#46 – Heart Failure


Definition of Heart Failure

  • Complex clinical syndrome resulting from conditions that affect the structure and/or function of the heart culminating in reduced systemic perfusion that is inadequate to meet the metabolic demands of the body
    • Main effect is decreased cardiac output
  • No more “congestive”


  • 5.7 million adults in US
    • 550,000 new cases each year
    • 1.4 million are under 60 years of age
  • Annual incidence is 10 per 1,000 population AFTER 65 years of age
  • 287,000 deaths per year
    • 1 in 9 deaths included heart failure as contributing causes
    • Most common diagnosis in hospital patients over 65 years of age
  • Responsible for 11 million office visits each year in the US and more hospitalizations than all cancers COMBINED
  • 50% of adults who develop heart failure die within 5 years
  • Cost to US is ~$30 billion/year

Causes and Pathophysiology

Any condition that leads to alteration in left ventricular structure or function can cause heart failure and the specific causes depends on the preservation of ejection fraction.  There is considerable overlap between these with coronary artery disease and hypertension causes the majority of cases.

The problem is that the rest of the body feel the effects of the decreased cardiac output and activate the neurohormonal systems to compensate.  The issue is that this makes the heart failure worse and it is a vicious cycle until it can be broken.

Signs and Symptoms

  • History
    • Reduced cardiac output
      • Fatigue, weakness
    • Excessive fluid accumulation
      • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, leg swelling, abdominal discomfort, palpitations
  • Physical Examination
    • Appearance and Vital Signs
      • Resting sinus tachycardia
      • Narrow pulse pressure
      • Cool, pale skin (peripheral vasoconstriction)
    • Volume Assessment
      • Pulmonary congestion
        • Rales on auscultation
        • AUDIO
      • Peripheral edema
        • Leg swelling, hepatic congestion, ascites, scrotal edema
      • Elevated jugular venous pressure
        • Hepatojugular reflux
  • Cardiac
    • S3 with gallop (if systolic failure)
    • S4 (if diastolic failure)
    • Displaced PMI past midclavicular line and below the 5th intercostal space
    • Pulsus alternans
      • Evenly spaced alternating strong and weak peripheral pulses
Pulsus Alternans

Framingham Clinical Criteria for Heart Failure

Clinical Decision Rule for Heart Failure

  • Age
    • < 60 = 0 points
    • 60-70 = 4 point
    • 71-80 = 7 points
    • > 80 = 10 points
  • History of coronary disease = 15 points
    • AMI, CABG, PCI
  • Loop diuretic = 10 points
  • Displaced PMI = 20 points
  • Rales = 14 points
  • Irregularly irregular pulse = 11 points
  • Heart murmur = 10 points
  • Pulse Rate = (HR-60)/3 points
  • Elevated jugular venous pressure = 12 points
  • NT-proBNP (pg/mL)
    • < 100 = 0 points
    • 100-200 = 8 points
    • 200-400 = 16 points
    • 400-800 = 24 points
    • 800-1600 = 32 points
    • 1600-3200 = 40 points
    • > 3200 = 48 points
  • Interpretation
    • < 13 points = < 10% probability of heart failure
    • > 54 points = > 70% probability of heart failure

Diagnostic Studies

  • Electrocardiogram
    • Not really diagnostic, but can evaluate for current ischemia, past infarction, low voltage, dysrhythmias
    • A normal EKG makes systolic dysfunction unlikely (98% NPV)
  • Laboratory studies
    • Brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)
      • Released from ventricles  when stretched
      • < 100 pg/mL = very high NPV and rule out heart failure
    • Cardiac enzymes
    • CBC
    • CMP
  • Chest Radiography
    • Increased cardiothoracic ratio
    • Cephalization of pulmonary vessels
    • Kerley B-lines
    • Pleural effusions
  • Echocardiography
    • Recommended for all patient with dyspnea and suspicion of heart failure
    • Provides vital information on:
      • Ejection fraction
        • < 40% = reduced = systolic
        • > 50% = preserved = diastolic
      • Valvular disease
        • Aortic and mitral regurgitation/insufficiency
      • Atrial and Ventricular size and function
        • Enlarged left ventricle = systolic
        • Left atrial enlargement with normal/small left ventricle = diastolic
      • Left ventricular wall size
        • Thin = systolic
        • Thick = diastolic
  • Exercise/Stress Testing
    • Evaluate for underlying coronary disease, as well as potential candidates for transplantation
      • Patients with a peak oxygen uptake (VO2) < 14 mL/kg/min have better outcomes with transplanted
  • Coronary angiography
    • Not strongly recommended as part of the work-up, but can be useful to evaluate for underlying coronary disease and get an accurate ejection fraction

Classification and Grading

Current Nomenclature

Heart failure with reduced ejection fraction (HFrEF)

  • Systolic
  • < 40% EF

Heart failure with preserved ejection fraction (HFpEF)

  • Diastolic
  • > 50% EF


  • Heart failure with reduced ejection fraction (HFrEF)
    • Lifestyle Modifications
      • Smoking cessation
      • Restrict sodium to < 3g/day
      • Restrict fluid to < 2L/day
    • Pharmacotherapy
      • Loop diuretic (if overload is present)
        • Furosemide, bumetanide, torsemide
      • ACE inhibitors
        • Lisinopril, enalapril
      • Angiotension receptor-neprilysin inhibitor (ARNI)
        • NYHA II or III and:
          • BNP > 150 ng/mL or hospitalized with last 12 months
          • SBP > 100 mmHg
          • GFR > 30 mL/min
          • No history of angioedema
      • ARB
        • Candesartan, valsartan
      • Beta blockers
        • Carvedilol, metoprolol, bisoprolol
      • Mineralcorticoid receptor antagonist (MRA)
        • Spironolactone, eplerenone
      • Selective sinus node inhibitor
        • Ivabradine
        • Need a resting HR > 70 bpm on maximum BB therapy
    • Ischemic heart disease
      • Increase coronary perfusion
      • Decrease myocardial demand
    • Hyperlipidemia
      • High-intensity statin
    • Cardiac rehabilitation
  • Heart failure with preserved ejection fraction (HFpEF)
    • Differences with HFrEF
      • ACEI/ARB not as useful
      • MRA used more often
      • Diuretics OK but be careful for volume depletion
      • Don’t use BB unless compelling indication


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  2. CDC Heart Failure Data Sheet. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm
  3. Emory Healthcare Heart Failure Statistics. https://www.emoryhealthcare.org/heart-vascular/wellness/heart-failure-statistics.html
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  12. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. Journal of the American College of Cardiology. 1993; 22(4 Suppl A):6A-13A. [pubmed]
  13. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013; 128(16):1810-52. [pubmed]
  14. Yancy CW, Jessup M, et al. 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure: An Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2016; 134(13):e282-93. [pubmed]
  15. Ponikowski P, Voors AA, Anker SD, et al. 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 heart journal. 2016; 37(27):2129-2200. [pubmed]
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