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Congestive Heart Failure Microchapters

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Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

Causes

Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Cardiac MRI

Echocardiography

Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies

Treatment

Invasive Hemodynamic Monitoring

Medical Therapy:

Summary

Acute Pharmacotherapy

Chronic Pharmacotherapy in HFpEF

Chronic Pharmacotherapy in HFrEF

Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
Positive Inotropics
Anticoagulants
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure treatment of underlying causes On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Congestive heart failure treatment of underlying causes

CDC on Congestive heart failure treatment of underlying causes

Congestive heart failure treatment of underlying causes in the news

Blogs on Congestive heart failure treatment of underlying causes

Directions to Hospitals Treating Congestive heart failure treatment of underlying causes

Risk calculators and risk factors for Congestive heart failure treatment of underlying causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:  Edzel Lorraine Co, DMD, MD[2]

## Overview[edit | edit source]

Treatment of the underlying cause of heart failure including ischemic heart disease, hypertension, renovascular disease, or valvular heart disease is critical in the management of the patient with congestive heart failure.

## Ischemic Heart Disease[edit | edit source]

Underlying ischemic heart disease is the most common cause of chronic congestive heart failure and is the underlying cause of heart failure in 50% to 75% of patients. [1]. Ischemic heart disease results in systolic dysfunction of the heart due to irreversible damage of the left ventricle if there has been a prior MI. There can also be viable tissue that is stunned or hibernating as a cause of heart failure. The management of these patients consists of risk factor modification (for example with the use of statins or beta blockers ) as well as the relief of angina (for example with the use of nitrates ). Revascularization (percuataneous coronary intervention or coronary artery bypass grafting) is indicated in the following scenarios:

* To improve symptoms.
* To improve prognosis. If there is a perfusion defect, revascularization may improve prognosis.
* To prevent recurrent heart failure decompensation. If the patient has repeated episodes of congestive heart failure decompensation, revascularization may be indicated.

## 2022 ACC/AHA/HFSA Heart Failure Guideline (DO NOT EDIT) [2][edit | edit source]

#### Revascularization for CAD[edit | edit source]

Class I

"1. In selected patients with HF, reduced EF (EF ≤ 35%), and suitable coronary anatomy, surgical revascularization plus GDMT is beneficial to improve symptoms, cardiovascular hospitalizations, and long-term all-cause mortality. [3][4][5][6][7][8][9][10] (Level of Evidence: B-R) "

## Hypertension[edit | edit source]

Hypertension is a common underlying cause of congestive heart failure. There are 2 goals in the treatment of the congestive heart failure patient with hypertension:

1\. Reduce the preload and

2\. Reduce the afterload

The following agents improve survival in the heart failure patient and are the preferred antihypertensive agents:

* Beta blockers
* Angiotensin-converting enzyme inhibitors
* Angiotensin receptor blockers in patients who cannot tolerate a angiotensin converting enzyme inhibitor
* Aldosterone antagonists

Patients with bilateral renal artery stenosis tend to have a greater risk of flash pulmonary edema than those patients with unilateral renal artery stenosis[11]. This combination of flash pulmonary edema and bilateral renal artery stenosis is known as Pickering syndrome[12]. Is not unreasonable for patients with recurrent flash pulmonary edema and renal artery stenosis to undergo revascularization. The data in support of this recommendation however is modest.

### 2022 AHA/ACC/HFSA Heart Failure Guidelines[edit | edit source]

#### Management of Hypertension[edit | edit source]

Class I

"1. In patients with HFrEF and hypertension, uptitration of GDMT to the maximally tolerated target dose is recommended. [13][14](Level of Evidence: C-LD) "

## Valvular Heart Disease[edit | edit source]

In 10% to 12% of patients, valvular heart disease is the underlying cause of congestive heart failure. [15]. It should also be noted that as the heart dilates in the setting of heart failure, there is often secondary mitral regurgitation and tricuspid regurgitation in many patients with a dilated cardiomyopathy. Please consult of the chapters on either mitral regurgitation or aortic regurgitation regarding the treatment of valvular heart disease. In general, once the left ventricular systolic diameter begins to increase, mitral valve repair ( left ventricular end systolic diameter greater than 45 mm) or aortic valve replacement (left ventricular end systolic diameter greater than 55 mm) is often indicated.

## 2022 AHA/ACC/HFSA Heart Failure Guidelines (DO NOT EDIT) [2][edit | edit source]

### Valvular Heart Disease[edit | edit source]

Class I

"1. In patients with HF, VHD should be managed in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes. [16][17][18][19][20][21][22][23][24][25][26] (Level of Evidence: B-R) "
"2. In patients with chronic severe secondary MR and HFrEF, optimization of GDMT is recommended before any intervention for secondary MR related to LV dysfunction. [18][19][20][27][28][29] (Level of Evidence: C-LD) "

## Other Underlying Disorders That May Warrant Treatment[edit | edit source]

There are a variety of other systemic or cardiovascular disorders that may secondarily cause heart failure, and these primary disorders may warrant treatment as well:

* Alcohol abuse: the patient should be directed to the appropriate rehabilitation program
* Cocaine abuse: the patient should be directed to the appropriate rehabilitation program
* Hemochromatosis
* Myocarditis
* Obstructive sleep apnea: a vigorous weight loss program should be implemented
* Sarcoidosis
* Systemic lupus erythematosus
* Thyroid storm

## External Link[edit | edit source]

* 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[30]

## References[edit | edit source]

1. ↑ Bortman G, Sellanes M, Odell DS, Ring WS, Olivari MT (1994). "Discrepancy between pre- and post-transplant diagnosis of end-stage dilated cardiomyopathy". The American Journal of Cardiology. 74 (9): 921–4. PMID 7977122. Retrieved 2013-04-25. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
3. ↑ Caracciolo EA, Davis KB, Sopko G, Kaiser GC, Corley SD, Schaff H; et al. (1995). "Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience". Circulation. 91 (9): 2335–44. doi:10.1161/01.cir.91.9.2335. PMID 7729019.CS1 maint: Multiple names: authors list (link)
4. ↑ Howlett JG, Stebbins A, Petrie MC, Jhund PS, Castelvecchio S, Cherniavsky A; et al. (2019). "CABG Improves Outcomes in Patients With Ischemic Cardiomyopathy: 10-Year Follow-Up of the STICH Trial". JACC Heart Fail. 7 (10): 878–887. doi:10.1016/j.jchf.2019.04.018. PMC 7375257 Check `|pmc=` value (help). PMID 31521682.CS1 maint: Multiple names: authors list (link)
5. ↑ Mark DB, Knight JD, Velazquez EJ, Wasilewski J, Howlett JG, Smith PK; et al. (2014). "Quality-of-life outcomes with coronary artery bypass graft surgery in ischemic left ventricular dysfunction: a randomized trial". Ann Intern Med. 161 (6): 392–9. doi:10.7326/M13-1380. PMC 4182862. PMID 25222386.CS1 maint: Multiple names: authors list (link)
6. ↑ Park S, Ahn JM, Kim TO, Park H, Kang DY, Lee PH; et al. (2020). "Revascularization in Patients With Left Main Coronary Artery Disease and Left Ventricular Dysfunction". J Am Coll Cardiol. 76 (12): 1395–1406. doi:10.1016/j.jacc.2020.07.047. PMID 32943156 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
7. ↑ Petrie MC, Jhund PS, She L, Adlbrecht C, Doenst T, Panza JA; et al. (2016). "Ten-Year Outcomes After Coronary Artery Bypass Grafting According to Age in Patients With Heart Failure and Left Ventricular Systolic Dysfunction: An Analysis of the Extended Follow-Up of the STICH Trial (Surgical Treatment for Ischemic Heart Failure)". Circulation. 134 (18): 1314–1324. doi:10.1161/CIRCULATIONAHA.116.024800. PMC 5089908. PMID 27573034.CS1 maint: Multiple names: authors list (link)
8. ↑ Tam DY, Dharma C, Rocha R, Farkouh ME, Abdel-Qadir H, Sun LY; et al. (2020). "Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease". J Am Coll Cardiol. 76 (10): 1153–1164. doi:10.1016/j.jacc.2020.06.052. PMC 7861124 Check `|pmc=` value (help). PMID 32883408 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
9. ↑ Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A; et al. (2011). "Coronary-artery bypass surgery in patients with left ventricular dysfunction". N Engl J Med. 364 (17): 1607–16. doi:10.1056/NEJMoa1100356. PMC 3415273. PMID 21463150.CS1 maint: Multiple names: authors list (link)  Review in: Ann Intern Med. 2011 Aug 16;155(4):JC2-9 Review in: Evid Based Med. 2012 Dec;17(6):178-9
10. ↑ Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA; et al. (2016). "Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy". N Engl J Med. 374 (16): 1511–20. doi:10.1056/NEJMoa1602001. PMC 4938005. PMID 27040723.CS1 maint: Multiple names: authors list (link)  Review in: Ann Intern Med. 2016 Aug 16;165(4):JC15 Review in: Evid Based Med. 2017 Mar;22(1):32
11. ↑ Pickering TG, Herman L, Devereux RB, Sotelo JE, James GD, Sos TA, Silane MF, Laragh JH (1988). "Recurrent pulmonary oedema in hypertension due to bilateral renal artery stenosis: treatment by angioplasty or surgical revascularisation". Lancet. 2 (8610): 551–2. PMID 2900930. Unknown parameter `|month=` ignored (help); Check date values in: `|accessdate=` (help); `|access-date=` requires `|url=` (help)CS1 maint: Multiple names: authors list (link)
12. ↑ Messerli FH, Bangalore S, Makani H, Rimoldi SF, Allemann Y, White CJ, Textor S, Sleight P (2011). "Flash pulmonary oedema and bilateral renal artery stenosis: the Pickering syndrome". European Heart Journal. 32 (18): 2231–5. doi:10.1093/eurheartj/ehr056. PMID 21406441. Retrieved 2013-04-25. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
13. ↑ Banach M, Bhatia V, Feller MA, Mujib M, Desai RV, Ahmed MI; et al. (2011). "Relation of baseline systolic blood pressure and long-term outcomes in ambulatory patients with chronic mild to moderate heart failure". Am J Cardiol. 107 (8): 1208–14. doi:10.1016/j.amjcard.2010.12.020. PMC 3072746. PMID 21296319.CS1 maint: Multiple names: authors list (link)
14. ↑ Lee TT, Chen J, Cohen DJ, Tsao L (2006). "The association between blood pressure and mortality in patients with heart failure". Am Heart J. 151 (1): 76–83. doi:10.1016/j.ahj.2005.03.009. PMID 16368295.CS1 maint: Multiple names: authors list (link)
15. ↑ Jessup M, Brozena S (2003). "Heart failure". The New England Journal of Medicine. 348 (20): 2007–18. doi:10.1056/NEJMra021498. PMID 12748317. Retrieved 2013-04-25. Unknown parameter `|month=` ignored (help)
16. ↑ Nasser R, Van Assche L, Vorlat A, Vermeulen T, Van Craenenbroeck E, Conraads V; et al. (2017). "Evolution of Functional Mitral Regurgitation and Prognosis in Medically Managed Heart Failure Patients With Reduced Ejection Fraction". JACC Heart Fail. 5 (9): 652–659. doi:10.1016/j.jchf.2017.06.015. PMID 28859754.CS1 maint: Multiple names: authors list (link)
17. ↑ Lowes BD, Gill EA, Abraham WT, Larrain JR, Robertson AD, Bristow MR; et al. (1999). "Effects of carvedilol on left ventricular mass, chamber geometry, and mitral regurgitation in chronic heart failure". Am J Cardiol. 83 (8): 1201–5. doi:10.1016/s0002-9149(99)00059-4. PMID 10215284.CS1 maint: Multiple names: authors list (link)
18. ↑ 18.0 18.1 Capomolla S, Febo O, Gnemmi M, Riccardi G, Opasich C, Caporotondi A; et al. (2000). "Beta-blockade therapy in chronic heart failure: diastolic function and mitral regurgitation improvement by carvedilol". Am Heart J. 139 (4): 596–608. doi:10.1016/s0002-8703(00)90036-x. PMID 10740140.CS1 maint: Multiple names: authors list (link)
19. ↑ 19.0 19.1 Kang DH, Park SJ, Shin SH, Hong GR, Lee S, Kim MS; et al. (2019). "Angiotensin Receptor Neprilysin Inhibitor for Functional Mitral Regurgitation". Circulation. 139 (11): 1354–1365. doi:10.1161/CIRCULATIONAHA.118.037077. PMID 30586756.CS1 maint: Multiple names: authors list (link)
20. ↑ 20.0 20.1 van Bommel RJ, Marsan NA, Delgado V, Borleffs CJ, van Rijnsoever EP, Schalij MJ; et al. (2011). "Cardiac resynchronization therapy as a therapeutic option in patients with moderate-severe functional mitral regurgitation and high operative risk". Circulation. 124 (8): 912–9. doi:10.1161/CIRCULATIONAHA.110.009803. PMID 21810666.CS1 maint: Multiple names: authors list (link)
21. ↑ Obadia JF, Messika-Zeitoun D, Leurent G, Iung B, Bonnet G, Piriou N; et al. (2018). "Percutaneous Repair or Medical Treatment for Secondary Mitral Regurgitation". N Engl J Med. 379 (24): 2297–2306. doi:10.1056/NEJMoa1805374. PMID 30145927.CS1 maint: Multiple names: authors list (link)  Review in: Ann Intern Med. 2019 Jan 15;170(2):JC8
22. ↑ Inohara T, Manandhar P, Kosinski AS, Matsouaka RA, Kohsaka S, Mentz RJ; et al. (2018). "Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement". JAMA. 320 (21): 2231–2241. doi:10.1001/jama.2018.18077. PMC 6583475 Check `|pmc=` value (help). PMID 30512100.CS1 maint: Multiple names: authors list (link)
23. ↑ Kapadia SR, Leon MB, Makkar RR, Tuzcu EM, Svensson LG, Kodali S; et al. (2015). "5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial". Lancet. 385 (9986): 2485–91. doi:10.1016/S0140-6736(15)60290-2. PMID 25788231.CS1 maint: Multiple names: authors list (link)  Review in: Ann Intern Med. 2015 Aug 18;163(4):JC3 Review in: Ann Intern Med. 2015 Aug 18;163(4):JC4 Review in: Evid Based Med. 2015 Dec;20(6):212-3
24. ↑ Evangelista A, Tornos P, Sambola A, Permanyer-Miralda G, Soler-Soler J (2005). "Long-term vasodilator therapy in patients with severe aortic regurgitation". N Engl J Med. 353 (13): 1342–9. doi:10.1056/NEJMoa050666. PMID 16192479.CS1 maint: Multiple names: authors list (link)
25. ↑ Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J; et al. (2007). "Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction". J Am Coll Cardiol. 49 (13): 1465–71. doi:10.1016/j.jacc.2007.01.026. PMID 17397676.CS1 maint: Multiple names: authors list (link)
26. ↑ Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM; et al. (2015). "5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial". Lancet. 385 (9986): 2477–84. doi:10.1016/S0140-6736(15)60308-7. PMID 25788234.CS1 maint: Multiple names: authors list (link)  Review in: Evid Based Med. 2015 Dec;20(6):212-3
27. ↑ Agricola E, Ielasi A, Oppizzi M, Faggiano P, Ferri L, Calabrese A; et al. (2009). "Long-term prognosis of medically treated patients with functional mitral regurgitation and left ventricular dysfunction". Eur J Heart Fail. 11 (6): 581–7. doi:10.1093/eurjhf/hfp051. PMID 19398488.CS1 maint: Multiple names: authors list (link)
28. ↑ Karaca O, Omaygenc MO, Cakal B, Cakal SD, Gunes HM, Barutcu I; et al. (2016). "Effect of QRS Narrowing After Cardiac Resynchronization Therapy on Functional Mitral Regurgitation in Patients With Systolic Heart Failure". Am J Cardiol. 117 (3): 412–9. doi:10.1016/j.amjcard.2015.11.010. PMID 26721652.CS1 maint: Multiple names: authors list (link)
29. ↑ St John Sutton MG, Plappert T, Abraham WT, Smith AL, DeLurgio DB, Leon AR; et al. (2003). "Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure". Circulation. 107 (15): 1985–90. doi:10.1161/01.CIR.0000065226.24159.E9. PMID 12668512.CS1 maint: Multiple names: authors list (link)
30. ↑ 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 (May 2022). "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". Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check `|pmid=` value (help).

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