Overview
What are the signs and symptoms of heart failure?
What are the Framingham diagnostic criteria for heart failure?
What are the Framingham major diagnostic criteria for heart failure?
What are the Framingham minor diagnostic criteria for heart failure?
How does the New York Heart Association (NYHA) classification system categorize heart failure?
What is the American College of Cardiology/American Heart Association (ACC/AHA) staging system?
Which tests may be performed in the initial evaluation for suspected heart failure?
What are the nonsurgical treatment options for heart failure?
What are the surgical treatment options for heart failure?
What are the signs and symptoms of heart failure?
How is heart failure classified?
What is the role of lab studies in the diagnosis of heart failure?
What is included in patient care for acute heart failure?
What are the goals of drug treatment for heart failure?
How is heart failure progression pathophysiologically perpetuated?
Which pathophysiological adaptations prevent heart failure?
What is the role of norepinephrine in the pathogenesis of heart failure?
What is the pathophysiology of acute heart failure?
What is the role of chronic increased wall stress in the pathogenesis of heart failure?
What can trigger hemodynamic and neurohormonal derangements in the pathogenesis of heart failure?
What is the role of epinephrine in the pathogenesis of heart failure?
What is the role of calcium overload in the pathophysiology of heart failure?
What is the paradigm of myocyte biology and heart failure?
What is the role of angiotensin II in the pathogenesis of heart failure?
What is the role of myocardial volume in the pathogenesis of heart failure?
What are the features of myocardial remodeling in the pathogenesis of heart failure?
What is the pathophysiology of advanced heart failure?
What is the pathophysiology of systolic and diastolic heart failure?
What is the role of neuro-hormone mediated events in the pathogenesis of heart failure?
Which vasoactive systems have a role in the pathogenesis of heart failure?
What is the role of tumor necrosis factor (TNF)-alpha in the pathogenesis of heart failure?
What is systolic heart failure?
What is diastolic heart failure?
What is the pathophysiology of heart failure with preserved ejection fraction (HFpEF)?
How does the rise in filling pressure affect the pathogenesis of heart failure?
What is the role of ventricular pressure-volume curve in the pathophysiology of heart failure?
What is parallel upward displacement in the pathogenesis of heart failure?
What is the role of increased diastolic pressure in the pathogenesis of heart failure?
What is the role of arrhythmias in the pathogenesis of heart failure?
What are the categories used to classify causes of heart failure?
Which underlying factors cause heart failure?
What are the underlying causes of systolic heart failure?
What are the underlying causes of diastolic heart failure?
What are the underlying causes of acute heart failure?
What are the underlying causes of high-output heart failure?
What are the underlying causes of right heart failure?
How does decompensation result in heart failure?
What is the most common cause of decompensation in heart failure?
How does systemic infection cause heart failure?
How does cardiac infection and inflammation cause heart failure?
What causes fever, tachypnea, and tachycardia due to heart failure?
What are common precipitants of cardiac decomposition causing heart failure?
How does salt retention cause heart failure?
What are the high-output states that can precipitate heart failure?
What is the role of genetics in the etiology of heart failure?
Which patients at high-risk of heart failure should be screened and followed?
What is the prevalence of heart failure in the US?
What is the incidence of heart failure in the US?
What is the mortality rate for heart failure?
What are the AHA statistics for heart failure in the US?
What are the racial predilections of heart failure in the US?
How does the presentation of heart failure in the US vary by sex?
How does the prevalence of heart failure vary by age in the US?
How does the mortality rate for heart failure vary between industrialized and developing countries?
What are the trends for heart failure in developing nations?
What is the mortality rate for heart failure?
What is the mortality rate for systolic heart failure?
What variables are used as prognostic factors in heart failure?
How does the prognosis of heart failure compare to that of coronary artery disease?
How does pulmonary artery systolic pressure (PASP) affect the prognosis of heart failure?
Which factors worsen the prognosis of heart failure?
How can recurrence of heart failure be prevented?
What information about heart failure should patients receive?
Presentation
What should be the focus of clinical history during the evaluation of heart failure?
What are common cardiac signs and symptoms of heart failure?
What are non-cardiac symptoms of heart failure?
What is a common presentation of heart failure in the elderly?
How is exertional dyspnea characterized in patients with heart failure?
How is orthopnea characterized in patients with heart failure?
How is paroxysmal nocturnal dyspnea characterized in patients with heart failure?
What causes dyspnea at rest in heart failure?
How is acute pulmonary edema characterized in heart failure?
What causes chest pain or chest pressure in heart failure?
What causes palpitations in heart failure?
How are fatigue and weakness characterized in heart failure?
What causes nocturia and oliguria in heart failure?
Which symptoms of heart failure in the elderly are caused by cerebrovascular atherosclerosis?
How do the presentations of mild and severe heart failure differ?
What are the clinical presentations of recently onset heart failure?
What are the clinical presentations of mild or moderate heart failure?
What causes ascites in patients with heart failure?
What are the signs and symptoms of increased adrenergic activity in patients with heart failure?
What is the significance of rales in patients with heart failure?
How is systemic venous hypertension manifested during heart failure?
What causes hepatojugular reflux in heart failure?
What is the significance of edema in heart failure?
What causes hepatomegaly in heart failure?
What causes hydrothorax in heart failure?
What is protodiastolic gallop in heart failure?
What is the significance of cardiomegaly in heart failure?
What is the significance of pulsus alternans in heart failure?
What are the common heart sounds in patients with heart failure?
What is the significance of cardiac cachexia in heart failure?
What are the clinical manifestations of predominant right-sided heart failure?
What are the clinical manifestations of heart failure in children?
What are the characteristics of right-sided venous congestion in heart failure?
What are the characteristics of left-sided venous congestion in heart failure?
What is required for the diagnosis of heart failure using the Framingham system?
What are the prevention measures for ACC/AHA stage A heart failure?
What screening should patients with a family history of dilated cardiomyopathy receive?
What are the clinical characteristics of ACC/AHA stage B heart failure?
What are the clinical characteristics of ACC/AHA stage C heart failure?
What are the clinical characteristics of ACC/AHA stage D heart failure?
DDX
What are the cardiac and noncardiac causes of heart failure?
What is the most common form of heart failure in the US?
How is heart failure differentiated from pulmonary edema?
Which features may differentiate cardiogenic from noncardiogenic pulmonary edema in heart failure?
What are the clinical features of noncardiogenic pulmonary edema in heart failure?
How is right-sided heart failure presented?
How is heart failure diagnosed in elderly patients?
What are the differential diagnoses for Heart Failure?
Workup
What is included in a careful workup of suspected heart failure?
When is endomyocardial biopsy indicated in the workup of suspected heart failure?
Which lab studies are performed in the diagnosis of heart failure?
Should iron levels be measured in the workup of heart failure?
What is the role of serum electrolyte values in the diagnosis of heart failure?
What is the role of potassium levels in the diagnosis of heart failure?
What is the role of pulmonary function testing (PFT) in the diagnosis of heart failure?
What is the role of renal function tests in the diagnosis of heart failure?
What is the role of liver function tests in the diagnosis of heart failure?
How is acute hepatic venous congestion identified in heart failure?
What is the role of genetic testing in the diagnosis of heart failure?
Where can one go for specific genetic testing information related to the diagnosis of heart failure?
Which types of cardiomyopathy have the highest yield of genetic testing for heart failure?
How is genetic testing used to diagnose dilated cardiomyopathy and heart failure?
How is genetic testing used to diagnose hypertrophic cardiomyopathy and heart failure?
When should genetic testing be considered for the diagnosis of heart failure?
When is the measurement of arterial blood gas (ABG) indicated for the diagnosis of heart failure?
What is the significance of a finding of hypoxemia in the evaluation of heart failure?
What is assessed with arterial blood gas (ABG) measurement in the evaluation of heart failure?
What is the role of mixed venous oxygen saturation in the diagnosis of heart failure?
How is pulse oximetry used for the diagnosis of heart failure?
What is the significance of oxygen saturation in the diagnosis of heart failure?
When is a screening electrocardiogram (ECG) indicated in the evaluation of heart failure?
What are the possible presentations of heart failure on electrocardiography?
What is the role of chest radiographs in the diagnosis of heart failure?
How is transesophageal echocardiography (TEE) used for the diagnosis of heart failure?
How is stress echocardiography used for the diagnosis of heart failure?
What is the role of two-dimensional (2-D) echocardiography in the diagnosis of heart failure?
What is the role of Doppler echocardiography in the diagnosis of heart failure?
How are CT scanning and MRI used in the diagnosis of heart failure?
What are the benefits of MRI in the diagnosis of heart failure?
How is radionuclide multiple-gated acquisition (MUGA) scan used for the diagnosis of heart failure?
What is the role of ECG-gated SPECT imaging in the diagnosis of heart failure?
How is equilibrium radionuclide angiocardiography (ERNA) used for the diagnosis of heart failure?
How is radionuclide ventriculography used for the diagnosis of heart failure?
What is the role of coronary angiography in the diagnosis of heart failure?
When is angiography indicated in the evaluation of heart failure?
What is the role of right heart catheterization in the diagnosis of heart failure?
What are normal right-sided hemodynamics in the evaluation of heart failure?
How is pulmonary capillary wedge pressure (PCWP) measured for the diagnosis of heart failure?
How is cardiopulmonary stress testing used in the evaluation of heart failure?
Treatment
What is the prognostic relationship between sleep apnea and heart failure?
What is the relationship between anemia and heart failure?
What is included in the medical care of heart failure?
Which invasive therapies are used in the treatment of heart failure?
What is the role of heart transplantation in the treatment of heart failure?
Why is it important to evaluate patients with heart failure for coronary artery disease?
What is the benefit of coronary artery bypass grafting (CABG) in patients with heart failure?
When is surgical revascularization recommended for the treatment of heart failure?
When is coronary angiography useful in the management of heart failure?
When are repeated evaluations for ischemia indicated in the management of heart failure?
What is the relationship between valvular heart disease and heart failure?
What are the treatment approaches to sleep apnea in patients with heart failure?
What risks are increased in patients with comorbid sleep apnea and heart failure?
What are the treatment approaches for anemia in patients with heart failure?
What is the relationship between cardiorenal syndrome and heart failure?
What are the classifications of cardiorenal syndrome in patients with heart failure?
What is the pathophysiology of CR1 and CR2 of cardiorenal syndrome in heart failure?
What are the indications for renal replacement therapy in heart failure?
What is the significance of an increase in creatine levels in heart failure?
How is dopamine used in the treatment of heart failure?
What is the role of nesiritide in the treatment of heart failure?
What is the role of tolvaptan in the treatment of heart failure?
What is the role of adenosine receptor antagonists in the treatment of heart failure?
What is the role of beta-blockers in the treatment of heart failure?
What is the relationship between atrial fibrillation and heart failure?
What is the role of catheter ablation in the treatment of heart failure?
What is the role of radiofrequency ablation in the treatment of heart failure?
What are the nonpharmacologic therapy options for heart failure?
What are the benefits of aerobic exercise in the treatment of heart failure?
Which measures improve treatment adherence in heart failure?
What are the dietary restrictions for patients with heart failure?
What is the benefit of polyunsaturated fatty acids (PUFA) in the treatment of heart failure?
Which pharmacologic therapies are used in the treatment of heart failure?
What is the role of combination therapies for the treatment of heart failure?
What is the role of anticoagulation therapy in the treatment of heart failure?
When is infusion of positive inotropic drugs indicated in the treatment of heart failure?
Which drugs should be avoided during the treatment of heart failure?
What is the role of digoxin in the treatment of heart failure?
What are the clinical characteristics of acute heart failure?
How is acute heart failure managed?
What are the treatment options to increase ventilation in patients with acute heart failure?
What are the goals of medical therapy for acute heart failure?
How is preload reduction achieved in the treatment of acute heart failure?
Which 3 drugs are used in combination to manage acute heart failure following preload reduction?
How is hypoperfusion treated in acute heart failure?
What is the role of calcium channel blockers in the treatment of acute heart failure?
What is the role of diuretics in the treatment of acute heart failure?
How are diuretics administered for the treatment of heart failure?
How is diuretic resistance diagnosed in acute heart failure?
How is diuretic resistance managed in the treatment of acute heart failure?
When is the transition to oral diuretic therapy made in the treatment of acute heart failure?
What is the role of vasodilators in the treatment of acute heart failure?
What is the role of nitrates in the treatment of acute heart failure?
What is the role of sodium nitroprusside in the treatment of acute heart failure?
What is the role of nesiritide in the treatment of acute heart failure?
What is the role of ultrafiltration in the treatment of acute heart failure?
When is inpatient treatment required for acute heart failure?
When should hospitalization be considered for the treatment of acute heart failure?
What is included in inpatient treatment of acute heart failure?
What is the role of invasive hemodynamic monitoring in the treatment of acute heart failure?
When is invasive hemodynamic monitoring used to guide therapy for acute heart failure?
What is the role of monitoring in the management of acute heart failure?
Which implantable wireless hemodynamic monitoring system are FDA approved for acute heart failure?
What are the discharge criteria following treatment of acute heart failure?
What are the predischarge requirements for patients with acute heart failure?
What further care is required following treatment for acute heart failure?
What is the treatment approach for right ventricular (RV) heart failure?
What are the general measures for the management of right ventricular (RV) heart failure?
What are the precipitating factors for right ventricular (RV) heart failure?
What is the role of ACEI/ARB therapy in the treatment of right ventricular (RV) heart failure?
What is the role of inotropic therapy in the treatment of right ventricular (RV) heart failure?
When are anticoagulants indicated for the treatment of right ventricular (RV) heart failure?
When is atrial septostomy considered for the treatment of right ventricular (RV) heart failure?
What is the prognosis of right ventricular (RV) heart failure?
What are the electrophysiological interventions used to treat heart failure?
What is the role of biventricular pacemakers in the treatment of heart failure?
When are dual chamber pacemakers contraindicated in the management of heart failure?
How is cardiac resynchronization therapy (CRT) used in the treatment of heart failure?
What are the benefits of combined CRT-ICD for the treatment of heart failure?
When is cardiac resynchronization therapy (CRT) contraindicated in the treatment of heart failure?
What is the CRT techniques used in the treatment of heart failure?
What is the efficacy of combined CRT-ICD treatment for heart failure?
What is the role of carvedilol in the treatment of heart failure?
How does CRT affect mortality in patients with heart failure?
What decrease in mortality was seen from biventricular pacing in the treatment of heart failure?
What is a common cause of mortality in patients with heart failure?
What is the efficacy of biventricular pacing for the treatment of heart failure?
What is the efficacy of surgical revascularization for the treatment of heart failure?
What are the benefits of surgical revascularization in ischemic heart failure?
What is the efficacy of combined medical therapy and CABG for the treatment of heart failure?
In which patient groups is medical therapy alone effective for the treatment of heart failure?
What is the relationship between valvular heart disease and heart failure?
What is the relationship between diseases of the aortic valve and heart failure?
When is aortic valve replacement indicated in the treatment of heart failure?
What precautions should be taken when treating heart failure in patients with aortic valve disease?
In which patient group is valvular surgery recommended for the treatment of heart failure?
Which common symptom of aortic stenosis is a strong indicator of mortality from heart failure?
What is the age-corrected survival rate for heart failure following aortic valve replacement (AVR)?
Why is precise measurement of the aortic valve difficult in patients with heart failure?
How does surgical timing affect the survival in heart failure?
What the relationship between mitral valve regurgitation and heart failure?
What are the goals of mitral valve surgery in patients with heart failure?
What are the benefits of mitral valve repair for the treatment of heart failure?
What are the limitations of mitral valve repair in patients with heart failure?
What is the role of mitral regurgitation etiology in treatment selection for heart failure?
In which patients should mitral valve surgery be considered for the treatment of heart failure?
What is the role of annuloplasty in the treatment of heart failure?
What are the limitations of annuloplasty in the treatment of heart failure?
How is mitral valve replacement performed in the treatment of heart failure?
What is the role of percutaneous mitral valve repair in the treatment of heart failure?
What is the efficacy of percutaneous mitral valve repair in the treatment of heart failure?
What is the ventricular response to heart failure?
What is the goal of ventricular restoration following heart failure?
What is the role of the Batista procedure in the treatment of heart failure?
What is the focus of ventricular restoration following heart failure?
What are the benefits from ventricular restoration in the treatment of heart failure?
What is the efficacy of ventricular restoration in the treatment of heart failure?
What is the role of extracorporeal membrane oxygenation (ECMO) in the treatment of heart failure?
What is the role of ventricular assist devices in the treatment of heart failure?
How are ventricular assistive devices used in the treatment of heart failure?
What are the options for bridging patient with heart failure to recovery and transplantation?
What is efficacy of left ventricular assist devices (LVADs) in the treatment of heart failure?
Which types of ventricular assist devices (VADs) can be used by outpatients with heart failure?
How is class IV stage D heart failure treated?
What is the role of heart transplantation in the treatment of heart failure?
What are the benefits of heart transplantation for heart failure?
Which factors are critical for a good outcome following heart transplantation for heart failure?
What are the absolute indications for heart transplantation for treatment of heart failure?
What are the relative indications for heart transplantation for treatment of heart failure?
Which indications in isolation are not sufficient for heart transplantation to treat heart failure?
When is heart transplantation contraindicated for the treatment of heart failure?
Which treatments are not recommended by the HFSA for the treatment of heart failure?
How often is heart transplantation performed in the US?
What is the role of the total artificial heart (TAH) in the treatment of heart failure?
What are the advantages of the total artificial heart (TAH) in the treatment of heart failure?
Which artificial hearts (TAHs) are commercially available for the treatment of heart failure?
What is the SynCardia TAH for the treatment of heart failure?
What is the AbioCor TAH for the treatment of heart failure?
What are the limitations of the AbioCor TAH for the treatment of heart failure?
What surgery is required prior to implementation of TAHs for the treatment of heart failure?
How is the CARMAT TAH used in the treatment of heart failure?
What are the clinical applications of artificial-heart technology in the treatment of heart failure?
Guidelines
Who is the contributor for heart failure guidelines?
What is the Framingham classification of heart failure?
What are the major diagnostic criteria for heart failure?
What are the minor diagnostic criteria for heart failure?
What are the New York Heart Association (NYHA) functional classifications of heart failure?
What is the ACCF/AHA staging system for heart failure?
Which organizations have issued guidelines for the diagnosis and management of heart failure?
Which basic lab tests are recommended for the initial evaluation of suspected heart failure?
What are the guidelines for use of imaging studies in evaluation of suspected heart failure?
According to guidelines, which studies may be indicated in selected patients with heart failure?
What are the CCS/CHFS recommendations when cardiac amyloidosis is suspected?
When does the ACCF/AHA recommend a 6-minute walk test in the diagnosis of heart failure?
What are the guidelines for nonpharmacologic therapy of heart failure?
What are the treatment guidelines for chronic heart failure?
What is the purpose of patient education in the management of heart failure?
What are the dietary treatment guidelines for heart failure?
Which agents should be avoided by patients with heart failure?
When are angiotensin receptor blockers (ARBs) recommended in patients with chronic heart failure?
Which organizations have aligned their guidelines for pharmacologic therapy of heart failure?
What evidence is there for ARNIs and for SGLT2 inhibitors heart failure?
When is ivabradine recommended in the treatment of chronic heart failure?
What is the role of device therapy for heart failure?
What are the HFSA recommendations for the use of pacemakers in patients with heart failure?
When is cardiac resynchronization therapy (CRT) contraindicated in the treatment of heart failure?
For which patients with heart failure is revascularization recommended?
In which patients with heart failure is the benefit-risk balance of revascularization uncertain?
What are the ESC recommendations for valvular surgery in heart failure?
Which mechanical circulatory support (MCS) devices are available for the treatment of heart failure?
What are the HFSA recommended treatment goals for acute decompensated heart failure (ADHF)?
What is the aim of diuretic therapy for heart failure?
What are the recommended doses of diuretics for the treatment of heart failure?
When is beta-blocker therapy initiated in hospitalized patients with heart failure?
What are the recommendations for adjuvant treatment in heart failure?
What are the HFSA guidelines for invasive hemodynamic monitoring in patients with heart failure?
Medications
What are the goals of drug treatment for the treatment of heart failure?
What is the role of ivabradine (Corlanor) in the treatment of heart failure?
Which drugs should be avoided by patients with heart failure?
Which medications in the drug class SGLT2 Inhibitors are used in the treatment of Heart Failure?
Which medications in the drug class Diuretics, Other are used in the treatment of Heart Failure?
Which medications in the drug class Diuretics, Thiazide are used in the treatment of Heart Failure?
Which medications in the drug class Diuretics, Loop are used in the treatment of Heart Failure?
Which medications in the drug class I(f) Inhibitors are used in the treatment of Heart Failure?
Which medications in the drug class Nitrates are used in the treatment of Heart Failure?
Which medications in the drug class Vasodilators are used in the treatment of Heart Failure?
Which medications in the drug class Inotropic Agents are used in the treatment of Heart Failure?
Which medications in the drug class ARBs are used in the treatment of Heart Failure?
Which medications in the drug class ACE Inhibitors are used in the treatment of Heart Failure?
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Heart Failure. This chest radiograph shows an enlarged cardiac silhouette and edema at the lung bases, signs of acute heart failure.
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Heart Failure. Cardiac cirrhosis. Congestive hepatopathy with large renal vein.
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Heart Failure. Cardiac cirrhosis. Congestive hepatopathy with large inferior vena cava.
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Heart Failure. This electrocardiogram (ECG) is from a 32-year-old female with recent-onset congestive heart failure and syncope. The ECG demonstrates a tachycardia with a 1:1 atrial:ventricular relationship. It is not clear from this tracing whether the atria are driving the ventricles (sinus tachycardia) or the ventricles are driving the atria (ventricular tachycardia [VT]). At first glance, sinus tachycardia in this ECG might be considered with severe conduction disease manifesting as marked first-degree atrioventricular block with left bundle branch block. On closer examination, the ECG morphology gives clues to the actual diagnosis of VT. These clues include the absence of RS complexes in the precordial leads, a QS pattern in V6, and an R wave in aVR. The patient proved to have an incessant VT associated with dilated cardiomyopathy.
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Heart Failure. This is a posteroanterior view of a right ventricular endocardial activation map during ventricular tachycardia in a patient with a previous septal myocardial infarction. The earliest activation is recorded in red; late activation displays as blue to magenta. Fragmented low-amplitude diastolic local electrocardiograms were recorded adjacent to the earliest (red) breakout area, and local ablation in this scarred zone (red dots) resulted in termination and noninducibility of this previously incessant arrhythmia.
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Heart Failure. A 28-year-old woman presented with acute heart failure secondary to chronic hypertension. The enlarged cardiac silhouette on this anteroposterior (AP) radiograph is caused by acute heart failure due to the effects of chronic high blood pressure on the left ventricle. The heart then becomes enlarged, and fluid accumulates in the lungs (ie, pulmonary congestion).
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Heart Failure. Epsilon wave on an electrocardiogram in a patient with arrhythmogenic right ventricular dysplasia (ARVD). ARVD is a congenital cardiomyopathy that is characterized by infiltration of adipose and fibrous tissue into the RV wall and loss of myocardial cells. Primary injuries usually are at the free wall of the RV and right atria, resulting in ventricular and supraventricular arrhythmias. The most significant of all rhythms associated with heart failure are the life-threatening ventricular arrhythmias.
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Heart Failure. Electrocardiogram depicting ventricular fibrillation in a patient with a left ventricular assist device (LVAD). Ventricular fibrillation is often due to ischemic heart disease and can lead to myocardial infarction and/or sudden death.
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Heart Failure. The rhythm on this electrocardiogram (ECG) is sinus with borderline PR prolongation. There is evidence of an acute/evolving anterior ischemia/myocardial infarction (MI) superimposed on the left bundle branch block (LBBB)–like pattern. Note the primary T-wave inversions in leads V2-V4, rather than the expected discordant (upright) T waves in the leads with a negative QRS. Although this finding is not particularly sensitive for ischemia/MI with LBBB, such primary T-wave changes are relatively specific. The prominent voltage with left atrial abnormality and leftward axis in concert with the left ventricular intraventricular conduction delay (IVCD) are consistent with underlying left ventricular hypertrophy. This ECG is an example of "bundle branch block plus." Image courtesy of http://ecg.bidmc.harvard.edu.
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Heart Failure. This electrocardiogram (ECG) shows evidence of severe left ventricular hypertrophy (LVH) with prominent precordial voltage, left atrial abnormality, lateral ST-T abnormalities, and a somewhat leftward QRS axis (–15º). The patient had malignant hypertension with acute heart failure, accounting also for the sinus tachycardia (blood pressure initially 280/180 mmHg). The ST-T changes seen here are nonspecific and could be due to, for example, LVH alone or coronary artery disease. However, the ECG is not consistent with extensive inferolateral myocardial infarction. Image courtesy of http://ecg.bidmc.harvard.edu.
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Heart Failure. The rhythm on this electrocardiogram is atrial tachycardia (rate, 154 beats/min) with a 2:1 atrioventricular (AV) block. Note the partially hidden, nonconducted P waves on the ST segments (eg, leads I and aVL). The QRS is very wide with an atypical intraventricular conduction defect (IVCD) pattern. The rSR' type complex in the lateral leads (I, aVL) is not due to a right bundle branch block (RBBB) but to an atypical left ventricular conduction defect. These unexpected rSR' complexes in the lateral leads (El-Sherif sign) correlate with underlying extensive myocardial infarction (MI) and, occasionally, ventricular aneurysm. (El-Sherif. Br Heart J. 1970;32:440-8.) The notching on the upstroke of the S waves in lead V4 with a left bundle branch block-type pattern also suggests underlying MI (Cabrera sign). This patient had severe cardiomyopathy secondary to coronary artery disease, with extensive left ventricular wall motion abnormalities. Image courtesy of http://ecg.bidmc.harvard.edu.
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Heart Failure. On this electrocardiogram, baseline artifact is present, simulating atrial fibrillation. Such artifact may be caused by a variety of factors, including poor electrode contact, muscle tremor, and electrical interference. A single premature ventricular complex (PVC) is present with a compensatory pause such that the RR interval surrounding the PVC is twice as long as the preceding sinus RR interval. Evidence of a previous anterior myocardial infarction is present with pathologic Q waves in leads V1-V3. Borderline-low precordial voltage is a nonspecific finding. Cardiac catheterization showed a 90% stenosis in the patient's proximal portion the left anterior descending coronary artery, which was treated with angioplasty and stenting. Broad P waves in lead V1 with a prominent negative component is consistent with a left atrial abnormality. Image courtesy of http://ecg.bidmc.harvard.edu.
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Heart Failure. This electrocardiogram (ECG) is from a patient who underwent urgent cardiac catheterization, which revealed diffuse severe coronary spasm (most marked in the left circumflex system) without any fixed obstructive lesions. Severe left ventricular wall motion abnormalities were present, involving the anterior and inferior segments. A question of so-called takotsubo cardiomyopathy (left ventricular apical ballooning syndrome) is also raised (see Bybee et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Int Med 2004:141:858-65). The latter is most often reported in postmenopausal, middle-aged to elderly women in the context of acute emotional stress and may cause ST elevations acutely with subsequent T-wave inversions. A cocaine-induced cardiomyopathy (possibly related to coronary vasospasm) is a consideration but was excluded here. Myocarditis may also be associated with this type of ECG and the cardiomyopathic findings shown here. No fixed obstructive epicardial coronary lesions were detected by coronary arteriography. The findings in this ECG include low-amplitude QRS complexes in the limb leads (with an indeterminate QRS axis), loss of normal precordial R-wave progression (leads V1-V3), and prominent anterior/lateral T-wave inversions. Image courtesy of http://ecg.bidmc.harvard.edu.
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Heart Failure. This electrocardiogram shows an extensive acute/evolving anterolateral myocardial infarction pattern, with ST-T changes most apparent in leads V2-V6, I, and aVL. Slow R-wave progression is also present in leads V1-V3. The rhythm is borderline sinus tachycardia with a single premature atrial complex (PAC) (fourth beat). Note also the low limb-lead voltage and probable left atrial abnormality. Left ventriculography showed diffuse hypokinesis as well as akinesis of the anterolateral and apical walls, with an ejection fraction estimated at 33%. Image courtesy of http://ecg.bidmc.harvard.edu.
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Heart Failure. This electrocardiogram shows a patient is having an evolving anteroseptal myocardial infarction secondary to cocaine. There are Q waves in leads V2-V3 with ST-segment elevation in leads V2-V5 associated with T-wave inversion. Also noted are biphasic T waves in the inferior leads. These multiple abnormalities suggest occlusion of a large left anterior descending artery that wraps around the apex of the heart (or multivessel coronary artery disease). Image courtesy of http://ecg.bidmc.harvard.edu.
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Heart Failure. A color-enhanced angiogram of the left heart shows a plaque-induced obstruction (top center) in a major artery, which can lead to myocardial infarction (MI). MIs can precipitate heart failure.
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Heart Failure. Emphysema is included in the differential diagnosis of heart failure. In this radiograph, emphysema bubbles are noted in the left lung; these can severely impede breathing capacity.
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Heart Failure. Cervicocephalic fibromuscular dysplasia (FMD) can lead to complications such as hypertension and chronic kidney failure, which can lead to heart failure. In this color Doppler and spectral Doppler ultrasonographic examination of the left internal carotid artery (ICA) in a patient with cervicocephalic FMD, stenoses of about 70% is seen in the ICA.
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Heart Failure. Cervicocephalic fibromuscular dysplasia (FMD) can lead to complications such as hypertension and chronic kidney failure, which, in turn, can lead to heart failure. Nodularity in an artery is known as the "string-of-beads sign," and it can be seen this color Doppler ultrasonographic image from a 51-year-old patient with low-grade stenosing FMD of the internal carotid artery (ICA).
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Heart Failure. Electrocardiogram from a 46-year-old man with long-standing hypertension. Note the left atrial abnormality and left ventricular hypertrophy with strain.
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Heart Failure. Electrocardiogram from a 46-year-old man with long-standing hypertension. Left atrial abnormality and left ventricular hypertrophy with strain is revealed.
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Heart Failure. Apical four-chamber echocardiogram in a 37-year-old man with arrhythmogenic right ventricular dysplasia (ARVD), a congenital cardiomyopathy. Note the prominent trabeculae and abnormal wall motion of the dilated RV. ARVD can result in ventricular and supraventricular arrhythmias. The most significant of all rhythms associated with heart failure are the life-threatening ventricular arrhythmias.
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Heart Failure. Cardiac magnetic resonance image (CMRI), short-axis view. This image shows right ventricular (RV) dilatation, trabucular derangement, aneurysm formation, and dyskinetic free wall in a patient with arrhythmogenic RV dysplasia.
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Heart Failure. This transthoracic echocardiogram demonstrates severe mitral regurgitation with a heavily calcified mitral valve and prolapse of the posterior leaflet into the left atrium.
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Heart Failure. Echocardiogram of a patient with severe pulmonic stenosis. This image shows a parasternal short-axis view of a thickened pulmonary valve. Pulmonic stenosis can lead to pulmonary hypertension, which can result in hepatic congestion and in right-sided heart failure.
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Heart Failure. Echocardiogram of a patient with severe pulmonic stenosis. This image shows a Doppler scan of the peak velocity (5.2 m/s) and gradients (peak 109 mmHg, mean 65 mmHg) across the valve.
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Heart Failure. Echocardiogram of a patient with severe pulmonic stenosis. This image shows moderately severe pulmonary insufficiency (orange color flow) is also present.
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Heart Failure. This video is an echocardiogram of a patient with severe pulmonic stenosis. The first segment shows the parasternal short-axis view of the thickened pulmonary valve. The second segment shows the presence of moderate pulmonary insufficiency (orange color flow). AV = aortic valve, PA = pulmonary artery, PI = pulmonary insufficiency, PV = pulmonary valve.
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Heart Failure. Transesophageal echocardiogram with continuous wave Doppler interrogation across the mitral valve. An increased mean gradient of 16 mmHg is revealed, consistent with severe mitral stenosis.
Tables
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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Nonpharmacologic Therapy
- Pharmacologic Therapy
- Acute Heart Failure Treatment
- Treatment of Heart Failure with Preserved LVEF
- Treatment of Right Ventricular Heart Failure
- Electrophysiologic Intervention
- Revascularization Procedures
- Valvular Surgery
- Ventricular Restoration
- Extracorporeal Membrane Oxygenation
- Ventricular Assist Devices
- Heart Transplantation
- Total Artificial Heart
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- Guidelines
- Guidelines Summary
- Screening and Genetic Testing
- Diagnostic Procedures
- Nonpharmacologic Therapy
- Pharmacologic Therapy
- Electrophysiologic Intervention
- Revascularization Procedures
- Valvular Surgery
- Mechanical Circulatory Support Devices
- Heart Transplantation
- Management of Acute Decompensated Heart Failure (ADHF)
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- Medication
- Medication Summary
- Beta-Blockers, Alpha Activity
- Beta-Blockers, Beta-1 Selective
- ACE Inhibitors
- ARBs
- Inotropic Agents
- Vasodilators
- Nitrates
- B-type Natriuretic Peptides
- I(f) Inhibitors
- Angiotensin Receptor-Neprilysin Inhibitors (ARNi)
- Diuretics, Loop
- Diuretics, Thiazide
- Diuretics, Other
- Diuretics, Potassium-Sparing
- Aldosterone Antagonists, Selective
- SGLT2 Inhibitors
- Dual SGLT1/2 Inhibitors
- Soluble Guanylate Cyclase Stimulators
- Alpha/Beta Adrenergic Agonists
- Calcium Channel Blockers
- Anticoagulants, Cardiovascular
- Opioid Analgesics
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- Questions & Answers
- Media Gallery
- Tables
- References