Congestive cardiac failure (CCF), also known as congestive heart failure (CHF) or simply heart failure, refers to the clinical syndrome caused by inherited or acquired abnormalities of heart structure and function, causing a constellation of symptoms and signs that lead to decreased quality and quantity of life.
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Epidemiology
Congestive cardiac failure is common, affecting 2% of all adults in developed nations, and up to 10% of adults over 65 years old 1. The condition is thought to affect up to 20 million people worldwide 1.
Clinical presentation
Clinical features traditionally associated with left and right ventricular dysfunction, respectively, may include:
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left-predominant symptoms and signs 1,2
fatigue, syncope
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dyspnea
subjective discomfort or difficulty breathing
chest pain
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abnormal auscultatory heart sounds 1,2
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an audible "S3" may be appreciated during early diastole and/or an "S4" in late diastole
the former may originate from taut mitral subvalvular structures secondary to ventricular dilation, and the latter from decreased ventricular compliance
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pulsus alternans 1,2
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right-predominant symptoms and signs 1,2
nocturia
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dependent, pitting edema
commonly bipedal or sacral
jugular venous distension
The severity of clinical presentation and functional status of a patient is often classified according to the New York Heart Association (NYHA), which assigns a grade between I and IV dependent on symptoms and on how limited the physical activity has become 1,2:
NYHA I: no symptoms during normal physical activity, no limitation
NYHA II: symptoms during ordinary physical activity, slight limitation
NYHA III: symptoms during less than ordinary physical activity, marked limitation (patients generally only comfortable at rest)
NYHA IV: symptoms even when at rest, severe limitation
Pathology
Classification
In the presence of consistent symptoms and clinical signs, elevated natriuretic peptides, and the presence of diastolic dysfunction and/or structural cardiac abnormalities (e.g. left atrial dilation, left ventricular hypertrophy), patients are commonly grouped by left ventricular ejection fraction (LVEF) as follows:
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heart failure with a reduced ejection fraction (HFrEF)
those with an LVEF of <40%
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heart failure with a preserved ejection fraction (HFpEF)
an LVEF equal to or greater than 50%
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heart failure with a midrange ejection fraction (HFmrEF)
those falling between the cutoffs above (40-49%)
Etiology
While significant overlap exists, etiological associations may correspond to the phenotypes delineated by LVEF as follows:
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associated with a decreased left ventricular ejection fraction
ischemic dilated cardiomyopathy 1,2
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non-ischemic dilated cardiomyopathy
toxic (e.g. sympathomimetics, alcohol)
hypothyroidism 1,2
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regurgitant valve disease
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left-to-right shunts
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associated with a preserved left ventricular ejection fraction
chronic hypertension 1,2
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valvulopathies
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infiltrative diseases
Danon disease 1,2
A somewhat distinct entity is that of high-output heart failure in which a primary decrease in systemic vascular resistance triggers a neurohormonal cascade akin to that observed with a decreased cardiac output. Etiologies of this syndrome include:
morbid obesity 1,2
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systemic arteriovenous shunts
sepsis 1,2
anemia 1,2
hyperthyroidism 1,2
wet beriberi 1,2
Radiographic features
Plain radiograph
According to one study 5, the accuracy of interpreting chest radiographs regarding congestive cardiac failure was only around 70%.
With left-sided congestive cardiac failure, the features are that of pulmonary edema which includes (from early to late stages) 1,2,4-8:
cardiomegaly (may or may not be present depending on etiology)
Ultrasound
Echocardiography is the most common imaging modality to evaluate patients with congestive cardiac failure 1,2. Some features assessed during a complete transthoracic echocardiography exam include:
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left ventricular function
the surrogate measure ejection fraction is a common method to estimate global systolic function
diastolic dysfunction may also be assessed, involving spectral Doppler as well as 2D measurements
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structure of the left ventricle
wall thickness and left ventricular end-diastolic internal diameter may yield a derived mass, the basis of diagnosing remodeling and hypertrophy
valvular anatomy and function
right ventricular structure and function
pericardial space
CT
CT chest may demonstrate the same features as the plain radiograph but in greater detail and clarity 6,7,9. The following signs have been specifically described for CT 18:
enlarged heart
bilateral interlobular septal thickening
increased vascular diameter
bilateral ground glass opacification
bilateral pleural effusions
In the setting of acute dyspnea, two or more of these five signs seem to be highly specific 18.
Furthermore, electrocardiograph-gated CT and cardiac CT angiography may provide estimates of cardiac function and detailed visualization of various cardiac structures 9.
Mediastinal lymph node enlargement may be present in some cases 13,14.
MRI
Cardiac MRI (CMR) can provide highly accurate ejection fraction estimates and determine the presence of any structural abnormalities and is considered by many to be the gold standard imaging modality 2,9-11. Patterns of late gadolinium enhancement may be useful in delineating an etiology 10,11.
Treatment and prognosis
Treatment involves a multidisciplinary team and incorporates lifestyle, allied health, pharmacological, and surgical therapies, often specific to the underlying etiology 1,2. General principles include:
treatment of comorbidities and complications
lifestyle interventions
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pharmacotherapy
depending on the clinical context, examples include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors 1,2,12
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invasive/surgical management may include:
cardiac resynchronisation therapy
Despite advances in management, prognosis remains poor with 30-40% of patients dying within 1 year, and up to 70% dying within 5 years 1.
Complications
acute decompensated heart failure
arrhythmias (e.g. ventricular tachycardia)