++
For further information, see CMDT Part 10-40: Heart Failure
+++
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
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
+++
General Considerations
++
HF occurs as a result of
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 COVID-19)
Chagas disease
Idiopathic dilated cardiomyopathy
Diastolic dysfunction is
Associated with abnormal filling of a ("stiff") LV
Caused by chronic hypertension, LV hypertrophy, and diabetes
++
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
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
++
++
Obtain complete blood count, blood urea nitrogen, serum electrolytes, creatinine, thyroid-stimulating hormone ferritin
ECG to look for
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 ...