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Reduced Ejection Fraction

  1. What is the definition and classification of heart failure?

  2. What is the mortality and morbidity of heart failure?

  3. What is the recommended testing for a patient with newly diagnosed heart failure?

  4. What are the standard therapies for heart failure?

  5. How can we remove congestion in heart failure?

Preserved Ejection Fraction

  1. How do you diagnose heart failure (HF)?

  2. What are the predisposing risk factors for HF with preserved ejection fraction?

  3. What is the recommended evaluation for patients newly diagnosed with HF?

  4. How do you treat HF?

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Case 130-1

A 66-year-old man presents with progressive history of breathlessness, decrease in activity tolerance, orthopnea and paroxysmal nocturnal dyspnea. His past medical history includes diabetes and a myocardial infarction 5 years ago.

On physical examination the patient appears dyspneic with a blood pressure of 145/90 and a heart rate of 100 beats per minute (bpm). The jugular venous pressure is 14 cm H2O, the point of maximum impulse is displaced laterally, and the heart sounds are distant with an S3 gallop. There are rales in the lung bases with abdominal right upper quadrant fullness; the lower extremities are cold with significant pitting edema.


Heart failure (HF) is a condition that affects millions in the United States, and over half a million people are newly diagnosed each year. The incidence of HF increases with age, affecting 6% to 10% of people age older than 65. It is the leading cause of hospital admissions in the United States and is responsible for 6.5 million hospital-days each year and up to 15 million office visits. Over the past decade, the rate of hospitalizations for HF has increased by 159%, and 45% of patients hospitalized with acute heart failure will be rehospitalized at least once (and 15% at least twice) within 12 months.

Approximately 260,000 patients die of HF in the United States each year. The number of HF deaths has increased steadily despite advances in treatment, in part because of aging of the population and improved survival after acute myocardial infarction (MI). The estimated direct and indirect cost of HF is $27.9 billion per year, and approximately $2.9 billion annually is spent on drugs for the treatment of HF.

Heart failure has been identified by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a priority focus for hospital core measure development. The four HF core measures are

  • HF-1—Discharge instructions
  • HF-2—Evaluation of left ventricular systolic function
  • HF-3—Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction
  • HF-4—Adult smoking cessation advice/counseling.


Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ...

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