Updated: 4/10/2019

Heart Failure

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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
  • Epidemiology
    • risk factors 
      • coronary artery disease
      • viral infection
      • alcohol abuse
      • hypertension
      • arrhythmias
      • metabolic syndrome
      • drugs (e.g., doxorubicin)
      • smoking
  • Etiology
    • 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
  • 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
    • high-output heart failure
      • high cardiac output and ↓ systemic vascular resistance
      • often occurs in the setting of existing systolic or diastolic dysfunction
  • Associated conditions
    • obstructive sleep apnea
    • major depression disorder
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 reflex
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
Class Limitations of Physical Activity
Heart Failure Symptoms
I
  • None
  • No symptoms
II
  • Mild
  • Symptoms with significant exertion; comfortable at rest or mild activity
III
  • Marked limitation
  • Symptoms with mild exertion; only comfortable at rest
IV
  • 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 
    • 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
      • 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
          • 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
      • indication
        • dilated cardiomyopathy with QRS complex > 120 msec
Complications
  • CHF exacerbation
  • Cardiac arrhythmias
  • Respiratory failure
 

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Questions (9)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.CV.4694) A 64-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and type II diabetes presents to his primary care physician with increasing shortness of breath and ankle swelling over the past month. Which of the following findings is more likely to be seen in left-sided heart failure and less likely to be seen in right-sided heart failure? Review Topic

QID: 107870
1

Increased ejection fraction on echocardiogram

0%

(0/0)

2

Basilar crackles on pulmonary auscultation

0%

(0/0)

3

Hepatojugular reflex

0%

(0/0)

4

Lower extremity edema

0%

(0/0)

5

Abdominal fullness

0%

(0/0)

M2

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