Patients with high output heart failure present with dyspnea, tachypnea, non-productive cough, fatigability, pulmonary rales, pleural effusion and peripheral edema, as a result of pulmonary and venous congestion due to neurohormonal activation and increased salt and water retention. Also, they are often tachycardic, with a heart rate between 85 and 105 beats per minute. A third heart sound and bilateral basal crackles are often heard in these patients [1]. Jugular and femoral venous hum may be sometimes observed. Peripheral vasodilatation leads to warm extremities.

High output heart failure is caused by a number of conditions each with their own signs and symptoms, that can sometimes also be found in affected individuals, such as chronic anemia, systemic arterio-venous fistulae, Paget's disease, hyperthyroidism, chronic hypercapnia, obesity, beriberi heart disease and sepsis.

Anemia causes cutaneous pallor and fatigability which overlaps with that induced by the heart failure, peripheral vasodilatation caused by vascular nitric oxide synthase [2] and low systemic vascular resistance [3].

Arteriovenous fistulae are associated with a specific hum on auscultation and may be congenital or acquired. They lead to a decrease in the systemic vascular resistance and thus high output heart failure [4]. Fistulae may be found in the context of certain congenital diseases, such as Osler-Weber-Rendu disease, Parkes-Weber or Klippel–Trénaunay syndrome. They can cause decreased pulse pressure distal to their location [1].

Paget's disease is associated with pain and warmth of the affected area, but a large amount of bone must be involved before heart failure occurs. A similar mechanism for the malfunction of the heart has been described in multiple myeloma, and Albright's disease [5].

Hypercapnia caused by chronic obstructive pulmonary disease may also cause high output heart failure [6]. The pulmonary pathology is recognized by auscultation and symptoms like dyspnea and fatigability.

Hyperthyroidism causes tachycardia-mediated cardiomyopathy and thus high output heart failure [7] and is often accompanied by atrial fibrillation [8].

Sepsis causes systemic vasodilatation, arterial hypotension and heart failure [9] and is recognized most often using laboratory workup, but also by fever, tachycardia, and tachypnea.

Beriberi is associated with chronic alcohol consumption or impaired nutrient absorption, that lead to weight loss and steatorrhea. Heart beriberi causes peripheral edema and fatigability and decreased systemic vascular resistance, leading to high output heart failure.

Obesity leads to systolic and diastolic malfunction of the heart and increased total blood volume, thus causing high output heart failure [10].

• Congestive Heart Failure

  Her symptoms and cardiovascular changes were consistent with congestive heart failure and severe preeclampsia. [ncbi.nlm.nih.gov]

  […] preserved ejection fraction [HFpEF] I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure [icd10coded.com]

  There was an initial concern for congestive heart failure secondary to an ischemic etiology as an echocardiogram revealed a depressed ejection fraction. [hindawi.com]

• Anemia

  High-output heart failure (HOHF) is associated with several diseases including chronic anemia, psoriasis, systemic arteriovenous fistula, sepsis, hypercapnia, multiple myeloma, and hyperthyroidism. [ncbi.nlm.nih.gov]

  These conditions include anemia, hyperthyroidism, and pregnancy. [uofmhealth.org]

• Dyspnea

  After the procedure, dyspnea was improved and procedure related complication was not seen. [ncbi.nlm.nih.gov]

• Orthopnea

  He denied orthopnea, paroxysmal nocturnal dyspnea, and lower-extremity swelling. He also denied abdominal pain, hematochezia, melena, diarrhea, and flushing. He was thin, mildly tremulous, and afebrile and had no evidence of sepsis. [annals.org]

  Orthopnea and paroxysmal nocturnal dyspnea are related to congestion of the pulmonary blood vessels and edema of the lung tissues. [medical-dictionary.thefreedictionary.com]

  In fact, some physicians will ask patients to use terms such as ‘2 pillow’ or ‘3 pillow’ orthopnea to differentiate how severe their congestion is. [ausmed.com]

  Orthopnea 3. Fatigue 4. Edema 5. Paroxysmal noctural dyspnea ..Cardiogenic asthma는 발작성 야간 호흡 및 기침과 관련이 있으며 기관지 경 련에 의한 2차적인 천명이 특징이고 특히 밤... [kmle.co.kr]

• Rales

  Rales were heard over both lung bases. An abdominal examination showed a moderately distended abdomen with an enlarged liver. He had trace edema. The skin color was normal with no telangiectasia. [annals.org]

  A chest examination detected no rales. Heart auscultation demonstrated accentuated first and second heart sounds, and grade 3/6 pansystolic ejection murmur in the mitral and tricuspid area. [circheartfailure.ahajournals.org]

  Patients with high output heart failure present with dyspnea, tachypnea, non-productive cough, fatigability, pulmonary rales, pleural effusion and peripheral edema, as a result of pulmonary and venous congestion due to neurohormonal activation and increased [symptoma.com]

  On physical exam, she has jugular venous distention, pulmonary rales, cardiac S3 sound, and pitting edema. Her electrocardiogram shows sinus tachycardia and chest radiograph shows pleural effusions and cardiomegaly. [medbullets.com]

  Abstract Congestive heart failure describes a syndrome with complex and variable symptoms and signs, including dyspnea, increased fatigability, tachypnea, tachycardia, pulmonary rales, and peripheral edema. [ncbi.nlm.nih.gov]

• Exertional Dyspnea

  A 64-year-old woman was admitted with systemic edema and exertional dyspnea. High-output heart failure was diagnosed by right heart catheterization and she was treated with diuretics. [ncbi.nlm.nih.gov]

  Introduction In February, 2012, a 33-year-old man was admitted to our hospital because of exertional dyspnea, chest distress, and fatigue of 1 month duration. On admission, his blood pressure was 124/80 mm Hg and heart rate was 120 beats per minute. [circheartfailure.ahajournals.org]

• Basilar Rales

  rales may be audible on auscultation. [amboss.com]

• Abdominal Bruit

  A continuous abdominal bruit was heard. The chest X-ray showed cardiomegaly and dilatation of the pulmonary artery. Abdominal three-dimensional computed tomography scanning clearly revealed an arteriovenous fistula. [ncbi.nlm.nih.gov]

• Heart Disease

  ICD-10-CM Codes › I00-I99 Diseases of the circulatory system › I30-I52 Other forms of heart disease › I50- Heart failure › High output heart failure 2018 - New Code 2019 Billable/Specific Code I50.83 is a billable/specific ICD-10-CM code that can be used [icd10data.com]

  I50.1 Left ventricular failure, unspecified Inclusion term(s): Cardiac asthma Edema of lung with heart disease NOS Edema of lung with heart failure Left heart failure Pulmonary edema with heart disease NOS Pulmonary edema with heart failure I50.2 [icd10coded.com]

  They include: Obesity Liver disease Anemia Hyperthyroidism Pregnancy Lung disease Septic shock Paget's disease Arteriovenous fistula Beriberi heart disease Symptoms Common signs of high-output heart failure are similar to those of other types. [webmd.com]

  Also excluded were patients with severe anemia (hemoglobin 8 mg/dl), thyrotoxicosis, valvular heart disease ( mild stenosis, moderate regurgitation), constrictive pericarditis, left ventricular systolic dysfunction (ejection fraction [EF] 45%), cardiomyopathies [acc.org]

• Tachycardia

  Patients may present with the usual signs of high-output heart failure including tachycardia, elevated pulse pressure, hyperkinetic precordium, and jugular venous distension. [ncbi.nlm.nih.gov]

  Her EKG showed sinus tachycardia at 108 beats per minute. ECHO showed a normal ejection fraction with moderate mitral regurgitation. [shmabstracts.com]

  Hyperthyroidism causes tachycardia-mediated cardiomyopathy and thus high output heart failure and is often accompanied by atrial fibrillation. [symptoma.com]

  Electrocardiography on presentation showed sinus tachycardia with asymmetrical T-wave inversion in lateral leads. A chest X-ray demonstrated cardiomegaly with no acute abnormality. [omicsonline.org]

  These mechanisms are responsible for the symptoms of diaphoresis, cool skin, tachycardia, cardiac arrhythmias, and oliguria. [medical-dictionary.thefreedictionary.com]

• Gallop Rhythm

  On the third day of life, she developed cardiac failure with gallop rhythm, hepatomegaly and a murmur in the anterior fontanel; an echocardiogram confirmed clinic aggravation with biventricular dysfunction and right cavities and superior vena cava dilatation [ncbi.nlm.nih.gov]

  B 12, 14 Heart failure can be ruled in if jugular venous distention, displacement of the apical pulsation, or a gallop rhythm is present. [aafp.org]

  There may be a gallop rhythm due to presence of S3 (see also the separate Heart Auscultation article) or murmurs of mitral or aortic valve disease. Bilateral basal end-inspiratory crackles wheeze ('cardiac asthma'). Tachypnoea. Pleural effusions. [patient.info]

  infection) Examination Again, a full examination should be undertaken, with particular emphasis being paid to the following points: Hemodynamic parameters and vital signs Blood pressure – adequate perfusion pressure Heart rate and rhythm Gallop rhythm [clinicaladvisor.com]

  Hemodynamic parameters of interest include blood pressure, HR and heart rhythm, gallop rhythm, oxygen saturation, and respiratory rate [47]. [oatext.com]

• S3 Gallop

  […] low-output CHF; particularly tachycardia, tachypnea, low blood pressure, and jugular distention with an audible hum over the internal jugular vein Pulsatile tinnitus Bounding peripheral pulses Laterally displaced apical heart beat Midsystolic murmur, S3 [amboss.com]

• Ejection Murmur

  A grade 2/6 systolic ejection murmur was heard over the second right intercostal space. Rales were heard over both lung bases. An abdominal examination showed a moderately distended abdomen with an enlarged liver. He had trace edema. [annals.org]

  Heart auscultation demonstrated accentuated first and second heart sounds, and grade 3/6 pansystolic ejection murmur in the mitral and tricuspid area. A grade 3/6 continuous machinery bruit over the left renal area was heard. [circheartfailure.ahajournals.org]

Blood workup shows elevated levels of atrial and brain natriuretic peptide in high output heart failure patients [11] [12]. Venous oxygen saturation, if high (above 75%), is an indirect indicator of a high output state. The oxygen content of arterial and mixed venous blood samples is expected to be decreased.

As in all heart failure individuals, a chest radiography is useful, as it might show cardiomegaly, pleural effusion or pulmonary congestion. A diagnosis of pneumonia in a septic patient with high output heart failure should lead the physician to suspect it as the underlying cause of the failure.

The diagnosis is ultimately confirmed with echocardiography showing an increased cardiac index. This investigation may show eccentric remodeling, chamber dilatation, and increased ventricular filling pressures, with a high ejection fraction. Pulmonary hypertension is another common finding in these patients.

Cardiac catheterization confirms increased cardiac filling pressures, high pulmonary artery pressure, stroke volume, ventricular preload, ejection fraction and decreased afterload as a result of low systemic vascular resistance [13].

• Hyperlactacidemia

  The hyperlactacidemia completely resolved after amputation, and the high output cardiac failure has not recurred for two years. High output cardiac failure is rare in MD patients and is related to myocardial abnormalities and hyperlactacidemia. [ncbi.nlm.nih.gov]

• T Wave Inversion

  Electrocardiography on presentation showed sinus tachycardia with asymmetrical T-wave inversion in lateral leads. A chest X-ray demonstrated cardiomegaly with no acute abnormality. [omicsonline.org]

1. MacRae J, Levin A, Belenkie I. The cardiovascular effects of arteriovenous fistulas in chronic kidney disease: a cause for concern? Semin Dial 2006;19: 349-352.
2. Ni Z, Morcos S, Vaziri N. Up-regulation of renal and vascular nitric oxide synthase in iron-deficiency anemia. Kidney Int. 1997;52:195-201.
3. Anand I, Chandrashekhar Y, Ferrari R, et al. Pathogenesis of oedema in chronic severe anaemia: studies of body water and sodium, renal function, haemodynamic variables, and plasma hormones. Br Heart J. 1993; 70:357-362.
4. Bourgeois N, Delcour C, Deviere J, et al. Osler-Weber-Rendu disease associated with hepatic involvement and high output heart failure. J Clin Gastroenterol. 1990; 12:236-238.
5. Inanir S, Haznedar R, Atavci S, et al. Arteriovenous shunting in patients with multiple myeloma and high-output failure. J Nucl Med. 1998; 39:1-3.
6. Anand I, Chandrashekhar Y, Ferrari R, et al. Pathogenesis of congestive state in chronic obstructive pulmonary disease. Studies of body water and sodium, renal function, hemodynamics, and plasma hormones during edema and after recovery. Circulation. 1992;86:12-21.
7. Froeschl M, Haddad H, Commons AS, et al. Thyrotoxicosis-an uncommon cause of heart failure. Cardiovasc Pathol. 2005; 14:24-27.
8. Watanabe H, Okamura K, Chinushi M, et al. Clinical characteristics, treatment, and outcome of tachycardia induced cardiomyopathy. Int Heart J. 2008;49:39-47.
9. Rotheram E. High output congestive heart failure in septic shock. Chest. 1989;95:1367-1368.
10. Galinier M, Pathak A, Roncalli J, et al. Obesity and cardiac failure. Arch Mal Coeur Vaiss. 2005;98:39-45.
11. Yakes W, Rossi P, Odink H. How I do it. Arteriovenous malformation management. Cardiovasc Intervent Radiol. 1996:19: 65-71.
12. Stern A, Klemmer P. High-output heart failure secondary to arteriovenous fistula. Hemodial Int. 2011; 15:104-107.
13. Reddy Y, Melenovsky V, Redfield M, et al. High-Output Heart Failure. A 15-Year Experience. JACC. 2016;68(5):473-782.