Diagnosis

Heart failure

Etiology

Cause [gaa][9u6]

• Ischemic

  • Coronary artery disease

  • Coronary dissection

  • Coronary embolism

• Valvular

  • Rheumatic heart disease

  • Degenerative valvular disease

• Hypertensive

• Primary genetic cardiomyopathies

  • Hypertrophic cardiomyopathy

  • Arrhythmogenic cardiomyopathy

  • Left ventricular noncompaction

  • Mitochondrial myopathies

  • Ion-channel disorders (long QT syndrome, Brugada, etc.)

• Primary acquired cardiomyopathies

  • Tachycardia-induced, peripartum, stress-induced (Takotsubo), toxic (alcohol, cocaine), toxin-related (anthracycline), myocarditis (inflammatory), infectious (Chagas, HIV, viral), giant cell myocarditis

• Secondary cardiomyopathies

  • Amyloidosis, sarcoidosis, storage disease (hemochromatosis, amyloidosis, Fabry disease), connective tissue disorder (scleroderma)

  • Thyroid disease: hyperthyroidism, hypothyroidism

  • Other: Endomyocardial fibrosis, nutritional deficiencies (selenium, beriberi, kwashiorkor), anemia, arteriovenous fistula, obesity

• Congenital heart disease

• Pericardial disease

• Other: Diabetes mellitus, emphysema, systemic lupus erythematosus, SIRS

Pathophysiology

1. Hypertension --> increases afterload/resistance --> decreased cardiac output

2. Compensatory mechanisms to maintain cardiac output:

   • Chronic activation of the sympathetic nervous system --> adrenaline

   • Neuroendocrine system: epinephrine, norepinephrine, endothelin-1, vasopressin

   • Activation of neurohumoral system (RAAS)

   • Myocardial hypertrophy (myocardial remodeling)

   • Myocardial hypercontractility

3. Myocardial remodeling --> increase myocardial oxygen demand require increased cardiac output to meet myocardial demand

4. Leads to myocardial cell death --> decreased cardiac contractility (Ejection Fraction)

5. Incomplete Left Ventricule emptying --> Heart failure and pulmonary congestion

6. Renal hypoperfusion --> antidiuretic hormone --> sodium and water retention

7. BNP and ANP are ineffective in counteracting the excess sodium and water retention

8. Decompensated CHF:

   • Peripheral vasoconstriction

   • Increased preload delivery to the overburdened heart

9. Classification of heart failure

   • Acute failure

   • Chronic failure

   • Left ventricular failure

   • Right ventricular failure

   • Systolic failure

   • Diastolic failure

Risk factors [9u6]

• Hypertension

• Diabetes

• Metabolic syndrome

• Cardiotoxic medications

• Genetic variant for cardiomyopathy

Complications [9u6]

• Reduced quality of life

• Arrhythmia and sudden cardiac death

• Cardiac cachexia

• Cardiorenal disease

• Liver dysfunction

• Functional valvular insufficiencies (eg, functional MR or TR)

• Mural thrombi and risk of thromboembolism (brain, kidney, lung, major limb vessels)

• Recurrent hospitalizations and nosocomial infection

• Mortality

Epidemiology

Incidence per 100.000 [hcs][gna][1bq][gmb]

Prevalence per 100.000 [hcs][gna][1bq][gmb]

Approach

• Blood test: Complete blood count, renal profile, liver enzymes, pro-BNP, Troponins

• Blood gas

• Chest x-ray

• ECG

• Echocardiography

• Stress test

• Cardiac CT

• Cardiac MRI

• Coronary angiography

• Genetic testing for cardiomyopathies

• Urine and serum electrophoresis: amyloidosis

Framingham Clinical Diagnostic Criteria for Heart Failure [9u6]

Requires 2 major criteria or 1 major and 2 minor criteria (high sensitivity, low specificity)

• Major criteria:

  • Acute pulmonary edema

  • Cardiomegaly

  • Hepatojugular reflex

  • Neck vein distention

  • Paroxysmal nocturnal dyspnea or orthopnea

  • Pulmonary rales

  • Third heart sound (S3 Gallop)

• Minor criteria:

  • Ankle edema

  • Dyspnea on exertion

  • Hepatomegaly

  • Nocturnal cough

  • Pleural effusion

  • Tachycardia (heart rate >120 beats per minute)

ACC/AHA stages [9u6]

• Stage A:

  • No signs or symptoms of HF

  • Risk factors are present: hypertension, diabetes, metabolic syndrome, cardiotoxic medications, or having a genetic variant for cardiomyopathy

• Stage B:

  • No signs or symptoms of HF

  • Risk factors are present

  • Structural heart disease (elevated filling pressures) or elevated cardiomarkers

• Stage C: Symptomatic HF

• Stage D: Advanced HF with refractory symptoms that interfere with daily life

NYHA classification [9u6]

1. Class I: Symptom onset with more than ordinary level of activity

2. Class II: Symptom onset with an ordinary level of activity

3. Class III: Symptom onset with minimal activity

   • Class IIIa: No dyspnea at rest

   • Class IIIb: Recent onset of dyspnea at rest

4. Class IV: Symptoms at rest

Treatment

1. Nonpharmacologic: [kr3][9u6]

   • Dietary (sodium and fluid restriction)

   • Physical activity

   • Weight loss

   • Avoidance of smoking

2. Pharmacologic:

   • SGLT-2 inhibitor if type 2 diabetes

   • Diuretics (thiazide)

   • Vasodilators

   • Inotropic agents

   • Anticoagulants

   • Beta blockers (if LVEF ≤40%)

   • Angiotensin-converting enzyme inhibitors (if LVEF ≤40%)

   • Angiotensin receptor blockers

   • Calcium channel blockers (if LVEF ≤50%)

   • Digoxin

   • B-type natriuretic peptides inhibitors

   • Guanylate cyclase stimulators

   • Sodium-glucose cotransporter-2 inhibitors

   • Mineralocorticoid receptor antagonists

3. Invasive:

   • Electrophysiologic intervention:

     • Cardiac resynchronization therapy

     • Pacemaker

     • Implantable cardioverter-defibrillator (ICD)

   • Revascularization procedures:

     • Coronary artery bypass grafting

     • Percutaneous coronary intervention

     • Valve replacement or repair

     • Heart transplantation

Differential diagnoses

Acute respiratory distress syndrome, Aortic stenosis, Arrhythmia, Cirrhosis, COPD, Emphysema, Goodpasture syndrome, Myocardial infarction, Nephrotic syndrome, Pneumonia, Pneumothorax, Pulmonary edema, Pulmonary embolism, Pulmonary fibrosis, Renal failure, Respiratory failure, Varices