Heart failure (aka congestive cardiac failure, CCF) is where the heart is unable to provide sufficient pump to maintain blood flow needs of the body.

• SOB, especially:
  • Exercise intolerance (SOB usually worse w/ exercise), and thus usually limits ability to exercise
  • Orthopnea (while lying down)
  • Paroxysmal nocturnal dyspnea (may wake the Pt at night)
• Fatigue (excessive tiredness)
• Peripheral edema (leg swelling)

• Either the structure or function of the heart is changed
• This in turn causes reduced force of contraction, due to increased workload, that is overloading of the ventricle
• In a healthy heart, per the Frank-Starling law, stroke volume increases in response to increased filling of the heart, thus causing a rise in cardiac output
• However, the ventricle is loaded with blood is loaded to the point, where heart muscle contraction becomes less efficient, due to reduced ability to cross-link actin and myosin filaments in over-stretched heart muscle

Any condition which reduces the efficiency of the heart muscle, through damage or overloading. This includes numerous conditions, including:

• CAD, including previous MI/heart attack, where heart muscle is starved of oxygen and dies
• HTN, which increases force of contraction needed to pump blood
• Atrial fibrillation
• Valvular heart disease
• Alcohol abuse (excess alcohol use)
• Infection
• Cardiomyopathy of an unknown cause
• Amyloidosis, where misfolded proteins are deposited in the heart muscle, causing it to stiffen
• High output states, where the ventricular systolic function is normal but the heart can't deal with an important augmentation of blood volume. It occurs in:
  • Overload situations (blood or serum infusions)
  • Kidney diseases
  • Chronic severe anemia
  • Beriberi (vitamin B1/thiamine deficiency)
  • Hyperthyroidism
  • Paget's disease
  • AV fistulae
  • AV malformations

• Depending on ejection fraction, which is the proportion of blood pumped out of the heart during a single contraction. It illustrates the ability of the left ventricle to contract, or the heart's ability to relax, and includes:
  • Systolic heart failure (aka HF due to reduced EF, HF due to LV systolic dysfunction, systolic heart failure), is where the EF<40%
  • Diastolic heart failure (aka HF with normal EF), is where the EF is normal/preserved. The heart muscle contracts well but the ventricle doesn't fill with blood well, in the relaxation phase. EF is in its normal range, which is between 50-75%
• Severity of disease is usually graded by the degree of problems w/ exercise

• Hx of Sx and physical exam
• Echocardiogram
• Framingham criteria, used to Dx CHF, requires simultaneous presence of at least 2 of the major criteria, or 1 major criteria w/ 2 minor criteria. It is 100% sensitive, and 78% specific for CHF
  • Major criteria, include:
    • Cardiomegaly (large heart) on CXR
    • S3 gallop (3rd heart sound)
    • Acute pulmonary edema
    • PND (waking up from sleep gasping for air)
    • Crackles on lung auscultation
    • CVP>16 cm H2O at the RA
    • Jugular vein distensino
    • Positive abdominojugular test
    • Weight loss>4.5 kg in 5 days in response to Tx, sometimes classified as a minor criterion
  • Minor criteria, which are ONLY acceptable if they CAN'T be attributed to another medical condition, e.g. pulmonary HTN, chronic lung disease, cirrhosis, ascites, or nephrotic syndrome. It includes:
    • Tachycardia (abnormally fast HR>120bpm)
    • Nocturnal cough
    • SOB w/ physical activity
    • Pleural effusion
    • Decrease in the vital capacity by 1/3rd from maximum recorded
    • Hepatomegaly (liver enlargement)
    • Bilateraly ankle edema (swelling)

• To determine cause:
  • Blood tests
  • ECG
  • CXR
• BNP
• Monitoring, including:
  • Fluid balance, calculating fluid intake and excretion
  • Monitoring body weight, which in the shorter term reflects fluid shifts

• Obesity
• Kidney failure
• Liver problems
• Anemia
• Thyroid disease

• Depends on severity and cause of disease
• Lifestyle modifications, in Pt's w/ chronic stable mild HF, including:
  • Smoking cessation
  • Light exercise
  • Dietary guidelines, regarding fluid and salt intake, being of particular importance
• Drugs, including:
  • Left ventricular dysfunction:
    • ACEi's or ARB's
    • Beta blockers
  • For severe disease:
    • Aldosterone antagonist
    • Hydralazine + nitrate
  • Diuretics, to prevent fluid retention
• Implanted device, e.g. placemaker or an implantable cardiac defibrillator, depending on the cause
• Cardiac resynchronization therapy, or cardiac contractility modulation, in moderate to severe cases
• Ventricular assist device or heart transplant, may be required in those w/ severe disease despite all other measures

• It is potentially fatal condition

• It is costly
• It is common, in developed countries, 2% of adults have HF, and in those >65yo this increases to 8%
• 1 year after Dx the risk of death is about 35%, after which it decreases to <10% each year. This is similar to the risks w/ numerous cancers
• It is responsible for 5% of ED admissions in the UK
• Has been known since 1550BC per Egyptian medical papyrus

• MI (heart muscle dies)
• Cardiac arrest (blood flow stops altogether)
• Arrhythmia
• Ventricular hypertrophy
• Conduction abnormalities