Nursing Diagnosis and Nursing Care Plan for Heart Failure: A Comprehensive Guide

Heart failure (HF) is a prevalent and intricate clinical syndrome arising from functional or structural heart disorders. It impairs the heart’s ability to fill with or eject blood effectively, hindering systemic circulation from meeting the body’s metabolic demands. This condition can stem from various underlying diseases, with the majority of HF patients exhibiting symptoms due to 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 based on left ventricular ejection fraction (LVEF) into two primary categories: heart failure with reduced ejection fraction (HFrEF), where LVEF is 40% or less, and heart failure with preserved ejection fraction (HFpEF), where LVEF is greater than 40%.[2] Effective nursing care plans are crucial in managing patients with heart failure, addressing both the underlying physiological issues and the patient’s symptomatic experience. This guide will explore common nursing diagnoses and interventions essential for the comprehensive care of heart failure patients.

Common Nursing Diagnoses for Heart Failure

Nursing diagnoses are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems and life processes. For patients with heart failure, several nursing diagnoses are pertinent, reflecting the multifaceted impact of the condition on their health and well-being. These diagnoses guide the development of individualized nursing care plans aimed at optimizing patient outcomes and quality of life. Based on the pathophysiology and clinical manifestations of heart failure, key nursing diagnoses include:

• Decreased Cardiac Output: This diagnosis addresses the heart’s inability to pump sufficient blood to meet the body’s metabolic needs. It’s a core problem in heart failure and contributes to many of the associated symptoms.
• Activity Intolerance: Fatigue and dyspnea due to reduced cardiac output limit the patient’s ability to perform activities of daily living.
• Excess Fluid Volume: Heart failure often leads to fluid retention, resulting in edema, pulmonary congestion, and related complications.
• Risk for Impaired Skin Integrity: Edema and poor tissue perfusion increase the risk of skin breakdown, particularly in dependent areas.
• Ineffective Tissue Perfusion: Reduced cardiac output and circulatory congestion can compromise blood flow to vital organs and peripheral tissues.
• Ineffective Breathing Pattern and Impaired Gas Exchange: Pulmonary congestion and edema interfere with normal respiratory function and oxygenation.
• Fatigue: A pervasive symptom in heart failure, stemming from reduced cardiac output, metabolic changes, and other factors.
• Anxiety: The chronic and potentially life-threatening nature of heart failure can induce significant anxiety in patients and their families.

These nursing diagnoses are interconnected and often addressed concurrently in a holistic nursing care plan. The following sections will delve into the development of a nursing care plan, outlining specific goals and interventions for each of these diagnoses.

Developing a Nursing Care Plan for Heart Failure

A comprehensive nursing care plan for heart failure is tailored to the individual patient’s needs, considering their specific symptoms, disease severity, and overall health status. The plan incorporates interventions aimed at managing symptoms, improving cardiac function, preventing complications, and enhancing the patient’s quality of life. Here we outline nursing interventions based on the previously identified nursing diagnoses:

Nursing Interventions for Decreased Cardiac Output

Goals: Improve cardiac output and tissue perfusion.

Interventions:

1. Monitor vital signs frequently: Regularly assess heart rate, blood pressure, respiratory rate, and oxygen saturation to detect changes in hemodynamic status.
2. Assess heart sounds: Auscultate for abnormal heart sounds such as S3 or S4 gallops, which may indicate ventricular dysfunction.
3. Monitor for signs of decreased cardiac output: Assess for symptoms like fatigue, weakness, dizziness, chest pain, cool extremities, and decreased urine output.
4. Administer medications as prescribed: This includes diuretics to reduce fluid overload, ACE inhibitors or ARBs to reduce afterload, beta-blockers to control heart rate and improve contractility, and digoxin to increase contractility. Ensure proper dosage and monitor for side effects.
5. Promote rest and reduce stress: Encourage periods of rest to decrease cardiac workload. Implement stress-reduction techniques such as relaxation exercises or guided imagery.
6. Position patient appropriately: Elevate the head of the bed to promote venous return and reduce preload, unless contraindicated.

Nursing Interventions for Activity Intolerance

Goals: Improve activity tolerance and reduce fatigue.

Interventions:

1. Assess patient’s activity level and tolerance: Determine the patient’s baseline activity level and identify factors contributing to activity intolerance, such as dyspnea or fatigue.
2. Plan rest periods: Schedule activities with planned rest periods to prevent overexertion and conserve energy.
3. Gradually increase activity: Encourage a gradual increase in activity as tolerated, starting with short walks and progressively increasing duration and intensity.
4. Monitor response to activity: Assess vital signs, oxygen saturation, and patient-reported symptoms before, during, and after activity.
5. Assist with activities of daily living (ADLs): Provide assistance with ADLs as needed to reduce energy expenditure and prevent fatigue.
6. Educate on energy conservation techniques: Teach patients strategies to conserve energy, such as pacing activities, using assistive devices, and prioritizing tasks.

Nursing Interventions for Excess Fluid Volume

Goals: Reduce fluid overload and maintain fluid balance.

Interventions:

1. Monitor fluid intake and output: Accurately record fluid intake and output, including urine, emesis, and drainage, to assess fluid balance.
2. Daily weight monitoring: Weigh the patient daily at the same time, using the same scale, to monitor for fluid retention.
3. Assess for signs of fluid overload: Evaluate for edema (peripheral, pulmonary, sacral), jugular venous distention (JVD), crackles in lungs, and shortness of breath.
4. Administer diuretics as prescribed: Administer diuretics as ordered, monitor effectiveness, and watch for electrolyte imbalances (especially potassium).
5. Fluid restriction: Implement fluid restriction as prescribed, typically 2 liters per day, and educate the patient and family on the importance of adherence.
6. Sodium restriction: Educate the patient on a low-sodium diet (2-3 grams per day) to reduce fluid retention.

Nursing Interventions for Ineffective Breathing Pattern and Impaired Gas Exchange

Goals: Improve breathing pattern, enhance gas exchange, and reduce dyspnea.

Interventions:

1. Assess respiratory status: Monitor respiratory rate, depth, and effort. Auscultate lung sounds for adventitious sounds (crackles, wheezes).
2. Monitor oxygen saturation: Continuously or intermittently monitor oxygen saturation via pulse oximetry.
3. Position patient for optimal breathing: Elevate the head of the bed to a high Fowler’s position to promote lung expansion.
4. Administer oxygen therapy: Administer supplemental oxygen as prescribed to maintain adequate oxygen saturation levels.
5. Encourage deep breathing and coughing exercises: Teach and encourage deep breathing and coughing exercises to promote lung expansion and clear secretions.
6. Monitor for signs of respiratory distress: Assess for signs of worsening dyspnea, cyanosis, and altered mental status, which may indicate respiratory failure.

Nursing Interventions for Fatigue

Goals: Reduce fatigue and improve energy levels.

Interventions:

1. Assess fatigue levels: Use a fatigue scale to quantify the patient’s fatigue and track changes over time.
2. Identify contributing factors to fatigue: Assess for factors that may exacerbate fatigue, such as sleep disturbances, pain, emotional distress, and medication side effects.
3. Promote adequate rest and sleep: Encourage regular sleep schedules and create a conducive sleep environment.
4. Energy conservation strategies: Reinforce energy conservation techniques and pacing of activities.
5. Nutritional support: Ensure adequate nutritional intake to support energy levels.
6. Address underlying causes: Manage underlying conditions contributing to fatigue, such as anemia or electrolyte imbalances.

Nursing Interventions for Anxiety

Goals: Reduce anxiety and promote psychological well-being.

Interventions:

1. Assess anxiety levels: Use anxiety scales to assess the patient’s level of anxiety.
2. Provide emotional support: Offer a calm and reassuring presence. Encourage the patient to express their feelings and concerns.
3. Educate about heart failure: Provide clear and accurate information about heart failure, its management, and prognosis to reduce anxiety related to uncertainty.
4. Teach relaxation techniques: Teach relaxation techniques such as deep breathing, progressive muscle relaxation, or guided imagery to manage anxiety.
5. Facilitate social support: Encourage interaction with family and friends. Refer to support groups or counseling services if needed.
6. Administer anti-anxiety medications: Administer anti-anxiety medications as prescribed, if necessary, in conjunction with non-pharmacological interventions.

Nursing Interventions for Risk for Impaired Skin Integrity

Goals: Maintain skin integrity and prevent skin breakdown.

Interventions:

1. Regular skin assessment: Assess skin condition regularly, paying particular attention to pressure points and areas prone to edema.
2. Pressure relief measures: Implement pressure relief measures such as frequent repositioning (at least every 2 hours), pressure-reducing mattresses, and cushions.
3. Maintain skin hygiene: Keep skin clean and dry. Use mild soaps and pat skin dry gently.
4. Moisturize skin: Apply moisturizing lotions to prevent dryness and cracking, especially in edematous areas.
5. Protect from friction and shear: Use lift sheets to reposition patients and avoid dragging, which can cause skin shear.
6. Nutritional support: Ensure adequate nutrition, especially protein and vitamins, to promote skin health and healing.

Nursing Interventions for Ineffective Tissue Perfusion

Goals: Improve tissue perfusion and prevent complications of poor circulation.

Interventions:

1. Assess peripheral circulation: Regularly assess peripheral pulses, skin color, temperature, and capillary refill in extremities.
2. Monitor for signs of poor perfusion: Assess for symptoms like pain, pallor, coolness, numbness, or tingling in extremities.
3. Positioning: Avoid prolonged pressure on extremities. Encourage leg elevation when sitting to promote venous return.
4. Maintain adequate hydration: Ensure adequate fluid intake (within fluid restrictions) to maintain blood volume and viscosity.
5. Prevent vasoconstriction: Avoid cold temperatures and advise patients to avoid smoking, as nicotine causes vasoconstriction.
6. Medication management: Ensure adherence to prescribed medications that improve cardiac output and vasodilation, as ordered.

Patient Assessment and Monitoring in Heart Failure

Continuous and vigilant assessment and monitoring are paramount in the nursing care of heart failure patients. Regular assessment helps in early detection of changes in the patient’s condition, allowing for timely interventions and preventing potential complications. Key aspects of patient assessment and monitoring include:

• Vital Signs Monitoring: Frequent monitoring of heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation is essential. Trends in these parameters provide valuable insights into the patient’s hemodynamic status and response to treatment.
• Fluid Balance Monitoring: Accurate intake and output measurement and daily weight monitoring are crucial for assessing fluid retention and the effectiveness of diuretic therapy.
• Respiratory Assessment: Regular auscultation of lung sounds, assessment of breathing effort, and monitoring for dyspnea and orthopnea are vital in detecting pulmonary congestion and edema.
• Cardiovascular Assessment: Assessment of heart sounds, peripheral pulses, capillary refill, and signs of peripheral edema are important for evaluating cardiac function and tissue perfusion.
• Symptom Assessment: Regularly inquire about and assess the patient’s symptoms, including fatigue, dyspnea, chest pain, palpitations, and edema. Use standardized scales to quantify symptom severity when appropriate.
• Electrolyte Monitoring: Heart failure and its treatment, particularly diuretics, can lead to electrolyte imbalances. Regular monitoring of serum electrolytes, especially potassium and sodium, is necessary.
• ECG Monitoring: Electrocardiograms (ECGs) are used to assess heart rhythm and detect arrhythmias, ischemia, or myocardial infarction. Continuous telemetry monitoring may be indicated for patients at high risk of arrhythmias.
• BNP/NT-proBNP Levels: Monitoring brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) levels can help assess the severity of heart failure and guide treatment.

Medical Management Overview

Medical management of heart failure is multifaceted and aims to reduce symptoms, improve quality of life, slow disease progression, and prolong survival. Pharmacological interventions are central to medical management and include:

• Diuretics: To reduce fluid overload and alleviate symptoms of congestion.
• ACE Inhibitors and Angiotensin Receptor Blockers (ARBs): To reduce afterload, improve ventricular remodeling, and decrease mortality in HFrEF.
• Beta-Blockers: To control heart rate, improve contractility, and reduce mortality in HFrEF.
• Angiotensin Receptor-Neprilysin Inhibitors (ARNIs): A combination therapy that has shown superior outcomes compared to ACE inhibitors in HFrEF.
• Mineralocorticoid Receptor Antagonists (MRAs): To reduce aldosterone-mediated fluid retention and improve outcomes in specific HF populations.
• Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors: Emerging as a cornerstone therapy in heart failure, demonstrating benefits across the spectrum of ejection fraction.
• Digoxin: To increase cardiac contractility and control heart rate in certain situations.
• Hydralazine and Isosorbide Dinitrate: Particularly beneficial in African American patients with persistent symptoms despite standard therapy.

Device therapy, including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT), plays a critical role in preventing sudden cardiac death and improving cardiac function in selected patients. In advanced heart failure, ventricular assist devices (VADs) or cardiac transplantation may be considered.

Patient Education and Discharge Planning

Patient education is an integral component of heart failure nursing care, aiming to empower patients to actively participate in their self-management. Key areas of patient education include:

• Medication Management: Detailed instruction on medication names, dosages, frequency, purpose, and potential side effects. Emphasis on medication adherence and strategies to manage missed doses.
• Dietary Modifications: Education on sodium restriction (2-3 grams per day) and fluid restriction (typically 2 liters per day). Guidance on reading food labels and making healthy food choices.
• Symptom Monitoring: Teaching patients to recognize and monitor symptoms of worsening heart failure, such as increased dyspnea, edema, weight gain, and fatigue. Instructions on when and how to seek medical attention.
• Daily Weight Monitoring: Education on the importance of daily weight monitoring and how to record and interpret weight changes. Action plan for weight gain thresholds.
• Activity and Exercise Recommendations: Guidance on safe and appropriate levels of physical activity and exercise. Emphasis on gradual activity progression and energy conservation techniques.
• Smoking Cessation and Lifestyle Modifications: Counseling on smoking cessation, alcohol moderation, and management of other risk factors such as hypertension, diabetes, and obesity.
• Follow-up Appointments: Reinforce the importance of regular follow-up appointments with healthcare providers for monitoring and treatment adjustments.

Effective discharge planning is crucial to ensure a smooth transition from hospital to home and prevent hospital readmissions. Discharge planning should include:

• Medication Reconciliation: Review and reconcile medications to ensure accuracy and address any discrepancies.
• Home Health Referrals: Arrange for home health nursing visits for ongoing monitoring, medication management, and patient education, particularly for high-risk patients.
• Emergency Action Plan: Provide a written emergency action plan outlining steps to take if symptoms worsen.
• Contact Information: Provide contact information for healthcare providers and resources.
• Support Services: Connect patients with community resources and support services, such as heart failure support groups.

Conclusion

Nursing care for patients with heart failure is a critical component of comprehensive management. By utilizing a patient-centered approach and focusing on key nursing diagnoses and interventions, nurses play a vital role in alleviating symptoms, improving functional status, enhancing quality of life, and reducing hospital readmissions for individuals living with heart failure. A well-structured nursing care plan, incorporating patient education and collaborative care, is essential for optimizing outcomes and empowering patients in their journey to manage this chronic condition effectively.

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]