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Abnormality of cardiac structure and/or function resulting in clinical symptoms (e.g., dyspnea, fatigue) and signs (e.g., edema, rales), hospitalizations, poor quality of life, and shortened survival. It is important to identify the underlying nature of the cardiac disease and the factors that precipitate acute CHF.

Underlying Cardiac Disease

Includes (1) states that depress systolic ventricular function with reduced ejection fraction (HFrEF; e.g., coronary artery disease [CAD], dilated cardiomyopathies, valvular disease, congenital heart disease); and (2) states of heart failure with preserved ejection fraction (HFpEF; e.g., restrictive cardiomyopathies, hypertrophic cardiomyopathy, fibrosis, endomyocardial disorders), also termed diastolic failure.

Acute Precipitating Factors

Include (1) excessive Na+ intake, (2) noncompliance with heart failure medications, (3) acute MI (may be silent), (4) exacerbation of hypertension, (5) acute arrhythmias, (6) infections and/or fever, (7) pulmonary embolism, (8) anemia, (9) thyrotoxicosis, (10) pregnancy, (11) acute myocarditis or infective endocarditis, and (12) certain drugs (e.g., nonsteroidal anti-inflammatory agents, verapamil).


Due to inadequate perfusion of peripheral tissues (fatigue) and elevated intracardiac filling pressures (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema).

Physical Examination

Jugular venous distention, S3 (in HFrEF/volume overload), pulmonary congestion (rales, dullness over pleural effusion), peripheral edema, hepatomegaly, and ascites. Sinus tachycardia is common.

In pts with HFpEF, S4 is often present.


CXR may reveal cardiomegaly, pulmonary vascular redistribution, interstitial edema, pleural effusions. Left ventricular systolic and diastolic dysfunction can be assessed by echocardiography with Doppler, and EF calculated or estimated. In addition, echo can identify underlying valvular, pericardial, or congenital heart disease, and regional wall motion abnormalities typical of CAD. Cardiac MR may be valuable in assessing ventricular structure, mass, volumes, and can help determine cause of heart failure (e.g., CAD, amyloid, hemochromatosis). Measurement of B-type natriuretic peptide (BNP) or N-terminal pro-BNP differentiates cardiac from pulmonary causes of dyspnea (elevated in the former).

Conditions that Mimic CHF

Pulmonary Disease: Chronic bronchitis, emphysema, and asthma (Chaps. 129 and 131); assess for sputum production and abnormalities on CXR and pulmonary function tests. Other Causes of Peripheral Edema: Obesity, varicose veins, and venous insufficiency do not cause jugular venous distention. Edema due to renal dysfunction is often accompanied by elevated serum creatinine and abnormal urinalysis (Chap. 36).


Aimed at symptomatic relief, prevention of adverse cardiac remodeling, and prolonging survival. Overview of treatment shown in Table 124-1; notably, ACE inhibitors and beta blockers are cornerstones of therapy in pts with HFrEF. Once symptoms develop:

  • Control excess fluid retention: (1) Dietary sodium restriction (eliminate salty foods, e.g., potato chips, canned soups, bacon, salt added at ...

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