Updated: 5/15/2020

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)
        • monitor cardiac function with echocardiography 
      • 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
      • 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
  • 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
          • 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
 

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(M3.CV.16.64) A 54-year-old woman is diagnosed with locally-advanced invasive ductal adenocarcinoma of the breast. She undergoes surgical resection, radiation therapy, and is now being started on adjunctive chemotherapy with cyclophosphamide and doxorubicin. The patient is scheduled for follow up by her primary care provider. Which of the following tests should be performed regularly to monitor her current treatment regimen? Tested Concept

QID: 103005
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Cardiac MRI

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Chest radiograph

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ECG

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Echocardiography

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No regular monitoring indicated

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(M2.CV.16.4694) 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? Tested Concept

QID: 107870
1

Increased ejection fraction on echocardiogram

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Basilar crackles on pulmonary auscultation

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Hepatojugular reflex

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Lower extremity edema

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5

Abdominal fullness

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