Snapshot A 70-year-old woman presents to the emergency room for shortness of breath. She has a past medical history of hypertension, type 2 diabetes mellitus, coronary artery disease, and alcohol use disorder. On physical exam, she has jugular venous distention, pulmonary rales, cardiac S3 sound, and pitting edema. Her electrocardiogram shows sinus tachycardia and chest radiograph shows pleural effusions and cardiomegaly. She is immediately given a loop diuretic and oxygen. Introduction Clinical definition inability of the heart to pump blood throughout the body, leading to congestion and decreased perfusion systolic dysfunction loss of contractile strength and results in low ejection fraction (< 45%) diastolic dysfunction impairment in filling of the heart and often has a normal ejection fraction high-output heart failure occurs in a minority of patients cardiac output exceeds metabolic demand decompensated heart failure occurs when symptoms are worsened or exacerbated precipitating factors include infections arrhythmias excessive salt in the diet (post-holiday heart) uncontrolled hypertension thyrotoxicosis myocardial infarction Epidemiology risk factors coronary artery disease viral infection alcohol abuse hypertension arrhythmias metabolic syndrome drugs (e.g., doxorubicin) smoking Etiology systolic dysfunction ischemic heart disease (most common) chronic hypertension dilated cardiomyopathy valvular disease congenital heart disease diastolic dysfunction hypertension with left ventricular hypertrophy hypertrophic cardiomyopathy amyloidosis sarcoidosis hemochromatosis scleroderma post-operative/radiation fibrosis high output heart failure obesity myeloproliferative disorder arterial-venous fistula thyrotoxicosis Pathogenesis systolic dysfunction ↓ contractility leading to ↓ ejection fraction and ↑ end diastolic volume ↑ systemic vascular resistance most commonly due to dilated cardiomyopathy and ischemic heart disease induces a state of hypoperfusion leading to compensatory activation of the sympathetic nervous system and renin release from the juxtaglomerular apparatus increased levels of renin, angiotensin, and aldosterone vasoconstrictive effect of angiotensin II causes increased peripheral resistance mineralocorticoid effects of aldosterone causes fluid retention and metabolic alkalosis diastolic dysfunction ↓ compliance leading to problems with relaxation and filling of the heart normal ejection fraction and normal end diastolic volume most commonly due to myocardial hypertrophy right heart failure most commonly results from left heart failure high output heart failure high cardiac output and ↓ systemic vascular resistance often occurs in the setting of existing systolic or diastolic dysfunction Associated conditions obstructive sleep apnea major depression disorder Presentation Symptoms dyspnea on exertion orthopnea paroxysmal nocturnal dyspnea fatigue pulmonary edema dysphagia due to enlargement of the left atrium Physical exam cardiovascular exam pitting lower extremity edema jugular venous distention S3 sound pulmonary exam Cheyne-Stokes respiration shortness of breath rales liquid accumulates in alveoli due to left heart pressure overload alveoli pop open during inhalation, causing rales on exam abdominal exam ascites hepatojugular reflex Imaging Chest radiograph findings pulmonary vascular congestion pleural effusion cardiomegaly Kerley-B lines interstitial edema Echocardiogram indications confirms the diagnosis of heart failure classifies whether heart failure is due to systolic or diastolic dysfunction findings assess for low ejection fraction systolic of diastolic dysfunction systolic heart failure is characterized by decreased cardiac index increased systemic vascular resistance increased left ventricular end diastolic pressure Studies Atrial and B-type (brain) natriuretic peptide (ANP and BNP) released by the ventricles and the atria in response to increased stretch elevated levels are often seen in decompensated CHF normal BNP excludes a diagnosis of CHF Electrocardiogram (ECG) findings sinus tachycardia may also have arrhythmias may show ventricular hypertrophy Making the diagnosis based on clinical presentation and echocardiogram Differential Acute respiratory distress syndrome distinguishing factors diffuse crackles in the lungs, no S3 heart sound, and increased work of breathing on exam chest radiograph with bilateral alveolar infiltrates Treatment Management approach mortality is decreased with angiotensin-converting enzyme inhibitors (ACE-inhibitors) or angiotensin II receptor blockers (ARBs), β-blockers, and spironolactone or eplerenone Conservative avoid excessive salt in the diet indication all patients Medical ACE-inhibitors or ARBs indications lowers mortality systolic or diastolic dysfunction hydralazine and nitrates indications systolic dysfunction when ACE-inhibitors or ARBs are contraindicated, such as in those with renal failure β-blockers indications lowers mortality systolic or diastolic dysfunction drugs metoprolol carvedilol bisoprolol spironolactone or eplerenone indication lowers mortality systolic or diastolic dysfunction side effects spironolactone has anti-androgen effects such as erectile dysfunction and gynecomastia in men hyperkalemia diuretics indications pulmonary edema CHF exacerbations lower extremity edema systolic or diastolic dysfunction drugs loop diuretics thiazide diuretics digoxin indications severe systolic dysfunction as an inotrope, it does not improve mortality, but it does reduce hospitalizations milrinone indications acute cardiogenic shock decompensated heart failure side effects hypokalemia bronchospams tremors Complications CHF exacerbation Cardiac arrhythmias Respiratory failure