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{====Stage C====
==Underlying Anatomic Abnormalities Causing Heart Failure==
{{familytree/start}}
Heart failure may result from an abnormality of any one of the anatomical structures of the heart:
{{familytree | A01 | |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Treatment goal''':<br>
*Disorders of the [[great vessels]] (e.g. [[pulmonary hypertension]])
❑ </div>}}
*[[Endocardium]]
{{familytree | |!| | |}}
*[[Myocardium]]
{{familytree | B02 | |B02=<div style="float: left; text-align: left; width: 20em; padding:1em;">
*[[Pericardium]]
❑ [[Acute decompensated heart failure resident survival guide#Diuretic Therapy|Diuretic therapy]] for fluid retention
*[[Valvular heart disease]] or
❑ [[ACE inhibitors]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
 
❑ [[Angiotensin II receptor antagonist|Angiotensin II receptor blocker]] ([[ARBs]]), use in:<br>
==Systolic versus Diastolic Heart Failure==
:❑ [[ACE inhibitor]] intolerant patients with reduced LVEF ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation
:❑ As an alternative to [[ACE inhibitor]] as first line therapy ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence A]])<br>
===Systolic Dysfunction===
❑ [[Beta blockers]] (for all stable patients) ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
The [[left ventricular ejection fraction]] is reduced in [[systolic dysfunction]] and there is depressed contractility of the heart.
❑ [[Aldosterone antagonist|Aldosterone receptor antagonist]]<br>
===Disastolic Dysfunciton===
:❑ NYHA class II-IV with LVEF ≤ 35% ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
The [[left ventricular ejection fraction]] is preserved in [[diastolic dysfunction]] and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.
❑ [[Hydralazine]] and [[isosorbide dinitrate]]<br>
 
:❑ <br>
==Left, Right and Biventricular Failure==
:❑  <br>
Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).
❑ [[Digoxin]] <br>
===Left Heart Failure===
:❑ <br>
*There is impaired left ventricular function with reduced flow into the aorta.
:❑ [[Omega-3 fatty acid]]
===Right Heart Failure===
❑ [[Implantable cardioverter defibrillator]] (ICD) to prevent sudden death in: <br>
*There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.
:❑ <br>
===Biventricular Failure===
:❑ <br>
*The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.
:❑ <br>
 
:❑ <br>
==High Output Versus Low Output Failure==
❑ [[Cardiac resynchronization therapy]] (CRT)<br>
===Low Output Failure===
:❑ <br>
*The [[cardiac output]] is reduced, and the [[systemic vascular resistance]] ([[SVR]]) is high.  In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.
:❑ <br>
 
:❑ <br>
===High Output Failure===
:❑ <br>
*The [[cardiac output]] is increased, and the [[systemic vascular resistance]] ([[SVR]]) is low.  Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B<sub>1</sub>/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s.
</div>}}
 
{{familytree/end}}
==Causes of Acute or Decompensated Heart Failure==
Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as [[pneumonia]]), [[myocardial infarction]] (a heart attack), [[cardiac arrhythmia|arrhythmias]], uncontrolled [[hypertension]], or a patient's failure to maintain a fluid restriction, diet, or medication.<ref name="OPTIMIZE-HF">{{cite journal |author=Fonarow GC, Abraham WT, Albert NM, ''et al.'' |title=Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF |journal=Arch. Intern. Med. |volume=168 |issue=8 |pages=847–854 |year=2008 |month=April |pmid=18443260 |doi=10.1001/archinte.168.8.847}}</ref> Other well recognized precipitating factors include [[anemia]] and [[hyperthyroidism]] which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as [[Non-steroidal anti-inflammatory drug|NSAIDs]] and [[thiazolidinedione]]s, may also precipitate decompensation.<ref>{{cite journal |author=Nieminen MS, Böhm M, Cowie MR, ''et al.'' |title=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 |journal=Eur. Heart J. |volume=26 |issue=4 |pages=384–416 |year=2005 |month=February |pmid=15681577 |doi=10.1093/eurheartj/ehi044 |url=http://eurheartj.oxfordjournals.org/cgi/content/full/26/4/384}}</ref>
 
==Differential Diagnosis of the Underlying Causes of Chronic Heart Failure==
===Common Causes of Left Sided Heart Failure===
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]
 
A 19 year study of 13,000 healthy adults in the United States (the [[National Health and Nutrition Examination Survey]] (NHANES I) found the following causes ranked by Population Attributable Risk score:<ref>{{cite journal |author=He J; Ogden LG; Bazzano LA; Vupputuri S, ''et al.'' |title=Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study|journal=Arch. Intern. Med. |volume=161 |issue=7 |pages=996–1002|year=2001 |pmid= 11295963 |doi=10.1001/archinte.161.7.996 }}</ref>
#[[Ischaemic heart disease]] 62%
#[[Tobacco smoking|Cigarette smoking]] 16%
#[[Hypertension]] (high blood pressure)10%
#[[Obesity]] 8%
#[[Diabetes]] 3%
#[[Valvular heart disease]] 2%  (much higher in older populations)
 
===Cardiomyopathies and Inflammatory Diseases===
 
=====[[Restrictive Cardiomyopathies]]=====
*[[Alcohol-Induced cardiomyopathy]]
*[[Amyloidosis]]
*[[Anthracycline induced cardiomyopathy]]
*[[Anthracyclines]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Becker's muscular dystrophy]]
*[[Cardiac transplant]]
*[[Cocaine related cardiomyopathy]]
*[[Diabetic cardiomyopathy]]
*[[Endocardial fibrosis]]
*[[Eosinophilic heart disease]]
*[[Hemochromatosis]]
*Primary (idiopathic)
*[[Kearns-Sayre syndrome]]
*[[Radiation therapy]]
*[[Sarcoidosis]]
*Storage diseases
*[[Tumor]] infiltration
 
=====[[Dilated Cardiomyopathies]]=====
*[[Duchenne muscular dystrophy]]
*[[Chagas' disease]]
*[[Limb-girdle muscular dystrophy]]
*[[Mitochondrial myopathy]]
*[[Peripartum cardiomyopathy]]
*[[Trastuzumab]] [[Herceptin-lnduced Cardiomyopathy]]
 
=====Inflammatory Cardiomyopathies=====
 
*[[Bacterial Myocarditis]]
*[[Fungal myocarditis]]
*[[Giant Cell Myocarditis]]
*[[Myocarditis|Protozoal Myocarditis]]: [[Trypanosomiasis]] ([[Chagas Disease]])
*[[Rickettsial Myocarditis]]
*[[Sarcoidosis]]
*[[Spirochetal Infections]]
*[[Viral Myocarditis]]
 
===Congestive Heart Failure as a Consequence of Valvular Heart Disease===
*[[Acute aortic regurgitation]]
*[[Acute mitral regurgitation]]
*[[Aortic stenosis with Left Ventricular Systolic Dysfunction]]
*[[Chronic aortic regurgitation]]
*[[Chronic mitral regurgitation]]
*[[Mitral Stenosis]]
 
===Congestive Hert Failure Secondary to Congenital Heart Disease===
 
'''A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases'''
*[[Arrhythmia]]  
*[[Atrial septal defect]] with [[mitral regurgitation]]] secondary to myxomatous mitral valve
*[[Congenital mitral regurgitation]]  
*[[Drug abuse]], [[alcohol abuse]]
*[[Eisenmenger's syndrome]]
*[[Endocarditis]]
*Fibrocalcific degeneration of abnormal [[aortic valve]]
*[[Pregnancy]]
*Systemic ventricular dysfunction and/or [[tricuspid regurgitation]] in congenitally corrected transposition of the great arteries
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
'''B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases'''
*[[Arrhythmia]]  
*[[Endocarditis]]  
*Myocardial dysfunction
*Persistent left-to-right shunt
*Prosthetic valve dysfunction
*Pulmonary vascular disease
*Status post [[Fontan operation]]
*Valvular regurgitation
*Other degenerative diseases ([[coronary artery disease]], [[hypertension]])
 
=== Right Ventricular Failure ===
Factors affected right ventricle and to be eliminated during management of congestive heart failure.
A. Right ventricular myocardial dysfunction
#[[Right ventricular myocardial infarction]]
#[[Dilated cardiomyopathy]]
#[[Arrhythmogenic right ventricular dysplasia|Right ventricular dysplasia]]
B. Primary right ventricular pressure overload
#[[Left ventricular failure]]
#[[Mitral valve]] disease
#[[Atrial myxoma]]
#[[Pulmonary veno-occlusive disease]]
#[[Cor pulmonale]]
#:*[[Chronic obstructive pulmonary disease]]  
#:*[[Primary pulmonary hypertension]]
#:*[[Pulmonary embolism]]
#[[Pulmonic stenosis]]
#:*[[Supravalvular pulmonic stenosis]]  
#:*[[Valvular pulmonic stenosis]]
#:*[[Subvalvular pulmonic stenosis]]
#[[Ventricular septal defect]]
#Aortopulmonary communication
C. Primary right ventricular volume overload
#[[Pulmonic regurgitation]]
#[[Tricuspid regurgitation]]
#[[Atrial septal defect]]  
#[[Partial anomalous pulmonary venous return]]
D. Impediment to right ventricular inflow
#[[Tricuspid stenosis]]
#[[Cardiac tamponade]]
#[[pericarditis |Constrictive pericarditis]]
#[[cardiomyopathy|Restrictive cardiomyopathy]]
 
== Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure==
===Left Ventricular Failure===
====Most Common Causes:====
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis|Aortic stenosis]]
* [[Hypertension]]
* [[Mitral Regurgitation|Mitral regurgitation]]
* [[Myocardial ischemia]]
 
====Expanded List of Causes:====
* [[Atrial fibrillation]]
* [[Alcoholism]]
* [[Anemia]]
* [[Angina]]
* [[Aortic Regurgitation|Aortic regurgitation]]
* [[Aortic Stenosis]]
* [[Arteriovenous fistula]]
* [[Beriberi]]
* [[aneurysm|Cardiac aneurysm]]
* [[Cardiomyopathy]]
* [[pericarditis|Constrictive pericarditis]]
* [[Drugs]], [[toxin]]s
* [[Hypertension]]
* [[Hyperthyroidism]]
* [[Hypovolemia]]
* [[Hypoxia]]
* Mediastinal tumors
* [[Mitral Regurgitation]]
* [[Myocardial Infarction]]
* [[Paget's Disease]]
* [[Pancoast's Tumor]]
* [[Pericardial effusion]]
* [[Pericardial tamponade]]
* [[Perimyocarditis]]
* [[Protein deficiency]]
* [[Restrictive cardiomyopathy]]
* [[Papillary muscle rupture|Rupture of the papillary muscles]]
* [[Sepsis]]
* [[Superior Vena Cava]] thrombosis
 
===Right Ventricular Failure ===
====Most Common Causes:====
* [[Cardiomyopathy]]
* [[Cor pulmonale]]
* [[myocarditis|Diffuse myocarditis]]
* Left heart failure
 
====Other Causes:====
* After [[left ventricular failure]]
* After pulmonary resection
* [[Alveolitis|Allergic alveolitis]]
* [[asthma|Bronchial asthma]]
* [[bronchitis|Chronic bronchitis]]
* [[Alveolitis|Honeycomb lung]]
* [[Hyperglobulia]]
* [[Emphysema]]
* [[Mitral Stenosis]]
* [[Right ventricular myocardial infarction]]
* [[Pickwickian Syndrome]]
* Pleural fibrosis
* [[Pneumoconiosis]]
* [[Pulmonary fibrosis]]
* [[Pulmonic regurgitation]]
* [[Pulmonic stenosis]]
* [[Sarcoidosis]]
* [[pulmonary emboli|Severe relapsing pulmonary emboli]]
* [[Silicosis]]
* [[Tachycardia]]
* [[Tricuspid insufficiency]]
 
===Others===
* [[Ascorbic acid deficiency]]
* [[Cardiac amyloidosis]]
* [[Carnitine deficiency]]
* Cervical vein stasis of non-cardiac genesis
* [[Congenital heart disease]]
* [[Cyanosis]] of non-cardiac genesis
* [[Diabetes Mellitus]]
* [[Ddx:Dyspnea|Dyspnea]] of non-cardiac genesis
* [[Edema]] of non-cardiac genesis
* [[Hemochromatosis]]
* [[Pleural effusion]] of non-cardiac genesis
* [[Pulmonary edema]] of non-cardiac genesis
* [[Thiamine deficiency]]
* [[Thyroid disease]]

Revision as of 14:34, 7 April 2014

Underlying Anatomic Abnormalities Causing Heart Failure

Heart failure may result from an abnormality of any one of the anatomical structures of the heart:

Systolic versus Diastolic Heart Failure

Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation

Systolic Dysfunction

The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.

Disastolic Dysfunciton

The left ventricular ejection fraction is preserved in diastolic dysfunction and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

Left, Right and Biventricular Failure

Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).

Left Heart Failure

  • There is impaired left ventricular function with reduced flow into the aorta.

Right Heart Failure

  • There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.

Biventricular Failure

  • The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

High Output Versus Low Output Failure

Low Output Failure

High Output Failure

Causes of Acute or Decompensated Heart Failure

Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, or a patient's failure to maintain a fluid restriction, diet, or medication.[2] Other well recognized precipitating factors include anemia and hyperthyroidism which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs and thiazolidinediones, may also precipitate decompensation.[3]

Differential Diagnosis of the Underlying Causes of Chronic Heart Failure

Common Causes of Left Sided Heart Failure

A 19 year study of 13,000 healthy adults in the United States (the National Health and Nutrition Examination Survey (NHANES I) found the following causes ranked by Population Attributable Risk score:[4]

  1. Ischaemic heart disease 62%
  2. Cigarette smoking 16%
  3. Hypertension (high blood pressure)10%
  4. Obesity 8%
  5. Diabetes 3%
  6. Valvular heart disease 2% (much higher in older populations)

Cardiomyopathies and Inflammatory Diseases

Restrictive Cardiomyopathies
Dilated Cardiomyopathies
Inflammatory Cardiomyopathies

Congestive Heart Failure as a Consequence of Valvular Heart Disease

Congestive Hert Failure Secondary to Congenital Heart Disease

A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases

B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases

Right Ventricular Failure

Factors affected right ventricle and to be eliminated during management of congestive heart failure. A. Right ventricular myocardial dysfunction

  1. Right ventricular myocardial infarction
  2. Dilated cardiomyopathy
  3. Right ventricular dysplasia

B. Primary right ventricular pressure overload

  1. Left ventricular failure
  2. Mitral valve disease
  3. Atrial myxoma
  4. Pulmonary veno-occlusive disease
  5. Cor pulmonale
  6. Pulmonic stenosis
  7. Ventricular septal defect
  8. Aortopulmonary communication

C. Primary right ventricular volume overload

  1. Pulmonic regurgitation
  2. Tricuspid regurgitation
  3. Atrial septal defect
  4. Partial anomalous pulmonary venous return

D. Impediment to right ventricular inflow

  1. Tricuspid stenosis
  2. Cardiac tamponade
  3. Constrictive pericarditis
  4. Restrictive cardiomyopathy

Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure

Left Ventricular Failure

Most Common Causes:

Expanded List of Causes:

Right Ventricular Failure

Most Common Causes:

Other Causes:

Others

  1. ↑ Template:DorlandsDict
  2. ↑ Fonarow GC, Abraham WT, Albert NM; et al. (2008). "Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF". Arch. Intern. Med. 168 (8): 847–854. doi:10.1001/archinte.168.8.847. PMID 18443260. Unknown parameter |month= ignored (help)
  3. ↑ Nieminen MS, Böhm M, Cowie MR; et al. (2005). "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". Eur. Heart J. 26 (4): 384–416. doi:10.1093/eurheartj/ehi044. PMID 15681577. Unknown parameter |month= ignored (help)
  4. ↑ He J; Ogden LG; Bazzano LA; Vupputuri S; et al. (2001). "Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study". Arch. Intern. Med. 161 (7): 996–1002. doi:10.1001/archinte.161.7.996. PMID 11295963.
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