Page 3 - The 5-Minute Clinical Consult 2021 29th Edition

Patients with systolic dysfunction may also have diastolic dysfunction.
Most common etiologies: coronary artery disease (CAD)/MI and hypertension (HTN)
Myocarditis and CM: alcoholic, viral, long-standing HTN, drugs (e.g., chemotherapeutic
agents), muscular dystrophy, infiltrative (e.g., amyloidosis, sarcoidosis), postpartum state,
infectious (e.g., Chagas disease, HIV), hypertrophic CM (HCM), inherited familial dilated
CM, left ventricular (LV) noncompaction
Valvular and vascular abnormalities: any valvular stenosis or regurgitation, rheumatic heart;
renal artery stenosis, usually bilateral, may cause recurrent “flash” pulmonary edema,
especially in setting of severe chronic HTN.
Chronic lung disease and pulmonary HTN (cor pulmonale)
Iatrogenic volume overload (requires extreme overload in patients with normal hearts and
kidneys)
Arrhythmias (atrial fibrillation and other tachyarrhythmias, high-grade heart block, frequent
PVCs)
Miscellaneous: high-output states: hyperthyroidism, anemia; cardiac depressants (β-blocker
overdose), stress induced
Idiopathic: 20–50% of idiopathic dilated cardiomyopathies are familial.
HF is progressive—manifested by the remodeling (altered heart geometry) process.
Genetics
Multiple genetic abnormalities responsible for a variety of phenotypes have been identified
(HCM, arrhythmogenic right ventricular [RV] dysplasia, LV noncompaction, dilated CM).
Consider genetic screening for first-degree relatives of HCM and arrhythmogenic RV dysplasia.
RISK FACTORS
For development of HF: CAD/MI, HTN (80% of cases of HF in the United States caused by
either CAD or HTN), valvular heart disease, diabetes mellitus, cardiotoxic medications (e.g.,
anthracyclines, tyrosine-kinase inhibitors, tumor necrosis factor-α inhibitors), obesity, older age
GENERAL PREVENTION
Control HTN and other risk factors. Thiazide diuretics and angiotensin-converting enzyme
inhibitors (ACE-I) are superior to other agents in preventing development of HF.

COMMONLY ASSOCIATED CONDITIONS
Sudden cardiac death and progressive pump failure are the leading causes of death. Most patients
have >5 comorbid medical conditions and take >5 medications.

DIAGNOSIS

HISTORY
Dyspnea on exertion: cardinal sign of left-sided HF. Deteriorating exercise capacity: easy
fatigued, general weakness
Nocturnal nonproductive cough, orthopnea, and paroxysmal nocturnal dyspnea; sometimes
frothy or pink sputum. Wheezing, especially nocturnal, in absence of history of asthma or
infection (cardiac asthma); Cheyne-Stokes respirations
Anorexia and/or fullness or dull pain in right upper quadrant (hepatic congestion). Nausea and
poor appetite may indicate advanced HF.