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 S3 sound 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 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 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 CHF exacerbations 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