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Heart Failure

Practice Essentials
Author: Ioana Dumitru, MD; Chief Editor: Henry H Ooi, MB, MRCPI more... Heart failure develops when the heart, via an abnormality of cardiac function (detectable or not), fails to pump blood at a rate commensurate Updated: Jul 13, 2013 with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure.

Essential update: New heart failure guidelines published jointly by the American College of Cardiology and the American Heart Association
In June 2013, the American College of Cardiology and the American Heart Association released updated guidelines for the management of heart failure. Key recommendations include the following[1, 2] : The use of aldosterone antagonists in heart failure is strongly recommended, not only for advanced heart failure but also for mild to moderate heart failure in patients with reasonably intact renal function Cardiac resynchronization therapy (CRT) may also be of benefit in mild to moderate heart failure Mechanical circulatory support is an important component of treatment for advanced heart failure Heart failure readmissions can be reduced by using in-hospital systems to identify heart failure patients appropriate for guideline-directed medical therapy; by developing transitional care and discharge planning that emphasizes patient education to increase treatment compliance, manage comorbid conditions, and tackle psychosocial barriers to care; by employing a multidisciplinary heart failure disease management program; and by following up every discharged patient with a phone call within 3 days and a doctor appointment within 2 weeks

Signs and symptoms

Signs and symptoms of heart failure include the following: Exertional dyspnea and/or dyspnea at rest Orthopnea Acute pulmonary edema Chest pain/pressure and palpitations Tachycardia Fatigue and weakness Nocturia and oliguria Anorexia, weight loss, nausea Exophthalmos and/or visible pulsation of eyes Distention of neck veins Weak, rapid, and thready pulse Rales, wheezing S3 gallop and/or pulsus alternans Increased intensity of P2 heart sound Hepatojugular reflux Ascites, hepatomegaly, and/or anasarca
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Central or peripheral cyanosis, pallor See Clinical Presentation for more detail.

Diagnosis
Heart failure criteria, classification, and staging The Framingham criteria for the diagnosis of heart failure consists of the concurrent presence of either 2 major criteria or 1 major and 2 minor criteria.[3] Major criteria include the following: Paroxysmal nocturnal dyspnea Weight loss of 4.5 kg in 5 days in response to treatment Neck vein distention Rales Acute pulmonary edema Hepatojugular reflux S3 gallop Central venous pressure greater than 16 cm water Circulation time of 25 seconds Radiographic cardiomegaly Pulmonary edema, visceral congestion, or cardiomegaly at autopsy Minor criteria are as follows: Nocturnal cough Dyspnea on ordinary exertion A decrease in vital capacity by one third the maximal value recorded Pleural effusion Tachycardia (rate of 120 bpm) Bilateral ankle edema The New York Heart Association (NYHA) classification system categorizes heart failure on a scale of I to IV,[4] as follows: Class Class Class Class I: No limitation of physical activity II: Slight limitation of physical activity III: Marked limitation of physical activity IV: Symptoms occur even at rest; discomfort with any physical activity

The American College of Cardiology/American Heart Association (ACC/AHA) staging system is defined by the following 4 stages [5, 6] : Stage A: Stage B: Stage C: Stage D: Testing The following tests may be useful in the initial evaluation for suspected heart failure[5, 7, 8] : Complete blood count (CBC) Urinalysis Electrolyte levels Renal and liver function studies Fasting blood glucose levels Lipid profile Thyroid stimulating hormone (TSH) levels B-type natriuretic peptide levels N-terminal pro-B-type natriuretic peptide
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High risk of heart failure but no structural heart disease or symptoms of heart failure Structural heart disease but no symptoms of heart failure Structural heart disease and symptoms of heart failure Refractory heart failure requiring specialized interventions

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Electrocardiography Chest radiography 2-dimensional (2-D) echocardiography Nuclear imaging[9] Maximal exercise testing Pulse oximetry or arterial blood gas See Workup for more detail.

Management
Treatment includes the following: Nonpharmacologic therapy: Oxygen and noninvasive positive pressure ventilation, dietary sodium and fluid restriction, physical activity as appropriate, and attention to weight gain Pharmacotherapy: Diuretics, vasodilators, inotropic agents, anticoagulants, beta blockers, and digoxin Surgical options Surgical treatment options include the following: Electrophysiologic intervention Revascularization procedures Valve replacement/repair Ventricular restoration Extracorporeal membrane oxygenation Ventricular assist devices Heart transplantation Total artificial heart See Treatment and Medication for more detail.

Image library

This chest radiograph show s an enlarged cardiac silhouette and edema at the lung bases, signs of acute heart failure.

Contributor Information and Disclosures

Author Ioana Dumitru, MD Associate Professor of Medicine, Division of Cardiology, Founder and Medical Director, Heart Failure and Cardiac Transplant Program, University of Nebraska Medical Center; Associate Professor of Medicine, Division of Cardiology, Veterans Affairs Medical Center Ioana Dumitru, MD is a member of the following medical societies: American College of Cardiology, Heart Failure Society of America, and International Society for Heart and Lung Transplantation Disclosure: Nothing to disclose. Coauthor(s) Mathue M Baker, MD Cardiologist, BryanLGH Heart Institute and Saint Elizabeth Regional Medical Center Mathue M Baker, MD is a member of the following medical societies: American College of Cardiology

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Disclosure: Nothing to disclose. Chief Editor Henry H Ooi, MB, MRCPI Director, Advanced Heart Failure and Cardiac Transplant Program, Nashville Veterans Affairs Medical Center; Assistant Professor of Medicine, Vanderbilt University School of Medicine Disclosure: Nothing to disclose. Additional Contributors Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York AcademyofSciences,and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Joseph Cornelius Cleveland Jr, MD Associate Professor, Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center Joseph Cornelius Cleveland Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Geriatrics Society, American Physiological Society, American Society of Transplant Surgeons, Association for Academic Surgery, Heart Failure Society of America, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association Disclosure: Thoratec Heartmate II Pivotal Tria; Grant/research funds Principal Investigator - Colorado; Abbott Vascular E-Valve E-clip Honoraria Consulting; Baxter Healthcare Corp Consulting fee Board membership; Heartware Advance BTT Trial Grant/research funds Principal Investigator- Colorado; Heartware Endurance DT trial Grant/research funds Principal Investigator-Colorado Shamai Grossman, MD, MS Assistant Professor, Department of Emergency Medicine, Harvard Medical School; Director, The Clinical Decision Unit and Cardiac Emergency Center, Beth Israel Deaconess Medical Center Shamai Grossman, MD, MS is a member of the following medical societies: American College of Emergency Physicians Disclosure: Nothing to disclose. John D Newell Jr, MD Professor of Radiology, Head, Division of Radiology, National Jewish Health; Professor, Department of Radiology, University of Colorado School of Medicine John D Newell Jr, MD is a member of the following medical societies: American College of Chest Physicians,
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American College of Radiology, American Roentgen Ray Society, American Thoracic Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology Disclosure: Siemens Medical Grant/research funds Consulting; Vida Corporation Ownership interest Board membership; TeraRecon Grant/research funds Consulting; Medscape Reference Honoraria Consulting; Humana Press Honoraria Other Craig H Selzman, MD, FACS Associate Professor of Surgery, Surgical Director, Cardiac Mechanical Support and Heart Transplant, Division of Cardiothoracic Surgery, University of Utah School of Medicine Craig H Selzman, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Surgeons, American Physiological Society, Association for Academic Surgery, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Southern Thoracic Surgical Association, and Western Thoracic Surgical Association Disclosure: Nothing to disclose. Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other Brett C Sheridan, MD, FACS Associate Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine Disclosure: Nothing to disclose. George A Stouffer III, MD Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Additional Contributors Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York AcademyofSciences,and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. David FM Brown, MD Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine Disclosure: Nothing to disclose.
emedicine.medscape.com/article/163062-overview 5/20

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William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Joseph Cornelius Cleveland Jr, MD Associate Professor, Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center Joseph Cornelius Cleveland Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Geriatrics Society, American Physiological Society, American Society of Transplant Surgeons, Association for Academic Surgery, Heart Failure Society of America, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association Disclosure: Thoratec Heartmate II Pivotal Tria; Grant/research funds Principal Investigator - Colorado; Abbott Vascular E-Valve E-clip Honoraria Consulting; Baxter Healthcare Corp Consulting fee Board membership; Heartware Advance BTT Trial Grant/research funds Principal Investigator- Colorado; Heartware Endurance DT trial Grant/research funds Principal Investigator-Colorado Shamai Grossman, MD, MS Assistant Professor, Department of Emergency Medicine, Harvard Medical School; Director, The Clinical Decision Unit and Cardiac Emergency Center, Beth Israel Deaconess Medical Center Shamai Grossman, MD, MS is a member of the following medical societies: American College of Emergency Physicians Disclosure: Nothing to disclose. John D Newell Jr, MD Professor of Radiology, Head, Division of Radiology, National Jewish Health; Professor, Department of Radiology, University of Colorado School of Medicine John D Newell Jr, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, American Thoracic Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology Disclosure: Siemens Medical Grant/research funds Consulting; Vida Corporation Ownership interest Board membership; TeraRecon Grant/research funds Consulting; Medscape Reference Honoraria Consulting; Humana Press Honoraria Other Craig H Selzman, MD, FACS Associate Professor of Surgery, Surgical Director, Cardiac Mechanical Support and Heart Transplant, Division of Cardiothoracic Surgery, University of Utah School of Medicine Craig H Selzman, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Surgeons, American Physiological Society, Association for Academic Surgery, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Southern Thoracic Surgical Association, and Western Thoracic Surgical Association Disclosure: Nothing to disclose. Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other Brett C Sheridan, MD, FACS Associate Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine Disclosure: Nothing to disclose.
emedicine.medscape.com/article/163062-overview 6/20

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George A Stouffer III, MD Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment

References
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50. Dunlay SM, Eveleth JM, Shah ND, McNallan SM, Roger VL. Medication adherence among communitydwelling patients with heart failure. Mayo Clin Proc . Apr 2011;86(4):273-81. [Medline]. [Full Text]. 51. Dewalt DA, Schillinger D, Ruo B, Bibbins-Domingo K, Baker DW, Holmes GM, et al. A Multisite Randomized Trial of a Single- versus Multi-Session Literacy Sensitive Self-Care Intervention for Patients with Heart Failure. Circulation. May 9 2012;[Medline]. 52. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. Jun 2010;16(6):e1-194. [Medline]. 53. Lainscak M, Cleland JG, Lenzen MJ, Follath F, Komajda M, Swedberg K. International variations in the treatment and co-morbidity of left ventricular systolic dysfunction: data from the EuroHeart Failure Survey. Eur J Heart Fail. Mar 2007;9(3):292-9. [Medline]. 54. [Guideline] Peacock WF, Fonarow GC, Ander DS, Maisel A, Hollander JE, Januzzi JL Jr, et al. Society of Chest Pain Centers Recommendations for the evaluation and management of the observation stay acute heart failure patient: a report from the Society of Chest Pain Centers Acute Heart Failure Committee. Crit Pathw Cardiol. Jun 2008;7(2):83-6. [Medline]. 55. [Best Evidence] Steinhart B, Thorpe KE, Bayoumi AM, Moe G, Januzzi JL Jr, Mazer CD. Improving the diagnosis of acute heart failure using a validated prediction model. J Am Coll Cardiol. Oct 13 2009;54(16):1515-21. [Medline]. 56. Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. Apr 14 2009;119(14):1977-2016. [Medline]. 57. Rich MW, McSherry F, Williford WO, Yusuf S. Effect of age on mortality, hospitalizations and response to digoxin in patients with heart failure: the DIG study. J Am Coll Cardiol. Sep 2001;38(3):806-13. [Medline]. 58. Badve SV, Roberts MA, Hawley CM, et al. Effects of Beta-adrenergic antagonists in patients with chronic kidney disease a systematic review and meta-analysis. J Am Coll Cardiol. Sep 6 2011;58(11):1152-61. [Medline]. 59. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. Jul 18 2002;347(3):161-7. [Medline]. 60. Januzzi JL Jr, Camargo CA, Anwaruddin S, et al. The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol. Apr 15 2005;95(8):948-54. [Medline]. 61. Wang CS, FitzGerald JM, Schulzer M, Mak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure?. JAMA. Oct 19 2005;294(15):1944-56. [Medline]. 62. Stevenson LW, Perloff JK. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA. Feb 10 1989;261(6):884-8. [Medline]. 63. Pinamonti B, Di Lenarda A, Sinagra G, Camerini F. Restrictive left ventricular filling pattern in dilated cardiomyopathy assessed by Doppler echocardiography: clinical, echocardiographic and hemodynamic correlations and prognostic implications. Heart Muscle Disease Study Group. J Am Coll Cardiol. Sep 1993;22(3):808-15. [Medline]. 64. Temporelli PL, Scapellato F, Eleuteri E, Imparato A, Giannuzzi P. Doppler echocardiography in advanced systolic heart failure: a noninvasive alternative to Swan-Ganz catheter. Circ Heart Fail. May 2010;3(3):38794. [Medline]. 65. Maisel AS, McCord J, Nowak RM, et al. Bedside B-Type natriuretic peptide in the emergency diagnosis of heart failure with reduced or preserved ejection fraction. Results from the Breathing Not Properly Multinational Study. J Am Coll Cardiol. Jun 4 2003;41(11):2010-7. [Medline]. 66. [Best Evidence] Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J . Feb 2006;27(3):330-7. [Medline].
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