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Heart failure
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{{short description|Failure of the heart to provide sufficient blood flow}}{{For|the medical emergency|cardiac arrest}}{{cs1 config|name-list-style=vanc}}{{Use dmy dates|date=January 2019}}- the content below is remote from Wikipedia
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Definition
Heart failure is not a disease but a syndrome – a combination of signs and symptoms – caused by the failure of the heart to pump blood to support the circulatory system at rest or during activity.{{rp|page=3612}} It develops when the heart fails to properly fill with blood during diastole, resulting in a decrease in intracardiac pressures or in ejection during systole, reducing cardiac output to the rest of the body.{{rp|page=3612}}{{rp|page=e272}} The filling failure and high intracardiac pressure can lead to fluid accumulation in the veins and tissue. This manifests as water retention and swelling due to fluid accumulation (edema) called (wikt:congestion#Noun|congestion). Impaired ejection can lead to inadequate blood flow to the body tissues, resulting in ischemia.JOURNAL, Girerd N, Seronde MF, Coiro S, Chouihed T, Bilbault P, Braun F, etal, Integrative Assessment of Congestion in Heart Failure Throughout the Patient Journey., JACC Heart Fail, 2018, 6, 4, 273–285, 29226815, 10.1016/j.jchf.2017.09.023,Signs and symptoms
(File:Heartfailure.jpg|thumb|upright=1.4|Signs and symptoms of severe heart failure)Congestive heart failure is a pathophysiological condition in which the heart’s output is insufficient to meet the needs of the body and lungs. The term “congestive heart failure” is often used because one of the most common symptoms is (wikt:congestion#Noun|congestion) or fluid accumulation in the tissues and veins of the lungs or other parts of a person’s body. Congestion manifests itself particularly in the form of fluid accumulation and swelling (edema), in the form of peripheral edema (causing swollen limbs and feet) and pulmonary edema (causing difficulty breathing) and ascites (swollen abdomen).JOURNAL, Thibodeau JT, Drazner MH, The Role of the Clinical Examination in Patients With Heart Failure., JACC Heart Fail, 2018, 6, 7, 543–551, 29885957, 10.1016/j.jchf.2018.04.005, free, Pulse pressure, which is the difference between the systolic (“top number“) and diastolic (“bottom number“) blood pressures, is often low/narrow (i.e. 25% or less of the level of the systolic) in people with heart failure, and this can be an early warning sign.WEB,my.clevelandclinic.org/health/symptoms/21629-pulse-pressure, Pulse pressure, 28 July 2021, Cleveland Clinic, 10 February 2023, A narrow pulse pressure — sometimes called a low pulse pressure — is where your pulse pressure is one-fourth or less of your systolic pressure (the top number). This happens when your heart isn’t pumping enough blood, which is seen in heart failure and certain heart valve diseases., 10 February 2023,web.archive.org/web/20230210055608/https://my.clevelandclinic.org/health/symptoms/21629-pulse-pressure, live, Symptoms of heart failure are traditionally divided into left-sided and right-sided because the left and right ventricles supply different parts of the circulation. In biventricular heart failure, both sides of the heart are affected. Left-sided heart failure is the more common.Left-sided failure
The left side of the heart takes oxygen-rich blood from the lungs and pumps it to the rest of the circulatory system in the body (except for the pulmonary circulation). Failure of the left side of the heart causes blood to back up into the lungs, causing breathing difficulties and fatigue due to an insufficient supply of oxygenated blood. Common respiratory signs include increased respiratory rate and labored breathing (nonspecific signs of shortness of breath). Rales or crackles heard initially in the lung bases and when severe in all lung fields indicate the development of pulmonary edema (fluid in the alveoli). Cyanosis, indicates deficiency of oxygen in the blood, is a late sign of extremely severe pulmonary edema.{{Citation |last1=Adeyinka |first1=Adebayo |title=Cyanosis |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK482247/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29489181 |access-date=2022-05-11 |last2=Kondamudi |first2=Noah P. |archive-date=13 March 2021 |archive-url=https://web.archive.org/web/20210313021701www.ncbi.nlm.nih.gov/books/NBK482247/ |url-status=live }}Other signs of left ventricular failure include a laterally displaced apex beat (which occurs when the heart is enlarged) and a gallop rhythm (additional heart sounds), which may be heard as a sign of increased blood flow or increased intracardiac pressure. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g., aortic stenosis) or as a consequence (e.g., mitral regurgitation) of heart failure.WEB, Heart Murmur: Types & Causes,my.clevelandclinic.org/health/diseases/17083-heart-murmur, 2022-05-11, Cleveland Clinic, 28 November 2022,web.archive.org/web/20221128033026/https://my.clevelandclinic.org/health/diseases/17083-heart-murmur, live, Reverse insufficiency of the left ventricle causes congestion in the blood vessels of the lungs, so that symptoms are predominantly respiratory. Reverse insufficiency can be divided into the failure of the left atrium, the left ventricle, or both within the left circuit. Patients will experience shortness of breath (dyspnea) on exertion and, in severe cases, dyspnea at rest. Increasing breathlessness while lying down, called orthopnea, also occurs. It can be measured by the number of pillows required to lie comfortably, with extreme cases of orthopnea forcing the patient to sleep sitting up. Another symptom of heart failure is paroxysmal nocturnal dyspnea: a sudden nocturnal attack of severe shortness of breath, usually occurring several hours after falling asleep.WEB, What is Exercise Intolerance?,www.webmd.com/fitness-exercise/what-to-know-about-exercise-intolerance, 2022-05-11, WebMD, en, 11 May 2022,web.archive.org/web/20220511094156/https://www.webmd.com/fitness-exercise/what-to-know-about-exercise-intolerance, live, There may be “cardiac asthma” or wheezing. Impaired left ventricular forward function can lead to symptoms of poor systemic perfusion such as dizziness, confusion, and cool extremities at rest. Loss of consciousness may also occur due to loss of blood supply to the brain.WEB, Heart Failure Signs and Symptoms,www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure, heart.org, American Heart Association, 16 November 2022, 17 November 2022,web.archive.org/web/20221117045606/https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure, live,Right-sided failure
(File:Combinpedal.jpg|thumb|upright=1.4|Severe peripheral pitting edema)Right-sided heart failure is often caused by pulmonary heart disease (cor pulmonale), which is typically caused by issues with pulmonary circulation such as pulmonary hypertension or pulmonic stenosis. Physical examination may reveal pitting peripheral edema, ascites, liver enlargement, and spleen enlargement. Jugular venous pressure is frequently assessed as a marker of fluid status, which can be accentuated by testing hepatojugular reflux. If the right ventricular pressure is increased, a parasternal heave which causes the compensatory increase in contraction strength may be present.JOURNAL, Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, Falk V, González-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P, 6, 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC, European Journal of Heart Failure, 37, 27, 2129–2200, 14 July 2016, 27207191, 10.1093/eurheartj/ehw128, free, 2434/427148, 221675744,academic.oup.com/eurheartj/article-pdf/37/27/2129/23748755/ehw128.pdf, Review, 7 February 2023, 7 February 2023,web.archive.org/web/20230207205925/https://academic.oup.com/eurheartj/article-pdf/37/27/2129/23748755/ehw128.pdf, live, Backward failure of the right ventricle leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body. This causes swelling under the skin (peripheral edema or anasarca) and usually affects the dependent parts of the body first, causing foot and ankle swelling in people who are standing up and sacral edema in people who are predominantly lying down. Nocturia (frequent night-time urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night. In progressively severe cases, ascites (fluid accumulation in the abdominal cavity causing swelling) and liver enlargement may develop. Significant liver congestion may result in impaired liver function (congestive hepatopathy), jaundice, and coagulopathy (problems of decreased or increased blood clotting).BOOK, Alcantara, Camille Abigael P., Chandra, Anjali, Morvey, Diana, von Schwarz, Ernst R., Right Heart Pathology, Acute Right Heart Failure, 2018-01-03, 215–225, 10.1007/978-3-319-73764-5_10, 7123149, 978-3-319-73763-8,Biventricular failure
Dullness of the lung fields when percussed and reduced breath sounds at the base of the lungs may suggest the development of a pleural effusion (fluid collection between the lung and the chest wall). Though it can occur in isolated left- or right-sided heart failure, it is more common in biventricular failure because pleural veins drain into both the systemic and pulmonary venous systems. When unilateral, effusions are often right-sided.JOURNAL, Bhatnagar R, Maskell N, The modern diagnosis and management of pleural effusions, BMJ, 351, h4520, September 2015, 26350935, 10.1136/bmj.h4520, 1983/deeb861e-d752-4e4c-a8d7-f00cc22eddac, 1883969,research-information.bris.ac.uk/en/publications/deeb861e-d752-4e4c-a8d7-f00cc22eddac, 13 February 2023, 9 August 2023,web.archive.org/web/20230809061730/https://research-information.bris.ac.uk/en/publications/the-modern-diagnosis-and-management-of-pleural-effusions, live, free, If a person with a failure of one ventricle lives long enough, it will tend to progress to failure of both ventricles. For example, left ventricular failure allows pulmonary edema and pulmonary hypertension to occur, which increase stress on the right ventricle. Though still harmful, right ventricular failure is not as deleterious to the left side.BOOK, Sayer, Gabriel, Semigran, Marc J., Heart Failure, Acute and Chronic Right Ventricular Failure, 2017-02-22, 65–84, 10.1007/978-1-4471-4219-5_4, 7122716, 978-1-4471-4218-8,Causes
Since heart failure is a syndrome and not a disease, establishing the underlying cause is vital to diagnosis and treatment.{{sfn|Ponikowski|Voors|Anker|Bueno|2016|p=2136}}BOOK,www.ncbi.nlm.nih.gov/books/NBK481485/, Types of heart failure, 2018-01-25, InformedHealth.org, Institute for Quality and Efficiency in Health Care (IQWiG), National Center for Biotechnology Information, U.S. National Library of Medicine, en, 9 August 2021, 20 February 2021,web.archive.org/web/20210220140029/https://www.ncbi.nlm.nih.gov/books/NBK481485/, live, In heart failure, the structure or the function of the heart or in some cases both are altered.{{rp|page=3612}} Heart failure is the potential end stage of all heart diseases.JOURNAL, Davis RC, Hobbs FD, Lip GY, ABC of heart failure. History and epidemiology, BMJ, 320, 7226, 39–42, January 2000, 10617530, 1117316, 10.1136/bmj.320.7226.39, Common causes of heart failure include coronary artery disease, including a previous myocardial infarction (heart attack), high blood pressure, atrial fibrillation, valvular heart disease, excess alcohol use, infection, and cardiomyopathy of an unknown cause.JOURNAL, McMurray JJ, Pfeffer MA, Heart failure, Lancet, 365, 9474, 1877–89, 2005, 15924986, 10.1016/S0140-6736(05)66621-4, 38678826, {{rp|page=e279}}{{rp|at=Table 5}} In addition, viral infection and subsequent inflammation of the heart’s myocardial tissue (termed myocarditis) can similarly contribute to the development of heart failure. Genetic predisposition plays an important role. If more than one cause is present, progression is more likely and prognosis is worse.JOURNAL, Hazebroek MR, Moors S, Dennert R, van den Wijngaard A, Krapels I, Hoos M, Verdonschot J, Merken JJ, de Vries B, Wolffs PF, Crijns HJ, Brunner-La Rocca HP, Heymans S, 6, Prognostic Relevance of Gene-Environment Interactions in Patients With Dilated Cardiomyopathy: Applying the MOGE(S) Classification, Journal of the American College of Cardiology, 66, 12, 1313–23, September 2015, 26383716, 10.1016/j.jacc.2015.07.023, free, Heart damage can predispose a person to develop heart failure later in life and has many causes including systemic viral infections (e.g., HIV), chemotherapeutic agents such as daunorubicin, cyclophosphamide, trastuzumab and substance use disorders of substances such as alcohol, cocaine, and methamphetamine. An uncommon cause is exposure to certain toxins such as lead and cobalt. Additionally, infiltrative disorders such as amyloidosis and connective tissue diseases such as systemic lupus erythematosus have similar consequences. Obstructive sleep apnea (a condition of sleep wherein disordered breathing overlaps with obesity, hypertension, and/or diabetes) is regarded as an independent cause of heart failure.JOURNAL, Khattak HK, Hayat F, Pamboukian SV, Hahn HS, Schwartz BP, Stein PK, Obstructive Sleep Apnea in Heart Failure: Review of Prevalence, Treatment with Continuous Positive Airway Pressure, and Prognosis, Texas Heart Institute Journal, 45, 3, 151–161, June 2018, 30072851, 6059510, 10.14503/THIJ-15-5678, free, Recent reports from clinical trials have also linked variation in blood pressure to heart failureJOURNAL, Muntner P, Whittle J, Lynch AI, Colantonio LD, Simpson LM, Einhorn PT, Levitan EB, Whelton PK, Cushman WC, Louis GT, Davis BR, Oparil S, 6, Visit-to-Visit Variability of Blood Pressure and Coronary Heart Disease, Stroke, Heart Failure, and Mortality: A Cohort Study, Annals of Internal Medicine, 163, 5, 329–38, September 2015, 26215765, 5021508, 10.7326/M14-2803, JOURNAL, Nuyujukian DS, Koska J, Bahn G, Reaven PD, Zhou JJ, Blood Pressure Variability and Risk of Heart Failure in ACCORD and the VADT, Diabetes Care, 43, 7, 1471–1478, July 2020, 32327422, 7305004, 10.2337/dc19-2540, free, 10150/641980, and cardiac changes that may give rise to heart failure.JOURNAL, Nwabuo CC, Yano Y, Moreira HT, Appiah D, Vasconcellos HD, Aghaji QN, Viera A, Rana JS, Shah RV, Murthy VL, Allen NB, Schreiner PJ, Lloyd-Jones DM, Lima JA, 6, Association Between Visit-to-Visit Blood Pressure Variability in Early Adulthood and Myocardial Structure and Function in Later Life, JAMA Cardiology, 5, 7, 795–801, July 2020, 32293640, 7160747, 10.1001/jamacardio.2020.0799,High-output heart failure
High-output heart failure happens when the amount of blood pumped out is more than typical and the heart is unable to keep up. This can occur in overload situations such as blood or serum infusions, kidney diseases, chronic severe anemia, beriberi (vitamin B1/thiamine deficiency), hyperthyroidism, cirrhosis, Paget’s disease, multiple myeloma, arteriovenous fistulae, or arteriovenous malformations.JOURNAL, McCulloch B, High-Output Heart Failure Caused by Thyrotoxicosis and Beriberi, Crit Care Nurs Clin North Am, 27, 4, 499–510, December 2015, 26567494, 10.1016/j.cnc.2015.07.004, JOURNAL, Carlisi M, Mancuso S, Lo Presti R, Siragusa S, Caimi G, High Output Heart Failure in Multiple Myeloma: Pathogenetic Considerations, Cancers (Basel), 14, 3, January 2022, 610, 35158878, 8833382, 10.3390/cancers14030610, free,Acute decompensation
File:Kerley-B-Linien.jpg|thumb|Kerley B lines in radiograph of acute cardiac decompensation. The short, horizontal lines can be found everywhere in the right lungright lungChronic stable heart failure may easily decompensate. This most commonly results from a concurrent illness (such as myocardial infarction (a heart attack) or pneumonia), abnormal heart rhythms, uncontrolled hypertension, or a person’s failure to maintain a fluid restriction, diet, or medication.JOURNAL, Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, O’Connor CM, Pieper K, Sun JL, Yancy CW, Young JB, 6, Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF, Archives of Internal Medicine, 168, 8, 847–54, April 2008, 18443260, 10.1001/archinte.168.8.847, 20912905, Other factors that may worsen CHF include: anemia, hyperthyroidism, excessive fluid or salt intake, and medication such as NSAIDs and thiazolidinediones.JOURNAL, Nieminen MS, Böhm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, Hasin Y, Lopez-Sendon J, Mebazaa A, Metra M, Rhodes A, Swedberg K, Priori SG, Garcia MA, Blanc JJ, Budaj A, Cowie MR, Dean V, Deckers J, Burgos EF, Lekakis J, Lindahl B, Mazzotta G, Morais J, Oto A, Smiseth OA, Garcia MA, Dickstein K, Albuquerque A, Conthe P, Crespo-Leiro M, Ferrari R, Follath F, Gavazzi A, Janssens U, Komajda M, Morais J, Moreno R, Singer M, Singh S, Tendera M, Thygesen K, 6, Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology, European Heart Journal, 26, 4, 384–416, February 2005, 15681577, 10.1093/eurheartj/ehi044,repositorio.chporto.pt/bitstream/10400.16/493/1/pdf.4.pdf, free, 18 September 2019, 10 August 2017,repositorio.chporto.pt/bitstream/10400.16/493/1/pdf.4.pdf," title="web.archive.org/web/20170810020623repositorio.chporto.pt/bitstream/10400.16/493/1/pdf.4.pdf,">web.archive.org/web/20170810020623repositorio.chporto.pt/bitstream/10400.16/493/1/pdf.4.pdf, live, NSAIDs increase the risk twofold.JOURNAL, Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C, 6, Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials, Lancet, 382, 9894, 769–79, August 2013, 23726390, 3778977, 10.1016/S0140-6736(13)60900-9,Medications
A number of medications may cause or worsen the disease. This includes NSAIDs, COX-2 inhibitors, a number of anesthetic agents such as ketamine, thiazolidinediones, some cancer medications, several antiarrhythmic medications, pregabalin, alpha-2 adrenergic receptor agonists, minoxidil, itraconazole, cilostazol, anagrelide, stimulants (e.g., methylphenidate), tricyclic antidepressants, lithium, antipsychotics, dopamine agonists, TNF inhibitors, calcium channel blockers (especially verapamil and diltiazemJOURNAL, Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, etal, 2018 ESC/ESH Guidelines for the management of arterial hypertension., Eur Heart J, 2018, 39, 33, 3021–3104, 30165516, 10.1093/eurheartj/ehy339, free, JOURNAL, Suchard MA, Schuemie MJ, Krumholz HM, You SC, Chen R, Pratt N, etal, Comprehensive comparative effectiveness and safety of first-line antihypertensive drug classes: a systematic, multinational, large-scale analysis., Lancet, 2019, 394, 10211, 1816–1826, 31668726, 10.1016/S0140-6736(19)32317-7, 6924620, ), salbutamol, and tamsulosin.JOURNAL, Page RL, O’Bryant CL, Cheng D, Dow TJ, Ky B, Stein CM, Spencer AP, Trupp RJ, Lindenfeld J, 6, Drugs That May Cause or Exacerbate Heart Failure: A Scientific Statement From the American Heart Association, Circulation, 134, 6, e32–69, August 2016, 27400984, 10.1161/CIR.0000000000000426, free, By inhibiting the formation of prostaglandins, NSAIDs may exacerbate heart failure through several mechanisms, including promotion of fluid retention, increasing blood pressure, and decreasing a person’s response to diuretic medications. Similarly, the ACC/AHA recommends against the use of COX-2 inhibitor medications in people with heart failure. Thiazolidinediones have been strongly linked to new cases of heart failure and worsening of pre-existing congestive heart failure due to their association with weight gain and fluid retention. Certain calcium channel blockers, such as diltiazem and verapamil, are known to decrease the force with which the heart ejects blood, thus are not recommended in people with heart failure with a reduced ejection fraction.Breast cancer patients are at high risk of heart failure due to several factors.JOURNAL, Lenneman, Carrie G., Sawyer, Douglas B., 2016-03-18, Cardio-Oncology: An Update on Cardiotoxicity of Cancer-Related Treatment,www.ahajournals.org/doi/10.1161/CIRCRESAHA.115.303633, Circulation Research, en, 118, 6, 1008–1020, 10.1161/CIRCRESAHA.115.303633, 26987914, 0009-7330, After analysing data from 26 studies (836,301 patients), the recent meta-analysis found that breast cancer survivors demonstrated a higher risk heart failure within first ten years after diagnosis (hazard ratio = 1.21; 95% CI: 1.1, 1.33).JOURNAL, Galimzhanov, Akhmetzhan, Istanbuly, Sedralmontaha, Tun, Han Naung, Ozbay, Benay, Alasnag, Mirvat, Ky, Bonnie, Lyon, Alexander R, Kayikcioglu, Meral, Tenekecioglu, Erhan, Panagioti, Maria, Kontopantelis, Evangelos, Abdel-Qadir, Husam, Mamas, Mamas A, 2023-07-27, Cardiovascular outcomes in breast cancer survivors: a systematic review and meta-analysis,academic.oup.com/eurjpc/advance-article/doi/10.1093/eurjpc/zwad243/7232455, European Journal of Preventive Cardiology, 30, 18, 2018–2031, en, 10.1093/eurjpc/zwad243, 37499186, 2047-4873, free, The pooled incidence of heart failure in breast cancer survivors was 4.44 (95% CI 3.33-5.92) per 1000 person-years of follow-up.Supplements
Certain alternative medicines carry a risk of exacerbating existing heart failure, and are not recommended. This includes aconite, ginseng, gossypol, gynura, licorice, lily of the valley, tetrandrine, and yohimbine. Aconite can cause abnormally slow heart rates and abnormal heart rhythms such as ventricular tachycardia. Ginseng can cause abnormally low or high blood pressure, and may interfere with the effects of diuretic medications. Gossypol can increase the effects of diuretics, leading to toxicity. Gynura can cause low blood pressure. Licorice can worsen heart failure by increasing blood pressure and promoting fluid retention. Lily of the valley can cause abnormally slow heart rates with mechanisms similar to those of digoxin. Tetrandrine can lead to low blood pressure through inhibition of L-type calcium channels. Yohimbine can exacerbate heart failure by increasing blood pressure through alpha-2 adrenergic receptor antagonism.Pathophysiology
File:Right side heart failure.jpg|thumb|upright=1.6|Model of a normal heart (left); and a weakened heart, with over-stretched muscle and dilation of left ventricle (right); both during diastolediastole Heart failure is caused by any condition that reduces the efficiency of the heart muscle, through damage or overloading. Over time, these increases in workload, which are mediated by long-term activation of neurohormonal systems such as the renin–angiotensin system and the sympathoadrenal system, lead to fibrosis, dilation, and structural changes in the shape of the left ventricle from elliptical to spherical.The heart of a person with heart failure may have a reduced force of contraction due to overloading of the ventricle. In a normal heart, increased filling of the ventricle results in increased contraction force by the Frank–Starling law of the heart, and thus a rise in cardiac output. In heart failure, this mechanism fails, as the ventricle is loaded with blood to the point where heart muscle contraction becomes less efficient. This is due to reduced ability to cross-link actin and myosin myofilaments in over-stretched heart muscle.BOOK, Boron WF, Boulpaep EL, Medical Physiology: A Cellular and Molecular Approach, Saunders, Updated, 2005, 978-0-7216-3256-8, 533,Diagnosis
No diagnostic criteria have been agreed on as the gold standard for heart failure, especially heart failure with preserved ejection fraction (HFpEF).In the UK, the National Institute for Health and Care Excellence recommends measuring N-terminal pro-BNP (NT-proBNP) followed by an ultrasound of the heart if positive. In Europe, the European Society of Cardiology, and in the United States, the AHA/ACC/HFSA, recommend measuring NT-proBNP or BNP followed by an ultrasound of the heart if positive. This is recommended in those with symptoms consistent with heart failure such as shortness of breath.The European Society of Cardiology defines the diagnosis of heart failure as symptoms and signs consistent with heart failure in combination with “objective evidence of cardiac structural or functional abnormalities”. This definition is consistent with an international 2021 report termed “Universal Definition of Heart Failure”.{{rp|p=3613}} Score-based algorithms have been developed to help in the diagnosis of HFpEF, which can be challenging for physicians to diagnose.{{rp|p=3630}} The AHA/ACC/HFSA defines heart failure as symptoms and signs consistent with heart failure in combination with shown “structural and functional alterations of the heart as the underlying cause for the clinical presentation”, for HFmrEF and HFpEF specifically requiring “evidence of spontaneous or provokable increased left ventricle filling pressures”.{{rp|pages=e276–e277}}Algorithms
The European Society of Cardiology has developed a diagnostic algorithm for HFpEF, named HFA-PEFF.{{rp|p=3630}}JOURNAL, Pieske, Burkert, Tschöpe, Carsten, de Boer, Rudolf A, Fraser, Alan G, Anker, Stefan D, Donal, Erwan, Edelmann, Frank, Fu, Michael, Guazzi, Marco, Lam, Carolyn S P, Lancellotti, Patrizio, Melenovsky, Vojtech, Morris, Daniel A, Nagel, Eike, Pieske-Kraigher, Elisabeth, 5, 2019-10-21, How to diagnose heart failure with preserved ejection fraction: the HFA–PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC),academic.oup.com/eurheartj/article/40/40/3297/5557740, European Heart Journal, en, 40, 40, 3297–3317, 10.1093/eurheartj/ehz641, 31504452, 0195-668X, 20 February 2023, 20 February 2023,web.archive.org/web/20230220182959/https://academic.oup.com/eurheartj/article/40/40/3297/5557740, live, free, HFA-PEFF considers symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes, elderly, atrial fibrillation), and diagnostic laboratory tests, ECG, and echocardiography.{{rp|p=e277}}Classification
“Left”, “right” and mixed heart failure
One historical method of categorizing heart failure is by the side of the heart involved (left heart failure versus right heart failure). Right heart failure was thought to compromise blood flow to the lungs compared to left heart failure compromising blood flow to the aorta and consequently to the brain and the remainder of the body’s systemic circulation. However, mixed presentations are common and left heart failure is a common cause of right heart failure.WEB,www.ucsfhealth.org/conditions/heart_failure/signs_and_symptoms.html, Heart Failure: Signs and Symptoms, UCSF Medical Center, live,www.ucsfhealth.org/conditions/heart_failure/signs_and_symptoms.html," title="web.archive.org/web/20140407080141www.ucsfhealth.org/conditions/heart_failure/signs_and_symptoms.html,">web.archive.org/web/20140407080141www.ucsfhealth.org/conditions/heart_failure/signs_and_symptoms.html, 7 April 2014, dmy-all,By ejection fraction
More accurate classification of heart failure type is made by measuring ejection fraction, or the proportion of blood pumped out of the heart during a single contraction.WEB,www.hrsonline.org/Patient-Resources/The-Normal-Heart/Ejection-Fraction#axzz31jSSC7Uo, Ejection Fraction, Heart Rhythm Society, live,www.hrsonline.org/Patient-Resources/The-Normal-Heart/Ejection-Fraction#axzz31jSSC7Uo," title="web.archive.org/web/20140502123346www.hrsonline.org/Patient-Resources/The-Normal-Heart/Ejection-Fraction#axzz31jSSC7Uo,">web.archive.org/web/20140502123346www.hrsonline.org/Patient-Resources/The-Normal-Heart/Ejection-Fraction#axzz31jSSC7Uo, 2 May 2014, 7 June 2014, dmy-all, Ejection fraction is given as a percentage with the normal range being between 50 and 75%. The types are:- Heart failure with reduced ejection fraction (HFrEF): Synonyms no longer recommended are “heart failure due to left ventricular systolic dysfunction” and “systolic heart failure”.JOURNAL, Santulli G, Wang X, Mone P, Updated ACC/AHA/HFSA 2022 guidelines on heart failure: what is new? From epidemiology to clinical management, Eur Heart J Cardiovasc Pharmacother, 8, 5, e23–e24, August 2022, 35460242, 10.1093/ehjcvp/pvac029, 9366633, free, HFrEF is associated with an ejection fraction less than 40%.WEB,www.heart.org/HEARTORG/Conditions/HeartFailure/SymptomsDiagnosisofHeartFailure/Ejection-Fraction-Heart-Failure-Measurement_UCM_306339_Article.jsp, Ejection Fraction Heart Failure Measurement, Feb 11, 2014, American Heart Association, live,www.heart.org/HEARTORG/Conditions/HeartFailure/SymptomsDiagnosisofHeartFailure/Ejection-Fraction-Heart-Failure-Measurement_UCM_306339_Article.jsp," title="web.archive.org/web/20140714140152www.heart.org/HEARTORG/Conditions/HeartFailure/SymptomsDiagnosisofHeartFailure/Ejection-Fraction-Heart-Failure-Measurement_UCM_306339_Article.jsp,">web.archive.org/web/20140714140152www.heart.org/HEARTORG/Conditions/HeartFailure/SymptomsDiagnosisofHeartFailure/Ejection-Fraction-Heart-Failure-Measurement_UCM_306339_Article.jsp, 14 July 2014, 7 June 2014, dmy-all,
- Heart failure with mildly reduced ejection fraction (HFmrEF), previously called “heart failure with mid-range ejection fraction”,WEB, 2021 ESC Clinical Practice Guidelines for the diagnosis and treatment of acute and chronic heart failure,www.escardio.org/Congresses-Events/ESC-Congress/Congress-resources/Congress-news/2021-esc-clinical-practice-guidelines-for-the-diagnosis-and-treatment-of-acute-a, 2021-08-27, 2023-02-06, European Society of Cardiology, en, 6 February 2023,web.archive.org/web/20230206211913/https://www.escardio.org/Congresses-Events/ESC-Congress/Congress-resources/Congress-news/2021-esc-clinical-practice-guidelines-for-the-diagnosis-and-treatment-of-acute-a, live, is defined by an ejection fraction of 41–49%.
- Heart failure with preserved ejection fraction (HFpEF): Synonyms no longer recommended include “diastolic heart failure” and “heart failure with normal ejection fraction.” HFpEF occurs when the left ventricle contracts normally during systole, but the ventricle is stiff and does not relax normally during diastole, which impairs filling.
Ultrasound
An echocardiogram (ultrasound of the heart) is commonly used to support a clinical diagnosis of heart failure. This can determine the stroke volume (SV, the amount of blood in the heart that exits the ventricles with each beat), the end-diastolic volume (EDV, the total amount of blood at the end of diastole), and the SV in proportion to the EDV, a value known as the ejection fraction (EF). In pediatrics, the shortening fraction is the preferred measure of systolic function. Normally, the EF should be between 50 and 70%; in systolic heart failure, it drops below 40%. Echocardiography can also identify valvular heart disease and assess the state of the pericardium (the connective tissue sac surrounding the heart). Echocardiography may also aid in deciding specific treatments, such as medication, insertion of an implantable cardioverter-defibrillator, or cardiac resynchronization therapy. Echocardiography can also help determine if acute myocardial ischemia is the precipitating cause, and may manifest as regional wall motion abnormalities on echo.JOURNAL, Sirajuddin, Arlene, Mirmomen, S. Mojdeh, Kligerman, Seth J., Groves, Daniel W., Burke, Allen P., Kureshi, Faraz, White, Charles S., Arai, Andrew E., 2021-07-01, Ischemic Heart Disease: Noninvasive Imaging Techniques and Findings, RadioGraphics, 41, 4, 990–1021, 10.1148/rg.2021200125, 0271-5333, 8262179, 34019437, File:UOTW 48 - Ultrasound of the Week 1.webm|Ultrasound showing severe systolic heart failureWEB, UOTW #48 – Ultrasound of the Week,www.ultrasoundoftheweek.com/uotw-48/, Ultrasound of the Week, 27 May 2017, 23 May 2015, live,web.archive.org/web/20170509130822/https://www.ultrasoundoftheweek.com/uotw-48/, 9 May 2017, dmy-all, File:UOTW 48 - Ultrasound of the Week 2.webm|Ultrasound showing severe systolic heart failureFile:UOTW 48 - Ultrasound of the Week 3.webm|Ultrasound of the lungs showing edema due to severe systolic heart failureFile:UOTW 48 - Ultrasound of the Week 4.webm|Ultrasound showing severe systolic heart failureFile:UOTW 48 - Ultrasound of the Week 5.jpg|Ultrasound showing severe systolic heart failureChest X-ray
File:Chest radiograph with signs of congestive heart failure - annotated.jpg|thumb|upright=1.3|Chest radiograph of a lung with distinct Kerley B lines, as well as an enlarged heart (as shown by an increased cardiothoracic ratio, cephalization of pulmonary veins, and minor pleural effusion as seen for example in the right horizontal fissure. Yet, no obvious lung edema is seen. Overall, this indicates intermediate severity (stage II) heart failure.]]Chest X-rays are frequently used to aid in the diagnosis of CHF. In a person who is compensated, this may show cardiomegaly (visible enlargement of the heart), quantified as the cardiothoracic ratio (proportion of the heart size to the chest). In left ventricular failure, evidence may exist of vascular redistribution (upper lobe blood diversion or cephalization), Kerley lines, cuffing of the areas around the bronchi, and interstitial edema. Ultrasound of the lung may also be able to detect Kerley lines.JOURNAL, Al Deeb M, Barbic S, Featherstone R, Dankoff J, Barbic D, Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis, Academic Emergency Medicine, 21, 8, 843–52, August 2014, 25176151, 10.1111/acem.12435, free, File:CHF2016.png|Congestive heart failure with small bilateral effusionsFile:Kerley b lines.jpg|Kerley B linesElectrophysiology
An electrocardiogram (ECG or EKG) may be used to identify arrhythmias, ischemic heart disease, right and left ventricular hypertrophy, and presence of conduction delay or abnormalities (e.g. left bundle branch block). Although these findings are not specific to the diagnosis of heart failure, a normal ECG virtually excludes left ventricular systolic dysfunction.BOOK, Loscalzo J, Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Harrison’s Principles of Internal Medicine, 17, McGraw-Hill Medical, 2008, 1447, 978-0-07-147693-5,Blood tests
N-terminal pro-BNP (NT-proBNP) is the favoured biomarker for the diagnosis of heart failure, according to guidelines published 2018 by NICE in the UK. Brain natriuretic peptide 32 (BNP) is another biomarker commonly tested for heart failure.BOOK, National Guideline Centre (UK),www.ncbi.nlm.nih.gov/books/NBK536086/, Chronic Heart Failure in Adults: Diagnosis and Management, 5. Diagnosing heart failure, September 2018, National Institute for Health and Care Excellence (NICE), 978-1-4731-3093-7, National Institute for Health and Care Excellence: Guidelines, London, 30645061, 12 February 2023, 20 March 2023,www.ncbi.nlm.nih.gov/books/NBK536086/," title="web.archive.org/web/20230320112711www.ncbi.nlm.nih.gov/books/NBK536086/,">web.archive.org/web/20230320112711www.ncbi.nlm.nih.gov/books/NBK536086/, live, JOURNAL, Ewald B, Ewald D, Thakkinstian A, Attia J, Meta-analysis of B type natriuretic peptide and N-terminal pro B natriuretic peptide in the diagnosis of clinical heart failure and population screening for left ventricular systolic dysfunction, Internal Medicine Journal, 38, 2, 101–13, February 2008, 18290826, 10.1111/j.1445-5994.2007.01454.x, 35294486, An elevated NT-proBNP or BNP is a specific test indicative of heart failure. Additionally, NT-proBNP or BNP can be used to differentiate between causes of dyspnea due to heart failure from other causes of dyspnea. If myocardial infarction is suspected, various cardiac markers may be used.Blood tests routinely performed include electrolytes (sodium, potassium), measures of kidney function, liver function tests, thyroid function tests, a complete blood count, and often C-reactive protein if infection is suspected.Hyponatremia (low serum sodium concentration) is common in heart failure. Vasopressin levels are usually increased, along with renin, angiotensin II, and catecholamines to compensate for reduced circulating volume due to inadequate cardiac output. This leads to increased fluid and sodium retention in the body; the rate of fluid retention is higher than the rate of sodium retention in the body, this phenomenon causes hypervolemic hyponatremia (low sodium concentration due to high body fluid retention). This phenomenon is more common in older women with low body mass. Severe hyponatremia can result in accumulation of fluid in the brain, causing cerebral edema and intracranial hemorrhage.JOURNAL, Abraham WT, Managing hyponatremia in heart failure, US Cardiology Review, 2008, 5, 1, 57–60, 10.15420/usc.2008.5.1.57,www.uscjournal.com/articles/managing-hyponatremia-heart-failure, 16 January 2018, free, 16 November 2021,web.archive.org/web/20211116040441/https://www.uscjournal.com/articles/managing-hyponatremia-heart-failure, live,Angiography
Angiography is the X-ray imaging of blood vessels, which is done by injecting contrast agents into the bloodstream through a thin plastic tube (catheter), which is placed directly in the blood vessel. X-ray images are called angiograms.NEWS,www.insideradiology.com.au/angiography/, Angiography – Consumer Information – InsideRadiology, 2016-09-23, InsideRadiology, 2017-08-22, en-US, live,web.archive.org/web/20170822134640/https://www.insideradiology.com.au/angiography/, 22 August 2017, dmy-all, Heart failure may be the result of coronary artery disease, and its prognosis depends in part on the ability of the coronary arteries to supply blood to the myocardium (heart muscle). As a result, coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or bypass surgery.Staging
Heart failure is commonly stratified by the degree of functional impairment conferred by the severity of the heart failure, as reflected in the New York Heart Association (NYHA) functional classification.BOOK, Criteria Committee, New York Heart Association, Diseases of the heart and blood vessels. Nomenclature and criteria for diagnosis, Little, Brown, Boston, 1964, 114, 6th, The NYHA functional classes (I–IV) begin with class I, which is defined as a person who experiences no limitation in any activities and has no symptoms from ordinary activities. People with NYHA class II heart failure have slight, mild limitations with everyday activities; the person is comfortable at rest or with mild exertion. With NYHA class III heart failure, a marked limitation occurs with any activity; the person is comfortable only at rest. A person with NYHA class IV heart failure is symptomatic at rest and becomes quite uncomfortable with any physical activity. This score documents the severity of symptoms and can be used to assess response to treatment. While its use is widespread, the NYHA score is not very reproducible and does not reliably predict the walking distance or exercise tolerance on formal testing.JOURNAL, Raphael C, Briscoe C, Davies J, Ian Whinnett Z, Manisty C, Sutton R, Mayet J, Francis DP, Limitations of the New York Heart Association functional classification system and self-reported walking distances in chronic heart failure, Heart, 93, 4, 476–82, April 2007, 17005715, 1861501, 10.1136/hrt.2006.089656, In its 2001 guidelines, the American College of Cardiology/American Heart Association working group introduced four stages of heart failure:JOURNAL, Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B, 6, ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society, Circulation, 112, 12, e154–235, September 2005, 16160202, 10.1161/CIRCULATIONAHA.105.167586, free,- Stage A: People at high risk for developing HF in the future, but no functional or structural heart disorder
- Stage B: A structural heart disorder, but no symptoms at any stage
- Stage C: Previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment
- Stage D: Advanced disease requiring hospital-based support, a heart transplant, or palliative care
- The degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/kidney failure, etc.
- Whether the problem is primarily increased venous back pressure (preload), or failure to supply adequate arterial perfusion (afterload)
- Whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high-output heart failure)
Histopathology
File:Histopathology of pulmonary congestion and siderophages.jpg|thumb|Siderophages (one indicated by white arrow) and pulmonary congestion, indicating left congestive heart failurecongestive heart failureHistopathology can diagnose heart failure in autopsies. The presence of siderophages indicates chronic left-sided heart failure, but is not specific for it.BOOK, Guido Majno, Isabelle Joris, Cells, Tissues, and Disease: Principles of General Pathology,books.google.com/books?id=8yAf6U7njlcC&pg=PA620, 19 March 2013, 12 August 2004, Oxford University Press, 978-0-19-974892-1, 620, It is also indicated by congestion of the pulmonary circulation.Prevention
A person’s risk of developing heart failure is inversely related to level of physical activity. Those who achieved at least 500 MET-minutes/week (the recommended minimum by U.S. guidelines) had lower heart failure risk than individuals who did not report exercising during their free time; the reduction in heart failure risk was even greater in those who engaged in higher levels of physical activity than the recommended minimum.JOURNAL, Pandey A, Garg S, Khunger M, Darden D, Ayers C, Kumbhani DJ, Mayo HG, de Lemos JA, Berry JD, 6, Dose-Response Relationship Between Physical Activity and Risk of Heart Failure: A Meta-Analysis, Circulation, 132, 19, 1786–1794, November 2015, 26438781, 10.1161/CIRCULATIONAHA.115.015853, free, Heart failure can also be prevented by lowering high blood pressure and high blood cholesterol, and by controlling diabetes. Maintaining a healthy weight, and decreasing sodium, alcohol, and sugar intake, may help. Additionally, avoiding tobacco use has been shown to lower the risk of heart failure.NEWS,www.webmd.com/heart-disease/heart-failure/tc/heart-failure-prevention, Heart Failure: Am I at Risk, and Can I Prevent It?, Webmd, 13 November 2018, 30 March 2018,web.archive.org/web/20180330212317/https://www.webmd.com/heart-disease/heart-failure/tc/heart-failure-prevention, live, According to Johns Hopkins and the American Heart Association there are a few ways to help to prevent a cardiac event. Johns Hopkins states that stopping tobacco use, reducing high blood pressure, physical activity and your diet can drastically effect the chances of developing heart disease. High blood pressure accounts for most cardiovascular deaths. High blood pressure can be lowered into the normal range by making dietary decisions such as consuming less salt. Exercise also helps to bring blood pressure back down. One of the best ways to help avoid heart failure is to promote healthier eating habits like eating more vegetables, fruits, grains, and lean protein.WEB, 2019 Updated Cardiovascular Disease Prevention Guidelines Announced - Johns Hopkins Medicine,clinicalconnection.hopkinsmedicine.org/news/2019-updated-cardiovascular-disease-prevention-guidelines-announced, 2022-04-29, clinicalconnection.hopkinsmedicine.org, 17 March 2019, en, 5 July 2022,web.archive.org/web/20220705093722/https://clinicalconnection.hopkinsmedicine.org/news/2019-updated-cardiovascular-disease-prevention-guidelines-announced, live, Diabetes is a major risk factor for heart failure. For women with Coronary Heart disease (CHD), diabetes was the strongest risk factor for heart failure.Thom, T., Haase, N., Rosamond, W., Howard, V., Rumsfeld, J., & Manolio, T. et al. (2006). Heart Disease and Stroke Statistics—2006 Update. Circulation, 113(6).doi.org/10.1161/circulationaha.105.171600 {{Webarchive|url=https://web.archive.org/web/20230809061723www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.105.171600 |date=9 August 2023 }} Diabetic women with depressed creatinine clearance or elevated BMI were at the highest risk of heart failure. While the annual incidence rate of heart failure for non-diabetic women with no risk factors is 0.4%, the annual incidence rate for diabetic women with elevated body mass index (BMI) and depressed creatinine clearance was 7% and 13%, respectively.Bibbins-Domingo, K., Lin, F., & Vittinghoff, E. (2005). Predictors of heart failure among women with coronary disease. ACC Current Journal Review, 14(2), 35–36.doi.org/10.1016/j.accreview.2004.12.100 {{Webarchive|url=https://web.archive.org/web/20230809061726www.sciencedirect.com/science/article/abs/pii/S1062145804011456?via%3Dihub |date=9 August 2023 }}Management
Treatment focuses on improving the symptoms and preventing the progression of the disease. Reversible causes of heart failure also need to be addressed (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, and hypertension). Treatments include lifestyle and pharmacological modalities, and occasionally various forms of device therapy. Rarely, cardiac transplantation is used as an effective treatment when heart failure has reached the end stage.JOURNAL, Cebeci F, Arikan B, Catal E, Bayezid O, A bridge to transplantation: The life experiences of patients with a left ventricular assist device, Heart & Lung, 50, 1, 106–112, 2021, 33069454, 10.1016/j.hrtlng.2020.09.020, 224780668,Acute decompensation
In acute decompensated heart failure, the immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing, and circulation are adequate. Immediate treatments usually involve some combination of vasodilators such as nitroglycerin, diuretics such as furosemide, and possibly noninvasive positive pressure ventilation. Supplemental oxygen is indicated in those with oxygen saturation levels below 90%, but is not recommended in those with normal oxygen levels in normal atmosphere.JOURNAL, Acute heart failure with dyspnoea. First-choice treatments, Prescrire International, 2018, 27, 194, 160–162,Chronic management
The goals of the treatment for people with chronic heart failure are the prolongation of life, prevention of acute decompensation, and reduction of symptoms, allowing for greater activity.Heart failure can result from a variety of conditions. In considering therapeutic options, excluding reversible causes is of primary importance, including thyroid disease, anemia, chronic tachycardia, alcohol use disorder, hypertension, and dysfunction of one or more heart valves. Treatment of the underlying cause is usually the first approach to treating heart failure. In the majority of cases, though, either no primary cause is found or treatment of the primary cause does not restore normal heart function. In these cases, behavioral, medical and device treatment strategies exist that can provide a significant improvement in outcomes, including the relief of symptoms, exercise tolerance, and a decrease in the likelihood of hospitalization or death. Breathlessness rehabilitation for chronic obstructive pulmonary disease and heart failure has been proposed with exercise training as a core component. Rehabilitation should also include other interventions to address shortness of breath including psychological and educational needs of people and needs of caregivers.JOURNAL, Man WD, Chowdhury F, Taylor RS, Evans RA, Doherty P, Singh SJ, Booth S, Thomason D, Andrews D, Lee C, Hanna J, Morgan MD, Bell D, Cowie MR, 6, Building consensus for provision of breathlessness rehabilitation for patients with chronic obstructive pulmonary disease and chronic heart failure, Chronic Respiratory Disease, 13, 3, 229–39, August 2016, 27072018, 5029782, 10.1177/1479972316642363, Iron supplementation appears to reduce hospitalization but not all-cause mortality in patients with iron deficiency and heartfailure.JOURNAL, Zhou X, Xu W, Xu Y, Qian Z, Iron Supplementation Improves Cardiovascular Outcomes in Patients with Heart Failure, The American Journal of Medicine, 132, 8, 955–963, August 2019, 30853478, 10.1016/j.amjmed.2019.02.018, 73725232,Advance care planning
The latest evidence indicates that advance care planning (ACP) may help to increase documentation by medical staff regarding discussions with participants, and improve an individual’s depression.JOURNAL, Nishikawa Y, Hiroyama N, Fukahori H, Ota E, Mizuno A, Miyashita M, Yoneoka D, Kwong JS, 6, Advance care planning for adults with heart failure, The Cochrane Database of Systematic Reviews, 2020, CD013022, February 2020, 2, 32104908, 7045766, 10.1002/14651858.CD013022.pub2, Cochrane Heart Group, This involves discussing an individual’s future care plan in consideration of the individual’s preferences and values. The findings are however, based on low-quality evidence.Monitoring
The various measures often used to assess the progress of people being treated for heart failure include fluid balance (calculation of fluid intake and excretion) and monitoring body weight (which in the shorter term reflects fluid shifts).JOURNAL, 6, Yu CM, Wang L, Chau E, Chan RH, Kong SL, Tang MO, Christensen J, Stadler RW, Lau CP, August 2005, Intrathoracic impedance monitoring in patients with heart failure: correlation with fluid status and feasibility of early warning preceding hospitalization, Circulation, 112, 6, 841–8, 10.1161/CIRCULATIONAHA.104.492207, 16061743, free, Remote monitoring can be effective to reduce complications for people with heart failure.JOURNAL, Bashi N, Karunanithi M, Fatehi F, Ding H, Walters D, January 2017, Remote Monitoring of Patients With Heart Failure: An Overview of Systematic Reviews, Journal of Medical Internet Research, 19, 1, e18, 10.2196/jmir.6571, 5291866, 28108430, free, JOURNAL, Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JG, October 2015, Structured telephone support or non-invasive telemonitoring for patients with heart failure,dspace.flinders.edu.au/xmlui/bitstream/2328/35732/1/Inglis%20Structured%202015.pdf, The Cochrane Database of Systematic Reviews, 2015, 10, CD007228, 10.1002/14651858.CD007228.pub3, 26517969, 8482064, 2328/35732, 25 September 2019, 28 August 2021,web.archive.org/web/20210828103110/https://dspace.flinders.edu.au/xmlui/bitstream/handle/2328/35732/Inglis%20Structured%202015.pdf;jsessionid=B2254F0FEBB8F13B06AFE621E018A88A?sequence=1, live,Lifestyle
Behavior modification is a primary consideration in chronic heart failure management program, with dietary guidelines regarding fluid and salt intake.WEB,www.heart.org/HEARTORG/Conditions/HeartFailure/PreventionTreatmentofHeartFailure/Lifestyle-Changes-for-Heart-Failure_UCM_306341_Article.jsp, Lifestyle Changes for Heart Failure, American Heart Association, live,www.heart.org/HEARTORG/Conditions/HeartFailure/PreventionTreatmentofHeartFailure/Lifestyle-Changes-for-Heart-Failure_UCM_306341_Article.jsp," title="web.archive.org/web/20150503123439www.heart.org/HEARTORG/Conditions/HeartFailure/PreventionTreatmentofHeartFailure/Lifestyle-Changes-for-Heart-Failure_UCM_306341_Article.jsp,">web.archive.org/web/20150503123439www.heart.org/HEARTORG/Conditions/HeartFailure/PreventionTreatmentofHeartFailure/Lifestyle-Changes-for-Heart-Failure_UCM_306341_Article.jsp, 3 May 2015, Fluid restriction is important to reduce fluid retention in the body and to correct the hyponatremic status of the body. The evidence of benefit of reducing salt, however, is poor as of 2018.JOURNAL, Mahtani KR, Heneghan C, Onakpoya I, Tierney S, Aronson JK, Roberts N, Hobbs FD, Nunan D, 6, Reduced Salt Intake for Heart Failure: A Systematic Review, JAMA Internal Medicine, 178, 12, 1693–1700, November 2018, 30398532, 10.1001/jamainternmed.2018.4673, 53241717, 6422065, Thirst is a common and burdensome symptom for patients to cope with. Chewing gum has been shown to be an effective intervention to relieve thirst in patients experiencing heart failure, although patient acceptability remains an issue.Exercise and physical activity
Exercise should be encouraged and tailored to suit individual’s capabilities. A meta-analysis found that centre-based group interventions delivered by a physiotherapist are helpful in promoting physical activity in HF.JOURNAL, Amirova A, Fteropoulli T, Williams P, Haddad M, Efficacy of interventions to increase physical activity for people with heart failure: a meta-analysis, English, Open Heart, 8, 1, e001687, June 2021, 34108272, 8191629, 10.1136/openhrt-2021-001687, 9066065537, There is a need for additional training for physiotherapists in delivering behaviour change intervention alongside an exercise programme. An intervention is expected to be more efficacious in encouraging physical activity than the usual care if it includes Prompts and cues to walk or exercise, like a phone call or a text message. It is extremely helpful if a trusted clinician provides explicit advice to engage in physical activity (Credible source). Another highly effective strategy is to place objects that will serve as a cue to engage in physical activity in the everyday environment of the patient (Adding object to the environment; e.g., exercise step or treadmill). Encouragement to walk or exercise in various settings beyond CR (e.g., home, neighbourhood, parks) is also promising (Generalisation of target behaviour). Additional promising strategies are Graded tasks (e.g., gradual increase in intensity and duration of exercise training), Self-monitoring, Monitoring of physical activity by others without feedback, Action planning, and Goal-setting.JOURNAL, Amirova A, Fteropoulli T, Williams P, Haddad M, Efficacy of interventions to increase physical activity for people with heart failure: a meta-analysis, Open Heart, 8, 1, e001687, June 2021, 34108272, 8191629, 10.1136/openhrt-2021-001687, free, The inclusion of regular physical conditioning as part of a cardiac rehabilitation program can significantly improve quality of life and reduce the risk of hospital admission for worsening symptoms, but no evidence shows a reduction in mortality rates as a result of exercise.Home visits and regular monitoring at heart-failure clinics reduce the need for hospitalization and improve life expectancy.JOURNAL, Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJ, Arvanitis M, Lohr KN, Middleton JC, Jonas DE, 6, Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis, Annals of Internal Medicine, 160, 11, 774–84, June 2014, 24862840, 10.7326/M14-0083, 262525144, 11250/2485759, free,Medication
Quadruple medical therapy using a combination of angiotensin receptor-neprilysin inhibitors (ARNI), beta blockers, mineralocorticoid receptor antagonists (MRA), and sodium/glucose cotransporter 2 inhibitors (SGLT2 inhibitors) is the standard of care as of 2021 for heart failure with reduced ejection fraction (HFrEF).JOURNAL, Greene S, Khan M, et al., Quadruple Medical Therapy for Heart Failure, J Am Coll Cardiol, March 2021, 77, 11, 1408–1411, 10.1016/j.jacc.2021.02.006, 33736822, 232299815, free, JOURNAL, Straw S, McGinlay M, Witte KK, Four pillars of heart failure: contemporary pharmacological therapy for heart failure with reduced ejection fraction, Open Heart (journal), Open Heart, 2021, 8, 1, e001585, 10.1136/openhrt-2021-001585, 33653703, 7929859, There is no convincing evidence for pharmacological treatment of heart failure with preserved ejection fraction (HFpEF).JOURNAL, McDonagh, Theresa A., Metra, Marco, Adamo, Marianna, Gardner, Roy S., Baumbach, Andreas, Böhm, Michael, Burri, Haran, Butler, Javed, Čelutkienė, Jelena, Chioncel, Ovidiu, Cleland, John G. F., Coats, Andrew J. S., Crespo-Leiro, Maria G., Farmakis, Dimitrios, Gilard, Martine, 6, 2021-09-21, 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC, European Heart Journal, 42, 36, 3599–3726, 10.1093/eurheartj/ehab368, free, 1522-9645, 34447992,academic.oup.com/eurheartj/article-pdf/42/36/3599/40594787/ehab368.pdf, 7 February 2023, 8 September 2022,web.archive.org/web/20220908043625/https://academic.oup.com/eurheartj/article-pdf/42/36/3599/40594787/ehab368.pdf, live, Medication for HFpEF is symptomatic treatment with diuretics to treat congestion. Managing risk factors and comorbidities such as hypertension is recommended in HFpEF.Inhibitors of the renin–angiotensin system (RAS) are recommended in heart failure. The angiotensin receptor-neprilysin inhibitors (ARNI) sacubitril/valsartan is recommended as first choice of RAS inhibitors in American guidelines published by AHA/ACC in 2022. Use of angiotensin-converting enzyme (ACE) inhibitors (ACE-I), or angiotensin receptor blockers (ARB) if the person develops a long-term cough as a side effect of the ACE-I,BOOK, Goljan EF, Rapid Review Pathology, 4th, Philadelphia, PA, Saunders/Elsevier, 2014, 978-0-323-08787-2, is associated with improved survival, fewer hospitalizations for heart failure exacerbations, and improved quality of life in people with heart failure.{{NICE|108|Chronic heart failure – managements (ARBs) of chronic heart failure in adults in primary and secondary care | August 2010}} European guidelines published by ESC in 2021 recommends that ARNI should be used in those who still have symptoms while on an ACE-I or ARB, beta blocker, and a mineralocorticoid receptor antagonist. Use of the combination agent ARNI requires the cessation of ACE-I or ARB therapy at least 36 hours before its initiation.Beta-adrenergic blocking agents (beta blockers) add to the improvement in symptoms and mortality provided by ACE-I/ARB.JOURNAL, Kotecha D, Manzano L, Krum H, Rosano G, Holmes J, Altman DG, Collins PD, Packer M, Wikstrand J, Coats AJ, Cleland JG, Kirchhof P, von Lueder TG, Rigby AS, Andersson B, Lip GY, van Veldhuisen DJ, Shibata MC, Wedel H, Böhm M, Flather MD, 6, Effect of age and sex on efficacy and tolerability of β blockers in patients with heart failure with reduced ejection fraction: individual patient data meta-analysis, BMJ, 353, i1855, April 2016, 27098105, 4849174, 10.1136/bmj.i1855, The mortality benefits of beta blockers in people with systolic dysfunction who also have atrial fibrillation is more limited than in those who do not have it.JOURNAL, Kotecha D, Holmes J, Krum H, Altman DG, Manzano L, Cleland JG, Lip GY, Coats AJ, Andersson B, Kirchhof P, von Lueder TG, Wedel H, Rosano G, Shibata MC, Rigby A, Flather MD, 6, Efficacy of β blockers in patients with heart failure plus atrial fibrillation: an individual-patient data meta-analysis, Lancet, 384, 9961, 2235–43, December 2014, 25193873, 10.1016/S0140-6736(14)61373-8, 25660815,pure-oai.bham.ac.uk/ws/files/21568198/Kotecha_et_al_Lancet_Efficacy_of_beta_blockers_The_Lancet_2014_Post_Print.pdf, 27 May 2019, 28 September 2020,pure-oai.bham.ac.uk/ws/files/21568198/Kotecha_et_al_Lancet_Efficacy_of_beta_blockers_The_Lancet_2014_Post_Print.pdf," title="web.archive.org/web/20200928221341pure-oai.bham.ac.uk/ws/files/21568198/Kotecha_et_al_Lancet_Efficacy_of_beta_blockers_The_Lancet_2014_Post_Print.pdf,">web.archive.org/web/20200928221341pure-oai.bham.ac.uk/ws/files/21568198/Kotecha_et_al_Lancet_Efficacy_of_beta_blockers_The_Lancet_2014_Post_Print.pdf, live, If the ejection fraction is not diminished (HFpEF), the benefits of beta blockers are more modest; a decrease in mortality has been observed, but reduction in hospital admission for uncontrolled symptoms has not been observed.JOURNAL, Liu F, Chen Y, Feng X, Teng Z, Yuan Y, Bin J, Effects of beta-blockers on heart failure with preserved ejection fraction: a meta-analysis, PLOS ONE, 9, 3, e90555, 5 March 2014, 24599093, 3944014, 10.1371/journal.pone.0090555, 2014PLoSO...990555L, free, In people who are intolerant of ACE-I and ARB or who have significant kidney dysfunction, the use of combined hydralazine and a long-acting nitrate, such as isosorbide dinitrate, is an effective alternate strategy. This regimen has been shown to reduce mortality in people with moderate heart failure.BOOK, Chapter 5: Treating heart failure, Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care, Partial Update [Internet]., National Clinical Guideline Centre (UK), Royal College of Physicians, London (UK), August 2010,www.ncbi.nlm.nih.gov/books/NBK65330/, 31 August 2017, 6 September 2017,web.archive.org/web/20170906120901/https://www.ncbi.nlm.nih.gov/books/NBK65330/, live, It is especially beneficial in the black population.{{efn|Specifically, in one randomized control trial the patients self-identified as black (defined as of African descent), and in one randomized control trial the patients were defined as black, without further details given.}}Use of a mineralocorticoid antagonist, such as spironolactone or eplerenone, in addition to beta blockers and ACE-I, can improve symptoms and reduce mortality in people with symptomatic heart failure with reduced ejection fraction (HFrEF).SGLT2 inhibitors are used for heart failure with reduced ejection fraction as they have demonstrated benefits in reducing hospitalizations and mortality, regardless of whether an individual has comorbid Type 2 Diabetes or not.JOURNAL, Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW, 6, 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, Journal of the American College of Cardiology, 79, 17, e263–e421, May 2022, 35379503, 10.1016/j.jacc.2021.12.012, 247882156, free, JOURNAL, Zannad, Faiez, Ferreira, João Pedro, Pocock, Stuart J., Anker, Stefan D., Butler, Javed, Filippatos, Gerasimos, Brueckmann, Martina, Ofstad, Anne Pernille, Pfarr, Egon, Jamal, Waheed, Packer, Milton, 2020-09-19, SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials,pubmed.ncbi.nlm.nih.gov/32877652/, Lancet (London, England), 396, 10254, 819–829, 10.1016/S0140-6736(20)31824-9, 1474-547X, 32877652,Other medications
Second-line medications for CHF do not confer a mortality benefit. Digoxin is one such medication. Its narrow therapeutic window, a high degree of toxicity, and the failure of multiple trials to show a mortality benefit have reduced its role in clinical practice. It is now used in only a small number of people with refractory symptoms, who are in atrial fibrillation, and/or who have chronic hypotension.WEB,www.lecturio.com/concepts/congestive-heart-failure/, Congestive Heart Failure, The Lecturio Medical Concept Library, 7 August 2020, 10 July 2021, 10 July 2021,web.archive.org/web/20210710035402/https://www.lecturio.com/concepts/congestive-heart-failure/, live, WEB, Digoxin,www.drugs.com/monograph/digoxin.html, The American Society of Health-System Pharmacists, 8 December 2016, live,web.archive.org/web/20161221004328/https://www.drugs.com/monograph/digoxin.html, 21 December 2016, Diuretics have been a mainstay of treatment against symptoms of fluid accumulation, and include diuretics classes such as loop diuretics (such as furosemide), thiazide-like diuretics, and potassium-sparing diuretics. Although widely used, evidence on their efficacy and safety is limited, with the exception of mineralocorticoid antagonists such as spironolactone.JOURNAL, von Lueder TG, Atar D, Krum H, Diuretic use in heart failure and outcomes, Clinical Pharmacology and Therapeutics, 94, 4, 490–8, October 2013, 23852396, 10.1038/clpt.2013.140, 7441258, Anemia is an independent factor in mortality in people with chronic heart failure. Treatment of anemia significantly improves quality of life for those with heart failure, often with a reduction in severity of the NYHA classification, and also improves mortality rates.JOURNAL, He SW, Wang LX, The impact of anemia on the prognosis of chronic heart failure: a meta-analysis and systemic review, Congestive Heart Failure, 15, 3, 123–30, 2009, 19522961, 10.1111/j.1751-7133.2008.00030.x, free, JOURNAL, Nunez-Gil MI, Peraira-Moral MJ, Anaemia in heart failure: intravenous iron therapy, e-Journal of the ESC Council for Cardiology Practice, 10, 16, 19 January 2012,www.escardio.org/communities/councils/ccp/e-journal/volume10/Pages/anemia-in-heart-failure-intravenous-iron-therapy-Peraira-Moral-J-Roberto-Nunez-Gil-Ivan-J.aspx, dead,www.escardio.org/communities/councils/ccp/e-journal/volume10/Pages/anemia-in-heart-failure-intravenous-iron-therapy-Peraira-Moral-J-Roberto-Nunez-Gil-Ivan-J.aspx," title="web.archive.org/web/20130603124155www.escardio.org/communities/councils/ccp/e-journal/volume10/Pages/anemia-in-heart-failure-intravenous-iron-therapy-Peraira-Moral-J-Roberto-Nunez-Gil-Ivan-J.aspx,">web.archive.org/web/20130603124155www.escardio.org/communities/councils/ccp/e-journal/volume10/Pages/anemia-in-heart-failure-intravenous-iron-therapy-Peraira-Moral-J-Roberto-Nunez-Gil-Ivan-J.aspx, 3 June 2013, dmy-all, 3 October 2012, European Society of Cardiology recommends screening for iron deficiency and treating with intravenous iron if deficiency is found.{{rp|pages=3668–3669}}The decision to anticoagulate people with HF, typically with left ventricular ejection fractions- content above as imported from Wikipedia
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