Heart Failure

Heart Failure

 

Heart failure (HF) is a clinical syndrome in which the heart muscle is unable to pump enough blood to meet tissue demands and is often referred to as congestive heart failure (CHF)

Epidemiology

  • Prevalence
    • 10% in patients >80 years
    • 1% in patients <50 years
  • Age – 65 years and older

Risk Factors

  • Hypertension
  • Diabetes mellitus
  • Alcoholism
  • Hyperlipidemia
  • Coronary artery disease
  • Thyroid disease

Etiology – numerous

  • Cardiac
    • Myocardial infarction/ischemic heart disease
    • Arrhythmias (atrial fibrillation is most common)
    • Hypertension
    • Myocarditis
    • Congenital heart disease
    • Valvular disease (aortic stenosis)
  • Infectious
    • Sepsis
    • Endocarditis
  • Pulmonary
    • Embolism
    • Hypertension
    • Chronic obstructive pulmonary disease
  • High output forms
    • Anemia
    • Thyrotoxicosis

Categorization

  • Diastolic versus systolic dysfunction
  • Low output versus high output
  • Acute versus chronic
  • Left-sided versus right-sided

Clinical Presentation

  • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
  • Fatigue and weakness
  • Nausea and anorexia
  • Physical examination includes tachycardia, S3/S4, pulsus alternans, pulmonary rales, ascites, hepatomegaly, jaundice, pedal edema, cachexia

Diagnosis

Framingham Criteria

To establish clinical diagnosis of congestive heart failure, at least 1 major and 2 minor criteria are required

  • Major criteria
    • Paroxysmal nocturnal dyspnea
    • Neck vein distention
    • Rales
    • Cardiomegaly
    • Acute pulmonary edema
    • S3 gallop
    • Increased venous pressure (>16cm H20)
  • Minor criteria
    • Extremity edema
    • Nocturnal cough
    • Dyspnea on exertion
    • Hepatomegaly/splenomegaly
    • Pleural effusion
    • Cardiac output reduced by one-third from normal
    • Tachycardia (≥120 bpm)
  • Major or Minor
    • Weight loss ≥4.5 kg over 5 days treatment
(Adapted with permission from Braunwald, 2005, 1371)
  • Other testing
    • EKG – Q waves, ventricular hypertrophy, heart block, atrial fibrillation
    • Echocardiogram – reduced ejection fraction
    • BNP and proBNP – high sensitivity and specificity for differentiating cardiac versus noncardiac causes
      • BNP <100 or NTproBNP <300 – heart failure unlikely
      • BNP 100-500 or NTproBNP 300-450 (<50 years) or 300-900 (50-75 years) – heart failure possible
      • BNP >500 or NTproBNP >450 (<50 years) or >900 (≥50 years) – heart failure likely
    • Chest X-ray – bilateral interstitial infiltrates, cephalization of vessels, cardiomegaly, Kerley B lines

See Also