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Heart failure (HF) affects over 6 million Americans and is the leading cause of hospitalization in adults over 65. It represents a clinical syndrome of impaired cardiac output or elevated filling pressures causing symptoms of dyspnea, fatigue, and fluid retention.
Heart failure is classified by ejection fraction: HFrEF (EF <40%), HFmrEF (EF 40-49%), and HFpEF (EF ≥50%). In HFrEF, loss of contractile myocardium activates neurohormonal pathways (RAAS, SNS) that initially compensate but ultimately cause maladaptive cardiac remodeling. In HFpEF, increased myocardial stiffness impairs diastolic filling. Pulmonary venous congestion causes dyspnea; systemic venous congestion causes edema, hepatomegaly, and ascites.
Clinical reasoning differentiates HF from other causes of dyspnea (PE, COPD exacerbation, pneumonia) using BNP/NT-proBNP (highly sensitive), chest X-ray (cardiomegaly, pulmonary vascular congestion, pleural effusions), and echocardiography. GDMT for HFrEF includes ACE inhibitors/ARBs/ARNIs, beta-blockers, MRAs, and SGLT2 inhibitors — each with mortality benefit. Acute decompensated HF management prioritizes diuresis and afterload reduction. Identifying the precipitant (arrhythmia, medication non-adherence, ACS, infection) is essential.
Key imaging focus: Cephalization, Kerley B lines, bat-wing edema, cardiomegaly; echo for EF
Common clinical reasoning questions about this topic
HFrEF (ejection fraction <40%) involves impaired systolic contraction, while HFpEF (EF ≥50%) involves impaired diastolic relaxation with preserved contractility. HFmrEF (40-49%) is a borderline category. Treatment differs significantly — GDMT with proven mortality benefit applies primarily to HFrEF.
Guideline-directed medical therapy for HFrEF includes: ACE inhibitor/ARB/ARNI (sacubitril-valsartan preferred), beta-blocker (carvedilol, metoprolol succinate, bisoprolol), mineralocorticoid receptor antagonist (spironolactone, eplerenone), and SGLT2 inhibitor (dapagliflozin, empagliflozin) — each with independent mortality benefit.
Common precipitants include medication or dietary non-adherence (excess sodium/fluid), arrhythmias (especially new AFib), myocardial ischemia, infection/sepsis, uncontrolled hypertension, and pulmonary embolism. Identifying and treating the precipitant is essential alongside diuresis.