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Key Features

Essentials of Diagnosis

  • Left ventricular (LV) failure

    • Due to systolic or diastolic dysfunction

    • Heart Failure with Reduced Ejection Fraction (HFrEF)

      • Systolic heart failure (HF)

    • Heart Failure with Preserved Ejection Fraction (HFpEF)

      • Diastolic HF

    • Predominant symptoms are those of low cardiac output and congestion including dyspnea

  • Right ventricular (RV) failure

    • Usually secondary to LV failure

    • Predominant symptoms are those of fluid overload

  • Assessment of LV function is a crucial part of diagnosis and management

  • Optimal management of chronic heart failure (HF) includes combination medical therapies, such as angiotensin-converting enzyme (ACE) inhibitors, aldosterone antagonists, and β-blockers

General Considerations

  • HF occurs as a result of depressed contractility with fluid retention and/or impaired cardiac output, or diastolic dysfunction with fluid retention

  • Acute exacerbations of chronic HF are caused by patient nonadherence to or alterations in therapy, excessive salt and fluid intake, arrhythmias, excessive activity, pulmonary emboli, intercurrent infection, progression of the underlying disease

  • High-output HF is caused by thyrotoxicosis, beriberi, severe anemia, arteriovenous shunting, Paget disease

  • Systolic dysfunction is caused by myocardial infarction (MI), ethanol abuse, long-standing hypertension, viral myocarditis (including HIV), Chagas disease, idiopathic dilated cardiomyopathy

  • Diastolic dysfunction is associated with abnormal filling of a ("stiff") LV; caused by chronic hypertension, LV hypertrophy, and diabetes

Clinical Findings

Symptoms and Signs

  • Symptoms of diastolic dysfunction are often difficult to distinguish clinically from those of systolic dysfunction

  • LV failure

    • Exertional dyspnea progressing to orthopnea and then dyspnea at rest

    • Paroxysmal nocturnal dyspnea

    • Chronic nonproductive cough (often worse in recumbency)

    • Nocturia

    • Fatigue and exercise intolerance

  • RV failure

    • Anorexia

    • Nausea

    • Right upper quadrant pain due to chronic passive congestion of the liver and gut

  • Tachycardia, hypotension, reduced pulse pressure, cold extremities, and diaphoresis

  • Long-standing severe HF: cachexia or cyanosis

  • Physical examination findings in LV HF

    • Crackles at lung bases, pleural effusions and basilar dullness to percussion, expiratory wheezing, and rhonchi

    • Parasternal lift, an enlarged and sustained LV impulse, a diminished first heart sound

    • S3 gallop

    • S4 gallop in diastolic dysfunction

  • Physical examination findings in RV HF

    • Elevated jugular venous pressure, abnormal pulsations, such as regurgitant v waves

    • Tender or nontender hepatic enlargement, heptojugular reflux, and ascites

    • Peripheral pitting edema sometimes extending to the thighs and abdominal wall

Differential Diagnosis

  • Chronic obstructive pulmonary disease (COPD)

  • Pneumonia

  • Cirrhosis

  • Peripheral venous insufficiency

  • Nephrotic syndrome


Laboratory Tests

  • Obtain complete blood count, blood urea nitrogen, serum electrolytes, creatinine, thyroid-stimulating hormone ferritin

  • ECG to look for

    • Arrhythmia

    • MI

    • Nonspecific changes, including low-voltage, intraventricular conduction delay; LV hypertrophy; and repolarization changes

  • B-type natriuretic peptide (BNP)

    • Elevation is a sensitive indicator of symptomatic (diastolic or systolic) HF but may be less specific, especially in older patients, women, and patients with COPD

    • Adds to clinical assessment in differentiating dyspnea due to HF from noncardiac ...

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