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Congestive Heart Failure

CHF

Congestive heart failure (CHF) or congestive cardiac failure (CCF) refers to chronic, usually biventricular failure of the heart.


Presentation

The patients of congestive cardiac failure present with features of left and right heart failure. The clinical manifestations are as below.

Features due to left heart failure:

  • Dyspnea, orthopnea and paroxysmal nocturnal dyspnea: These symptoms develop due to congestion of the lungs. Sometimes chronic cough may also be seen.
  • Fatigue and weakness: Fatigue and weakness result from decreased cardiac output to the skeletal muscles and the central nervous system.
  • Nocturia: Nocturia occurs due to excretion of fluid retained during the day and increased renal perfusion in recumbent position at night.

Features due to right heart failure:

  • Headache, insomnia and restlessness: These symptoms occur because of cerebral congestion.
  • Anorexia, nausea and vomiting: Congestion of the portal system causes these symptoms.
  • Pain in the right hypochondrium: Hepatic congestion causes stretching of the hepatic capsule which causes pain in the right hypochondrium.
  • Oliguria and nocturia: These symptoms result from renal congestion.
  • Peripheral edema: Edema develops in the feet in ambulatory patients and sacral edema in bed bound patients.

On examination, the findings include raised jugular pressure and positive hepatojugular reflex, tender hepatomegaly and features of heart disease.

Framignham criteria is used for the diagnosis of congestive cardiac failure. The presence of one major and two minor criteria is the minimal requirement for establishing the diagnosis.

The major criteria include:

The minor criteria include:

Fatigue
  • A 60-year-old man presented with exertional dyspnea, fatigue, and chest discomfort of 18-month history. Physical examination revealed S4, bilateral pretibial edema, and moderate amount of ascites.[ncbi.nlm.nih.gov]
  • Fatigue and weakness: Fatigue and weakness result from decreased cardiac output to the skeletal muscles and the central nervous system.[symptoma.com]
Weight Gain
  • These data demonstrate that, on average, weight gain begins in a gradual fashion at least 1 week before heart failure hospitalization, but the present findings do not indicate that all admissions are preceded by weight gain.[dx.doi.org]
  • Passing out during exercise Poor appetite Weight loss or lack of weight gain can be seen even in older children.[cincinnatichildrens.org]
  • Another symptom is weight gain (when fluid builds up).[cheyenneregional.org]
  • Signs & Symptoms Shortness of breath, especially when lying down Swelling (edema) in your legs, feet, ankles or abdomen Fatigue and weakness Increased cough Weight gain from fluid buildup (especially 2 pounds overnight or 3-4 pounds in a week) Managing[lourdes.com]
  • You should weigh yourself at least weekly and any 3lb or more weight gain should be reported to your physician. It may be the result of your body retaining fluid.[acls.net]
Weight Loss
  • loss 4.5 kg in 5 days in response to treatment Minor criteria: · Bilateral ankle edema · Nocturnal cough · Dyspnea on ordinary exertion · Hepatomegaly · Pleural effusion · Decrease in vital capacity by one third from maximum recorded · Tachycardia (heart[web.archive.org]
  • Dietary Changes – If you are even slightly overweight, weight loss is imperative to prevent further damage to your heart muscle.[acls.net]
  • Isa Oner Yuksel, Nihal Akar Bayram, Erkan Koklu, Cagin Mustafa Ureyen, Selcuk Kucukseymen, Sakir Arslan and Engin Bozkurt, Assessment of Impact of Weight Loss on Left and Right Ventricular Functions and Value of Tissue Doppler Echocardiography in Obese[oadoi.org]
Myxedema
  • […] independent of other risk factors. [25, 26] Because of increased myocardial oxygen consumption and demand beyond a critical level, the following high-output states can precipitate the clinical presentation of heart failure: Profound anemia Thyrotoxicosis Myxedema[emedicine.com]
Pallor
  • […] pulsation of eyes Distention of neck veins Weak, rapid, and thready pulse Rales, wheezing S 3 gallop and/or pulsus alternans Increased intensity of P 2 heart sound Hepatojugular reflux Ascites, hepatomegaly, and/or anasarca Central or peripheral cyanosis, pallor[emedicine.com]
Dyspnea
  • Dyspnea occurs because of the damming of blood in the lungs resulting in pulmonary venous congestion. Initially dyspnea occurs only at exertion. Later on orthopnea and paroxysmal nocturnal dyspnea also develop. Later on dyspnea occurs even at rest.[symptoma.com]
  • Major criteria: · Paroxysmal nocturnal dyspnea · Neck vein distention · Rales · Radiographic cardiomegaly (increasing heart size on chest radiography) · Acute pulmonary edema · S3 gallop · Increased central venous pressure ( 16 cm H2O at right atrium)[web.archive.org]
  • A 78-year-old woman presented with mild exertional dyspnea three weeks after starting osimertinib for the treatment of epidermal growth factor receptor (EGFR) T790M-positive non-small cell lung cancer.[ncbi.nlm.nih.gov]
Cough
  • A 66-year-old woman with a history of myocardial infarction 2 months prior presented to our respiratory department with several days of dry cough and night sweats.[ncbi.nlm.nih.gov]
  • […] chest radiography) · Acute pulmonary edema · S3 gallop · Increased central venous pressure ( 16 cm H2O at right atrium) · Hepatojugular reflux · Weight loss 4.5 kg in 5 days in response to treatment Minor criteria: · Bilateral ankle edema · Nocturnal cough[web.archive.org]
Rales
  • No rales were detected because of its paucity of fibrous components in the lung.[ncbi.nlm.nih.gov]
  • Major criteria: · Paroxysmal nocturnal dyspnea · Neck vein distention · Rales · Radiographic cardiomegaly (increasing heart size on chest radiography) · Acute pulmonary edema · S3 gallop · Increased central venous pressure ( 16 cm H2O at right atrium)[web.archive.org]
  • […] liquid accumulates in alveoli due to left heart pressure overload alveoli pop open during inhalation, causing rales on exam abdominal exam ascites hepatojugular reflex Imaging Chest radiograph findings pulmonary vascular congestion pleural effusion cardiomegaly[medbullets.com]
  • Resulting clinical syndromes including shortness of breath, pitting edema, enlarged tender liver, engorged neck veins, and pulmonary rales in various combinations. congestive heart failure See HEART FAILURE.[medical-dictionary.thefreedictionary.com]
Pleural Effusion
  • After 8 months of treatment, her symptoms improved and the pleural effusion showed significant regression.[ncbi.nlm.nih.gov]
  • effusion · Decrease in vital capacity by one third from maximum recorded · Tachycardia (heart rate 120 beats/min.)[web.archive.org]
Orthopnea
  • The patient's orthopnea was slightly ameliorated, and he was able to sleep at night. The technique of inserting a PICC in the sitting position is simple and feasible.[ncbi.nlm.nih.gov]
  • Later on orthopnea and paroxysmal nocturnal dyspnea also develop. Later on dyspnea occurs even at rest. Orthopnea refers to breathlessness on lying flat. It occurs because of the following two circulating changes when the person lies flat.[symptoma.com]
  • […] failure high cardiac output and systemic vascular resistance often occurs in the setting of existing systolic or diastolic dysfunction Associated conditions obstructive sleep apnea major depression disorder Presentation Symptoms dyspnea on exertion orthopnea[medbullets.com]
Nausea
  • Anorexia, nausea and vomiting: Congestion of the portal system causes these symptoms. Pain in the right hypochondrium: Hepatic congestion causes stretching of the hepatic capsule which causes pain in the right hypochondrium.[symptoma.com]
  • You’re sick to your stomach iStock/elenaleonova Some people notice decreased appetite or nausea due to the fact that the digestive system is getting less blood, which could lead to an upset stomach, says the AHA.[rd.com]
  • […] palpitations Chronic cough or wheezing Decreased urine production Difficulty sleeping Fatigue or fainting spells Feeling of fullness, loss of appetite, or abdominal pain Fluid retention, which causes swollen extremities or abdomen (edema) Loss of muscle mass Nausea[utswmedicine.org]
  • Nausea : This can be accompanied by a drop in appetite. A rapid heart rate : This occurs because the heart is unable to pump blood with a regular rhythm.[medicalnewstoday.com]
  • , abdominal swelling, tenderness or pain (may result from the buildup of fluid in the body and the backup of blood in the liver) Weight gain (due to fluid buildup) Weight loss as nausea causes a loss of appetite and as the body fails to absorb food well[cedars-sinai.edu]
Loss of Appetite
  • […] of appetite constipation.[betterhealth.vic.gov.au]
  • Heart Failure Symptoms Shortness of breath Weight gain Swelling of the lower extremities Fatigue Exercise intolerance Palpitations Loss of appetite Congestive Heart Failure Causes Many conditions that cause your heart to fail result in irreversible damage[wexnermedical.osu.edu]
  • Heart failure symptoms can include: Abnormal heart rhythm or palpitations Chronic cough or wheezing Decreased urine production Difficulty sleeping Fatigue or fainting spells Feeling of fullness, loss of appetite, or abdominal pain Fluid retention, which[utswmedicine.org]
  • Severe tiredness (fatigue) and weakness Loss of appetite, nausea, and belly pain Cough that doesn’t go away. It can cause blood-tinged or frothy sputum.[franciscanhealth.org]
  • Common symptoms are: Cough Fatigue, weakness, faintness Loss of appetite Need to urinate at night Pulse that feels fast or irregular, or a sensation of feeling the heartbeat (palpitations) Shortness of breath when you are active or after you lie down[nlm.nih.gov]
Vomiting
  • Anorexia, nausea and vomiting: Congestion of the portal system causes these symptoms. Pain in the right hypochondrium: Hepatic congestion causes stretching of the hepatic capsule which causes pain in the right hypochondrium.[symptoma.com]
  • Chronic cough or wheezing Decreased urine production Difficulty sleeping Fatigue or fainting spells Feeling of fullness, loss of appetite, or abdominal pain Fluid retention, which causes swollen extremities or abdomen (edema) Loss of muscle mass Nausea or vomiting[utswmedicine.org]
  • Main side effects are taste disturbances, while less common side effects are nausea, vomiting, abdominal pain, diarrhoea, flushing, bronchospasm, fever, myalgia and injection site reactions.[web.archive.org]
  • 847,073 209,017 24.7 12 Personality disorders 5,436 1,316 24.2 13 Nutritional deficiencies 9,845 2,355 23.9 14 Coagulation and hemorrhagic disorders 33,397 7,920 23.7 15 Respiratory failure, insufficiency, arrest (adult) 260,781 59,842 22.9 16 Nausea and vomiting[hcup-us.ahrq.gov]
Polydipsia
  • […] develops, it requires continuous therapy to M&M–ie, 1. non-pharmacologic maneuvers–eg, salt restriction in the form of a 'no salt added' regimen, reduction of alcohol intake, exercise as tolerated and, for Pts with impaired renal function or psychogenic polydipsia[medical-dictionary.thefreedictionary.com]
Hepatomegaly
  • Right upper quadrant sonogram revealed hepatomegaly of 15 cm, trace amount of perihepatic ascites, pericholecystic fluid, and also thickened edematous gallbladder wall with no stones, no common bile duct stones, and no portal vein thrombosis.[ncbi.nlm.nih.gov]
  • […] edema · S3 gallop · Increased central venous pressure ( 16 cm H2O at right atrium) · Hepatojugular reflux · Weight loss 4.5 kg in 5 days in response to treatment Minor criteria: · Bilateral ankle edema · Nocturnal cough · Dyspnea on ordinary exertion · Hepatomegaly[web.archive.org]
  • On examination, the findings include raised jugular pressure and positive hepatojugular reflex, tender hepatomegaly and features of heart disease. Framignham criteria is used for the diagnosis of congestive cardiac failure.[symptoma.com]
Heart Disease
  • In some people, heart disease and heart failure symptoms persist even after revascularisation.[doi.org]
  • disease with heart failure Hypertensive heart disease, w CHF Hypertensive heart failure Hypertensive heart/kidney dis w/ congestive heart fail Hypertensive kidney and heart disease Hypertensive kidney and heart disease, on dialysis Malignant hypertensive[icd9data.com]
  • A promising approach to the treatment of chronic ischaemic heart disease and congestive heart failure is the use of stem cells.[ncbi.nlm.nih.gov]
  • Valvular heart disease In patients with valvular heart disease, cardiac catheterization and coronary angiography are clearly indicated in the following situations: Before valve surgery or balloon valvotomy in an adult with chest discomfort, ischemia by[emedicine.com]
  • Related Criteria: Estimate of 10-Year Risk for Coronary Heart Disease for Men (Framingham Point Scores) Estimate of 10-Year Risk for Coronary Heart Disease for Women (Framingham Point Scores) NYHA Functional Classification for Congestive Heart Failure[web.archive.org]
Chest Pain
  • A middle-aged man having past history of treated pulmonary tuberculosis and obstructive uropathy presented with 2-weeks of progressive cough with scanty purulent sputum and breathlessness without any fever, chest pain, or pedal edema.[ncbi.nlm.nih.gov]
  • Symptoms of heart failure Some of the most common symptoms you may experience are reduced energy, confusion, chest pain, shortness of breath and swelling in the legs.[novanthealth.org]
  • pains congestive heart failure coronary coronary infarction coronary thrombosis myocardial infarction tachycardia heart disease noun disease of the heart angina cardiac infarction congenital heart disease congestive heart failure coronary thrombosis[thesaurus.com]
  • Some people may chest pain, which may range from excruciating, to a mild discomfort. The severity of pain does not indicate how severe the damage to the heart muscle may be.[chemocare.com]
  • Shortness of breath, chest pain, dizziness, or feeling faint may also occur with arrhythmias.[womenheart.org]
Tachycardia
  • Renal failure may also occur following heart transplantation as a result of long-term immunosuppression. [3] Cardiac rhythm disorders may be caused by the following: Complete heart block Supraventricular tachycardia Ventricular tachycardia Sinus node[emedicine.com]
  • SEE DEFINITION OF congestive heart failure as in coronary infarction as in heart disease as in cardiac arrest as in heart attack Synonyms for congestive heart failure cardiac arrest heart failure myocardial infarction tachycardia MOST RELEVANT Roget's[thesaurus.com]
  • A 12-lead electrocardiogram showed irregular wide QRS complex tachycardia with a slur at the initial portion of the QRS complex. He had preexisting long-standing persistent atrial fibrillation, but early excitation syndrome had never been noted.[ncbi.nlm.nih.gov]
Palpitations
  • A 56-year-old man was admitted because of palpitations and dyspnea. A 12-lead electrocardiogram showed irregular wide QRS complex tachycardia with a slur at the initial portion of the QRS complex.[ncbi.nlm.nih.gov]
  • You may experience palpitations. Some people may chest pain, which may range from excruciating, to a mild discomfort. The severity of pain does not indicate how severe the damage to the heart muscle may be.[chemocare.com]
  • […] failure Symptoms of heart failure include: new or worsening shortness of breath (particularly during physical activity or waking you up at night) weight gain muscular fatigue, tiredness swelling of ankles or legs swelling of abdomen dizziness heart palpitations[betterhealth.vic.gov.au]
  • Your ticker is working overtime Tyler Olson/Shutterstock “If some people were to check their heart rate, they would see it’s actually increased, and some might experience palpitations,” says Dr. Fonarow.[rd.com]
  • Heart Failure Symptoms Shortness of breath Weight gain Swelling of the lower extremities Fatigue Exercise intolerance Palpitations Loss of appetite Congestive Heart Failure Causes Many conditions that cause your heart to fail result in irreversible damage[wexnermedical.osu.edu]
Hypotension
  • Therefore, ASV may be effective for treating CHF in HD patients with LV dysfunction and chronic hypotension.[ncbi.nlm.nih.gov]
  • Exclusion criteria included recent myocardial infarction in the preceeding 2 months, ventricular or atrioventricular pacing for 40% of the day, atrial fibrillation or flutter, and symptomatic hypotension.[2minutemedicine.com]
Nocturia
  • Nocturia: Nocturia occurs due to excretion of fluid retained during the day and increased renal perfusion in recumbent position at night.[symptoma.com]
  • This may lead to peripheral edema or anasarca and nocturia (frequent nighttime urination when the fluid from the legs is returned to the bloodstream).[sciencedaily.com]
  • Similarly, patients with sleep apnea without heart failure have frequent awakenings, nocturia and may wake up short of breath due to the apnea.[web.archive.org]
  • Also common are nocturia, paroxysmal nocturnal dyspnea, orthopnea, anorexia, right upper quadrant abdominal discomfort due to hepatic congestion. At times, patients can present with altered mental status due to cerebral hypoperfusion.[clinicaladvisor.com]
  • Nocturia (frequent nighttime urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night.[en.wikipedia.org]
Oliguria
  • Oliguria and nocturia: These symptoms result from renal congestion. Peripheral edema: Edema develops in the feet in ambulatory patients and sacral edema in bed bound patients.[symptoma.com]
  • These mechanisms are responsible for the symptoms of diaphoresis, cool skin, tachycardia, cardiac arrhythmias, and oliguria.[medical-dictionary.thefreedictionary.com]
  • The full-blown syndrome includes anasarca with liver dysfunction and oliguria.[doi.org]
  • 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[emedicine.com]
Confusion
  • Depressive symptoms, however, sometimes are confused with the physical repercussions of heart failure. This article highlights different screening assessments for major depression and recommends treatment for this population.[ncbi.nlm.nih.gov]
  • Symptoms of heart failure Some of the most common symptoms you may experience are reduced energy, confusion, chest pain, shortness of breath and swelling in the legs.[novanthealth.org]
  • The term ‘failure’ can be confusing – the heart does not actually stop pumping. However, the heart is less effective at both delivering oxygen and nutrients to the rest of the body and carrying waste products away.[gosh.nhs.uk]
  • Without enough blood, the brain does not function well, resulting in lightheadedness and/or mental confusion. Lightheadedness is a sensation of dizziness or mild disorientation.[northshore.org]
  • It is not to be confused with "cessation of heartbeat", which is known as asystole, or with cardiac arrest, which is the cessation of normal cardiac function in the face of heart disease.[sciencedaily.com]
Dizziness
  • While symptoms of heart failure vary by person, swelling of the legs, irregular heartbeats or other unexplained symptoms like shortness of breath or dizziness could be early signs of heart failure.[novanthealth.org]
  • Symptoms of heart failure Symptoms of heart failure include: new or worsening shortness of breath (particularly during physical activity or waking you up at night) weight gain muscular fatigue, tiredness swelling of ankles or legs swelling of abdomen dizziness[betterhealth.vic.gov.au]
  • Dizziness, fatigue, and weakness. Less blood to your major organs and muscles makes you feel tired and weak. Less blood to the brain can cause dizziness or confusion. Rapid or irregular heartbeats.[webmd.com]
  • Shortness of breath, chest pain, dizziness, or feeling faint may also occur with arrhythmias.[womenheart.org]
  • Lightheadedness is a sensation of dizziness or mild disorientation. People with heart failure may also experience lightheadedness as a side effect of certain medications.[northshore.org]
Headache
  • Features due to right heart failure: Headache, insomnia and restlessness: These symptoms occur because of cerebral congestion. Anorexia, nausea and vomiting: Congestion of the portal system causes these symptoms.[symptoma.com]
  • No serious adverse events occurred in either group; however, constipation, headaches, and hypotension were more frequent in the conivaptan arms.[uscjournal.com]
  • Tolerance on continuous use Isosorbide dinitrate Acute heart failure, when blood pressure is adequate Start with 1 mg/h, increase to 10 mg/h Hypotension, headache Tolerance on continuous use Nitroprusside Hypertensive crisis, cardiogenic shock combined[doi.org]
  • Nervous System and Sense Organs 76 Meningitis 32,909 2,565 7.8 77 Encephalitis 8,487 1,219 14.4 79 Parkinson's disease 13,089 2,118 16.2 80 Multiple sclerosis 21,708 2,529 11.6 82 Paralysis 7,394 987 13.3 83 Epilepsy, convulsions 252,200 31,965 12.7 84 Headache[hcup-us.ahrq.gov]
Insomnia
  • Features due to right heart failure: Headache, insomnia and restlessness: These symptoms occur because of cerebral congestion. Anorexia, nausea and vomiting: Congestion of the portal system causes these symptoms.[symptoma.com]
  • […] strengthening of relationships with loved ones. 10 Although heart failure patients are often assumed principally to suffer from fatigue and dyspnea, a majority have pain, and depression is extremely common. 11 Other sources of suffering include edema, insomnia[doi.org]
  • Side effects of amiodarone have included thyroid abnormalities, pulmonary toxicity, hepatotoxicity, neuropathy, insomnia, and numerous other reactions.[content.onlinejacc.org]
  • Janszky, Insomnia and the risk of incident heart failure: a population study, European Heart Journal, 35, 21, (1382), (2014).[dx.doi.org]
Sleep Disturbance
  • Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF. (Level of Evidence: C) 6.[doi.org]
  • Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF. ( Level of Evidence: C ) 7.[content.onlinejacc.org]
  • Peter Johansson, Barbara Riegel, Erland Svensson, Anders Broström, Urban Alehagen, Ulf Dahlström and Tiny Jaarsma, The Contribution of Heart Failure to Sleep Disturbances and Depressive Symptoms in Older Adults, Journal of Geriatric Psychiatry and Neurology[dx.doi.org]

Workup

The main investigations in the diagnosis of congestive cardiac failure include the following.

Kerley B Lines
  • Kerley B lines – Dilated lymphatic channels. Typically 2 cm in length and horizontal, peripherally located perpendicular to pleura. Black arrowheads in following image are kerley b lines, white arrows are septal lines.[saem.org]
  • […] accumulates in alveoli due to left heart pressure overload alveoli pop open during inhalation, causing rales on exam abdominal exam ascites hepatojugular reflex Imaging Chest radiograph findings pulmonary vascular congestion pleural effusion cardiomegaly Kerley-B[medbullets.com]
  • The interlobular septal thickening is referred to as Kerley B lines. Early blunting of the lateral and posterior costophrenic angles may occur; such blunting indicates the presence of pleural fluid.[emedicine.com]
  • Kerley B lines. Apart from pulmonary congestion, CXR findings are only predictive of heart failure where there are co-existing typical signs and symptoms. Urinalysis. Lung function tests (peak flow or spirometry).[patient.info]
Pericardial Effusion
  • Echocardiography can also comment on chamber size, ejection fraction, stroke volume, abnormalities in myocardium (dilated CMP, hypertrophic obstructive cardiomyopathy [HOCM]) and pericardium (constrictive pericarditis, tamponade, pericardial effusion)[clinicaladvisor.com]
  • Patients were excluded if they met any of the following conditions: chronic primary pulmonary diseases, unstable angina, Q-wave myocardial infarction within the last 3 weeks, cardiac surgery within the previous 3 months, pericardial effusion or cachexia[doi.org]
Pulmonary Edema on Chest X-Ray
  • Clinical symptoms of heart failure include: unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention; or rales, jugular venous distension, pulmonary edema on physical exam, or pulmonary edema on chest x-ray[fpnotebook.com]
Kerley Lines
Cardiac Output Decreased
  • CHF occurs when the flow of blood from the heart ( cardiac output ) decreases, or fluid backs-up behind the failing ventricle, or both.[health.howstuffworks.com]
Echocardiogram Abnormal
  • Objective evidence of a structural or functional abnormality of the heart at rest: cardiomegaly, third heart sound, cardiac murmurs, echocardiogram abnormalities, raised natriuretic peptide concentration.[patient.info]
Hyponatremia
  • It seems that icodextrin may contribute to clinically relevant hyponatremia if the hyponatremia is compounded by other factors. Patients with extremely severe congestive heart failure are susceptible to this complication.[ncbi.nlm.nih.gov]
  • Classification of Hyponatremia The definition of hyponatremia is serum sodium concentration 4,5 Depletional hyponatremia is caused by certain disorders or drugs that produce a decrease in extracellular fluid, leading to an excessive loss of renal salts[uscjournal.com]
  • Other poor prognostic factors include left ventricular dysfunction with ejection fraction less than 20%, secondary renal insufficiency, hyponatremia and hypokalemia (with potassium less than 3 mEq/l).[symptoma.com]
Hypercapnia
  • These SRDB cause arousals, hypoxemia-reoxygenation, hypercapnia-hypocapnia, and changes in intrathoracic pressure.[web.archive.org]
  • Respiratory muscle fatigue may be diagnosed by a decrease in respiratory rate, associated with hypercapnia and confused state of mind.[doi.org]
Pleural Effusion
  • After 8 months of treatment, her symptoms improved and the pleural effusion showed significant regression.[ncbi.nlm.nih.gov]
  • effusion · Decrease in vital capacity by one third from maximum recorded · Tachycardia (heart rate 120 beats/min.)[web.archive.org]

Treatment

The treatment strategy for congestive cardiac failure has three components; namely correction of the underlying cause(s), removal of the precipitating cause(s) and control of congestive cardiac failure.

The general measures for controlling the congestive cardiac failure include the following.

  • Bed rest: Bed rest reduces the demands of the heart. Propping up of the head of the patient should be proposed to reduce lung congestion. 
  • Diet: Diet low in salt, general good nutrition and weight reduction should be advised.
  • Smoking: Complete cessation of smoking has to be ensured.
  • Exercise: Adequate exercise within the limits of the symptoms is beneficial.

Medical therapy

Initially, angiotensin converting enzyme (ACE) inhibitors are given to the patient which reduce cardiac workload by causing vasodilation [3]. Captopril and lisinopril are the commonly used agents [4].

If ACE inhibitors alone are not effective, a combination of other vasodilators (such as nitrates, hydralazine and neseritide) and diuretics (such as loop diuretics, thiazide diuretics and potassium sparing diuretics) may be used [5] [6].

If adequate control is still not achieved, positive ionotropic agents such as digoxin and digitalis are useful [7] [8].

Cardiac transplantation

Cardiac transplantation is indicated in end stage cardiac disease that is refractory to other kinds of therapy. Ideal candidates should have age less than 60 years, adequate renal function and pulmonary vascular resistance less than 3 RU [9] [10].

Prognosis

The prognosis depends upon the extent of cardiac failure and the type of treatment given. Prognosis is poor when the underlying heart disease is not treatable. Other poor prognostic factors include left ventricular dysfunction with ejection fraction less than 20%, secondary renal insufficiency, hyponatremia and hypokalemia (with potassium less than 3 mEq/l).

Ventricular arrhythmias and pump failure are the leading causes of death in these patients.

Etiology

Congestive cardiac failure results from the following types of conditions related to the heart.

Volume overload

Pressure overload

Myocardial diseases

Epidemiology

Heart failure is a relatively common outcome of various cardiac diseases. Approximately 0.67 million people are affected in the United States each year [1]. Out of these, 0.27 million die from it.

The increasing use of refined diets and higher incidence of hypertension and diabetes in developing countries is also causing a rise in the international incidence of cardiac failure [2].

Sex distribution
Age distribution

Pathophysiology

Congestive cardiac failure usually involves failure of both the left and right side of the heart. The features of left sided heart cardiac failure are mainly due to congestion of the lungs. Dyspnea occurs because of the damming of blood in the lungs resulting in pulmonary venous congestion. Initially dyspnea occurs only at exertion. Later on orthopnea and paroxysmal nocturnal dyspnea also develop. Later on dyspnea occurs even at rest. Orthopnea refers to breathlessness on lying flat. It occurs because of the following two circulating changes when the person lies flat.

  • There is redistribution of blood from the tissues into the plasma. Approximately half a liter of blood pooled in the leg veins during standing is returned to the heart increasing the venous return.
  • In upright position, hydrostatic pressure helps in draining the upper lung zones into the left atrium. Respiration can continue in the upper zones even if the lower zones are congested. Upon lying flat, this hydrostatic effect is lost and the whole lung becomes congested causing severe breathlessness.

Paroxysmal nocturnal dyspnea results from the same two mechanisms above along with the following:

  • Depression of the nervous system during sleep leads to reduced awareness of pulmonary congestion. The patient wakes up when extreme congestion and breathlessness have developed.
  • The sympathetic system is also depressed during sleep which causes reduction in the heart rate causing further pooling of the blood in the pulmonary vessels. 

Later on, pulmonary edema also develops and causes persistent breathlessness.

Right sided heart failure mainly causes tissue congestion because of the inability of the heart to empty properly. Many organs including the brain, liver and kidneys are affected. In addition, generalized congestion develops which manifests as peripheral edema.

Prevention

The causes that predispose to the development of myocardial or valvular diseases should be avoided. In case of active disease, early diagnosis and prompt treatment is necessary to reduce mortality.

Summary

Cardiac failure refers to the inability of the heart to maintain adequate cardiac output to meet the demands of the body. Depending upon the cause, there may be a failure of the left side or the right side of the heart; known as left and right sided cardiac failure respectively. The salient features are also different.

Biventricular cardiac failure is the condition in there is chronic failure of both the left and right sides of the heart. In most of the cases, right sided cardiac failure is a result of preexisting left sided cardiac failure.

Patient Information

Congestive cardiac failure refers to the failure of both sides of the heart. The blood is not adequately pumped by the heart. As a result, the organs of the body do not get sufficient amount of blood and damming of blood in the vessels also takes place. A healthy lifestyle and proper treatment prevents mortality from congestive cardiac failure.

References

Article

  1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation. Feb 1 2011;123(4):e18-e209
  2. Stewart S, Wilkinson D, Hansen C, et al. Predominance of heart failure in the Heart of Soweto Study cohort: emerging challenges for urban African communities. Circulation. Dec 2 2008;118(23):2360-2367.
  3. Cayley WE, Jr. Therapy with ACE inhibitors and ARBs in heart failure. American family physician. Jul 15 2004;70(2):261.
  4. Ball SG, Julian DG. ACE inhibitors and heart failure. Lancet. Mar 14 1992;339(8794):687-688.
  5. Jentzer JC, DeWald TA, Hernandez AF. Combination of loop diuretics with thiazide-type diuretics in heart failure. Journal of the American College of Cardiology. Nov 2 2010;56(19):1527-1534.
  6. Miraglia G, Nava A, Dalla Volta S. [Clinical amd metabolic results of a particular combination thiazide-antialdosterone in heart failure]. La Clinica terapeutica. Mar 15 1974;68(5):445-451.
  7. Batterman RC, De Graff AC. Comparative study on the use of the purified digitalis glycosides, digoxin, digitoxin, and lanatoside C, for the management of ambulatory patients with congestive heart failure. American heart journal. Nov 1947;34(5):663-673
  8. Digitalis Investigation G, Ahmed A, Waagstein F, et al. Effectiveness of digoxin in reducing one-year mortality in chronic heart failure in the Digitalis Investigation Group trial. The American journal of cardiology. Jan 1 2009;103(1):82-87.
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Last updated: 2019-07-11 20:34