Congestive heart failure natural history

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Congestive Heart Failure Microchapters


Patient Information


Historical Perspective



Systolic Dysfunction
Diastolic Dysfunction


Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors


Natural History, Complications and Prognosis


Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings


Chest X Ray

Cardiac MRI


Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies


Invasive Hemodynamic Monitoring

Medical Therapy:

Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Positive Inotropics
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Risk calculators and risk factors for Congestive heart failure natural history

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Saleh El Dassouki, M.D. [3]; Atif Mohammad, M.D.


Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life. Congestive heart failure is also associated with a poor prognosis. If left untreated, heart failure may result in death due to complications associated with the condition. Heart failure resulting from atherosclerotic coronary artery disease has been shown to be associated with higher incidence of fatal events compared to heart failure that results from other cardiac diseases. Heart failure is a progressive disease with a major impact on the patient's quality of life. With the exception of heart failure caused by reversible conditions, the condition usually worsens with time. Although some people survive many years, progressive disease is associated with an overall annual mortality rate of 10%. In the Framingham experience, 80% of men and 70% of women with heart failure who were under 65 years of age had died within 8 years of the diagnosis.

Natural History

  • If left untreated, heart failure may result in death due to complications associated with the condition. Heart failure is a progressive disease with a major impact on the patient's quality of life.
  • Heart failure resulting from atherosclerotic coronary artery disease has been shown to be associated with higher incidence of fatal events compared to heart failure that results from other cardiac diseases
  • Initiation of therapy for heart failure may lead to stabilization of the patient's clinical condition which is referred to as the stability phase.[1]
  • Months to years following the stability phase, the patient functional status may decline resulting in multiple hospitalizations and eventually the condition may become refractory to treatment whn ventricular remodeling sets in.[2]
  • Once refractory, heart failure may be managed titration of pharmacological therapy and by the use to left ventricular assist devices and cardiac transplantation.


1. Cardiac Arrhythmias:

  • Ventricular tachycardia and ventricular fibrillation can occur as serious complications of heart failure when its pump function is severely impaired. This further worsens the cardiac output and even possible death.
  • Atrial fibrillation which is rapid beating of atrium without optimal forward pumping of blood is another complication of heart failure which occurs as a result of resistance to blood flow from atrium to ventricles. These patients are at increased risk of stroke.
  • Left bundle branch block is an abnormality in electrical conduction in the heart.

2. Pulmonary Congestion:

3. Angina and myocardial infarction: Cardiac ischemia and infarction can also occur when heart failure patients undergo exertion. With LV dilation, LV wall stress increases, and this increases the risk of angina. Autopsy studies demonstrate that plaque rupture and coronary thrombosis is a common mode of death in patients with congestive heart failure.

4. Renal failure: Renal impairment can occur secondary to decreased renal perfusion. This further worsens heart failure by fluid retention.

5. Cardiac cachexia: Unintentional rapid weight loss (a loss of at least 7.5% of normal weight within 6 months) can occur in chronic heart failure[5]. This is a bad prognostic factor.


Risk Stratification Tools

The prognosis in patients with heart failure can be assessed using a variety of risk stratification tools and cardiopulmonary exercise testing. Clinical prediction rules use a composite of clinical factors such as lab tests and blood pressure to estimate prognosis. Among several clinical prediction rules for assessing the prognosis in acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying patients and identifying those at low risk of death during hospitalization or within 30 days.[6] Other simpler methods for identifying low risk patients include the:

A very important method for assessing prognosis in advanced heart failure patients is cardiopulmonary exercise testing (CPX testing). CPX testing is usually required prior to heart transplantation as an indicator of prognosis. Cardiopulmonary exercise testing involves measurement of exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 12-14 cc/kg/min indicates a poor survival and suggests that the patient may be a candidate for a heart transplant. Patients with a VO2 max<10 cc/kg/min have clearly poorer prognosis. The most recent International Society for Heart and Lung Transplantation (ISHLT) guidelines[7] also suggest two other parameters that can be used for evaluation of prognosis in advanced heart failure, the heart failure survival score and the use of a criterion of VE/VCO2 slope > 35 from the CPX test. The heart failure survival score is a score calculated using a combination of clinical predictors and the VO2 max from the cardiopulmonary exercise test.

Mortality Associated with Heart Failure

Based on the 44-year follow-up of the NHLBI’s Framingham Heart Study:


  1. Chaudhry SP, Stewart GC (July 2016). "Advanced Heart Failure: Prevalence, Natural History, and Prognosis". Heart Fail Clin. 12 (3): 323–33. doi:10.1016/j.hfc.2016.03.001. PMID 27371510.
  2. Allen LA, Stevenson LW, Grady KL, Goldstein NE, Matlock DD, Arnold RM, Cook NR, Felker GM, Francis GS, Hauptman PJ, Havranek EP, Krumholz HM, Mancini D, Riegel B, Spertus JA (April 2012). "Decision making in advanced heart failure: a scientific statement from the American Heart Association". Circulation. 125 (15): 1928–52. doi:10.1161/CIR.0b013e31824f2173. PMC 3893703. PMID 22392529.
  3. Bozkurt B, Hershberger RE, Butler J, Grady KL, Heidenreich PA, Isler ML, Kirklin JK, Weintraub WS (April 2021). "2021 ACC/AHA Key Data Elements and Definitions for Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for Heart Failure)". Circ Cardiovasc Qual Outcomes. 14 (4): e000102. doi:10.1161/HCQ.0000000000000102. PMC 8059763 Check |pmc= value (help). PMID 33755495 Check |pmid= value (help).
  4. Moussavian SN, Dincsoy HP, Goodman S, Helm RA, Bozian RC (1982). "Severe hyperbilirubinemia and coma in chronic congestive heart failure". Digestive Diseases and Sciences. 27 (2): 175–80. PMID 7075414. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  5. Freeman LM (2009). "The pathophysiology of cardiac cachexia". Current Opinion in Supportive and Palliative Care. 3 (4): 276–81. doi:10.1097/SPC.0b013e32833237f1. PMID 19797959. Retrieved 2011-04-30. Unknown parameter |month= ignored (help)
  6. Auble TE, Hsieh M, McCausland JB, Yealy DM (2007). "Comparison of four clinical prediction rules for estimating risk in heart failure". Annals of emergency medicine. 50 (2): 127–35, 135.e1–2. doi:10.1016/j.annemergmed.2007.02.017. PMID 17449141.
  7. Mandeep R. Mehra; et al. "Evaluation of listing criteria for cardiac transplantation". Journal of Heart and Lung Transplantation. Retrieved 8 April 2010.

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