Congestive heart failure causes

Congestive Heart Failure Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

There are several general causes of heart failure. Heart failure may be of pericardial origin such as tamponade and pericardial constriction, of valvular origin such as aortic or mitral regurgitation; of myocardial origin such as idiopathic dilated cardiomyopathy, familial dilated cardiomyopathy, ischemic cardiomyopathy, valvular heart disease; or of coronary vascular origin such as acute ischemic episodes, and rhythm disturbances such as tachycardia-induced heart failure. Other common secondary causes include anemia, obesity,drugs [(such as first generation calcium channel blockers, disopyramide, and sotalol, NSAIDs (may cause fluid retention), beta blockers (may cause heart failure with their negative inotropic effects)].

General Classification of Causes of Heart Failure

There are several classification schemes used to characterize the pathophysiology of heart failure as either systolic vs diastolic; left vs right; or low output vs high output. The anatomic structure underlying the disease process is often characterized as well.

Underlying Anatomic Abnormalities Causing Heart Failure

Heart failure may result from an abnormality of any one of the anatomical structures of the heart:

• Pericardium
• Myocardium
• Endocardium
• Valvular heart disease or
• Disorders of the great vessels (e.g. pulmonary hypertension)

Systolic versus Diastolic Heart Failure

Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation

Systolic Dysfunction

The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.

Disastolic Dysfunciton

The left ventricular ejection fraction is preserved in diastolic dysfunction and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

Left, Right and Biventricular Failure

Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).

Left Heart Failure

• There is impaired left ventricular function with reduced flow into the aorta.

Right Heart Failure

• There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.

Biventricular Failure

• The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

High Output Versus Low Output Failure

Low Output Failure

• The cardiac output is reduced, and the systemic vascular resistance (SVR) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.

High Output Failure

• The cardiac output is increased, and the systemic vascular resistance (SVR) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide. Causes of high output heart failure include severe anemia, Gram negative septicaemia, beriberi (vitamin B₁/thiamine deficiency), thyrotoxicosis, Paget's disease, arteriovenous fistulae, or arteriovenous malformations.

Causes of Acute or Decompensated Heart Failure

Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, or a patient's failure to maintain a fluid restriction, diet, or medication. Other well recognized precipitating factors include anemia and hyperthyroidism which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs and thiazolidinediones, may also precipitate decompensation.

Differential Diagnosis of the Underlying Causes of Chronic Heart Failure

Cardiomyopathies and Inflammatory Diseases

Restrictive Cardiomyopathies

• Primary (idiopathic)
• Tumor infiltration
• Amyloidosis
• Storage diseases
• Endocardial fibrosis
• Anthracyclines
• Eosinophilic heart disease
• Radiation
• Hemochromatosis
• Cardiac transplant
• Sarcoidosis

Dilated Cardiomyopathies

• Duchenne muscular dystrophy
• Becker's muscular dystrophy
• Limb-girdle muscular dystrophy
• Mitochondrial myopathy

  • Kearns-Sayre syndrome

• Arrhythmogenic right ventricular dysplasia
• Alcohol-Induced cardiomyopathy
• Cocaine related cardiomyopathy
• Diabetic cardiomyopathy
• Peripartum cardiomyopathy
• Anthracycline induced cardiomyopathy
• Trastuzumab Herceptin-lnduced Cardiomyopathy

Inflammations

• Viral Myocarditis
• Rickettsial Myocarditis
• Bacterial Myocarditis
• Spirochetal Infections
• Protozoal Myocarditis: Trypanosomiasis (Chagas Disease)
• Fungal myocarditis
• Giant Cell Myocarditis
• Sarcoidosis

Congestive Heart Failure as a Consequence of Valvular Heart Disease

• Aortic stenosis with Left Ventricular Systolic Dysfunction
• Chronic aortic regurgitation
• Mitral Stenosis
• Chronic mitral regurgitation
• Acute aortic regurgitation
• Acute mitral regurgitation

Congestive Hert Failure Secondary to Congenital Heart Disease

A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases

• Eisenmenger's syndrome
• Fibrocalcific degeneration of abnormal aortic valve
• Systemic ventricular dysfunction and/or tricuspid regurgitation in congenitally corrected transposition of the great arteries
• Atrial septal defect with mitral regurgitation] secondary to myxomatous mitral valve
• Congenital mitral regurgitation
• Arrhythmia
• Endocarditis
• Other degenerative diseases (coronary artery disease, hypertension)
• Drug abuse, alcohol abuse
• Pregnancy

B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases

• Myocardial dysfunction
• Valvular regurgitation
• Persistent left-to-right shunt
• Pulmonary vascular disease
• Prosthetic valve dysfunction
• Status post Fontan operation
• Arrhythmia
• Endocarditis
• Other degenerative diseases (coronary artery disease, hypertension)

Right Ventricular Failure

Factors affected right ventricle and to be eliminated during management of congestive heart failure. A. Right ventricular myocardial dysfunction

1. Right ventricular myocardial infarction
2. Dilated cardiomyopathy
3. Right ventricular dysplasia

B. Primary right ventricular pressure overload

1. Left ventricular failure
2. Mitral valve disease
3. Atrial myxoma
4. Pulmonary veno-occlusive disease
5. Cor pulmonale

   • Chronic obstructive pulmonary disease
   • Primary pulmonary hypertension
   • Pulmonary embolism

6. Pulmonic stenosis

   • Supravalvular pulmonic stenosis
   • Valvular pulmonic stenosis
   • Subvalvular pulmonic stenosis

7. Ventricular septal defect
8. Aortopulmonary communication

C. Primary right ventricular volume overload

1. Pulmonic regurgitation
2. Tricuspid regurgitation
3. Atrial septal defect
4. Partial anomalous pulmonary venous return

D. Impediment to right ventricular inflow

1. Tricuspid stenosis
2. Cardiac tamponade
3. Constrictive pericarditis
4. Restrictive cardiomyopathy

Differential Diagnosis of Causes of Heart Failure

A. Left Ventricular Failure

Most Common Causes:

• Aortic regurgitation
• Aortic stenosis
• Hypertension
• Mitral regurgitation
• Myocardial ischemia

Expanded List of Causes:

• Atrial fibrillation
• Alcoholism
• Anemia
• Angina
• Aortic regurgitation
• Aortic Stenosis
• Arteriovenous fistula
• Beriberi
• Cardiac aneurysm
• Cardiomyopathy
• Constrictive pericarditis
• Drugs, toxins
• Hypertension
• Hyperthyroidism
• Hypovolemia
• Hypoxia
• Mediastinal tumors
• Mitral Regurgitation
• Myocardial Infarction
• Paget's Disease
• Pancoast's Tumor
• Pericardial effusion
• Pericardial tamponade
• Perimyocarditis
• Protein deficiency
• Restrictive cardiomyopathy
• Rupture of the papillary muscles
• Sepsis
• Vena Cava Superior Thrombosis

B. Right Ventricular Failure

Most Common Causes:

• Cardiomyopathy
• Cor pulmonale
• Diffuse myocarditis
• Left heart failure

Other Causes:

• After left ventricular failure
• After pulmonary resection
• Allergic alveolitis
• Bronchial asthma
• Chronic bronchitis
• Honeycomb lung
• Hyperglobulia
• Emphysema
• Mitral Stenosis
• Right ventricular myocardial infarction
• Pickwickian Syndrome
• Pleural fibrosis
• Pneumoconiosis
• Pulmonary fibrosis
• Pulmonic regurgitation
• Pulmonic stenosis
• Sarcoidosis
• Severe relapsing pulmonary emboli
• Silicosis
• Tachycardia
• Tricuspid insufficiency

C. Others

• Ascorbic acid deficiency
• Cardiac amyloidosis
• Carnitine deficiency
• Cervical vein stasis of non-cardiac genesis
• Congenital heart disease
• Cyanosis of non-cardiac genesis
• Diabetes Mellitus
• Dyspnea of non-cardiac genesis
• Edema of non-cardiac genesis
• Hemochromatosis
• Pleural effusion of non-cardiac genesis
• Pulmonary edema of non-cardiac genesis
• Thiamine deficiency
• Thyroid disease