Heart failure
Heart failure is a clinical syndrome of impaired cardiac filling or ejection causing congestion and reduced perfusion, classified by ejection fraction. Diagnosis integrates symptoms, signs, natriuretic peptides, and echocardiography, and treatment of reduced-ejection-fraction disease is quadruple guideline-directed therapy, with device therapy and cause-specific management.
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What this article covers
- Overview
Definition: heart failure is a clinical syndrome in which impaired cardiac filling or ejection produces congestion and inadequate tissue perfusion.
- Epidemiology
Common and increasing with an aging population.
- Risk factors
Coronary artery disease and prior myocardial infarction (the leading cause of HFrEF).
- Pathophysiology
Impaired pump or filling: systolic dysfunction reduces ejection, while diastolic dysfunction impairs filling at normal ejection fraction.
- Clinical features
Exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.
- Differential diagnosis
Chronic obstructive pulmonary disease: dyspnea from airflow limitation, distinguished by obstructive spirometry and a normal natriuretic peptide.
- Diagnosis
Establish clinically with supportive natriuretic peptides and echocardiography, then classify by ejection fraction: the diagnostic basis is compatible symptoms and signs with an elevated BNP or…
- Management
First-line for HFrEF, start the four foundational therapies, each continued long term and titrated to target dose: An ARNI (sacubitril-valsartan), or an ACE inhibitor (lisinopril 10 to 40 mg PO daily) if an ARNI is not feasible.
- Complications
Acute decompensation and recurrent hospitalization.
- Prognosis
Improved markedly by guideline-directed therapy in HFrEF.
- Prevention
Control blood pressure below 130/80 mmHg.
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Related articles
- Acute heart failure
Acute heart failure is the rapid onset or worsening of heart failure symptoms requiring urgent therapy, most often pulmonary congestion from a precipitant such as ischemia, arrhythmia, or nonadherence. Management is oxygen, intravenous diuretics, and vasodilators for the congested-but-perfused patient, with inotropes or support for the hypoperfused patient.
- Dilated cardiomyopathy
Dilated cardiomyopathy is left ventricular (often biventricular) dilation with systolic dysfunction not explained by loading conditions or coronary disease, from genetic, viral, toxic, or peripartum causes, presenting as heart failure with reduced ejection fraction. Diagnosis is by echocardiography with a workup for reversible causes, and treatment is guideline-directed heart-failure therapy with device therapy for high-risk patients.
- Atrial fibrillation
Atrial fibrillation is a supraventricular tachyarrhythmia with disorganized atrial activation and an irregularly irregular ventricular response, the most common sustained arrhythmia and a major cause of stroke. Diagnosis is by ECG showing no discrete P waves with irregular RR intervals, and management addresses rate or rhythm control, stroke prevention by CHA2DS2-VASc-guided anticoagulation, and the underlying cause.
- Constrictive pericarditis
Constrictive pericarditis is a rigid, often calcified pericardium that impairs diastolic filling, causing predominantly right-sided heart failure. It follows pericardial injury (post-surgical, tuberculous, radiation, or idiopathic), is distinguished from restrictive cardiomyopathy by hemodynamic and imaging features, and definitive treatment is pericardiectomy.
- Chronic venous insufficiency
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- Aortic stenosis
Aortic stenosis is obstruction to left ventricular outflow from a narrowed aortic valve, most often calcific degeneration in older adults or a bicentric bicuspid valve earlier in life. Symptoms of angina, syncope, or heart failure mark a poor prognosis, and severe symptomatic disease is treated with valve replacement (surgical or transcatheter).