Congestive Cardiac Failure

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Congestive cardiac failure (CCF) is a complex clinical syndrome characterized by functional

or structural impairment of ventricular filling or ejection of blood resulting in failure to meet
systemic demands.It can be classified based on reduced ejection fraction <50% (or systolic
heart failure) and preserved ejection fraction >50% (or diastolic heart failure), based on left
or right sided failure or based on acute and chronic heart failure. CCF commonly manifests
clinically as fatigue, dyspnea and oedema.
Cardiac failure has an estimated worldwide prevalence of 26 million people with high
morbidity and mortality rate. It is caused by valvular heart disease, congenital heart disease,
uncontrolled arrhythmia, diabetes, uncontrolled hypertension, cardiomyopathies, obesity,
severe anemia among many others.
In initial stages of CCF, compensatory mechanisms such as changes in myocyte regeneration,
myocardial hypercontractility and myocardial hypertrophy maintain cardiac output in order to
meet systemic demands. Over time, compensation by eccentric remodeling worsens loading
and wall stress. A progression of events will result in increased contractility and decreased
myocardial relaxation. Decreased cardiac output will activate the
renin-angiotensin-aldosterone system(RAAS) causing salt and water retention along with
vasoconstriction.
Risk factors for CCF include:
- aging which can weaken or stiffen the heart. Persons who are 65 years and above are
at higher risk
- family history of heart failure
- unhealthy lifestyle choices
- heart or blood vessel conditions, lung disease, infections
- black or African American

Presentation
- exertional dyspnea or dyspnea at rest
- fatigue
- peripheral oedema
- ascites
- rapid weight gain suggesting volume overload; weight loss in advanced disease
- others: non productive cough, chest pain, syncope, palpitations, confusion especially
in the elderly

Physical Examination
Specific signs:
- laterally displaced apical pulse
- positive hepatojugular reflux
- prominent jugular venous distention
 - S3 gallop with systolic heart failure; diastolic heart failure may have S4 gallop

Less specific signs (possibly associated with other conditions)

- cool extremities
- narrow pulse pressure
- tachypnea and tachycardia
- wheezes, crackles or rales
- peripheral oedema, ascites
- hepatomegaly
- cachexia (in advanced disease)

Differentials
- cirrhosis
- pulmonary embolism
- acute renal failure
- nephrotic syndrome
- acute respiratory distress syndrome (ARDS)
- pulmonary fibrosis
Investigations
- comprehensive metabolic panel including LFTs, UEC, assessment for anemia and iron
deficiency
- serum BNP or NT-proBNP to differentiate cardiac from non cardiac causes of
dyspnea (both markers can be elevated in atrial fib, renal dysfunction, elderly patients;
BNP can be low in patients with hypothyroidism, obesity, advanced HF due to
myocardial fibrosis)
- CXR for pulmonary congestion and CCF
- Echocardiography to assess systolic and diastolic dysfunction and wall motion or
vascular abnormalities
- TEE (alternative to ECHO)
- ECG
- CT and MRI

Patients with heart failure are classified according to severity of symptoms and physical
activity limitation, based on the New York Heart Association Functional Classification:
Treatment

- Non pharmacologic therapy : oxygen, sodium and fluid restriction, appropriate

physical activity, non invasive positive pressure ventilation
- Pharmacotherapy: diuretics, vasodilators, beta blockers, ACEis, ARBs, CCB, nitrates,
digoxin, B-type natriuretic peptides, SGLT2i, inotropes, guanylate cyclase
stimulators, sinus node inhibitor, ARNI (Angiotensin Receptor-Neprilysin
Inhibitor)
- surgical options: valve repair/replacement, electrophysiologic intervention, ventricular
assist device, revascularization procedures, implantable cardioverter-defibrillator
(ICD), Cardiac resynchronization therapy (CRT), heart transplantation
(Australian clinical guidelines for the management of heart failure)

Complications
- cardiac cachexia (unintentional weight loss)
- cardiorenal disease (renal dysfunction)
- hepatic congestion (liver dysfunction)
- valvular dysfunction with dilated cardiomyopathy
- MI
- ventricular arrhythmias
- sudden cardiac death

Prognosis
Mortality following hospitalization for heart failure patients is about 10% at 30 dyas, 22% at
1 year and 42% at 5 years in spite of improvements in therapy.
Mortality is over 50% for patients in stage D heart failure (ACC/AHA). Heart failure with
systolic dysfunction has a mortality rate of 50% after 5 years and approaches 80% in persons
who are also hypotensive (cardiogenic shock).

References
1. Arrigo, M., Jessup, M., Mullens, W., Reza, N., Shah, A. M., Sliwa, K., & Mebazaa,
A. (2020). Acute heart failure. Nature Reviews Disease Primers, 6(1).
https://doi.org/10.1038/s41572-020-0151-7
2. Heart Failure: Practice Essentials, Background, Pathophysiology. (2022). EMedicine.
https://emedicine.medscape.com/article/163062-overview?icd=ssl_login_success_221
115
3. Inamdar, A., & Inamdar, A. (2016). Heart failure: Diagnosis, management and
utilization. Journal of Clinical Medicine, 5(7), 62.
https://doi.org/10.3390/jcm5070062
4. Malik, A., Brito, D., Vaqar, S., & Chhabra, L. (2022, September 19). Congestive heart
failure. National Library of Medicine; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK430873/
5. Ziaeian, B., & Fonarow, G. C. (2016). Epidemiology and aetiology of heart failure.
Nature Reviews. Cardiology, 13(6), 368–378.
https://doi.org/10.1038/nrcardio.2016.25