Cardiac Related Nursing Diagnoses: A Comprehensive Guide to Heart Failure

Introduction

Heart failure (HF) is a prevalent and intricate clinical syndrome arising from any functional or structural cardiac disorder. This condition impairs the heart’s ability to fill with or eject blood, hindering systemic circulation from meeting the body’s metabolic demands. Diverse diseases can lead to heart failure, but the majority of patients experience symptoms stemming from compromised left ventricular myocardial function. Common patient presentations include dyspnea, fatigue, reduced exercise capacity, and fluid retention, manifesting as pulmonary and peripheral edema.[1]

Heart failure resulting from left ventricular dysfunction is classified by left ventricular ejection fraction (LVEF) into two primary categories: heart failure with reduced ejection fraction (HFrEF), characterized by an LVEF of 40% or less, and heart failure with preserved ejection fraction (HFpEF), where LVEF exceeds 40%.[2] Understanding these classifications and associated cardiac related nursing diagnoses is crucial for effective patient care.

Common Cardiac Related Nursing Diagnoses for Heart Failure

Nurses play a pivotal role in the management of heart failure. Accurate cardiac related nursing diagnoses are essential for developing effective care plans. Here are some key nursing diagnoses frequently associated with heart failure:

• Decreased Cardiac Output: This diagnosis is central to heart failure, reflecting the heart’s inability to pump sufficient blood to meet the body’s needs. It’s a primary concern in both HFrEF and HFpEF, though the underlying mechanisms differ.
• Activity Intolerance: Reduced cardiac output leads to inadequate oxygen delivery to tissues, resulting in fatigue and shortness of breath during physical exertion. This significantly limits a patient’s ability to perform daily activities.
• Excess Fluid Volume: Heart failure often causes the body to retain fluid, leading to edema, pulmonary congestion, and ascites. This fluid overload contributes to many heart failure symptoms and complications.
• Risk for Impaired Skin Integrity: Edema and poor tissue perfusion increase the risk of skin breakdown, particularly in dependent areas like the legs and sacrum.
• Ineffective Tissue Perfusion: Reduced cardiac output compromises blood flow to vital organs and peripheral tissues, potentially leading to organ dysfunction and ischemia.
• Ineffective Breathing Pattern: Pulmonary congestion and fluid overload can impair gas exchange and increase the work of breathing, resulting in dyspnea and an ineffective breathing pattern.
• Impaired Gas Exchange: Fluid accumulation in the lungs (pulmonary edema) hinders the efficient exchange of oxygen and carbon dioxide, leading to hypoxemia and shortness of breath.
• Fatigue: A pervasive symptom in heart failure, fatigue results from reduced cardiac output, poor tissue oxygenation, and metabolic changes. It significantly impacts quality of life.
• Anxiety: The chronic and progressive nature of heart failure, coupled with distressing symptoms like dyspnea and activity limitations, can lead to significant anxiety and emotional distress.

Causes of Heart Failure

Heart failure is not a disease itself but a syndrome resulting from various underlying conditions that damage or overwork the heart. These causes can be broadly categorized and understanding them is vital for identifying potential cardiac related nursing diagnoses and tailoring treatment. Heart failure can stem from disorders affecting:

• Pericardium: Conditions like pericarditis or cardiac tamponade can restrict heart function.
• Myocardium: Diseases such as cardiomyopathies, myocarditis, and ischemic heart disease directly damage the heart muscle.
• Endocardium: Endocarditis and other endocardial diseases can impair valve function and contribute to heart failure.
• Cardiac Valves: Valvular heart diseases, including stenosis and regurgitation, place extra strain on the heart.
• Vasculature: Hypertension and pulmonary hypertension increase the heart’s workload.
• Metabolism: Metabolic disorders, such as thyroid disease and diabetes, can affect heart function.

The most frequent causes of systolic dysfunction (HFrEF) include:

• Idiopathic Dilated Cardiomyopathy (DCM): A condition where the heart chambers enlarge and weaken for unknown reasons.
• Coronary Heart Disease (Ischemic): Reduced blood flow to the heart muscle due to narrowed coronary arteries, often leading to myocardial infarction.
• Hypertension: Chronic high blood pressure forces the heart to work harder, eventually leading to weakening and failure.
• Valvular Disease: Conditions affecting heart valves, such as aortic stenosis or mitral regurgitation.

For diastolic dysfunction (HFpEF), common causes are similar, with the addition of:

• Hypertrophic Obstructive Cardiomyopathy: A condition characterized by thickened heart muscle, which can obstruct blood flow.
• Restrictive Cardiomyopathy: A condition where the heart muscle becomes stiff and less compliant, impairing ventricular filling. [1]

Risk Factors for Heart Failure

Identifying risk factors is crucial for preventative strategies and early intervention. Recognizing these factors helps in anticipating potential cardiac related nursing diagnoses. Key risk factors include:

• Coronary Artery Disease: The most significant risk factor, as it can lead to myocardial infarction and ischemic cardiomyopathy.
• Myocardial Infarction (Heart Attack): Damage to the heart muscle from a heart attack is a major cause of heart failure.
• Hypertension: Long-term high blood pressure significantly increases the risk.
• Diabetes Mellitus: Diabetes increases the risk of heart disease and cardiomyopathy.
• Obesity: Excess weight strains the heart and is associated with other risk factors like hypertension and diabetes.
• Smoking: Damages blood vessels and increases the risk of heart disease.
• Alcohol Use Disorder: Excessive alcohol consumption can weaken the heart muscle (alcoholic cardiomyopathy).
• Atrial Fibrillation: An irregular heart rhythm that can lead to heart failure or worsen existing HF.
• Thyroid Diseases: Both hyperthyroidism and hypothyroidism can affect heart function.
• Congenital Heart Disease: Structural heart defects present at birth can lead to heart failure later in life.
• Aortic Stenosis: Narrowing of the aortic valve increases the workload on the heart.

Assessment of Heart Failure

A thorough assessment is vital for identifying cardiac related nursing diagnoses and monitoring disease progression. Symptoms of heart failure can be broadly categorized into those related to fluid overload and those due to reduced cardiac output. [1]

Symptoms of Fluid Overload:

• Dyspnea (Shortness of Breath): Especially on exertion or lying down (orthopnea).
• Orthopnea: Shortness of breath when lying flat, relieved by sitting up.
• Edema: Swelling in the ankles, legs, abdomen (ascites), and sacral area.
• Pain from Hepatic Congestion: Right upper quadrant pain due to liver enlargement from fluid backup.
• Abdominal Distension from Ascites: Fluid accumulation in the abdominal cavity.

Symptoms of Reduced Cardiac Output:

• Fatigue: Persistent tiredness and lack of energy.
• Weakness: Muscle weakness, especially with physical activity.

Presentation Timeline:

• Acute and Subacute (Days to Weeks): Characterized by sudden onset or worsening of:

  • Shortness of breath at rest or with exertion.
  • Orthopnea.
  • Paroxysmal Nocturnal Dyspnea (PND): Sudden onset of severe shortness of breath at night, waking the patient.
  • Right Upper Quadrant Discomfort: Due to acute hepatic congestion.
  • Palpitations: May occur with atrial or ventricular tachyarrhythmias.

• Chronic (Months): Symptoms may develop gradually and include:

  • Fatigue.
  • Anorexia (Loss of Appetite).
  • Abdominal Distension.
  • Peripheral Edema.
  • Dyspnea may be less prominent initially compared to fatigue and edema.
  • Anorexia can be secondary to poor splanchnic circulation, bowel edema, and nausea from hepatic congestion. [1]

Characteristic Physical Exam Findings:

• Pulsus Alternans: Alternating strong and weak peripheral pulses, indicating severe left ventricular dysfunction.
• Apical Impulse: Laterally displaced apical impulse, suggesting left ventricular enlargement.
• S3 Gallop: A low-frequency heart sound in early diastole, a sensitive indicator of ventricular dysfunction.
• Peripheral Edema: Swelling in the extremities.
• Pulmonary Rales (Crackles): Abnormal lung sounds indicating fluid in the lungs.

New York Heart Association (NYHA) Functional Classification[3]

The NYHA classification is used to categorize the severity of heart failure based on symptoms and activity limitations. This classification is crucial for guiding treatment and understanding the patient’s functional capacity, which directly informs cardiac related nursing diagnoses.

• Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitations. Symptoms occur only with more than ordinary activity.
• Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, dyspnea, or palpitations. Symptoms occur with ordinary activity.
• Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, dyspnea, or palpitations. Symptoms occur with minimal activity.
• Class IV: Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. Symptoms present even at rest.

Evaluation and Diagnostic Tests for Heart Failure

Diagnostic tests are essential to confirm the diagnosis of heart failure, determine the underlying cause, assess severity, and guide management. These evaluations directly support the identification and management of cardiac related nursing diagnoses. Common tests include:

• Electrocardiogram (ECG): Detects evidence of myocardial infarction, ischemia, rhythm abnormalities (e.g., atrial fibrillation).
• Chest X-ray: Evaluates heart size (cardiac-to-thoracic ratio > 50%), pulmonary congestion (cephalization of pulmonary vessels, Kerley B-lines), and pleural effusions.

• Blood Tests:
  • Cardiac Troponin (T or I): Elevated levels indicate myocardial damage, helpful in ruling out acute myocardial infarction as a cause.
  • Complete Blood Count (CBC): Assesses overall health and can identify anemia, which can exacerbate heart failure symptoms.
  • Serum Electrolytes: Evaluates sodium, potassium, and other electrolytes, which can be imbalanced in heart failure and with diuretic therapy.
  • Blood Urea Nitrogen (BUN) and Creatinine: Assess kidney function, often impaired in heart failure.
  • Liver Function Tests (LFTs): Evaluate liver function, which can be affected by heart failure, especially right-sided heart failure.
  • Brain Natriuretic Peptide (BNP) or N-terminal pro-BNP (NT-proBNP): Elevated levels strongly support the diagnosis of heart failure and can help assess severity. BNP is often more diagnostically valuable than other initial tests when combined with history and physical exam.
• Transthoracic Echocardiogram (TTE): A crucial test to assess ventricular function, ejection fraction, valve function, and hemodynamics. It differentiates between HFrEF and HFpEF and helps determine the cause and severity of heart failure.

Medical Management of Heart Failure

Medical management aims to alleviate symptoms, improve quality of life, slow disease progression, and reduce mortality. Pharmacological and device therapies are cornerstone treatments, directly impacting the cardiac related nursing diagnoses and patient outcomes.

Pharmacological Management:

• Diuretics: Reduce fluid overload, alleviating symptoms like edema and dyspnea. Common diuretics include loop diuretics (furosemide, bumetanide), thiazide diuretics (hydrochlorothiazide), and potassium-sparing diuretics (spironolactone).
• Beta-Blockers: Reduce heart rate and blood pressure, improve heart function, and decrease mortality in HFrEF. Examples include metoprolol, carvedilol, and bisoprolol.
• Angiotensin-Converting Enzyme Inhibitors (ACEIs): Block the renin-angiotensin-aldosterone system (RAAS), reduce afterload, and improve survival in HFrEF. Examples include enalapril, lisinopril, and ramipril.
• Angiotensin Receptor Blockers (ARBs): Similar to ACEIs, ARBs block the RAAS and are used when ACEIs are not tolerated. Examples include valsartan, losartan, and candesartan.
• Angiotensin Receptor Neprilysin Inhibitor (ARNI): Combines an ARB (valsartan) with a neprilysin inhibitor (sacubitril). ARNIs have shown superior outcomes compared to ACEIs in HFrEF. Sacubitril/valsartan is a common example.
• Hydralazine and Isosorbide Dinitrate: A combination therapy that dilates blood vessels, reducing afterload and preload. Particularly beneficial in African-American patients with persistent symptoms despite optimal therapy.
• Digoxin: A cardiac glycoside that increases contractility and slows heart rate. Used primarily for symptom control in patients with atrial fibrillation and heart failure.
• Aldosterone Antagonists (Mineralocorticoid Receptor Antagonists – MRAs): Block aldosterone, reducing fluid retention and improving survival in HFrEF. Spironolactone and eplerenone are common examples.

Combination therapy with these agents is often necessary to optimize outcomes and reduce hospitalizations. Improved survival has been demonstrated with beta-blockers, ACEIs/ARNIs, hydralazine/nitrate, and aldosterone antagonists. Diuretics are primarily used for symptom management, with more limited evidence of survival benefit. ARNIs should not be administered within 36 hours of an ACEI dose due to the risk of angioedema. [3]

Device Therapy:

• Implantable Cardioverter-Defibrillator (ICD): Used for primary or secondary prevention of sudden cardiac death in patients at high risk of ventricular arrhythmias.
• Cardiac Resynchronization Therapy (CRT): Biventricular pacing improves symptoms and survival in selected patients with reduced LVEF, prolonged QRS duration, and in sinus rhythm. Often combined with an ICD (CRT-D).
• Ventricular Assist Device (VAD): Mechanical pumps that support heart function. Used as a bridge to transplant or as destination therapy in severe heart failure.
• Cardiac Transplant: Heart transplantation is reserved for patients with end-stage heart failure who are not responding to other therapies.

Nursing Management of Heart Failure

Nursing care is integral to the comprehensive management of heart failure. The nursing care plan, guided by cardiac related nursing diagnoses, focuses on symptom relief, patient education, and improving adherence to treatment. [4] Key components include:

• Relieving Fluid Overload Symptoms:
  • Administering diuretics as prescribed and monitoring their effectiveness.
  • Assessing and documenting edema, lung sounds, and daily weights.
  • Implementing fluid restrictions as ordered.
  • Positioning patients to promote comfort and reduce dyspnea (e.g., high Fowler’s position).
• Relieving Symptoms of Anxiety and Fatigue:
  • Providing emotional support and reassurance.
  • Educating patients about their condition and management to reduce anxiety.
  • Encouraging rest and energy conservation strategies.
  • Monitoring and managing pain and discomfort.
• Promoting Physical Activity:
  • Encouraging regular, moderate exercise within the patient’s tolerance.
  • Providing guidance on safe exercise and activity progression.
  • Collaborating with physical therapy as needed.
• Increasing Medication Compliance:
  • Providing thorough medication education, including purpose, dosage, side effects, and importance of adherence.
  • Simplifying medication regimens when possible.
  • Addressing barriers to medication adherence.
• Decreasing Adverse Effects of Treatment:
  • Monitoring for and managing side effects of medications (e.g., electrolyte imbalances with diuretics, hypotension with vasodilators).
  • Educating patients about potential side effects and how to manage them.
• Teaching Patients About Dietary Restrictions:
  • Educating about sodium restriction (typically 2-3 grams per day).
  • Educating about fluid restriction (typically 2 liters per day).
  • Providing dietary counseling and resources.
• Teaching Patient About Self-Monitoring of Symptoms:
  • Educating patients on recognizing and reporting worsening symptoms (e.g., increased dyspnea, edema, weight gain).
  • Teaching daily weight monitoring at home and when to report changes.
  • Providing clear instructions on when to seek medical attention.

When To Seek Help for Heart Failure

Prompt medical attention is crucial when heart failure symptoms worsen. Patients should be educated on recognizing these warning signs and instructed to seek immediate help in the following situations:

• Worsening Symptoms of Fluid Overload: Rapid weight gain, increased edema, worsening shortness of breath, orthopnea, or PND.
• Worsening Hypoxia: Increased shortness of breath, especially at rest, or new onset of cyanosis (bluish discoloration of lips or skin).
• Uncontrolled Tachycardia: Rapid heart rate that does not resolve, regardless of rhythm.
• Change in Cardiac Rhythm: New onset of irregular heart rhythm or palpitations.
• Change in Mental Status: Confusion, dizziness, lightheadedness, or fainting.
• Decreased Urinary Output: Significant reduction in urine production despite diuretic therapy.

Monitoring Heart Failure Patients

Regular monitoring is essential for managing heart failure effectively and adjusting treatment plans based on patient status and cardiac related nursing diagnoses. Key monitoring parameters include:

• Vital Signs: Frequent monitoring of heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation.
• Telemetry Monitoring: Continuous monitoring of heart rate and rhythm, especially in hospitalized patients or those at risk for arrhythmias.
• Symptom Assessment: Regular and frequent assessment for heart failure symptoms, including dyspnea, edema, fatigue, and chest pain.
• Daily Weight Monitoring: Essential for detecting fluid retention or loss and guiding diuretic therapy.

Coordination of Care for Heart Failure

Optimal heart failure management requires a multidisciplinary approach. Effective coordination among healthcare professionals is vital to ensure comprehensive care and address all aspects of the patient’s needs, informed by accurate cardiac related nursing diagnoses. The interprofessional team typically includes:

• Primary Care Physician: Provides ongoing management and coordination of care.
• Emergency Department Physician: Manages acute exacerbations of heart failure.
• Cardiologist: Specializes in the diagnosis and management of heart disease, including heart failure.
• Radiologist: Interprets imaging studies like chest x-rays and echocardiograms.
• Cardiac Nurses: Provide specialized nursing care, patient education, and care coordination.
• Internist: Manages co-existing medical conditions.
• Cardiac Surgeons: May be involved in advanced therapies like cardiac transplantation or VAD implantation.

Treating the underlying cause of heart failure is paramount. Healthcare providers must adhere to current treatment guidelines. Clinical nurses play a crucial role in patient education regarding medication adherence and lifestyle modifications. Poorly managed heart failure is associated with high morbidity and mortality, significantly impacting quality of life. [5]

Health Teaching and Health Promotion for Heart Failure

Patient education is a cornerstone of heart failure management. Effective health teaching and promotion strategies, aligned with cardiac related nursing diagnoses, can improve clinical outcomes and reduce hospital readmissions. Key areas for patient education include:

• Self-Monitoring of Symptoms: Teach patients how to monitor for and recognize worsening symptoms at home.
• Medication Compliance: Emphasize the importance of taking medications as prescribed and provide strategies to improve adherence.
• Daily Weight Monitoring: Instruct patients on how to accurately weigh themselves daily and when to report weight changes.
• Dietary Sodium Restriction: Educate patients about limiting sodium intake to 2-3 grams per day and provide practical dietary advice.
• Fluid Restriction: Educate patients about limiting fluid intake to 2 liters per day, if recommended.
• Risk Factor Modification: Aggressively address modifiable risk factors such as:
  • Diabetes Mellitus: Encourage blood sugar control.
  • Hypertension: Promote blood pressure management.
  • Obesity: Recommend weight loss strategies.
  • Nicotine Use: Strongly advise smoking cessation.
  • Alcohol Use Disorder: Counsel patients on limiting or abstaining from alcohol.
  • Recreational Drug Use (especially cocaine): Advise cessation of drug use.
• Sleep Apnea Management: Encourage CPAP therapy for patients with sleep apnea and heart failure, as untreated sleep apnea can worsen heart failure outcomes.

Discharge Planning for Heart Failure Patients

Effective discharge planning is crucial to ensure a smooth transition from hospital to home and to minimize readmissions. Discharge planning, informed by the patient’s cardiac related nursing diagnoses, should include:

• Medication Management: Provide a clear and concise medication list, dosage instructions, and refill information.
• Medication Compliance: Reinforce the importance of medication adherence and address any potential barriers.
• Low-Sodium Diet and Fluid Restriction: Review dietary and fluid restrictions and provide written materials.
• Activity and Exercise Recommendations: Provide guidelines for safe physical activity and exercise.
• Smoking Cessation: Offer resources and support for smoking cessation.
• Recognition of Worsening Heart Failure Signs and Symptoms: Ensure patients understand when and how to seek medical attention.
• Follow-up Appointments: Schedule timely follow-up appointments to ensure ongoing medical care and monitoring.

Nurse-driven education at discharge has been proven to enhance therapy compliance and improve patient outcomes in heart failure. [6]

Review Questions

Figure

Congestive Heart Failure, Radiograph

Chest radiographs are valuable in assessing for pulmonary congestion or edema in acute decompensated heart failure.

References

1.Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW., ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 May 03;145(18):e895-e1032. [PubMed: 35363499]

2.Ziaeian B, Fonarow GC. Epidemiology and aetiology of heart failure. Nat Rev Cardiol. 2016 Jun;13(6):368-78. [PMC free article: PMC4868779] [PubMed: 26935038]

3.CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med. 1987 Jun 04;316(23):1429-35. [PubMed: 2883575]

4.Lind L, Ingelsson M, Sundstrom J, Ärnlöv J. Impact of risk factors for major cardiovascular diseases: a comparison of life-time observational and Mendelian randomisation findings. Open Heart. 2021 Sep;8(2) [PMC free article: PMC8438838] [PubMed: 34518286]

5.Noubiap JJ, Agbor VN, Bigna JJ, Kaze AD, Nyaga UF, Mayosi BM. Prevalence and progression of rheumatic heart disease: a global systematic review and meta-analysis of population-based echocardiographic studies. Sci Rep. 2019 Nov 19;9(1):17022. [PMC free article: PMC6863880] [PubMed: 31745178]

6.Kim KH, Pereira NL. Genetics of Cardiomyopathy: Clinical and Mechanistic Implications for Heart Failure. Korean Circ J. 2021 Oct;51(10):797-836. [PMC free article: PMC8484993] [PubMed: 34327881]

7.Rezkalla SH, Kloner RA. Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics. Trends Cardiovasc Med. 2021 Apr;31(3):163-169. [PMC free article: PMC7965406] [PubMed: 33383171]

8.Muchtar E, Blauwet LA, Gertz MA. Restrictive Cardiomyopathy: Genetics, Pathogenesis, Clinical Manifestations, Diagnosis, and Therapy. Circ Res. 2017 Sep 15;121(7):819-837. [PubMed: 28912185]

9.Shams P, Ahmed I. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 30, 2023. Cardiac Amyloidosis. [PubMed: 35593829]

10.Brown KN, Pendela VS, Ahmed I, Diaz RR. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 30, 2023. Restrictive Cardiomyopathy. [PubMed: 30725919]

11.Matta AG, Carrié D. Epidemiology, Pathophysiology, Diagnosis, and Principles of Management of Takotsubo Cardiomyopathy: A Review. Med Sci Monit. 2023 Mar 06;29:e939020. [PMC free article: PMC9999670] [PubMed: 36872594]

12.Bairashevskaia AV, Belogubova SY, Kondratiuk MR, Rudnova DS, Sologova SS, Tereshkina OI, Avakyan EI. Update of Takotsubo cardiomyopathy: Present experience and outlook for the future. Int J Cardiol Heart Vasc. 2022 Apr;39:100990. [PMC free article: PMC8913320] [PubMed: 35281752]

13.Ahmad SA, Brito D, Khalid N, Ibrahim MA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 22, 2023. Takotsubo Cardiomyopathy. [PubMed: 28613549]

14.DeFilippis EM, Beale A, Martyn T, Agarwal A, Elkayam U, Lam CSP, Hsich E. Heart Failure Subtypes and Cardiomyopathies in Women. Circ Res. 2022 Feb 18;130(4):436-454. [PMC free article: PMC10361647] [PubMed: 35175847]

15.Wong CM, Hawkins NM, Jhund PS, MacDonald MR, Solomon SD, Granger CB, Yusuf S, Pfeffer MA, Swedberg K, Petrie MC, McMurray JJ. Clinical characteristics and outcomes of young and very young adults with heart failure: The CHARM programme (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity). J Am Coll Cardiol. 2013 Nov 12;62(20):1845-54. [PubMed: 23850914]

16.Sciomer S, Moscucci F, Salvioni E, Marchese G, Bussotti M, Corrà U, Piepoli MF. Role of gender, age and BMI in prognosis of heart failure. Eur J Prev Cardiol. 2020 Dec;27(2_suppl):46-51. [PMC free article: PMC7691623] [PubMed: 33238736]

17.Volpe M, Gallo G. Obesity and cardiovascular disease: An executive document on pathophysiological and clinical links promoted by the Italian Society of Cardiovascular Prevention (SIPREC). Front Cardiovasc Med. 2023;10:1136340. [PMC free article: PMC10040794] [PubMed: 36993998]

18.Kim DY, Kim SH, Ryu KH. Tachycardia induced Cardiomyopathy. Korean Circ J. 2019 Sep;49(9):808-817. [PMC free article: PMC6713829] [PubMed: 31456374]

19.Anakwue RC, Onwubere BJ, Anisiuba BC, Ikeh VO, Mbah A, Ike SO. Congestive heart failure in subjects with thyrotoxicosis in a black community. Vasc Health Risk Manag. 2010 Aug 09;6:473-7. [PMC free article: PMC2922308] [PubMed: 20730063]

20.Schoenenberger AW, Schoenenberger-Berzins R, der Maur CA, Suter PM, Vergopoulos A, Erne P. Thiamine supplementation in symptomatic chronic heart failure: a randomized, double-blind, placebo-controlled, cross-over pilot study. Clin Res Cardiol. 2012 Mar;101(3):159-64. [PubMed: 22057652]

21.DiNicolantonio JJ, Liu J, O’Keefe JH. Thiamine and Cardiovascular Disease: A Literature Review. Prog Cardiovasc Dis. 2018 May-Jun;61(1):27-32. [PubMed: 29360523]

22.Reddy YNV, Melenovsky V, Redfield MM, Nishimura RA, Borlaug BA. High-Output Heart Failure: A 15-Year Experience. J Am Coll Cardiol. 2016 Aug 02;68(5):473-482. [PubMed: 27470455]

23.Chayanupatkul M, Liangpunsakul S. Cirrhotic cardiomyopathy: review of pathophysiology and treatment. Hepatol Int. 2014 Jul;8(3):308-15. [PMC free article: PMC4160726] [PubMed: 25221635]

24.Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW., American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation. 2020 Mar 03;141(9):e139-e596. [PubMed: 31992061]

25.Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol. 1993 Oct;22(4 Suppl A):6A-13A. [PubMed: 8376698]

26.Benjamin EJ, Blaha MJ, Chiuve SE, Cushman M, Das SR, Deo R, de Ferranti SD, Floyd J, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Mackey RH, Matsushita K, Mozaffarian D, Mussolino ME, Nasir K, Neumar RW, Palaniappan L, Pandey DK, Thiagarajan RR, Reeves MJ, Ritchey M, Rodriguez CJ, Roth GA, Rosamond WD, Sasson C, Towfighi A, Tsao CW, Turner MB, Virani SS, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P., American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation. 2017 Mar 07;135(10):e146-e603. [PMC free article: PMC5408160] [PubMed: 28122885]

27.Yusuf S, Joseph P, Rangarajan S, Islam S, Mente A, Hystad P, Brauer M, Kutty VR, Gupta R, Wielgosz A, AlHabib KF, Dans A, Lopez-Jaramillo P, Avezum A, Lanas F, Oguz A, Kruger IM, Diaz R, Yusoff K, Mony P, Chifamba J, Yeates K, Kelishadi R, Yusufali A, Khatib R, Rahman O, Zatonska K, Iqbal R, Wei L, Bo H, Rosengren A, Kaur M, Mohan V, Lear SA, Teo KK, Leong D, O’Donnell M, McKee M, Dagenais G. Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study. Lancet. 2020 Mar 07;395(10226):795-808. [PMC free article: PMC8006904] [PubMed: 31492503]

28.Opie LH, Commerford PJ, Gersh BJ, Pfeffer MA. Controversies in ventricular remodelling. Lancet. 2006 Jan 28;367(9507):356-67. [PubMed: 16443044]

29.Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovasc Pathol. 2012 Sep-Oct;21(5):365-71. [PubMed: 22227365]

30.Ait Mou Y, Bollensdorff C, Cazorla O, Magdi Y, de Tombe PP. Exploring cardiac biophysical properties. Glob Cardiol Sci Pract. 2015;2015:10. [PMC free article: PMC4448074] [PubMed: 26779498]

31.Abassi Z, Khoury EE, Karram T, Aronson D. Edema formation in congestive heart failure and the underlying mechanisms. Front Cardiovasc Med. 2022;9:933215. [PMC free article: PMC9553007] [PubMed: 36237903]

32.Prausmüller S, Arfsten H, Spinka G, Freitag C, Bartko PE, Goliasch G, Strunk G, Pavo N, Hülsmann M. Plasma Neprilysin Displays No Relevant Association With Neurohumoral Activation in Chronic HFrEF. J Am Heart Assoc. 2020 Jun 02;9(11):e015071. [PMC free article: PMC7428996] [PubMed: 32427034]

33.Docherty KF, Vaduganathan M, Solomon SD, McMurray JJV. Sacubitril/Valsartan: Neprilysin Inhibition 5 Years After PARADIGM-HF. JACC Heart Fail. 2020 Oct;8(10):800-810. [PMC free article: PMC8837825] [PubMed: 33004114]

34.Obokata M, Reddy YNV, Borlaug BA. Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: Understanding Mechanisms by Using Noninvasive Methods. JACC Cardiovasc Imaging. 2020 Jan;13(1 Pt 2):245-257. [PMC free article: PMC6899218] [PubMed: 31202759]

35.Kao DP, Lewsey JD, Anand IS, Massie BM, Zile MR, Carson PE, McKelvie RS, Komajda M, McMurray JJ, Lindenfeld J. Characterization of subgroups of heart failure patients with preserved ejection fraction with possible implications for prognosis and treatment response. Eur J Heart Fail. 2015 Sep;17(9):925-35. [PMC free article: PMC4654630] [PubMed: 26250359]

36.Harjola VP, Mullens W, Banaszewski M, Bauersachs J, Brunner-La Rocca HP, Chioncel O, Collins SP, Doehner W, Filippatos GS, Flammer AJ, Fuhrmann V, Lainscak M, Lassus J, Legrand M, Masip J, Mueller C, Papp Z, Parissis J, Platz E, Rudiger A, Ruschitzka F, Schäfer A, Seferovic PM, Skouri H, Yilmaz MB, Mebazaa A. Organ dysfunction, injury and failure in acute heart failure: from pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail. 2017 Jul;19(7):821-836. [PMC free article: PMC5734941] [PubMed: 28560717]

37.King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012 Jun 15;85(12):1161-8. [PubMed: 22962896]

38.Ali AS, Rybicki BA, Alam M, Wulbrecht N, Richer-Cornish K, Khaja F, Sabbah HN, Goldstein S. Clinical predictors of heart failure in patients with first acute myocardial infarction. Am Heart J. 1999 Dec;138(6 Pt 1):1133-9. [PubMed: 10577445]

39.Klein L, O’Connor CM, Leimberger JD, Gattis-Stough W, Piña IL, Felker GM, Adams KF, Califf RM, Gheorghiade M., OPTIME-CHF Investigators. Lower serum sodium is associated with increased short-term mortality in hospitalized patients with worsening heart failure: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study. Circulation. 2005 May 17;111(19):2454-60. [PubMed: 15867182]

40.Kelder JC, Cramer MJ, van Wijngaarden J, van Tooren R, Mosterd A, Moons KG, Lammers JW, Cowie MR, Grobbee DE, Hoes AW. The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation. 2011 Dec 20;124(25):2865-73. [PubMed: 22104551]

41.Rørth R, Jhund PS, Yilmaz MB, Kristensen SL, Welsh P, Desai AS, Køber L, Prescott MF, Rouleau JL, Solomon SD, Swedberg K, Zile MR, Packer M, McMurray JJV. Comparison of BNP and NT-proBNP in Patients With Heart Failure and Reduced Ejection Fraction. Circ Heart Fail. 2020 Feb;13(2):e006541. [PubMed: 32065760]

42.Hacker M, Hoyer X, Kupzyk S, La Fougere C, Kois J, Stempfle HU, Tiling R, Hahn K, Störk S. Clinical validation of the gated blood pool SPECT QBS processing software in congestive heart failure patients: correlation with MUGA, first-pass RNV and 2D-echocardiography. Int J Cardiovasc Imaging. 2006 Jun-Aug;22(3-4):407-16. [PubMed: 16328851]

43.Jain S, Londono FJ, Segers P, Gillebert TC, De Buyzere M, Chirinos JA. MRI Assessment of Diastolic and Systolic Intraventricular Pressure Gradients in Heart Failure. Curr Heart Fail Rep. 2016 Feb;13(1):37-46. [PubMed: 26780916]

44.Cahill TJ, Ashrafian H, Watkins H. Genetic cardiomyopathies causing heart failure. Circ Res. 2013 Aug 30;113(6):660-75. [PubMed: 23989711]

45.Peterson PN, Rumsfeld JS, Liang L, Albert NM, Hernandez AF, Peterson ED, Fonarow GC, Masoudi FA., American Heart Association Get With the Guidelines-Heart Failure Program. A validated risk score for in-hospital mortality in patients with heart failure from the American Heart Association get with the guidelines program. Circ Cardiovasc Qual Outcomes. 2010 Jan;3(1):25-32. [PubMed: 20123668]

46.Lam CSP, Mulder H, Lopatin Y, Vazquez-Tanus JB, Siu D, Ezekowitz J, Pieske B, O’Connor CM, Roessig L, Patel MJ, Anstrom KJ, Hernandez AF, Armstrong PW., VICTORIA Study Group. Blood Pressure and Safety Events With Vericiguat in the VICTORIA Trial. J Am Heart Assoc. 2021 Nov 16;10(22):e021094. [PMC free article: PMC8751950] [PubMed: 34743540]

47.Armstrong PW, Pieske B, Anstrom KJ, Ezekowitz J, Hernandez AF, Butler J, Lam CSP, Ponikowski P, Voors AA, Jia G, McNulty SE, Patel MJ, Roessig L, Koglin J, O’Connor CM., VICTORIA Study Group. Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2020 May 14;382(20):1883-1893. [PubMed: 32222134]

48.Lucas C, Johnson W, Hamilton MA, Fonarow GC, Woo MA, Flavell CM, Creaser JA, Stevenson LW. Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure. Am Heart J. 2000 Dec;140(6):840-7. [PubMed: 11099986]

49.Rider I, Sorensen M, Brady WJ, Gottlieb M, Benson S, Koyfman A, Long B. Disposition of acute decompensated heart failure from the emergency department: An evidence-based review. Am J Emerg Med. 2021 Dec;50:459-465. [PubMed: 34500232]

Disclosures:

Ahmad Malik declares no relevant financial relationships with ineligible companies.

Lovely Chhabra declares no relevant financial relationships with ineligible companies.

Chaddie Doerr declares no relevant financial relationships with ineligible companies.