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 login to view 1 more bullet diastolic dysfunction login to view 1 more bullet high-output heart failure login to view 2 more bullets decompensated heart failure login to view 8 more bullets 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 S3 sound pulmonary exam shortness of breath rales login to view 2 more bullets 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 FailureClassLimitations of Physical ActivityHeart Failure SymptomsINoneNo symptomsIIMildSymptoms with significant exertion; comfortable at rest or mild activityIIIMarked limitationSymptoms with mild exertion; only comfortable at restIVConfined to bed or chairSymptoms 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 login to view 1 more bullet Medical systolic dysfunction ACE-inhibitors or ARBs login to view 5 more bullets hydralazine and nitrates login to view 4 more bullets β-blockers login to view 7 more bullets spironolactone or eplerenone login to view 7 more bullets diuretics login to view 10 more bullets digoxin login to view 3 more bullets positive pressure ventilation Medical devices automatic implantable cardioverter/defibrillator (AICD) indication login to view 1 more bullet biventricular pacemaker indications login to view 3 more bullets Complications CHF exacerbation Cardiac arrhythmias Respiratory failure