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High Output Heart Failure

High output heart failure is a poorly understood condition characterized by signs and symptoms of heart failure and a resting cardiac index above 4 l/min x m2. Classical heart failure treatment can be detrimental in this instance.


Presentation

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].

Dyspnea
  • After the procedure, dyspnea was improved and procedure related complication was not seen.[ncbi.nlm.nih.gov]
  • Endovascular sealing with a 16 60 mm bifurcated stent graft (S & G Biotech, Seoul, Korea) was performed which led to complete resolution of the patient's dyspnea.[ncbi.nlm.nih.gov]
  • 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]
  • A 40-year-old man who was referred to our hospital due to dyspnea was found to have high output cardiac failure on Swan-Ganz catheterization.[ncbi.nlm.nih.gov]
  • A 55-year-old Japanese housewife, who had Osler-Weber-Rendu disease, was admitted to our hospital because of frequent epistaxis and worsening exertional dyspnea.[ncbi.nlm.nih.gov]
Orthopnea
  • 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]
  • Heaves Displaced Apex Beat [sign of cardiomegaly] Gallop [S3] Bilateral Crepitations Cardiomegaly on CXR Cachexia [dec. appetite, weight loss, lethargy, muscle atrophy] Hepatic Tenderness Dyspnea due to pulmonary edema and respiratory muscle weakness Orthopnea[almostadoctor.co.uk]
  • Among them is dyspnea on exertion or even at rest at a more advanced stage, asthma (cardiac asthma) and orthopnea, symmetric edema, especially on the ankles, on the tibia and on top of the foot.[lecturio.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]
Rales
  • 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]
  • 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]
  • 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]
  • C 8 Dependent edema and pulmonary rales are of limited value in diagnosing heart failure resulting from left ventricular dysfunction.[aafp.org]
  • Typical signs: tachycardia, tachypnoea, pulmonary rales, pleural effusion, raised jugular venous pressure (JVP), peripheral oedema, hepatomegaly.[patient.info]
Exertional Dyspnea
  • A 51-yr-old man presented exertional dyspnea as a consequence of iliocaval fistula combined with paradoxical pulmonary embolism and high-output heart failure.[ncbi.nlm.nih.gov]
  • 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]
  • A 55-year-old Japanese housewife, who had Osler-Weber-Rendu disease, was admitted to our hospital because of frequent epistaxis and worsening exertional dyspnea.[ncbi.nlm.nih.gov]
  • A 36-year-old male presented with progressive exertional dyspnea over months. Physical examination showed jugular venous distension, lung crecipitations, femoral bruit and pitting pedal edema.[ncbi.nlm.nih.gov]
  • Leg oedema and exertional dyspnea due to aortocaval fistula complicating an abdominal aortic aneurysm. Int J Cardiol . 2004 ; 94 :335–337. Crossref Medline Google Scholar 2. Oda T, Yasunaga H, Hosokawa Y, Nomura Y, Shojima T, Zaima Y, Kawara T .[circ.ahajournals.org]
Congestive Heart Failure
  • Her symptoms and cardiovascular changes were consistent with congestive heart failure and severe preeclampsia.[ncbi.nlm.nih.gov]
  • Neonates typically present with severe congestive heart failure. Here we present a case in which a systolic heart murmur was the first manifestation of high output heart failure due to a VGAM.[ncbi.nlm.nih.gov]
  • Blood gas analysis and chest X-ray showed congestive heart failure. Enhanced computed tomography of the pelvis showed a 10 x 4 cm hypervascular tumor in the retroperitoneal space.[ncbi.nlm.nih.gov]
  • Congestive heart failure (CHF) due to high output states is known to occur in a variety of systemic illnesses and in patients with arterial-venous fistulas.[ncbi.nlm.nih.gov]
  • Congestive heart failure (CHF) is an important source of morbidity and mortality in end-stage renal disease patients. Although CHF is commonly associated with low cardiac output (CO), it may also occur in high CO states.[ncbi.nlm.nih.gov]
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]
  • Anemia causes cutaneous pallor and fatigability which overlaps with that induced by the heart failure, peripheral vasodilatation caused by vascular nitric oxide synthase and low systemic vascular resistance.[symptoma.com]
  • These conditions include anemia , hyperthyroidism , and pregnancy.[agavesurgery.com]
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]
  • 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]
  • Various forms of congenital heart disease can lead to systolic dysfunction and can usually be identified on echocardiography.[barnardhealth.us]
  • For most adults, HF results from diminished myocardial contractility caused by ischemic heart disease. In contrast, decreased contractile states account for a smaller percentage of causes of pediatric HF.[pedsinreview.aappublications.org]
Tachycardia
  • Hyperthyroidism causes tachycardia-mediated cardiomyopathy and thus high output heart failure and is often accompanied by atrial fibrillation.[symptoma.com]
  • 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]
  • His cardiovascular exam was remarkable for 12 cm of jugular venous distension and tachycardia with a 2/6 systolic flow murmur at the left upper sternal border.[radcliffecardiology.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]
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]
Increased Jugular Venous Pressure
  • Physical findings are increased jugular venous pressure, tachycardia usually with a third heart sound, bilateral bibasilar crackles and a wide pulse pressure. The examination of the AVF may yield additional clues to diagnosis.[omicsonline.org]
Bounding Pulse
  • pulses, wide pulse pressure, accentuated heart sounds, peripheral vasodilatation, increased cardiac output and ejection fraction, moderate four-chamber enlargement Low cardiac output syndrome Fatigue, loss of lean body mass, prerenal azotemia, peripheral[aafp.org]
Epistaxis
  • A 55-year-old Japanese housewife, who had Osler-Weber-Rendu disease, was admitted to our hospital because of frequent epistaxis and worsening exertional dyspnea.[ncbi.nlm.nih.gov]
  • A 61-year-old female with a history of secundum atrial septal defect repair and hereditary hemorrhagic telangiectasia presented with epistaxis. She was found to have atypical atrial flutter with 2:1 atrioventricular conduction.[ncbi.nlm.nih.gov]
Polyneuropathy
  • A diagnosis of Crow-Fukase syndrome was made based on the presence of polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes.[ncbi.nlm.nih.gov]
Intracranial Hemorrhage
  • This can lead to earlier diagnosis, rapid treatment, and prevention of brain damage and other complications such as intracranial hemorrhage and hydrocephaly. 7 Vascular embolization is the therapy that has so far shown to be the most effective.[elsevier.es]

Workup

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].

Treatment

  • Endovenous laser ablation treatment has become the less invasive therapeutic choice for the treatment of superficial venous insufficiency and varicose veins.[ncbi.nlm.nih.gov]
  • Temporary or permanent central venous catheter (CVC) insertion has been performed frequently for hemodialysis treatment. One of the most important long-term complications of CVC is the central venous occlusion (CVO).[ncbi.nlm.nih.gov]
  • In this case, we successfully used TACE in the treatment of hepatic EHE with high-output heart failure.[ncbi.nlm.nih.gov]
  • The authors also discuss the follow-up method, intervals, and threshold for further treatment for these lesions, and present a review of the literature.[ncbi.nlm.nih.gov]
  • This article outlines the medical treatment and nursing care needed to return these patients to a normal state.[ncbi.nlm.nih.gov]

Prognosis

  • References: [33] [34] [35] Prognosis Prognosis estimates vary depending on patient characeristics, type and severity of heart disease, medication regimens, and lifestyle changes.[amboss.com]
  • The prognosis for people with heart failure and preserved LV ejection fraction is a little better than the prognosis for people with heart failure and reduced ejection fraction. Generally, the lower the ejection fraction, the poorer the prognosis.[patient.info]
  • Once the morphologic anomaly is detected, N-butyl-cyanoacrylate (NBCA) injection or other embolic agents are administered by means of radio-opaque agents. 10–12 These endovascular advancements have markedly improved the prognosis of VGAM in the past few[elsevier.es]
  • Symptoms of Congestive Heart Failure Symptoms of Congestive Heart Failure Rehabilitate Your Heart #Save a #Life CONGESTIVE HEART FAILURE (CHF) -- Description, causes, signs & symptoms, risk factors, diagnosis, treatment, prognosis, prevention.[pinterest.de]
  • J Am Coll Cardiol 2009;54:1747-1762 Cohn HN, Levine TB, Olivari MT, Garberg V, Lura D, Francis GS, Simon AB, Rector T: Plasma norepinephrine as a guide to prognosis in patients with chronic congestive heart failure.[karger.com]

Etiology

  • The etiology of his CHF together with the cardiomegaly and hyperdynamic left ventricular systolic function was unknown.[ncbi.nlm.nih.gov]
  • Characteristics of high-output HF etiologies Most hemodynamic and ventricular function findings were fairly uniform among the different etiologies of high-output HF, although there were some notable differences ( Table 2 ).[onlinejacc.org]
  • OBJECTIVES: This study sought to characterize the etiologies, pathophysiology, clinical and hemodynamic characteristics, and outcomes of high-output HF in the modern era.[ncbi.nlm.nih.gov]
  • Through noninvasive testing, hepatic arteriovenous malformation was diagnosed as the etiologic factor.[journals.lww.com]
  • The study authors found that most common etiologies of high-output HF (n 120) were obesity (31%), liver disease (23%), arteriovenous shunts (23%), lung disease (16%), and myeloproliferative disorders (8%).[acc.org]

Epidemiology

  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Back to Top Epidemiology It is difficult to estimate the incidence of PDB because most patients are asymptomatic.[clevelandclinicmeded.com]
  • References: [2] [3] Epidemiological data refers to the US, unless otherwise specified. Etiology The three major causes of heart failure are coronary artery disease , hypertension , and diabetes mellitus .[amboss.com]
  • Although the symptoms, causes, prevalence, and epidemiology of the six different types of heart failure are somewhat different, there is substantial overlap, and types may coexist.[aafp.org]
  • Mortality was assessed from the medical records, the Mayo Clinic registration database, the Rochester Epidemiology Project death database, and the Social Security Death Index to obtain 100% verification of vital status.[onlinejacc.org]
Sex distribution
Age distribution

Pathophysiology

  • In the absence of cardiopulmonary pathophysiology, we presume that our patient's hemangioma was causing a right-to-left shunt as opposed to an expected left-to-right shunt.[ncbi.nlm.nih.gov]
  • The underlying pathophysiology was believed to be caused by the high-output state of pregnancy and by the increased peripheral vascular resistance of preeclampsia.[ncbi.nlm.nih.gov]
  • This indicates that excessive reduction in afterload indeed plays the dominant role in the pathophysiology of high-output HF.[onlinejacc.org]
  • OBJECTIVES: This study sought to characterize the etiologies, pathophysiology, clinical and hemodynamic characteristics, and outcomes of high-output HF in the modern era.[ncbi.nlm.nih.gov]

Prevention

  • When addressing the problem of high-output heart failure, the nephrologist is faced with the dilemma of preventing progression of heart failure at the expense of loss of vascular access.[ncbi.nlm.nih.gov]
  • Treatment of the erythroderma flare can help prevent or treat the serious secondary complications.[shmabstracts.com]
  • […] the diastole phase of the cardiac cycle, which can occur when the mitral valve is narrowed, as in rheumatic mitral stenosis, or when there is an accumulation of fluid within the pericardial sac ( cardiac tamponade ) pressing against the ventricles, preventing[medical-dictionary.thefreedictionary.com]
  • However, VGAM can go undetected despite appropriate prenatal screening, and early detection and treatment after birth can prevent complications.[elsevier.es]
  • An accurate diagnosis will prevent morbidity and unnecessary hospital admissions.[omicsonline.org]

References

Article

  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.

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Last updated: 2018-06-21 21:37