Heart Failure

Sheldon Gottlieb, M.D.


  • Heart failure (HF) definition: the heart, when functioning at a normal filling pressure, is unable to pump enough blood to meet the needs of the body; this leads to maladaptive responses including volume overload (congestion) and ventricular remodeling, shortness of breath and fatigue, and an increased risk of sudden death; these signs and symptoms comprise the syndrome of heart failure.
  • Congestive heart failure ("CHF") is a less-preferred term for HF, in which symptoms and signs of congestion predominate. Most patients with HF do not have clinical signs of congestion (although BNP/ProBNP levels may be elevated, see below) ([4]page 25).
  • Systolic HF: also called heart failure with reduced ejection fraction (HFrEF), when ejection fraction (EF) < 45%
  • Diastolic HF: also called HF with preserved EF (HFpEF), when HF occurs with EF ≥ 45%
  • Chronic HF: usually treated as an outpatient
  • Acute decompensated HF: a medical emergency usually requiring hospitalization.
  • Advanced HF: when symptoms that limit normal daily activities persist despite appropriate treatment.


  • Incidence and prevalence of HF increase exponentially with age; at age 60, prevalence about 1%; by age 80, about 10%. Persons >age 40 have 20% lifetime risk of HF.
  • HF is the most frequent reason for hospital admission and readmission in patients older than 65 years; most HF patients have >5 comorbid problems.
  • Treatment of HF consumes 1-3% of the total health care budget in developed countries. Direct costs projected to more than double over next 20 years due to aging of the population.[5]
  • Annual hospitalization rates in U.S. about 200 per 10,000 population; patients with chronic HF hospitalized 1 or 2 times per year on average, even with excellent care.
  • 5 year mortality for HF higher than for breast or colon cancer.
  • Diabetes increases risk of developing HF about 2 fold in men and up to 5 fold in women.
  • Hypertension and coronary heart disease, often in association with diabetes or metabolic syndrome, are most common etiologies of HF in developed countries. Rheumatic heart disease and cardiomyopathy due to infection (Chaga’s disease in South America), HIV, or malnutrition with vitamin deficiency (Beri Beri) are frequent causes in developing countries.
  • Strong association of smoking with HF.


  • HF is a clinical syndrome, not a disease. Need to establish the underlying cause of HF; this may require repeated investigations.
  • History of shortness of breath/fatigue and signs of congestion suggest but do not necessarily make diagnosis of HF. See below.
  • Diagnostic tests: EKG (arrhythmia, LVH, ischemia), chest x-ray (heart size and shape, cardiothoracic ratio >0.5, pulmonary congestion), echocardiogram (regional and overall cardiac function, cardiomyopathy, valvular heart disease, pericardial disease, tumors) and blood tests for natriuretic peptides, BNP and ProBNP.
  • BNP and ProBNP have a very high negative predictive value: normal values rule out diagnosis of HF. High values still require "clinical correlation" (see below), do not differentiate between HF due to systolic or diastolic dysfunction. Normal values and cut points for HF diagnosis depend on age and renal function[3]. Obesity with insulin resistance is associated with lower values of BNP and ProBNP[7].
  • Troponin I frequently elevated in acute decompensated HF even without coronary heart disease, due to subendocardial ischemia caused by markedly elevated left ventricular end diastolic pressure.
  • Association of hemoglobin A1C with mortality in HF may be U-shaped, with lowest mortality among those with fair glycemic control (A1C = 7.1 to 7.8 %)[10].
  • Cardiac catheterization should be done for heart failure thought to be due to CAD or when etiology is not determined by non-invasive testing.
  • Clinical suspicion guides screening for less common causes of HF: hemochromatosis, sarcoidosis, amyloidosis, HIV infection, thyroid disease (hyper or hypo), pheochromocytoma, rheumatological diseases, nutritional deficiencies (eg, thiamine), sleep apnea[4]


  • Common presenting symptoms are: dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, weakness, exercise intolerance, dependent edema, cough, weight gain, abdominal distension ("belly bloat"), nocturia, cool extremities.
  • Less common presentations include: cognitive impairment, altered mentation or delirium, nausea, abdominal discomfort, oliguria, anorexia, cyanosis. See table 2 in Arnold, 2006[4]. Nocturnal cough typically precedes decompensated HF by 7 to 14 days.
  • Boston criteria see Table Boston criteria for congestive heart failure below.
  • Patients with compensated HF frequently have no signs of congestion ("Warm-Dry patients" when cardiac output at rest is normal, "Cold-Dry patients" when cardiac output at rest is low)[14].
  • BNP/ProBNP levels are useful when diagnosis uncertain, especially in setting of advanced pulmonary disease, and for prognosis when levels are followed serially[13].
  • Caveat: Obesity with insulin resistance is associated with lower values of BNP/ProBNP.
  • Functional capacity classes: 1 very active, 2 moderately active, 3 sedentary, 4 very sedentary or bed rest. See Veterans Specific Activity Questionnaire[16]; New York Heart Association Classification:
  1. No symptoms
  2. Symptoms with ordinary activity
  3. Symptoms with less than ordinary activity -- may require assistance to bathe and dress
  4. Symptoms at rest
  • Delirium is frequently seen in elderly patients with acutely decompensated chronic HF; when HF becomes compensated, elderly often are found to have cognitive impairment.
  • Older patients often present with acute decompensated HF due to pneumonia, sepsis, myocardial infarction, or acute arrhythmias such as atrial fibrillation.
  • Valvular heart disease, most frequently aortic stenosis, is a frequent cause of HF in elderly patients who also have coronary heart disease and diabetes.
  • Clinical course of chronic HF: often a slow and clinically imperceptible progression with episodes of acute decompensation. Patients with HF die suddenly or from end-stage HF with organ failure, in about equal proportions.
  • Frail elderly patients frequently have delirium with decompensated HF and cognitive impairment when HF is compensated[3].
Boston criteria for congestive heart failure



Category I: History

Rest dyspnea




Paroxysmal nocturnal dyspnea


Dyspnea on walking on level


Dyspnea on climbing


Category II: Physical examination

Heart rate abnormality (if 91- 110 beats/min, 1 point;
if >110 beats/min. 2 points)


Jugular-venous pressure elevation (if >6 cm H20, 2 points; if >6 cm H20 plus
hepatomegaly or edema, 3 points)


Lung crackles (if basilar, 1 point; if more than basilar, 2 points)




Third heart sound


Category III: Chest radiography

Alveolar pulmonary edema


Interstitial pulmonary edema


Bilateral pleural effusions


Cardiothoracic ratio >0.50
(posteroanterior projection)


Upper zone flow redistribution


A No more than 4 points were allowed from each of three categories,
and hence the composite score, the sum of the subtotal from each
category, had a maximum possible of 12 points. The diagnosis of heart
failure was classified definite for a score of 8 to 12 points, possible for a
score of to 7 points, and unlikely for a score of 4 points or less.[17]


  • Treat symptoms due to congestion, then find and treat precipitating causes and underlying causes of HF.
  • Acute decompensated HF with diuretics, oxygen, sitting position; morphine IV is often useful to relieve agitation due to dyspnea.
  • Acute decompensated HF in the elderly often due to infection or sepsis with associated demand ischemia; in younger patients, often due to accelerated hypertension or myocardial infarction.
  • Chronic HF: Dietary sodium and fluid restriction is usually recommended in chronic HF, but limited evidence. "Moderate" dietary sodium restriction (2 g/daily) is reasonable. Fluid restriction (1500 ml/day) perhaps in patients with hyponatremia (sodium < 135 mmol/l); hyponatremia itself is a cardinal sign of advanced heart failure and most heart failure patients have both excess fluid and sodium that is not relieved by fluid restriction. Diet: high fiber, whole grains, fruits and vegetable, polyunsaturated fats, protein, low saturated fat, seasonings other than table salt, and moderate alcohol use (Mediterranean diet) is recommended. Check weight daily with individualized instructions to adjust diuretic dose or to be seen in clinic based on pattern of weight change.
  • Systolic HF is treated with diuretics, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBS), beta blockers, aldosterone blockers, digitalis, and statins when ischemic heart disease is present. Control heart rate and blood pressure; Diuretics, beta blockers, and ACE/ARBS are the cornerstone of treatment.
  • Diastolic HF often seen in obese patients and those with type 2 diabetes, frequently with sleep apnea.Treatment: diuretics for control of congestion, treat blood pressure, heart rate, lipids and hyperglycemia; CPAP for sleep apnea.
  • Strongly evidence-based treatment is available for systolic HF; less evidence to guide treatment of diastolic HF -- diuretics and renin-angiotensin blockers improve symptoms. (Table Evidence-based drugs and oral doses as shown in large clinical trials and Figure, provided below).
  • Insulin causes sodium retention[6] and may cause volume overload and decompensated HF in patients with type 2 diabetes, especially when insulin is started at relatively high doses. Patients with HF started on insulin should follow a sodium controlled diet. A1C goals 7-8%.
  • Metformin often discontinued with HF out of concern for lactic acidosis; but evidence is scanty. One prospective trial (Roberts) found reduced mortality in diabetic patients treated with metformin. FDA has removed the Black Box Warning for metformin in HF. Therefore, if normal renal function (GFR > 60 ml/min), metformin may safely be continued.

Figure Permission from Pulsus Group Inc.

Evidence-based drugs and oral doses as shown in large clinical trials


Start dose

Target dose

ACE inhibitor


6.25 mg to 12.5 mg three times a day

25 mg to 50 mg three times a day


1.25 mg to 2.5 mg twice daily

10 mg twice daily


1.25 mg to 2.5 mg twice daily

5 mg twice daily*


2.5 mg to 5 mg once a day

20 mg to 35 mg once a day



3.125 mg twice daily

25 mg twice daily


1.25 mg once a day

10 mg once a day

Metoprolol CR/XL+

12.5 mg to 25 mg once a day

200 mg once a day



4 mg once a day

32 mg every day


40 mg twice daily

160 mg twice daily

Aldosterone antagonist


12.5 mg every day

50 mg once a day


25 mg every day

50 mg once a day


Isosorbide dinitrate

20 mg three times a day

40 mg three times a day


37.5 mg three times a day

75 mg three times a day

*The Healing and Early Afterload Reducing Therapy (HEART) trial (165) showed that 10 mg once a day was effective for attenuating left ventricular remodelling;
+ Not available in Canada. ACE Angiotensin-converting enzyme; ARB Angiotensin receptor blocker; bid Twice a day; CR/XL Controlled release/extended release; tid Three times a day
Permission from Pulsus Group Inc.

  • Thiazolidinediones are associated with HF with a hazard ratio of about 2:1; as above, do not use in patients with a history of HF.
  • HF due to valvular heart disease usually requires surgical repair or replacement of the valve. Timing requires clinical experience and consultation with a cardiologist.
  • Pacemaker re-synchronization useful for some patients with systolic dysfunction HF and left bundle branch block or wide QRS complexes. Recent studies provide evidence of better outcome with resynchronization pacemaker therapy for moderate HF.
  • Patients who smoke cigarettes should be strongly advised to stop smoking.
  • Heavy alcohol use associated with poor outcomes in HF. Moderate alcohol use (1 drink/day in women, 1-2 drinks/day in men) associated in most studies with decreased risk and improved outcomes in HF.


  • Acute decompensated HF is a medical emergency requiring hospitalization.
  • Chronic HF requires frequent outpatient follow up; optimally, a team that includes physician, nurse, nutritionist, CDE and pharmacist.
  • Important to determine and maintain the patient’s "dry weight" (weight at which signs of congestion have resolved but BP control and renal function are not impaired).
  • Observe jugular venous pressure at every visit: patient lying supine at 45 degrees, jugular venous pressure should be just at the clavicle, or about 12 to 15 cm vertically from the sternal angle.
  • Specific treatment goals, for patients with systolic HF: sodium 135 - 145 mmol/l, potassium 4.5 mmol/l, HR 55 to 70 bpm at rest, BP < 140/90 or as tolerated by symptoms of orthostasis, weight at "dry weight", hematocrit > 34%.


  • Patients with diabetes and HF require frequent follow up. If possible, care should not be fragmented between Cardiology, Endocrinology and Internal medicine. "Team Care" has repeatedly been shown to be effective for patients with HF. They may require monthly office visits with "open access" if there are any concerns regarding progression of symptoms.
  • Examine elderly patients who complain of feeling unwell for signs of HF and measure BNP/ProBNP.
  • Maintaining the patient at their "dry weight" is essential. The patient must know their "dry weight" and must weigh themselves daily.
  • Many guidelines, including Arnold[4] recommend A1c goal of < 7%, but the ideal A1c for patients with diabetes and HF may be slightly above 7%[10].
  • Flu shots and pneumonia vaccination must be kept current.
  • Treatment for advanced HF is essentially palliative care. End of life issues must be discussed with the patient and their family or significant others[8].

Basis for recommendation

  1. Howlett JG, McKelvie RS, Arnold JM, et al. Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials. Can J Cardiol. 2009;25(2):85-105.  [PMID:19214293]

    Comment: Part 3 of the Canadian Cardiovascular Society review of HF. All 3 are beautifully written, concise guides to the science and art of treating patients who have HF.

  2. Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53(15):e1-e90.  [PMID:19358937]

    Comment: Authoritative review. Lengthy, not easy to read.

  3. Arnold JM, Howlett JG, Dorian P, et al. Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: Prevention, management during intercurrent illness or acute decompensation, and use of biomarkers. Can J Cardiol. 2007;23(1):21-45.  [PMID:17245481]

    Comment: Concise and beautifully written, many clinical pearls; Detailed advice re: when and how to use biomarkers to diagnose and treat HF. Review of use of metformin in HF is outstanding. They recommend an A1C goal of <7 for patients with diabetes and heart failure. See "expert comments" above for criticism of this goal.

  4. Arnold JM, Liu P, Demers C, et al. Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management. Can J Cardiol. 2006;22(1):23-45.  [PMID:16450016]

    Comment: Concise and beautifully written; The tables and figures are all well prepared and contain clinical pearls.


  1. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the Impact of Heart Failure in the United States: A Policy Statement From the American Heart Association. Circ Heart Fail. 2013.  [PMID:23616602]
  2. Brands MW, Manhiani MM. Sodium-retaining effect of insulin in diabetes. Am J Physiol Regul Integr Comp Physiol. 2012;303(11):R1101-9.  [PMID:23034715]
  3. Khan AM, Cheng S, Magnusson M, et al. Cardiac natriuretic peptides, obesity, and insulin resistance: evidence from two community-based studies. J Clin Endocrinol Metab. 2011;96(10):3242-9.  [PMID:21849523]
  4. Bekelman DB, Nowels CT, Retrum JH, et al. Giving voice to patients' and family caregivers' needs in chronic heart failure: implications for palliative care programs. J Palliat Med. 2011;14(12):1317-24.  [PMID:22107107]
  5. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes (RECORD): a multicentre, randomised, open-label trial. Lancet. 2009;373(9681):2125-35.  [PMID:19501900]

    Comment: Thiazolidinediones must be used with great caution, if at all, in patients with HF. See also Arnold 2007
    Rating: Important

  6. Aguilar D, Bozkurt B, Ramasubbu K, et al. Relationship of hemoglobin A1C and mortality in heart failure patients with diabetes. J Am Coll Cardiol. 2009;54(5):422-8.  [PMID:19628117]

    Comment: Demonstration of "U-shaped curve" of A1C levels in HF.
    Rating: Important

  7. Noyes K, Corona E, Veazie P, et al. Examination of the effect of implantable cardioverter-defibrillators on health-related quality of life: based on results from the Multicenter Automatic Defibrillator Trial-II. Am J Cardiovasc Drugs. 2009;9(6):393-400.  [PMID:19929037]

    Comment: Important review of use of device therapy in HF

  8. Roberts F, Ryan GJ. The safety of metformin in heart failure. Ann Pharmacother. 2007;41(4):642-6.  [PMID:17374622]

    Comment: Important review.
    Rating: Important

  9. Doust JA, Pietrzak E, Dobson A, et al. How well does B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review. BMJ. 2005;330(7492):625.  [PMID:15774989]

    Comment: Biomarkers have become essential tools in the diagnosis and management of HF.

  10. Nohria A, Tsang SW, Fang JC, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41(10):1797-804.  [PMID:12767667]

    Comment: Study of utility of clinical assessment of 4 different profiles of perfusion-congestion in HF patients.

  11. Davis RC, Hobbs FD, Lip GY. ABC of heart failure. History and epidemiology. BMJ. 2000;320(7226):39-42.  [PMID:10617530]

    Comment: First of a 10 part series on HF in the British Medical Journal. The presentation is outstanding; still a very useful series of articles.
    Rating: Important

  12. Myers J, Do D, Herbert W, et al. A nomogram to predict exercise capacity from a specific activity questionnaire and clinical data. Am J Cardiol. 1994;73(8):591-6.  [PMID:8147307]

    Comment: The Veterans Specific Activity Scale quickly and accurately estimates exercise capacity.
    Rating: Important

  13. Marantz PR, Tobin JN, Wassertheil-Smoller S, et al. The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria. Circulation. 1988;77(3):607-12.  [PMID:3342491]

    Comment: Presentation of the "Boston Criteria" for diagnosis of heart failure



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Last updated: May 22, 2013