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:

• Paroxysmal nocturnal dyspnea
• Distention of neck veins
• Crepitations
• Cardiomegaly
• Acute pulmonary edema
• S3 gallop rhythm
• Increased venous pressure (greater than 16 cm of water)
• Positive hepatojugular reflux

The minor criteria include:

• Pedal edema
• Night cough
• Dyspnea on exertion
• Hepatomegaly
• Pleural effusion
• Tachycardia
• Vital capacity reduced by at least one third of normal

• Fatigue

  The results suggest that fatigue is a circular process in which the consequences of fatigue further exaggerate the experience. However, fatigue could be alleviated by restorative activities. [dx.doi.org]

  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]

  Mental fatigue can manifest as somnolence, lethargy, or directed attention fatigue.[4] Fatigue and 'feelings of fatigue' are sometimes confused.[5] Unlike weakness, fatigue usually can be alleviated by periods of rest. [en.wikipedia.org]

  Forward failure also decreases the blood flow to various organs, causing weakness and fatigue. Time-dependent heart failure: Acute heart failure: This describes heart failure that occurs suddenly. [health.howstuffworks.com]

• Weight Gain

  The strength of the association increased with increasing amounts of weight gain, so that a weight gain of >5 and up to 10 pounds had an adjusted, matched OR of 4.46 (95% CI 1.45 to 13.75) and a gain of >10 pounds had an adjusted, matched OR of 7.65 [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]

  At home, watch for changes in your heart rate, pulse, blood pressure, and weight. Weight gain, especially over a day or two, can be a sign that your body is holding on to extra fluid and your heart failure is getting worse. [nlm.nih.gov]

• Weight Loss

  […] 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) · Hepatojugular reflux · Weight [medicalcriteria.com]

  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

  It is associated with such conditions as lymphedema, lipedema, and myxedema. [en.wikipedia.org]

  […] 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.medscape.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.medscape.com]

• Cough

  Chronic Cough & Wheezing: Just like with the shortness of breath, a chronic cough becomes more prominent in the final months and weeks of congestive heart failure. [crossroadshospice.com]

  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]

• 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 [medicalcriteria.com]

  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]

  Presentation History The most classic presentation for CHF includes dyspnea, especially with exertion. Dyspnea on exertion has a sensitivity of 100% and specificity 17%. And the absence of exertional dyspnea decreases the likelihood of CHF. [saem.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 [medicalcriteria.com]

  […] 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]

• 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]

  In right-sided heart failure, fluid backs up into the body causing peripheral edema, JVD, and hepatomegaly, while in left-sided heart failure, fluid builds up in the lungs causing dyspnea, crackles, orthopnea, and paroxysmal nocturnal dyspnea. [youtube.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.) [medicalcriteria.com]

• Nausea

  Dizziness or nausea Irregular heartbeat. A heart attack is a medical emergency. If someone appears to be having a heart attack, call 911 or your local medical emergency number. [aurorahealthcare.org]

  Symptoms of CHF may include: Shortness of breath when lying down Fatigue Weakness Lack of appetite Nausea Abdominal swelling Irregular heartbeat Wheezing If not treated, CHF may lead to kidney or liver damage, heart valve problems, and heart attack or [dmc.org]

  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 (anorexia); nausea and/or vomiting. General feeling of poor health. Anxiety; in severe cases irritability, restlessness, and mental confusion may occur. [healthcentral.com]

  Lack of appetite, nausea ...a feeling of being full or sick to your stomach. The digestive system receives less blood, causing problems with digestion. Confusion, impaired thinking ...memory loss and feelings of disorientation. [heart.org]

• 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]

• Vomiting

  Loss of appetite (anorexia); nausea and/or vomiting. General feeling of poor health. Anxiety; in severe cases irritability, restlessness, and mental confusion may occur. [healthcentral.com]

  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]

• 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]

• Heart Disease

  In some people, heart disease and heart failure symptoms persist even after revascularisation. [doi.org]

  (CHF) Hypertensive heart 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 [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]

  Angiography Cardiac catheterization and coronary angiography have a useful role in patients with congestive heart failure, those with valvular heart disease, and those with congenial heart disease, as well as patients with other conditions. [14] CHF For [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 [medicalcriteria.com]

• 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]

  Seek emergency treatment if you experience any of the following: Chest pain Fainting or severe weakness Rapid or irregular heartbeat associated with shortness of breath, chest pain or fainting Sudden, severe shortness of breath and coughing up pink, foamy [mayoclinic.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]

• 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]

  ECG and telemetry revealed relatively slow supraventricular tachycardia, which did not trigger the alert, and catheter ablation successfully controlled the heart failure. [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]

  However, ordinary physical activity such as walking causes some breathlessness, fatigue, or palpitations. [patient.info]

  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]

  […] of breath during physical activity Difficulty breathing when lying in a flat position Waking at night feeling short of breath Swollen neck ( jugular ) veins Abdominal swelling ( ascites ) from excess fluid Lower leg or foot swelling ( pedal edema ) Palpitations [jama.ama-assn.org]

• Hypotension

  Therefore, ASV may be effective for treating CHF in HD patients with LV dysfunction and chronic hypotension. [ncbi.nlm.nih.gov]

  In patients with hypotension, therapy should be started without a bolus. [doi.org]

• 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]

  · 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 [medicalcriteria.com]

  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]

• Periorbital Edema

  Edema surrounding the eyes is called periorbital edema or eye puffiness. The periorbital tissues are most noticeably swollen immediately after waking, perhaps as a result of the gravitational redistribution of fluid in the horizontal position. [en.wikipedia.org]

• Neck Swelling

  The symptoms include high fever, muffled voice, difficulty opening the mouth, increased salivation and drooling and neck swelling. See a doctor if these symptoms occur. [aboutkidshealth.ca]

• 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]

  […] exercise Accumulation of fluid, usually in the lower legs (peripheral edema) or lower back (sacral edema) A distended jugular vein in the neck Rapid heart rate (tachycardia) Chest pain or pressure Dizziness Chronic coughing Frequent nighttime urination (nocturia [verywellhealth.com]

  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]

• 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.medscape.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]

  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]

  Confusion & Delirium: As with any chronic, life-threatening illness, some confusion and delirium can be expected. CHF patients often times experience disorientation due to changing sodium levels in the blood. [crossroadshospice.com]

  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]

• 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]

  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]

  Poor circulation to the body leads to dizziness, confusion and diaphoresis and cool extremities at rest. The right side of the heart pumps blood returned from the tissues to the lungs to exchange carbon dioxide for oxygen. [sciencedaily.com]

  Fatigue and dizziness – because less blood is reaching the organs of the body, it can cause feelings of weakness. Because less blood is reaching the brain is can also cause dizziness and confusion. [medicalnewstoday.com]

  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]

• 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]

  […] failure symptoms poster PDF" src="https://assets.aboutkidshealth.ca/akhassets/congestive_heart_failure_PDFdownload.jpg" /> </figure> </a> <p>Symptoms of heart failure can affect different areas of the body:</p><h3>Brain</h3><ul><li>Irritability</li><li>Headaches [aboutkidshealth.ca]

  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]

• 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]

• Sleep Disturbance

  In older people, presenting complaints may be atypical, such as confusion, delirium, falls, sudden functional decline, nocturnal urinary incontinence, or sleep disturbance. [msdmanuals.com]

  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]

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

• Electrocardiography (ECG): ECG may show signs of right and left ventricular enlargement, myocardial infarction and arrhythmias.
• X-ray of the chest: Possible findings include hilar congestion and bat wings appearance in the lungs, cardiomegaly, pleural effusion and evidence of pulmonary hypertension.
• Echocardiography: Echocardiography may demonstrate systolic or diastolic impairment of the left or right ventricle, valve diseases, motion abnormalities of the heart walls, cardiomyopathies, reduced ejection fraction and intracardiac thrombus.

• 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]

  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]

  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]

• Pericardial Effusion

  (in pneumothorax), water-bottle heart (in pericardial effusion), and hyperinflation (in chronic obstructive pulmonary disease (COPD) and asthma) can all give clues to diagnosis. [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]

  Echocardiography can help evaluate chamber dimensions, valve function, LVEF, wall motion abnormalities, LV hypertrophy, diastolic function, pulmonary artery pressure, LV and RV filling pressures, RV function, and pericardial effusion. [msdmanuals.com]

• 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

  Ultrasound of the lung may also be able to detect Kerley lines.[37] Congestive heart failure with small bilateral effusions. Kerley b lines. [en.wikipedia.org]

• 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]

• 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]

• 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]

  […] explained clearly including: Asthma, COPD, Acute Renal Failure, Mechanical Ventilation, Coronary Artery Disease, Cardiomyopathy, Oxygen Hemoglobin Dissociation Curve, Hypertension, Shock, Diabetic Ketoacidosis (DKA), Medical Acid Base, VQ Mismatch, Hyponatremia [youtube.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]

  Thus, poor ventilation leading to hypercapnia, left heart failure leading to interstitial edema (impairing gas exchange), asthma causing bronchoconstriction (limiting airflow) and muscle fatigue leading to ineffective respiratory muscle action could all [en.wikipedia.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.) [medicalcriteria.com]

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].

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.

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

Volume overload

• Aortic regurgitation
• Mitral regurgitation
• Atrial septal defect
• Tricuspid regurgitation

Pressure overload

• Systemic hypertension
• Aortic stenosis
• Pulmonary hypertension
• Pulmonary stenosis

Myocardial diseases

• Ischemic heart disease
• Cardiomyopathies
• Myocarditis
• Diabetes mellitus
• Alcohol toxicity
• Sarcoidosis

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].

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.

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.

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.

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.

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.
9. Villar E, Boissonnat P, Sebbag L, et al. Poor prognosis of heart transplant patients with end-stage renal failure. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. May 2007;22(5):1383-1389.
10. Hori M, Koretsune Y, Takemura K, et al. Prognosis of patients with severe congestive heart failure referred to the cardiac transplant program. Osaka University Cardiac Transplant Program. Japanese circulation journal. Jun 1994;58(6):395-402.