Heart Failure: Pathophysiology and Diagnosis
Despite repeated attempts to develop a mechanistic definition that encompasses the heterogeneity and complexity of heart failure (HF), no single conceptual paradigm has withstood the test of time. The current American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines define HF as a complex clinical syndrome that results from structural or functional impairment of ventricular filling or ejection of blood, which in turn leads to the cardinal clinical symptoms of dyspnea and fatigue and signs of HF, namely edema and rales. Because many patients present without signs or symptoms of volume overload, the term “heart failure” is preferred over the older term “congestive heart failure.”
HF is a burgeoning problem worldwide, with >20 million people affected. The overall prevalence of HF in the adult population in developed countries is 2%. HF prevalence follows an exponential pattern, rising with age, and affects 6–10% of people aged >65. Although the relative incidence of HF is lower in women than in men, women constitute at least one-half the cases of HF because of their longer life expectancy. In North America and Europe, the lifetime risk of developing HF is approximately one in five for a 40-year-old. The overall prevalence of HF is thought to be increasing, in part because current therapies for cardiac disorders, such as myocardial infarction (MI), valvular heart disease, and arrhythmias, are allowing patients to survive longer. The prevalence of HF in emerging nations is uncertain because of the lack of population-based studies in those countries. HF was once thought to arise primarily in the setting of a depressed left ventricular (LV) ejection fraction (EF); however, epidemiologic studies have shown that approximately one-half of patients who develop HF have a normal or preserved EF (EF ≥50%). Accordingly, the historical terms “systolic” and “diastolic” HF have been abandoned, and HF patients are now broadly categorized into HF with a reduced EF (HFpEF; formerly systolic failure) or HF with a preserved EF (HRpEF; formerly diastolic failure). Patients with a LV EF between 40 and 50% have been considered as having a borderline or mid-range EF. At the time of this writing, the epidemiology of these patients is unclear.
As shown in Table 252-1, any condition that leads to an alteration in LV structure or function can predispose a patient to developing HF. Although the etiology of HF in patients with a preserved EF differs from that of patients with depressed EF, there is considerable overlap between the etiologies of these two conditions. In industrialized countries, coronary artery disease (CAD) has become the predominant cause in men and women and is responsible for 60–75% of cases of HF. Hypertension contributes to the development of HF in 75% of patients, including most patients with CAD. Both CAD ...