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Heart failure

Last updated: November 28, 2023

Summarytoggle arrow icon

Heart failure (HF) is a complex clinical syndrome caused by structural or functional impairment of ventricular filling and/or ejection of blood. The three main underlying causes of HF are coronary artery disease, diabetes mellitus, and hypertension; incidence increases with age. Typical clinical features include dyspnea and peripheral edema. The initial diagnostic workup includes measurement of natriuretic peptide levels, echocardiography, chest x-ray, and an ECG. Classification of patients based on left ventricular ejection fraction (LVEF), symptoms and functional capacity (NYHA class), and ACC/AHA stage helps guide management. Guideline-directed medical therapy for HF includes lifestyle modifications and treatment of associated conditions (e.g., hypertension) and comorbidities (e.g., anemia), along with a combination of pharmacological agents that reduce cardiac workload (e.g., SGLT2is, ARNIs, beta blockers, mineralocorticoid receptor antagonists). Treatment options for patients with advanced HF, a highly morbid condition, include device therapy for HF, mechanical circulatory support, and/or heart transplant. Acute heart failure (AHF) may occur as an exacerbation of HF (i.e., acute decompensated HF) or be caused by an acute cardiac condition such as myocardial infarction.

Definitiontoggle arrow icon

Preferred terminology [1][2][3]

The term “heart failure” is preferred over “congestive heart failure” because not all patients present with symptoms of fluid overload. [8]

Historical terminology [1][2]

Epidemiologytoggle arrow icon

  • Approx. 1.9% of the US population (6.2 million individuals) has HF. [9]
  • Incidence is higher among African American and Hispanic individuals. [10]
  • Incidence increases with age: Approx. 20% of individuals aged > 75 years are affected. [11]
  • An increasing proportion of patients with HF have HFpEF (≥ 50%). [1]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

The three major causes of HF are CAD, hypertension, and diabetes mellitus. Patients typically have multiple risk factors that contribute to the development of HF.

Classificationtoggle arrow icon

Classification of HF by LVEF [1]

American College of Cardiology/American Heart Association (ACC/AHA) stages [1]

The ACC/AHA classification system categorizes patients based on an objective assessment of clinical features and diagnostic findings.

ACC/AHA stages of heart failure [1]
Stage Definition and criteria

Stage A: at risk for HF

  • Asymptomatic
Stage B: pre-HF
Stage C: symptomatic HF
Stage D: advanced HF
  • Symptoms of HF that disrupt daily life, with frequent hospitalizations despite GDMT optimization

Patients with stage C HF will always remain categorized as such, even if they become asymptomatic (i.e., NYHA class I) with treatment. [1]

New York Heart Association NYHA functional classification [1]

The NYHA classification system is used to assess limitations in physical activity and symptoms of patients with symptomatic HF (i.e., ACC/AHA stages C and D); it helps determine treatment eligibility and prognosis.

NYHA functional classification [1][2]
NYHA class Characteristics
Class I
  • No limitations in physical activity
  • No symptoms of HF
Class II
  • Mild symptoms and slight limitations during ordinary physical activity
  • No symptoms at rest
Class III
  • Marked limitations in physical activity
  • Less-than-ordinary activity causes symptoms.
  • Comfortable only at rest
Class IV
  • Severe limitations
  • Symptoms during any form of physical activity
  • Symptoms at rest

Pathophysiologytoggle arrow icon

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

HF 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.

Clinical featurestoggle arrow icon

General features of heart failure

Clinical features of left-sided heart failure

Clinical features of right-sided heart failure

Subtypes and variantstoggle arrow icon

High-output heart failure

Diagnosticstoggle arrow icon

See “Diagnosis of AHF” for the evaluation of acute decompensated HF.

General principles

Multiple conditions can mimic HF and/or impact therapeutic decisions, e.g., anemia or kidney or liver failure. No single laboratory finding, imaging study, or clinical feature either excludes or is diagnostic for HF. [1][2]

Clinical evaluation

Laboratory studies [1][20]

BNP or NT-proBNP

  • Indication: all patients with suspected HF
  • Uses: to help confirm the diagnosis and assess disease severity and prognosis [1][21]
  • Interpretation

Normal BNP or NT-proBNP levels do not exclude HF. Always consider the complete clinical picture. [1][20]

Additional laboratory studies

Order the following studies to assess for causes of HF, comorbidities, and suitability for pharmacological treatment.

Most patients with HF (> 85%) have two or more associated chronic conditions. [1]

Transthoracic echocardiogram (TTE) [1][20]

Chest x-ray [1]

12-lead ECG [1][30][31]

Additional assessment [1][2]

Clinical composite scores

Advanced studies

The following studies may be ordered by a specialist if there is diagnostic uncertainty and/or to evaluate for underlying causes.

Identifying the specific cause of HF is crucial because it allows for tailored treatment in addition to GDMT. [1]

Pathologytoggle arrow icon

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

Differential diagnosestoggle arrow icon

Managementtoggle arrow icon

Management of AHF is detailed in “Acute HF.”

Approach [1][2]

Multidisciplinary management of HF that includes nurses, cardiologists, and clinical pharmacists is associated with lower hospitalization and mortality rates. [1][2]

Nonpharmacological interventions [1][20]

Encourage and/or provide the following in combination with pharmacotherapy for HF.

Nonpharmacological interventions are associated with better patient outcomes, e.g., decreased rates of hospitalization and all-cause and cardiovascular mortality. [1]

Management of comorbidities [1][2]

The following recommendations are specific to comorbidities in HF. Treat other comorbidities (e.g., lipid disorders, ASCVD, atrial fibrillation) as recommended by guidelines.

Monitoring [1][2]

To optimize GDMT, the following factors should be assessed at each patient visit.

Pharmacotherapytoggle arrow icon

General principles [1][2]

Pharmacotherapy for HFrEF [1][3]

Initial pharmacotherapy for HFrEF [1][3]
Class Indications Recommended agents
Diuretics Loop diuretics
  • Preferred option for all patients with congestion
Thiazide diuretics
RAAS inhibitors Angiotensin receptor-neprilysin inhibitors (ARNIs)
  • All patients with ACC/AHA stages C and D HFrEF (preferred initial agent for RAAS inhibition) [1]
  • For patients already prescribed an ACEI, stop ACEIs 36 hours before starting an ARNI to avoid an elevated risk of angioedema.

ACE inhibitors (ACEIs)

  • All patients with ACC/AHA stage B HFrEF
  • Patients with ACC/AHA stages C and D HFrEF if ARNI is not tolerated or affordable
Angiotensin receptor blockers (ARBs)
  • Patients with ACC/AHA stages B, C, and D HFrEF if ARNI and ACEIs are not tolerated (e.g., because of a dry cough or history of angioedema) or affordable
Beta blockers
  • All patients with ACC/AHA stages B, C, and D HFrEF
SGLT2 inhibitors (SGLT2is)
  • All patients with ACC/AHA stage C HFrEF
Mineralocorticoid receptor antagonists (MRAs)
  • All patients with ACC/AHA stage C HFrEF without contraindications i.e., eGFR < 30 mL/min/1.73 m2 and serum K+ > 5.0 mEq/L

Drugs that improve prognosis (i.e., reduce morbidity, mortality, and hospitalization rates) are beta blockers, ACEIs, ARNIs, MRAs, hydralazine with isosorbide dinitrate, and SGLT2is.

Additional pharmacotherapy for HFrEF [1][3]
Class Indications Recommended agents
Isosorbide dinitrate with hydralazine
  • Add to first-line therapy for African American patients with NYHA III–IV HFrEF [1]
  • May be considered in patients who cannot tolerate ARNI, ACEIs, or ARBs (e.g., due to impaired kidney function) [1]
If channel inhibitor
Digoxin
  • Refractory symptoms despite first-line GDMT [1]
Soluble guanylate cyclase stimulator
  • Vericiguat
Omega-3 fatty acid
  • May be added to first-line GDMT in patients with NYHA II–IV HFrEF

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

Pharmacotherapy for HFpEF [2][3][20]

Drugs that may worsen HF [1]

The following drugs should be avoided or used with caution in patients with HF.

Device therapy and advanced HF managementtoggle arrow icon

Device therapy in HF

Automated implantable cardioverter defibrillators (AICDs) and cardiac resynchronization therapy devices (CRTs) are beneficial in select patients with HF who are at risk for sudden cardiac death from ventricular tachyarrhythmias and who have worsening HF from cardiac dyssynchrony. [1][40]

AICDs in heart failure [1]

For more information, see “AICDs.”

CRT in heart failure [1]

For more information, see “CRTs.”

  • Goal consists of synchronizing contractions of the right and left ventricles, resulting in:
  • Indications: The following criteria apply to patients with stage C HFrEF on optimized medical therapy and an expected survival of > 1 year.
    • LVEF ≤ 35% with NYHA class II–IV symptoms and sinus rhythm OR select patients with AFib PLUS:
      • QRS duration of > 150 ms with or without LBBB pattern
      • OR QRS duration of 120–149 ms with LBBB pattern
    • LVEF ≤ 35% requiring pacing for other purposes, e.g., replacement of existing PPM
    • LVEF 36–50% with high-risk AV block

Consider CRT-D in patients with indications for both CRT and AICD.

Advanced heart failure management (ACC/AHA stage D) [1][3]

Promptly refer all patients with advanced HF to an HF specialist for management.

Complicationstoggle arrow icon

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

Cardiorenal syndrometoggle arrow icon

Prognosistoggle arrow icon

The prognosis depends on the patient, type and severity of heart disease, and adherence to GDMT and nonpharmacological interventions. Risk stratification scales may be used to determine prognosis (e.g., CHARM and CORONA risk scores).

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Referencestoggle arrow icon

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