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For further information, see CMDT Part 10-40: 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

    • 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 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

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


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 ...

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