Heart Failure

Basics

  • A chronic, progressive syndrome of cardiac dysfunction leading to elevated cardiac filling pressures and inadequate perfusion
  • HF results from impaired systolic or diastolic function, increasing preload, afterload, and neurohormonal activation, leading to fluid retention and congestion
  • Affects ∼6.2 million Americans, with a high 5-yr mortality (>50%) and annual cost exceeding $30 billion in 2021
  • 4 common phenotypical presentations:
    • Warm and wet: High perfusion, pulmonary congestion (most common)
    • Cold and wet: Hypoperfusion with congestion, high mortality risk
    • Cold and dry: Low-output state, needs inotropes
    • Warm and dry: Compensated HF, often stable
  • Left ventricular ejection fraction (LVEF) classification:
    • LVEF <40%: Heart failure with reduced ejection fraction (HFrEF), systolic dysfunction with reduced cardiac output
    • LVEF 41–49%: HF with mid-range EF (HFmrEF), intermediate dysfunction requiring mixed treatment approaches
    • LVEF ≥50%: HF with preserved EF, diastolic dysfunction often associated with hypertension, obesity, and aging
  • Acute decompensated heart failure (ADHF):
    • Rapid worsening over hours to days often requiring hospitalization
    • Common ADHF triggers include arrhythmias, ischemia, infections, volume overload, medication noncompliance, and progressive cardiac disease:
  • ACCF/AHA stages: Progressive stages denote nonreversible cardiac dysfunction. A–D, where A = risk but no disease, and D = advanced HF

Etiology

  • Ischemic cardiomyopathy
  • Nonischemic cardiomyopathies:
    • Familial, obesity, diabetic
    • Endocrine: Hypothyroid, acromegaly, Pregnancy-related dilated CMP
    • Toxin related (alcohol, cocaine, chemotherapy)
    • Inflammatory: Infectious and noninfectious myocarditis (viral, Chagas, SLE, HIV)
    • Tachycardia induced
    • Amyloidosis
    • Cardiac sarcoidosis
    • Takotsubo cardiomyopathy
    • Radiation-induced cardiomyopathy
    • Hemochromatosis
  • Increased pressure states:
    • HTN
    • Valvular abnormalities
    • Congenital heart disease
    • RH failure due to pulmonary hypertension:
      • Primary PAH
      • Chronic lung disease: OSA, COPD, interstitial lung disease
    • Thromboembolic disease: Chronic thromboembolic pulmonary hypertension, acute pulmonary embolism
  • Volume overload:
    • Dietary indiscretion (sodium overload)
    • Drugs leading to sodium retention (glucocorticoids, NSAIDs)
    • Overload due to transfusion or IV fluid
    • Primary renal failure and nephrotic syndrome
  • High-demand states:
    • Hyperthyroidism, thyrotoxicosis
    • Pregnancy and peripartum cardiomyopathy
    • A-V fistula
    • Beriberi (thiamine deficiency)
    • Paget disease
    • Severe anemia
    • Aortic insufficiency
    • Sepsis-induced cardiomyopathy
  • Pediatric etiologies:
    • 1st 6 mo: VSD and PDA
    • Older children: Subvalvular aortic stenosis, coarctation
    • Acquired dysfunction: Nonspecific age of onset, including myocarditis, valvular disease, and cardiomyopathies
  • Adolescent causes:
    • Stimulant/cocaine-induced cardiomyopathy

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