY OEDEMA: SIT UP, OXYGEN, intravenous diuretic. 19. Then ask WHY NOW — find the precipitant. 20. Precipitants: MI, arrhythmia, infection, missed drugs, salt, anaemia, NSAID. 21. RHEUMATIC FEVER follows a STREPTOCOCCAL SORE THROAT weeks later. 22. Acute rheumatic fever: fever, MIGRATORY arthritis, carditis, chorea. 23. Valve damage presents DECADES later. 24. The MITRAL valve is most often affected, then the aortic. 25. Treating the sore throat prevents the FIRST attack. 26. SECONDARY PROPHYLAXIS prevents recurrence and cumulative damage. 27. AORTIC STENOSIS: ejection systolic, radiates to the CAROTIDS, slow-rising pulse. 28. Aortic stenosis with SYNCOPE, ANGINA or HEART FAILURE — urgent referral. 29. MITRAL REGURGITATION: PANSYSTOLIC at the apex, radiates to the AXILLA. 30. MITRAL STENOSIS: mid-DIASTOLIC rumble, loud first sound, classically rheumatic. 31. AORTIC REGURGITATION: early diastolic, COLLAPSING pulse, wide pulse pressure. 32. Mitral stenosis with AF needs ANTICOAGULATION — high stroke risk. 33. A NEW MURMUR WITH FEVER — think INFECTIVE ENDOCARDITIS, culture before antibiotics.

💡 Exam angle: three habits carry this chapter. Decide which side is failing from the findings. Remember that echocardiography, not the bedside, separates reduced from preserved ejection fraction — and that only one of them has prognostic drugs. And in any acute decompensation, ask what tipped the patient over.

Syllabus points

Why the findings follow the backlog
Left-sided features
Right-sided features
Isolated right failure and the lungs
Reduced versus preserved ejection fraction
Why echocardiography is essential
Symptom relief versus prognostic benefit
Acute pulmonary oedema
Finding the precipitant
The rheumatic chain and its prevention
Acute rheumatic fever
Reading a murmur systematically
The four main valve lesions

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