Heart Failure
Basics
Description
Description
- CHF, now referred to simply as “heart failure” (HF), is a heterogeneous clinical syndrome resulting from either impaired filling or ejection of blood from the ventricle
- HF often results in progressive debility, episodes of acute decompensation
- High (>50%) 5-yr mortality
- Affects ∼5.1 million Americans
- Estimated 2013 cost of CHF is >$30 billion
- Leading Medicare diagnosis for hospitalized patients ≥65 yr old
- Acute decompensated heart failure (ADHF): Acute onset of new or worsening symptoms of HF (hr–days)
- Common reason for presentation to the ED:
- 70% are recurrent exacerbations of chronic HF
- 15% are new diagnosis of HF
- 5% end-stage/terminal event
- ADHF may result from worsening cardiac pump function, or from changes in preload or afterload:
- Precipitating events include rapid increase in sympathetic tone, concomitant illness, arrhythmia, myocardial ischemia, progressive valve disease, intravascular volume increase
- 4 common phenotypical presentations based on adequacy of perfusion (warm versus cold) and presence of congestion (wet vs. dry)
- Common reason for presentation to the ED:
- Chronic HF is a progressive failure state (mo–yr) characterized by structural and functional changes, with two main subclasses:
- Heart failure with reduced ejection fraction (HFrEF):
- Impaired contractility or pump function causing decreased ejection fraction (EF <40%)
- Estimated prevalence 50%
- Many have concomittent diastolic dysfunction
- Heart failure with preserved ejection fraction (HFpEF) EF >50%
- Impaired ventricular relaxation and compliance resulting in decreased cardiac filling
- More common in older patients, women, patients with HTN
- Heart failure with reduced ejection fraction (HFrEF):
- ACCF/AHA stages: Progressive stages denote nonreversible cardiac dysfunction. A–D, where A = risk but no disease, and D = refractory HF
- NYHA classification: Functional classes I–IV, where I has no limit on physical ability and IV has symptoms of HF at rest. Patients may improve class with therapy
Etiology
Underlying causes and acute precipitants:Etiology
- HF may result from disorders of the heart valves, endocardium, myocardium, pericardium, and metabolic derangements
- Decreased myocardial contractility:
- 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
- Increased pressure states:
- HTN
- Valvular abnormalities
- Congenital heart disease
- RH failure due to pulmonary hypertension: Primary PAH, OSA, COPD, CTEPH, IPF, and others
- Pulmonary embolism
- Volume overload:
- Dietary indiscretion (sodium overload)
- Drugs leading to sodium retention (glucocorticoids, NSAIDs)
- Overload due to transfusion or IV fluid
- High demand states:
- Hyperthyroidism, thyrotoxicosis
- Pregnancy
- A-V fistula
- Beriberi (thiamine deficiency)
- Paget disease
- Severe anemia
- Aortic insufficiency
- Pediatric etiologies: Volume/pressure overload lesions vs. acquired HD:
- First 6 mo: VSD and PDA
- Older children: Subvalvular aortic stenosis, coarctation
- Acquired dysfunction: Nonspecific age of onset, including myocarditis, valvular disease, and cardiomyopathies; cocaine/stimulant abuse in adolescents
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Citation
Schaider, Jeffrey J., et al., editors. "Heart Failure." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307728/0.1/Heart_Failure.
Heart Failure. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307728/0.1/Heart_Failure. Accessed December 3, 2024.
Heart Failure. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307728/0.1/Heart_Failure
Heart Failure [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 December 03]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307728/0.1/Heart_Failure.
* Article titles in AMA citation format should be in sentence-case
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T1 - Heart Failure
ID - 307728
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BT - 5-Minute Emergency Consult
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