Congestive heart failure

Last updated: November 28, 2022

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Congestive heart failure (CHF) is a clinical condition in which the heart is unable to pump enough blood to meet the metabolic needs of the body because of pathological changes in the myocardium. The three main causes of CHF are coronary artery disease, diabetes mellitus, and hypertension. These conditions cause ventricular dysfunction with low cardiac output, which results in blood congestion and poor systemic perfusion. CHF is classified as either left heart failure (LHF) or right heart failure (RHF), while a combination of both is called biventricular or global CHF. LHF leads to pulmonary edema and consequent dyspnea, while RHF leads to systemic venous congestion that causes symptoms such as pitting edema, jugular venous distension, and hepatomegaly. Biventricular CHF manifests with clinical features of both RHF and LHF, as well as general symptoms such as tachycardia, fatigue, and nocturia. In rare cases, high-output CHF may occur as a result of conditions that increase metabolic demands, leading to an increased cardiac output that eventually overwhelms the heart. CHF is diagnosed based on clinical presentation and requires an initial workup to assess the severity of the disease and determine the possible causes. Initial workup includes measurement of brain natriuretic peptide levels, chest x-ray, ECG, and an echocardiogram. Management of CHF includes lifestyle modifications and treatment of associated conditions (e.g., hypertension) and comorbidities (e.g., anemia), along with pharmacological agents that reduce the workload of the heart. Acute heart failure may occur as an exacerbation of CHF (acute decompensated heart failure) or be caused by an acute cardiac condition such as myocardial infarction (see “Acute heart failure”).

  • Approx. 1.9% of the US population has CHF (approx. 6.2 million individuals) [2]
  • The incidence is higher among African Americans and Hispanics. [3]
  • Incidence increases with age: ∼ 10% of individuals > 60 years old are affected. [4]
  • Systolic heart disease is the most common form of CHF overall.

Epidemiological data refers to the US, unless otherwise specified.

The three major causes of heart failure are coronary artery disease, hypertension, and diabetes mellitus. Patients typically have multiple risk factors that contribute to the development of CHF.

American Heart Association (AHA) classification (2013) [1]

The AHA classification system categorizes patients according to the stage of disease based on an objective assessment of clinical features and diagnostic findings.

AHA classification
Stages Objective assessment Corresponding NYHA functional class
Stage A
Stage B
Stage C
Stage D
  • Terminal stage heart failure

NYHA functional classification [1]

The NYHA (New York Heart Association) functional classification system is used to assess the patient's functional capacities (i.e., limitations of physical activity and symptoms) and has prognostic value.

NYHA functional classification
NYHA class Characteristics
Class I
  • No limitations of physical activity
  • No symptoms of CHF
Class II
  • Slight limitations of moderate or prolonged physical activity (e.g., symptoms after climbing 2 flights of stairs or heavy lifting)
  • Comfortable at rest
Class III
  • Marked limitations of physical activity (e.g., symptoms during daily activities like dressing, walking across rooms)
  • Comfortable only at rest
Class IV
  • Confined to bed, discomfort during any form of physical activity
  • Symptoms at rest

Cardiac output, which is stroke volume times heart rate, is determined by three factors: preload, afterload, and ventricular contractility.

Underlying mechanism of reduced cardiac output

Consequences of decompensated heart failure

CHF is characterized by reduced cardiac output that results in venous congestion and poor systemic perfusion.

Compensation mechanisms

The compensation mechanisms are meant to maintain the cardiac output when stroke volume is reduced.

General features of heart failure

Clinical features of left-sided heart failure

Clinical features of right-sided heart failure

High-output heart failure


Laboratory studies

Routine laboratory studies [1]

Cardiac biomarkers [1][16]


Transthoracic echocardiogram (TTE)

Chest x-ray [1]

Electrocardiogram (ECG) [27][28]

ECG abnormalities in CHF are common but mostly nonspecific.

Additional studies [1]

The following tests are not always part of the standard workup for heart failure but can be helpful when there is diagnostic uncertainty and to evaluate for underlying causes. For details on the evaluation for myocardial ischemia see “Diagnostics” in “Coronary artery disease”.

Advanced cardiac imaging


Sputum analysis in patients with pulmonary edema may show heart failure cells (hemosiderin-containing cells).


General measures [1]

Lifestyle modifications

These interventions reduce general risk factors that are known to lead to the progression of CHF or other comorbidities (e.g., diabetes mellitus, hypertension).

Patient/family education

Making sure that the patient understands the pathophysiological basis of the disease improves the effectiveness of treatment and quality of life.

  • Diet and fluid restriction [1]
  • Self-monitoring and symptom recognition
    • Daily weight check: Patients with a weight gain of > 4–5 lbs (> 2 kg) within 3 days should consult a doctor.
    • Patients may be counseled to independently adjust their diuretic dose if there is weight gain and advised that this needs regular review by a heart failure specialist to avoid overtreatment with diuretics. [34]
    • Recognition of symptoms of worsening heart failure
    • Monitoring of potential medication side effects
  • Awareness of travel precautions: e.g., carrying a copy of medical records and avoiding destinations with limited healthcare [35][36]

Treatment of comorbid conditions

The following conditions may worsen the symptoms of heart failure and accelerate progression.

Avoidance of drugs that may worsen CHF [1]

Avoid the simultaneous use of nondihydropyridine calcium channel blockers with beta blockers as this can cause complete heart block. [40]

Medical treatment of heart failure

Initial therapy [1][16]

  • Treatment is based on the stage of heart failure.
    • Additional therapies are added to the baseline medications as symptoms worsen.
    • From stage B onward, device therapy can be considered alongside medical therapy.
  • Start all new medications at the lowest recommended dose and slowly titrate up to the target dose where applicable.
  • The following table deals predominantly with the management of HFrEF; there is a paucity of evidence supporting best practice in HFpEF.
  • For modifications in pregnancy and lactation see “Use of heart failure medications in pregnancy and lactation.”
Initial medical treatment of heart failure [1][16]
Stage A
Treatment of cardiovascular risk factors
Stage B
Class Indications Administration

ACE inhibitors (ACEIs)

  • Every patient with HFrEF

Angiotensin receptor blockers (ARBs)

  • Patients who cannot tolerate ACEIs (e.g., because of a dry cough)
Beta blockers
  • Add once the patient is stable on ACEIs. [1][41]
  • Avoid in patients with decompensated cardiac failure until they are stabilized.
Stage C (additions)
Indications Administration
Aldosterone antagonsists
  • All HFrEF patients with NYHA class II–IV symptoms and an LVEF of < 35%
  • Consider adding for patients with HFpEF.
Loop diuretics and thiazide diuretics
Isosorbide dinitrate (ISDN) and hydralazine
  • Patients who cannot tolerate ACEIs or ARBs
  • Certain African American patients with HFrEF [1]
Angiotensin receptor-neprilysin inhibitors (ARNIs)
SGLT2 inhibitors
  • HFrEF with NYHA class II–IV symptoms
  • Administered in conjunction with first-line drugs
  • Reduction in cardiovascular mortality and hospitalization rates in patients with and without type 2 diabetes [43]
Stage D (additions)
Additional measures

Drugs that improve prognosis are beta blockers, ACE inhibitors, ARNIs, aldosterone antagonists, hydralazine with nitrate, and SGLT2 inhibitors.

Diuretics and digoxin improve symptoms and significantly reduce the number of hospitalizations.

Conducting regular blood tests to assess electrolyte levels (K+ and Na+) is mandatory if the patient is taking diuretics.

Therapy for refractory symptoms

Consider adding the following drugs if patients are adherent and have persistent symptoms despite maximum tolerated doses of first-line medical therapy. Invasive interventions may also be considered.

Additional medical treatment options for heart failure
Class Indications Administration
  • HFrEF with persistent symptoms despite treatment with appropriate first-line medications. [1]
  • Example: Digoxin [1]
  • Monitoring: renal impairment [1]
If channel inhibitor (Ivabradine)

Invasive interventions

Patients with CHF are at risk of sudden cardiac death (SCD) from arrhythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF) and heart failure may be worsened by cardiac dyssynchrony. Devices may only pace or have both pacing and defibrillator functions. [44]

Management of end-stage heart failure

We list the most important complications. The selection is not exhaustive.

The prognosis depends on the patient, type and severity of heart disease, medication regimens, and lifestyle changes. The prognosis for patients with preserved EF is similar to or better than for patients with decreased EF. Risk stratification scales may be used to evaluate the prognosis (e.g., CHARM and CORONA risk scores).

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