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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and dyspnea at rest (late stage)

  • Jugular venous distention, peripheral edema, sinus tachycardia, pulmonary rales, cardiomegaly, S3, and liver enlargement

  • Left ventricular (LV) systolic dysfunction

GENERAL CONSIDERATIONS

  • Lifetime risk of developing heart failure is 20% for Americans ≥ 40 years old

  • Approximately 600,000 new patients each year

  • Complex clinical syndrome characterized by dysfunction of the left, right, or both ventricles and changes in neurohumoral regulation

  • Effort intolerance, fluid retention, and shortened survival

  • Principal clinical manifestations result from inadequate forward cardiac output

  • Neurohumoral activation responsible for fluid retention, peripheral edema, and an increase in peripheral resistance

  • Manifestations depend on the rate of heart failure development with adaptive mechanisms minimizing symptoms and chronic heart failure

  • Causes:

    • – Coronary artery disease

    • – Idiopathic/familial dilated cardiomyopathy

    • – Metabolic causes (alcohol, nutritional and thyroid disorders, pheochromocytoma)

    • – Drugs and toxins

    • – Myocarditis

    • – Connective tissue diseases

    • – Chemotherapy-induced

    • – Inherited storage diseases

    • – Infiltrative diseases

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Dyspnea

  • Paroxysmal nocturnal dyspnea

  • Orthopnea

  • Cough

  • Fatigue and weakness

  • Nocturia and oliguria

  • Abdominal bloating and discomfort

PHYSICAL EXAM FINDINGS

  • Tachycardia

  • Hypotension

  • Tachypnea

  • Diaphoresis

  • Elevated jugular venous pressure

  • Pulmonary rales

  • Reduced breath sounds and dullness to percussion consistent with pleural effusions

  • Laterally displaced, enlarged, and sustained ventricular impulse

  • Murmurs of tricuspid and mitral regurgitation

  • S3 and sometimes S4

  • Hepatomegaly, pulsatile liver with tricuspid regurgitation

  • Abdominal fluid wave due to ascites

  • Peripheral edema

  • Pulses alternans

  • Reduced pulse pressure

  • Cool, clammy skin

DIFFERENTIAL DIAGNOSIS

  • Chronic lung disease, chronic bronchitis

  • Pneumonia

  • Pulmonary emboli

  • Pericardial disease—tamponade or constriction

  • Nephrosis

  • Hepatic cirrhosis

  • Hypothyroidism

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC: to exclude anemia or infection

  • Serum electrolytes (including calcium and magnesium), blood urea nitrogen, creatinine, glucose

  • Urinalysis

  • Liver function tests

  • Fasting lipid profile

  • Thyroid function tests

  • Measurement of B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) may be useful

  • Measurement of cardiac troponin

ELECTROCARDIOGRAPHY

  • Sinus tachycardia

  • Atrial fibrillation

  • Ventricular premature beats

  • Intraventricular conduction delay

  • Nonspecific ST- and T-wave segment changes

IMAGING STUDIES

  • Chest x-ray findings:

    • – Cardiomegaly

    • – Interstitial and perivascular edema

    • – Kerley B lines

    • – Pleural effusions

  • Typical transthoracic echocardiography findings:

    • – Biatrial enlargement

    • – Left and/or right ventricular wall motion abnormalities, hypertrophy, enlargement, and/or reduced contractility

    • – Diastolic dysfunction due to elevated cardiac filling pressures

    • – Eccentric hypertrophy

    • – Functional mitral and tricuspid regurgitation

  • Noninvasive imaging to detect myocardial ischemia and myocardial viability is reasonable for patients with known coronary artery disease unless the patient is not eligible for revascularization

  • Cardiac MRI is reasonable when echocardiography is inadequate and for assessing for myocardial infiltrative processes

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