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Updated: Jul 29 2022

Heart Failure

  • Snapshot
    • A 60-year-old man presents to his primary care physician for several months of dyspnea on exertion, exercise intolerance, and lower-extremity swelling. He has a past medical history of sarcoidosis. On physical exam, he has jugular venous distension and pitting edema in the lower extremities. An echocardiogram shows an ejection fraction of 35%.
  • Introduction
    • Clinical definition
      • the inability of the heart to pump blood throughout the body, leading to congestion and decreased perfusion
        • systolic dysfunction
          • loss of contractile strength and results in low ejection fraction (< 45%)
        • diastolic dysfunction
          • impairment in filling of the heart and often has a normal ejection fraction
        • high-output heart failure
          • occurs in a minority of patients
          • cardiac output exceeds metabolic demand
        • decompensated heart failure
          • occurs when symptoms are worsened or exacerbated
          • precipitating factors include
            • infections
            • arrhythmias
            • excessive salt in the diet (post-holiday heart)
            • uncontrolled hypertension
            • thyrotoxicosis
            • myocardial infarction
    • Associated conditions
      • obstructive sleep apnea
      • major depression disorder
  • Epidemiology
    • Risk factors
      • coronary artery disease
      • viral infection
      • alcohol abuse
      • hypertension
      • arrhythmias
      • metabolic syndrome
      • drugs (e.g., doxorubicin)
        • monitor cardiac function with echocardiography
      • smoking
  • Etiology
    • Pathogenesis
      • systolic dysfunction
        • ↓ contractility leading to ↓ ejection fraction and ↑ end diastolic volume
        • ↑ systemic vascular resistance
        • most commonly due to dilated cardiomyopathy and ischemic heart disease
      • diastolic dysfunction
        • ↓ compliance leading to problems with relaxation and filling of the heart
        • normal ejection fraction and normal end diastolic volume
        • most commonly due to myocardial hypertrophy
      • right heart failure most commonly results from left heart failure
        • can be caused by elevated pulmonary artery pressure from COPD or idiopathic pulmonary hypertension
      • high-output heart failure
        • high cardiac output and ↓ systemic vascular resistance
        • often occurs in the setting of existing systolic or diastolic dysfunction
    • Systolic dysfunction
      • ischemic heart disease (most common)
      • chronic hypertension
      • dilated cardiomyopathy
      • valvular disease
      • congenital heart disease
    • Diastolic dysfunction
      • hypertension with left ventricular hypertrophy
      • hypertrophic cardiomyopathy
      • amyloidosis
      • sarcoidosis
      • hemochromatosis
      • scleroderma
      • post-operative/radiation fibrosis
    • High-output heart failure
      • obesity
      • myeloproliferative disorder
      • arterial-venous fistula
      • thyrotoxicosis
  • Presentation
    • Symptoms
      • dyspnea on exertion
      • orthopnea
      • paroxysmal nocturnal dyspnea
      • fatigue
      • pulmonary edema
    • Physical exam
      • cardiovascular exam
        • pitting lower extremity edema
        • jugular venous distention
      • pulmonary exam
        • shortness of breath
        • rales
          • liquid accumulates in alveoli due to left heart pressure overload
          • alveoli pop open during inhalation, causing rales on exam
      • abdominal exam
        • ascites
        • hepatojugular reflux 
  • Imaging
    • Chest radiograph
      • findings
        • pulmonary vascular congestion
        • pleural effusion
        • cardiomegaly
        • Kerley-B lines
        • interstitial edema
    • Echocardiogram
      • indication
        • confirms the diagnosis of heart failure
        • classifies whether heart failure is due to systolic or diastolic dysfunction
      • findings
        • assess for low ejection fraction
        • systolic of diastolic dysfunction
  • Studies
    • Atrial and B-type (brain) natriuretic peptide (ANP and BNP)
      • released by the ventricles and the atria in response to increased stretch
      • elevated levels are often seen in decompensated CHF
      • normal BNP excludes a diagnosis of CHF
    • Electrocardiogram (ECG)
      • findings
        • sinus tachycardia
        • may also have arrhythmias
        • may show ventricular hypertrophy
    • Making the diagnosis
      • based on clinical presentation and echocardiogram
    • New York Heart Association Functional Classification of Heart Failure
      ClassLimitations of Physical Activity
      Heart Failure Symptoms
      • None
      • No symptoms
      • Mild
      • Symptoms with significant exertion; comfortable at rest or mild activity
      • Marked limitation
      • Symptoms with mild exertion; only comfortable at rest
      • Confined to bed or chair
      • Symptoms occur at rest
  • Differential
    • Acute respiratory distress syndrome
      • distinguishing factors
        • diffuse crackles in the lungs, no S3 heart sound, and increased work of breathing on exam
        • chest radiograph with bilateral alveolar infiltrates
  • Treatment
    • Management approach
      • acute decompensated heart failure
        • supplemental oxygen (for SpO2 <90%), loop diuretics, nitrates
      • long-term management
        • mortality is decreased with angiotensin-converting enzyme inhibitors (ACE-inhibitors) or angiotensin II receptor blockers (ARBs), β-blockers, and spironolactone or eplerenone
    • Conservative
      • avoid excessive salt in the diet
        • indication
          • all patients
    • Medical
      • systolic dysfunction
        • ACE-inhibitors or ARBs
          • indications
            • lowers mortality (in particular when there is a decreased ejection fraction)
            • renin-angiotensin-aldosterone system and ADH is upregulated in these patients
            • systolic or diastolic dysfunction
            • asymptomatic left ventricular systolic dysfunction
        • hydralazine and nitrates
          • indications
            • when ACE-inhibitors or ARBs are contraindicated, such as in those with renal failure
            • systolic dysfunction
            • in acute episodes of congestive heart failure (via preload and afterload reduction)
        • β-blockers
          • indications
            • lowers mortality
            • systolic or diastolic dysfunction
          • drugs (mortality lowering)
            • metoprolol
            • carvedilol
            • bisoprolol
        • spironolactone or eplerenone
          • indications
            • lowers mortality
              • in particular in more severe disease with reduced ejection fraction
            • systolic or diastolic dysfunction
          • side effects
            • spironolactone has anti-androgen effects such as erectile dysfunction and gynecomastia in men
            • hyperkalemia
        • diuretics
          • indications
            • pulmonary edema
            • lower extremity edema
            • systolic or diastolic dysfunction
          • drugs
            • loop diuretics
              • for acute symptoms
              • not effective long-term due to nephrogenic adaptations
            • thiazide diuretics
        • digoxin
          • indications
            • severe systolic dysfunction
            • as an inotrope, it does not improve mortality but it does reduce hospitalizations
        • positive pressure ventilation
    • Medical devices
      • automatic implantable cardioverter/defibrillator (AICD)
        • indication
          • dilated cardiomyopathy with ejection fraction < 35%
      • biventricular pacemaker
        • indications
          • severe left ventricular systolic dysfunction with ejection fraction < 35%
          • dilated cardiomyopathy
          • left bundle branch block
  • Complications
    • CHF exacerbation
    • Cardiac arrhythmias
    • Respiratory failure
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