Heart Failure

Key Features

Essentials of Diagnosis

• Left ventricular (LV) failure

  • Either due to systolic or diastolic dysfunction

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

• Right ventricular (RV) failure

  • Symptoms of fluid overload predominate

  • Usually RV failure is secondary to LV failure

• 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

  • Beta-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 and SARS-CoV-2)

  • 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 liver enlargement, hepatojugular 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

Diagnosis

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 ...