Heart failure accounts for roughly 15 to 18 per cent of the SCE Cardiology exam. The ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure (2023) are the primary reference. This page summarises the high-yield content for exam preparation.
Classification
Heart failure is classified by ejection fraction: HFrEF (LVEF 40 per cent or below), HFmrEF (LVEF 41 to 49 per cent), and HFpEF (LVEF 50 per cent or above). The distinction is critical because the evidence base for pharmacotherapy differs between categories — the strongest evidence applies to HFrEF.
NT-proBNP is the recommended biomarker for diagnosis and risk stratification. The ESC uses a threshold of 125 pg/mL for chronic HF and 300 pg/mL for acute HF to guide further investigation. Echocardiography is mandatory for structural and functional assessment.
HFrEF pharmacotherapy — the four pillars
The ESC recommends four drug classes for all patients with HFrEF, initiated as early as possible and titrated to target doses. These are an ACE inhibitor or ARB (or sacubitril-valsartan), a beta-blocker (bisoprolol, carvedilol, metoprolol succinate, or nebivolol), a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and an SGLT2 inhibitor (dapagliflozin or empagliflozin).
The 2023 guidelines position SGLT2 inhibitors as a core pillar alongside the established three, based on the DAPA-HF and EMPEROR-Reduced trials. This is a high-yield exam topic — questions frequently test which drug classes are recommended, the evidence base for each, target doses, and contraindications.
Sacubitril-valsartan is recommended in preference to an ACE inhibitor for patients who remain symptomatic despite optimised therapy. The switch requires a 36-hour washout from ACE inhibitors to reduce the risk of angioedema.
Device therapy
An ICD is recommended for primary prevention in patients with symptomatic HFrEF (LVEF 35 per cent or below) despite three or more months of optimised medical therapy, with a life expectancy of more than one year. CRT is recommended for patients with LVEF 35 per cent or below, NYHA class II to IV despite optimised therapy, and QRS duration of 150 ms or more with LBBB morphology.
The QRS duration and morphology criteria are frequently tested. CRT benefit is strongest in patients with LBBB and QRS 150 ms or more. The evidence for CRT in non-LBBB morphology or QRS 130 to 149 ms is weaker, and this nuance appears in exam questions.
Acute heart failure
Acute HF management follows the ESC algorithm based on the clinical profile: wet-warm (diuretics and vasodilators), wet-cold (inotropes and consider mechanical support), dry-warm (optimise oral therapy), dry-cold (consider fluid challenge and inotropes). IV furosemide is first-line for congestion. Vasodilators (GTN infusion) are used for hypertensive acute HF. Inotropes (dobutamine, milrinone) are reserved for cardiogenic shock.
HFpEF and HFmrEF
The evidence base for HFpEF pharmacotherapy is weaker than for HFrEF. The ESC recommends SGLT2 inhibitors for HFpEF based on EMPEROR-Preserved and DELIVER trials. Diuretics are recommended for congestion. Beyond these, management focuses on treating comorbidities (AF, hypertension, obesity, diabetes) and addressing volume status.
HFmrEF management follows similar principles to HFrEF, with the caveat that the evidence base is extrapolated rather than directly demonstrated for most drug classes.
What the exam tests
SCE Cardiology questions on heart failure typically test pharmacotherapy sequencing (which drug to add next for a patient on suboptimal therapy), device eligibility criteria (particularly CRT with specific QRS parameters), acute HF management based on clinical profile, and the evidence base for SGLT2 inhibitors across the ejection fraction spectrum. Ensure you can apply these guidelines to specific clinical scenarios rather than simply listing the recommendations.
iatroX's SCE Cardiology bank includes extensive heart failure content aligned to the 2023 ESC guidelines, with questions testing all of the above domains. The adaptive algorithm ensures heart failure questions are weighted proportionally. All included at £29 per month or £99 per year.