Heart failure
Classification and external resources
The major signs and symptoms of heart failure.
ICD-10	I50
ICD-9	428.0
DiseasesDB	16209
MedlinePlus	000158
eMedicine	med/3552 emerg/108 radio/189 med/1367150 ped/2636
MeSH	D006333

Heart failure (HF) often called congestive heart failure (CHF) or congestive cardiac failure (CCF) is generally defined as the inability of the heart to supply sufficient blood flow to meet the needs of the body.^[1][2][3] Heart failure can cause a number of symptoms including shortness of breath, leg swelling, and exercise intolerance. The condition is diagnosed with echocardiography and blood tests. Treatment commonly consists of lifestyle measures (such as smoking cessation, light exercise including breathing protocols, decreased salt intake and other dietary changes) and medications. Sometimes it is treated with implanted devices (pacemakers or ventricular assist devices) and occasionally a heart transplant.

Common causes of heart failure include myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease, and cardiomyopathy.^[4] The term "heart failure" is sometimes incorrectly used to describe other cardiac-related illnesses, such as myocardial infarction (heart attack) or cardiac arrest, which can cause heart failure but are not equivalent to heart failure.

Heart failure is a common, costly, disabling, and potentially deadly condition.^[4] In developed countries, around 2% of adults suffer from heart failure, but in those over the age of 65, this increases to 6–10%.^[4][5]

Terminology[link]

Heart failure is a global term for the physiological state in which cardiac output is insufficient in meeting the needs of the body and lungs. Often termed "congestive heart failure" or CHF, this is most commonly caused when cardiac output is low and the body becomes congested with fluid.^[6]

It may also occur when the body's requirements for oxygen and nutrients are increased and the demand outstrips what the heart can provide, (termed "high output cardiac failure").^[7] This can occur from severe anemia, Gram negative septicaemia, beriberi (vitamin B₁/thiamine deficiency), thyrotoxicosis, Paget's disease, arteriovenous fistulae, or arteriovenous malformations.

Fluid overload is a common problem for people with heart failure but is not synonymous with it. Patients with treated heart failure will often be euvolaemic (a term for normal fluid status), or more rarely, dehydrated.

Medical professionals use the words "acute" to mean of rapid onset and "chronic" of long duration. Chronic heart failure is therefore a long term situation, usually with stable treated symptomatology.

Acute decompensated heart failure is a term used to describe exacerbated or decompensated heart failure, referring to episodes in which a patient can be characterized as having a change in heart failure signs and symptoms resulting in a need for urgent therapy or hospitalization.^[8]

There are several terms which are closely related to heart failure, and may be the cause of heart failure, but should not be confused with it:

• Cardiac arrest and asystole refer to situations in which there is no cardiac output at all. Without urgent treatment these result in sudden death.
• Myocardial infarction ("Heart attack") refers to heart muscle damage due to insufficient blood supply, usually as a result of a blocked coronary artery.
• Cardiomyopathy refers specifically to problems within the heart muscle, and these problems can result in heart failure. Ischemic cardiomyopathy implies that the cause of muscle damage is coronary artery disease. Dilated cardiomyopathy implies that the muscle damage has resulted in enlargement of the heart. Hypertrophic cardiomyopathy involves enlargement and thickening of the heart muscle.

Classification[link]

There are many different ways to categorize heart failure, including:

• the side of the heart involved (left heart failure versus right heart failure). Left heart failure compromises aortic flow to the body and brain. Right heart failure compromises pulmonic flow to the lungs. Mixed presentations are common, especially when the cardiac septum is involved.
• whether the abnormality is due to insufficient contraction (systolic dysfunction), or due to insufficient relaxation of the heart (diastolic dysfunction), or to both.
• whether the problem is primarily increased venous back pressure (preload), or failure to supply adequate arterial perfusion (afterload).
• whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high-output heart failure).
• the degree of functional impairment conferred by the abnormality (as reflected in the New York Heart Association Functional Classification^[9])
• the degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/renal failure, etc.

Functional classification generally relies on the New York Heart Association functional classification. The classes (I-IV) are:

• Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
• Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
• Class III: marked limitation of any activity; the patient is comfortable only at rest.
• Class IV: any physical activity brings on discomfort and symptoms occur at rest.

This score documents severity of symptoms, and can be used to assess response to treatment. While its use is widespread, the NYHA score is not very reproducible and doesn't reliably predict the walking distance or exercise tolerance on formal testing.^[10]

In its 2001 guidelines the American College of Cardiology/American Heart Association working group introduced four stages of heart failure:^[11]

• Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder.
• Stage B: a structural heart disorder but no symptoms at any stage.
• Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment.
• Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

The ACC staging system is useful in that Stage A encompasses "pre-heart failure" — a stage where intervention with treatment can presumably prevent progression to overt symptoms. ACC Stage A does not have a corresponding NYHA class. ACC Stage B would correspond to NYHA Class I. ACC Stage C corresponds to NYHA Class II and III, while ACC Stage D overlaps with NYHA Class IV.

Signs and symptoms[link]

A man with congestive heart failure and marked jugular venous distension. External jugular vein marked by an arrow.

Signs[link]

Left-sided failure[link]

Common respiratory signs are tachypnea (increased rate of breathing) and increased work of breathing (non-specific signs of respiratory distress). Rales or crackles, heard initially in the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary edema (fluid in the alveoli). Cyanosis which suggests severe hypoxemia, is a late sign of extremely severe pulmonary edema.

Additional signs indicating left ventricular failure include a laterally displaced apex beat (which occurs if the heart is enlarged) and a gallop rhythm (additional heart sounds) may be heard as a marker of increased blood flow, or increased intra-cardiac pressure. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g., mitral regurgitation) of the heart failure.

Right-sided failure[link]

Physical examination can reveal pitting peripheral edema, ascites, and hepatomegaly. Jugular venous pressure is frequently assessed as a marker of fluid status, which can be accentuated by eliciting hepatojugular reflux. If the right ventricular pressure is increased, a parasternal heave may be present, signifying the compensatory increase in contraction strength.

Biventricular failure[link]

Dullness of the lung fields to finger percussion and reduced breath sounds at the bases of the lung may suggest the development of a pleural effusion (fluid collection in between the lung and the chest wall). Though it can occur in isolated left- or right-sided heart failure, it is more common in biventricular failure because pleural veins drain both into the systemic and pulmonary venous system. When unilateral, effusions are often right sided.

Symptoms[link]

Heart failure symptoms are traditionally and somewhat arbitrarily divided into "left" and "right" sided, recognizing that the left and right ventricles of the heart supply different portions of the circulation. However, heart failure is not exclusively backward failure (in the part of the circulation which drains to the ventricle).

There are several other exceptions to a simple left-right division of heart failure symptoms. Left sided forward failure overlaps with right sided backward failure. Additionally, the most common cause of right-sided heart failure is left-sided heart failure. The result is that patients commonly present with both sets of signs and symptoms.

Left-sided failure[link]

Backward failure of the left ventricle causes congestion of the pulmonary vasculature, and so the symptoms are predominantly respiratory in nature. Backward failure can be subdivided into failure of the left atrium, the left ventricle or both within the left circuit. The patient will have dyspnea (shortness of breath) on exertion (dyspnée d'effort) and in severe cases, dyspnea at rest. Increasing breathlessness on lying flat, called orthopnea, occurs. It is often measured in the number of pillows required to lie comfortably, and in severe cases, the patient may resort to sleeping while sitting up. Another symptom of heart failure is paroxysmal nocturnal dyspnea a sudden nighttime attack of severe breathlessness, usually several hours after going to sleep. Easy fatigueability and exercise intolerance are also common complaints related to respiratory compromise.

"Cardiac asthma" or wheezing may occur.

Compromise of left ventricular forward function may result in symptoms of poor systemic circulation such as dizziness, confusion and cool extremities at rest.

Right-sided failure[link]

Backward failure of the right ventricle leads to congestion of systemic capillaries. This generates excess fluid accumulation in the body. This causes swelling under the skin (termed peripheral edema or anasarca) and usually affects the dependent parts of the body first (causing foot and ankle swelling in people who are standing up, and sacral edema in people who are predominantly lying down). Nocturia (frequent nighttime urination) may occur when fluid from the legs is returned to the bloodstream while lying down at night. In progressively severe cases, ascites (fluid accumulation in the abdominal cavity causing swelling) and hepatomegaly (enlargement of the liver) may develop. Significant liver congestion may result in impaired liver function, and jaundice and even coagulopathy (problems of decreased blood clotting) may occur.

Causes[link]

Chronic heart failure[link]

The predominance of causes of heart failure are difficult to analyze due to challenges in diagnosis, differences in populations, and changing prevalence of causes with age.

A 19 year study of 13000 healthy adults in the United States (the National Health and Nutrition Examination Survey (NHANES I) found the following causes ranked by Population Attributable Risk score:^[12]

1. Ischaemic heart disease 62%
2. Cigarette smoking 16%
3. Hypertension (high blood pressure)10%
4. Obesity 8%
5. Diabetes 3%
6. Valvular heart disease 2% (much higher in older populations)

An Italian registry of over 6200 patients with heart failure showed the following underlying causes:^[13]

1. Ischaemic heart disease 40%
2. Dilated cardiomyopathy 32%
3. Valvular heart disease 12%
4. Hypertension 11%
5. Other 5%

Rarer causes of heart failure include:

• Viral myocarditis (an infection of the heart muscle)
• Infiltrations of the muscle such as amyloidosis
• HIV cardiomyopathy (caused by human immunodeficiency virus)
• Connective tissue diseases such as systemic lupus erythematosus
• Abuse of drugs such as alcohol and cocaine
• Pharmaceutical drugs such as chemotherapeutic agents
• Arrhythmias

Obstructive sleep apnea a condition of sleep disordered breathing overlaps with obesity, hypertension, and diabetes and is regarded as an independent cause of heart failure.

Acute decompensated heart failure[link]

Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, or a patient's failure to maintain a fluid restriction, diet, or medication.^[14] Other well recognized precipitating factors include anemia and hyperthyroidism which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs and thiazolidinediones, may also precipitate decompensation.^[15]

Pathophysiology[link]

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Heart failure is caused by any condition which reduces the efficiency of the myocardium, or heart muscle, through damage or overloading. As such, it can be caused by as diverse an array of conditions as myocardial infarction (in which the heart muscle is starved of oxygen and dies), hypertension (which increases the force of contraction needed to pump blood) and amyloidosis (in which protein is deposited in the heart muscle, causing it to stiffen). Over time these increases in workload will produce changes to the heart itself:

• Reduced force of contraction, due to overloading of the ventricle. In health, increased filling of the ventricle results in increased force of contraction (by the Frank–Starling law of the heart) and thus a rise in cardiac output. In heart failure this mechanism fails, as the ventricle is loaded with blood to the point where heart muscle contraction becomes less efficient. This is due to reduced ability to cross-link actin and myosin filaments in over-stretched heart muscle.^[16]
• A reduced stroke volume, as a result of a failure of systole, diastole or both. Increased end systolic volume is usually caused by reduced contractility. Decreased end diastolic volume results from impaired ventricular filling – as occurs when the compliance of the ventricle falls (i.e. when the walls stiffen).
• Reduced spare capacity. As the heart works harder to meet normal metabolic demands, the amount cardiac output can increase in times of increased oxygen demand (e.g. exercise) is reduced. This contributes to the exercise intolerance commonly seen in heart failure. This translates to the loss of one's cardiac reserve. The cardiac reserve refers to the ability of the heart to work harder during exercise or strenuous activity. Since the heart has to work harder to meet the normal metabolic demands, it is incapable of meeting the metabolic demands of the body during exercise.
• Increased heart rate, stimulated by increased sympathetic activity^[17] in order to maintain cardiac output. Initially, this helps compensate for heart failure by maintaining blood pressure and perfusion, but places further strain on the myocardium, increasing coronary perfusion requirements, which can lead to worsening of ischemic heart disease. Sympathetic activity may also cause potentially fatal arrhythmias.
• Hypertrophy (an increase in physical size) of the myocardium, caused by the terminally differentiated heart muscle fibres increasing in size in an attempt to improve contractility. This may contribute to the increased stiffness and decreased ability to relax during diastole.
• Enlargement of the ventricles, contributing to the enlargement and spherical shape of the failing heart. The increase in ventricular volume also causes a reduction in stroke volume due to mechanical and contractile inefficiency.^[18]

The general effect is one of reduced cardiac output and increased strain on the heart. This increases the risk of cardiac arrest (specifically due to ventricular dysrhythmias), and reduces blood supply to the rest of the body. In chronic disease the reduced cardiac output causes a number of changes in the rest of the body, some of which are physiological compensations, some of which are part of the disease process:

• Arterial blood pressure falls. This destimulates baroreceptors in the carotid sinus and aortic arch which link to the nucleus tractus solitarius. This center in the brain increases sympathetic activity, releasing catecholamines into the blood stream. Binding to alpha-1 receptors results in systemic arterial vasoconstriction. This helps restore blood pressure but also increases the total peripheral resistance, increasing the workload of the heart. Binding to beta-1 receptors in the myocardium increases the heart rate and make contractions more forceful, in an attempt to increase cardiac output. This also, however, increases the amount of work the heart has to perform.
• Increased sympathetic stimulation also causes the hypothalamus to secrete vasopressin (also known as antidiuretic hormone or ADH), which causes fluid retention at the kidneys. This increases the blood volume and blood pressure.
• Reduced perfusion (blood flow) to the kidneys stimulates the release of renin – an enzyme which catalyses the production of the potent vasopressor angiotensin. Angiotensin and its metabolites cause further vasocontriction, and stimulate increased secretion of the steroid aldosterone from the adrenal glands. This promotes salt and fluid retention at the kidneys, also increasing the blood volume.
• The chronically high levels of circulating neuroendocrine hormones such as catecholamines, renin, angiotensin, and aldosterone affects the myocardium directly, causing structural remodelling of the heart over the long term. Many of these remodelling effects seem to be mediated by transforming growth factor beta (TGF-beta), which is a common downstream target of the signal transduction cascade initiated by catecholamines^[19] and angiotensin II,^[20] and also by epidermal growth factor (EGF), which is a target of the signaling pathway activated by aldosterone^[21]
• Reduced perfusion of skeletal muscle causes atrophy of the muscle fibres. This can result in weakness, increased fatigueability and decreased peak strength - all contributing to exercise intolerance.^[22]

The increased peripheral resistance and greater blood volume place further strain on the heart and accelerates the process of damage to the myocardium. Vasoconstriction and fluid retention produce an increased hydrostatic pressure in the capillaries. This shifts the balance of forces in favour of interstitial fluid formation as the increased pressure forces additional fluid out of the blood, into the tissue. This results in edema (fluid build-up) in the tissues. In right-sided heart failure this commonly starts in the ankles where venous pressure is high due to the effects of gravity (although if the patient is bed-ridden, fluid accumulation may begin in the sacral region.) It may also occur in the abdominal cavity, where the fluid build-up is called ascites. In left-sided heart failure edema can occur in the lungs - this is called cardiogenic pulmonary edema. This reduces spare capacity for ventilation, causes stiffening of the lungs and reduces the efficiency of gas exchange by increasing the distance between the air and the blood. The consequences of this are dyspnea (shortness of breath), orthopnea and paroxysmal nocturnal dyspnea.

The symptoms of heart failure are largely determined by which side of the heart fails. The left side pumps blood into the systemic circulation, whilst the right side pumps blood into the pulmonary circulation. Whilst left-sided heart failure will reduce cardiac output to the systemic circulation, the initial symptoms often manifest due to effects on the pulmonary circulation. In systolic dysfunction, the ejection fraction is decreased, leaving an abnormally elevated volume of blood in the left ventricle. In diastolic dysfunction, end-diastolic ventricular pressure will be high. This increase in volume or pressure backs up to the left atrium and then to the pulmonary veins. Increased volume or pressure in the pulmonary veins impairs the normal drainage of the alveoli and favors the flow of fluid from the capillaries to the lung parenchyma, causing pulmonary edema. This impairs gas exchange. Thus, left-sided heart failure often presents with respiratory symptoms: shortness of breath, orthopnea and paroxysmal nocturnal dyspnea.

In severe cardiomyopathy, the effects of decreased cardiac output and poor perfusion become more apparent, and patients will manifest with cold and clammy extremities, cyanosis, claudication, generalized weakness, dizziness, and syncope.

The resultant hypoxia caused by pulmonary edema causes vasoconstriction in the pulmonary circulation, which results in pulmonary hypertension. Since the right ventricle generates far lower pressures than the left ventricle (approximately 20 mmHg versus around 120 mmHg, respectively, in the healthy individual) but nonetheless generates cardiac output exactly equal to the left ventricle, this means that a small increase in pulmonary vascular resistance causes a large increase in amount of work the right ventricle must perform. However, the main mechanism by which left-sided heart failure causes right-sided heart failure is actually not well understood. Some theories invoke mechanisms that are mediated by neurohormonal activation.^[23] Mechanical effects may also contribute. As the left ventricle distends, the intraventricular septum bows into the right ventricle, decreasing the capacity of the right ventricle.

Systolic dysfunction[link]

Heart failure caused by systolic dysfunction is more readily recognized. It can be simplistically described as failure of the pump function of the heart. It is characterized by a decreased ejection fraction (less than 45%). The strength of ventricular contraction is attenuated and inadequate for creating an adequate stroke volume, resulting in inadequate cardiac output. In general, this is caused by dysfunction or destruction of cardiac myocytes or their molecular components. In congenital diseases such as Duchenne muscular dystrophy, the molecular structure of individual myocytes is affected. Myocytes and their components can be damaged by inflammation (such as in myocarditis) or by infiltration (such as in amyloidosis). Toxins and pharmacological agents (such as ethanol, cocaine, and amphetamines) cause intracellular damage and oxidative stress. The most common mechanism of damage is ischemia causing infarction and scar formation. After myocardial infarction, dead myocytes are replaced by scar tissue, deleteriously affecting the function of the myocardium. On echocardiogram, this is manifest by abnormal or absent wall motion.

Because the ventricle is inadequately emptied, ventricular end-diastolic pressure and volumes increase. This is transmitted to the atrium. On the left side of the heart, the increased pressure is transmitted to the pulmonary vasculature, and the resultant hydrostatic pressure favors extravassation of fluid into the lung parenchyma, causing pulmonary edema. On the right side of the heart, the increased pressure is transmitted to the systemic venous circulation and systemic capillary beds, favoring extravassation of fluid into the tissues of target organs and extremities, resulting in dependent peripheral edema.

Diastolic dysfunction[link]

Heart failure caused by diastolic dysfunction is generally described as the failure of the ventricle to adequately relax and typically denotes a stiffer ventricular wall. This causes inadequate filling of the ventricle, and therefore results in an inadequate stroke volume. The failure of ventricular relaxation also results in elevated end-diastolic pressures, and the end result is identical to the case of systolic dysfunction (pulmonary edema in left heart failure, peripheral edema in right heart failure.)

Diastolic dysfunction can be caused by processes similar to those that cause systolic dysfunction, particularly causes that affect cardiac remodeling.

Diastolic dysfunction may not manifest itself except in physiologic extremes if systolic function is preserved. The patient may be completely asymptomatic at rest. However, they are exquisitely sensitive to increases in heart rate, and sudden bouts of tachycardia (which can be caused simply by physiological responses to exertion, fever, or dehydration, or by pathological tachyarrhythmias such as atrial fibrillation with rapid ventricular response) may result in flash pulmonary edema. Adequate rate control (usually with a pharmacological agent that slows down AV conduction such as a calcium channel blocker or a beta-blocker) is therefore key to preventing decompensation.

Left ventricular diastolic function can be determined through echocardiography by measurement of various parameters such as the E/A ratio (early-to-atrial left ventricular filling ratio), the E (early left ventricular filling) deceleration time, and the isovolumic relaxation time.

Diagnosis[link]

Acute pulmonary edema. Note enlarged heart size, apical vascular redistribution ( circle ), and small bilateral pleural effusions ( arrow ).

No system of diagnostic criteria has been agreed as the gold standard for heart failure. Commonly used systems are the "Framingham criteria"^[24] (derived from the Framingham Heart Study), the "Boston criteria",^[25] the "Duke criteria",^[26] and (in the setting of acute myocardial infarction) the "Killip class".^[27]

Imaging[link]

Echocardiography is commonly used to support a clinical diagnosis of heart failure. This modality uses ultrasound to determine the stroke volume (SV, the amount of blood in the heart that exits the ventricles with each beat), the end-diastolic volume (EDV, the total amount of blood at the end of diastole), and the SV in proportion to the EDV, a value known as the ejection fraction (EF). In pediatrics, the shortening fraction is the preferred measure of systolic function. Normally, the EF should be between 50% and 70%; in systolic heart failure, it drops below 40%. Echocardiography can also identify valvular heart disease and assess the state of the pericardium (the connective tissue sac surrounding the heart). Echocardiography may also aid in deciding what treatments will help the patient, such as medication, insertion of an implantable cardioverter-defibrillator or cardiac resynchronization therapy. Echocardiography can also help determine if acute myocardial ischemia is the precipitating cause, and may manifest as regional wall motion abnormalities on echo.

Chest X-rays are frequently used to aid in the diagnosis of CHF. In the compensated patient, this may show cardiomegaly (visible enlargement of the heart), quantified as the cardiothoracic ratio (proportion of the heart size to the chest). In left ventricular failure, there may be evidence of vascular redistribution ("upper lobe blood diversion" or "cephalization"), Kerley lines, cuffing of the areas around the bronchi, and interstitial edema.

Electrophysiology[link]

An electrocardiogram (ECG/EKG) may be used to identify arrhythmias, ischemic heart disease, right and left ventricular hypertrophy, and presence of conduction delay or abnormalities (e.g. left bundle branch block). Although these findings are not specific to the diagnosis of heart failure a normal ECG virtually excludes left ventricular systolic dysfunction.^[28]

Blood tests[link]

Blood tests routinely performed include electrolytes (sodium, potassium), measures of renal function, liver function tests, thyroid function tests, a complete blood count, and often C-reactive protein if infection is suspected. An elevated B-type natriuretic peptide (BNP) is a specific test indicative of heart failure. Additionally, BNP can be used to differentiate between causes of dyspnea due to heart failure from other causes of dyspnea. If myocardial infarction is suspected, various cardiac markers may be used.

According to a meta-analysis comparing BNP and N-terminal pro-BNP (NTproBNP) in the diagnosis of heart failure, BNP is a better indicator for heart failure and left ventricular systolic dysfunction. In groups of symptomatic patients, a diagnostic odds ratio of 27 for BNP compares with a sensitivity of 85% and specificity of 84% in detecting heart failure.^[29]

Angiography[link]

Heart failure may be the result of coronary artery disease, and its prognosis depends in part on the ability of the coronary arteries to supply blood to the myocardium (heart muscle). As a result, coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or bypass surgery.

Monitoring[link]

Various measures are often used to assess the progress of patients being treated for heart failure. These include fluid balance (calculation of fluid intake and excretion), monitoring body weight (which in the shorter term reflects fluid shifts).

Algorithms[link]

There are various algorithms for the diagnosis of heart failure. For example, the algorithm used by the Framingham Heart Study adds together criteria mainly from physical examination. In contrast, the more extensive algorithm by the European Society of Cardiology (ESC) weights the difference between supporting and opposing parameters from the medical history, physical examination, further medical tests as well as response to therapy.

Framingham criteria[link]

By the Framingham criteria, diagnosis of congestive heart failure (heart failure with impaired pumping capability)^[6] requires the simultaneous presence of at least 2 of the following major criteria or 1 major criterion in conjunction with 2 of the following minor criteria:

Major criteria:^[30]

• Cardiomegaly on chest radiography
• S3 gallop (a third heart sound)
• Acute pulmonary edema
• Paroxysmal nocturnal dyspnea
• Crackles on lung auscultation
• Central venous pressure of more than 16 cm H2O at the right atrium
• Jugular vein distension
• Positive abdominojugular test
• Weight loss of more than 4.5 kg in 5 days in response to treatment (sometimes classified as a minor criterium^[31])

Minor criteria:^[30]

• Tachycardia of more than 120 beats per minute
• Nocturnal cough
• Dyspnea on ordinary exertion
• Pleural effusion
• Decrease in vital capacity by one third from maximum recorded
• Hepatomegaly
• Bilateral ankle edema

Minor criteria are acceptable only if they can not be attributed to another medical condition such as pulmonary hypertension, chronic lung disease, cirrhosis, ascites, or the nephrotic syndrome.^[30] The Framingham Heart Study criteria are 100% sensitive and 78% specific for identifying persons with definite congestive heart failure.^[30]

ESC algorithm[link]

The ESC algorithm weights the following parameters in establishing the diagnosis of heart failure:^[32]

Management[link]

Treatment focuses on improving the symptoms and preventing the progression of the disease. Reversible causes of the heart failure also need to be addressed: (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, hypertension). Treatments include lifestyle and pharmacological modalities.

Acute decompensation[link]

In acute decompensated heart failure (ADHF), the immediate goal is to re-establish adequate perfusion and oxygen delivery to end organs. This entails ensuring that airway, breathing, and circulation are adequate. Immediated treatments usually involve some combination of vasodilators such as nitroglycerin, diuretics such as furosemide, and possibly non invasive positive pressure ventilation (NIPPV).

Chronic management[link]

The goal is to prevent the development of acute decompensated heart failure, to counteract the deleterious effects of cardiac remodeling, and to minimize the symptoms that the patient suffers. First-line therapy for all heart failure patients is angiotensin-converting enzyme (ACE) inhibition. ACE inhibitors (i.e., enalapril, captopril, lisinopril, ramipril) improve survival and quality of life in heart failure patients, and have been shown to reduce mortality in patients with left ventricular dysfunction in numerous randomized trials.^[33][34] In addition to pharmacologic agents (oral loop diuretics, beta-blockers, ACE inhibitors or angiotensin receptor blockers, vasodilators, and in severe cardiomyopathy aldosterone receptor antagonists), behavioral modification should be pursued, specifically with regard to dietary guidelines regarding salt and fluid intake. Exercise should be encouraged as tolerated, as sufficient conditioning can significantly improve quality-of-life.

In patients with severe cardiomyopathy, implantation of an automatic implantable cardioverter defibrillator (AICD) should be considered. A select population will also probably benefit from ventricular resynchronization.

In select cases, cardiac transplantation can be considered. While this may resolve the problems associated with heart failure, the patient generally must remain on an immunosuppressive regimen to prevent rejection, which has its own significant downsides.

Home dobutamine and milrinone[link]

These two medications are both inotropes with sympathomimetic effect. Both can be used in severe heart failure, generally in patients who require frequent exacerbations with hospitalization and/or refractory symptoms. While both medications have proven to improve symptoms, both also increase the risk of sudden cardiac death, and the research suggests an increased mortality rate for patients who are started on these medications. Extensive counseling about symptom management vs. risk of earlier death needs to be undertaken before starting the medication.^{[citation needed]}

Palliative care[link]

Patients with CHF often have significant symptoms, such as shortness of breath and chest pain. Both palliative care and cardiology are trying to get palliative care involved earlier in the course of patients with heart failure, and some would argue any patient with NYHA class III CHF should have a palliative care referral. Palliative care can not only provide symptom management, but also assist with advanced care planning, goals of care in the case of a significant decline, and making sure the patient has a medical power of attorney and discussed his or her wishes with this individual.

Hospice[link]

Without transplantation, heart failure may not be reversible and cardiac function typically deteriorates with time. The growing number of patients with Stage IV heart failure (intractable symptoms of fatigue, shortness of breath or chest pain at rest despite optimal medical therapy) should be considered for palliative care or hospice, according to American College of Cardiology/American Heart Association guidelines.

Prognosis[link]

Prognosis in heart failure can be assessed in multiple ways including clinical prediction rules 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 prognosing 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.^[35] Easy methods for identifying low risk patients are:

• ADHERE Tree rule indicates that patients with blood urea nitrogen < 43 mg/dl and systolic blood pressure at least 115 mm Hg have less than 10% chance of inpatient death or complications.
• BWH rule indicates that patients with systolic blood pressure over 90 mm Hg, respiratory rate of 30 or less breaths per minute, serum sodium over 135 mmol/L, no new ST-T wave changes have less than 10% chance of inpatient death or complications.

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^[36] 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.

Epidemiology[link]

Mostly as a result of the costs of hospitalization, it is associated with a high health expenditure; costs have been estimated to amount to 2% of the total budget of the National Health Service in the United Kingdom, and more than $35 billion in the United States.^[37][38] Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life.^[39][40] 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%.^[41]

Heart failure is the leading cause of hospitalization in people older than 65.^[42] In developed countries, the mean age of patients with heart failure is 75 years old. In developing countries, two to three percent of the population suffers from heart failure, but in those 70 to 80 years old, it occurs in 20—30 percent.

Heart failure affects close to 5 million people in the USA and each year close to 500,000 new cases are diagnosed. What is of more concern is that more than 50% of patients seek re-admission within 6 months after treatment and the average duration of hospital stay is 6 days.

In tropical countries, the most common cause of HF is valvular heart disease or some type of cardiomyopathy. Moreover as underdeveloped countries become more affluent, there has also been an increase in diabetes, hypertension and obesity which has resulted in heart failure.

In USA, HF is much higher in African Americans, Hispanics, Native Americans and recent immigrants from the eastern bloc countries like Russia. This high prevalence in these ethnic populations has been linked to high incidence of diabetes and hypertension. In many new immigrants to the USA the high prevalence of heart failure has largely been attributed to lack of preventive health care or substandard treatment.^[43]

Sex[link]

Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure.^[44] Women tend to be older when diagnosed with heart failure (after menopause), they are more likely than men to have diastolic dysfunction, and seem to experience a lower overall quality of life than men after diagnosis.^[44]

Race[link]

New information suggests that elements of heart failure in African Americans and Caucasians may be different^[45] and therapy for heart failure has different efficacies depending on racial, ethnic, and genetic backgrounds.

References[link]

External links[link]

Wikimedia Commons has media related to: Heart failure

• American Heart Association's Heart Failure web site - information and resources for treating and living with heart failure.
• Heart Failure Matters – patient information website of the Heart Failure Association of the European Society of Cardiology

This biographical article needs additional citations for verification. Please help by adding reliable sources. Contentious material about living persons that is unsourced or poorly sourced must be removed immediately, especially if potentially libelous or harmful. (May 2010)

The Basics
The Basics at the Oxford Art Factory, 2010
Background information
Origin	Melbourne, Australia
Genres	Rock
Years active	2002–present
Labels	Independent, Albert Records
Associated acts	Gotye, Down Hills Home, Dog With Wheels, Blood Red Bird
Website	The Basics Official Website
Members
Wally De Backer Kris Schroeder Tim Heath
Past members
Michael Hubbard
Notable instruments
Lead guitar, drums, bass guitar.

The Basics ( /ˈbæzɪtʃ/ BAZZ-ich) are a three-piece band from Melbourne, Australia, formed by Wally De Backer and Kris Schroeder in 2002. Their style has been described as anything from 'indie-pop' to 'rock'n'roll' to 'pop-rock', though their records show they span a wide range of genres, including reggae, ska, country, and electro-pop. They are "recognised as one of Australia's hardest-working bands".^[1]

With close to 1000 shows in their ten-year career, their live performances are well-known for their sense of humour and energy.^[2]

Formation[link]

The Basics were formed after Kris met Wally at a party in Melbourne.^[3] The event was to see off the young aspiring producer, who was about to depart for Los Angeles, and together with a number of musician friends, the two jammed on some blues-rock standards. Later that night, they bonded over a mutual love of The Beatles, 70s and 80s cartoon theme songs and old Sierra adventure games.

Initially, they played around Melbourne as an acoustic guitar/drums combo, starting at The Opposition in Frankston and the House of Fools in Footscray, where in late 2002 they met Michael Hubbard and later invited him to join them on electric guitar.^[4] Though lacking any real experience with the instrument, Kris willingly purchased his first bass guitar, and the trio was born. During this time, the group start performing songs with more complicated three-part harmony.

During late 2002 and early 2003, The Basics recorded and released an album called Get Back through MGM Distribution. They began what was to become regular tours of the East and West coasts of Australia.

2004-2005: Current lineup[link]

Tim Heath joined the group in June 2004, after Michael decided to pursue his solo career, which has included being one half of Down Hills Home.^[4] Tim was reportedly the only person to reply to an advertisement in Melbourne's Beat Magazine looking for a new guitarist. Tim apparently answered the advertisement - which said the applicant "must have a love of 50s and 60s rock'n'roll" - thinking that he would be meeting "a couple of old guys to play with on the weekends over some beers". They soon recorded For Girls Like You.

The Basics in 2005 continued to tour and play small festivals, and after releasing For Girls Like You through MGM Distribution, they departed for a national tour of Australia, which lasted for two months and took them to every Australian state and territory. Stuart Padbury, a young Melbourne sound engineer, joined them on much of this tour. On returning, the band began demonstrating songs for a new album.

2006-2009: Touring and soundtracks[link]

In 2006, The Basics began recording what was to become known as Stand Out/Fit In. Taking several months, it was not completed until the end of the year, despite intentions to have it released in June. Instead, they held a successful 'album preview', where each of the tracks was demonstrated in 'rough form' accompanied by a music video for each (produced by Melbourne photographic artist James Bryans). The band also talked about the origins of the songs. This event brought a lot of attention to the band for the idea's originality. They pre-released a radio single 'Just Hold On' from the album. The band were invited to play the hugely popular Homebake Festival in Sydney, where they received a great response, after being introduced onto the stage by a short stocky Asian guy with big calves ("one of the highlights" wrote The Daily Telegraph).

In 2007, the band departed on a tri-state residency which saw them play Melbourne, Sydney and Brisbane every week for the month of April - a bold move which brought further attention to the band for its original idea.^[5] Riding on the wave of this tour, Schroeder, De Backer and Heath departed on their first overseas tour which saw them performing 26 shows around Japan, Norway and the United Kingdom.^[6] They also toured twice more up the East Coast, one of which was with popular Japanese band The Bawdies. Their song 'Rattle My Chain' was used in a series of commercials for Volvo Australia. The song 'Hey There!' featured in the British film The Bank Job - starring Jason Statham - and was used as the backing for a February 2007 short film directed by Tim Longhurst called The Rip. Their song 'Better' was featured in a surfing documentary about the invention of the shortboard in 1967.

In 2008, the band appeared on Australia's Channel 9 for Australia Day celebrations, performing two of their songs - 'Just Hold On' and 'Hey There!' - to an estimated audience of 2 million. Securing an Australian Government grant, they embarked on a two-month tour of Australia, specifically targeting "culturally underprivileged groups" in rural and regional schoolchildren and Indigenous communities. The programme had them holding masterclasses and performing alongside Indigenous groups in the remote Northern Territory and Queensland.^[7][8] Their initiative also had them raising money for the charity Lifeline^{[disambiguation needed ]}, their contribution to which was recognised with a plaque at the end of the tour. Season two of Californication starring David Duchovny featured their cover of the classic 'Have Love, Will Travel', most famously covered by 'The Sonics'.

In 2009, The Basics for the first time enjoyed the support of Australian radio network Triple J, which had reportedly snubbed the band's previous material.^[9] The singles 'With This Ship' and 'Like A Brother' were added to the station's playlist, and momentum carried The Basics overseas for a second tour of the United Kingdom and Norway, and also a series of shows in Dublin, Ireland. They were joined by the longtime front-of-house engineer Stuart Padbury, who had been mixing them since 2005. The band was often seen in the Grafton Street Mall in Dublin, busking to promote their concerts there. Their second show in Oslo, Norway, saw the band perform with Hot Tub, one of the members of the Norwegian boy band "Boyzvoice", in his first performance for several years. Season Eight of Scrubs featured the song 'Lookin' Over My Shoulder'.

Despite all this promise, the band's album Keep Your Friends Close - produced and part-recorded by Peter Cobbin at London's Abbey Road Studios - though enjoying many favourable reviews,^{[10][11][12][13]} failed to impress Richard Kingsmill, music director of Triple J. This effectively ended the band's apparent upward spiral and the resulting album launch tour was reportedly "trying".

2010: Hiatus and live album[link]

In 2010, following the band's fourth stint at the Tamworth Country Music Festival, and the recording of a yet-unreleased live album, an indefinite hiatus was announced on the band's websites. This was in part due to the impending release of a new album produced by Wally for his Gotye project, and also to reported tensions within the band following the previous year's disappointments.

However, this hiatus was soon broken with a two-month residency at the Northcote Social Club in Melbourne, which saw an apparent return to form.^[14] The band's EP "Wait For You" enjoys airplay on Triple J.^[15] The Basics also played a one-off show at Sydney's Oxford Art Factory.^[16]

On 20 August 2010, The Basics released their fourth LP /ðəˈbæzɪtʃ/, available free and exclusively from their website for digital download^[17]. The band had reportedly moved to expand their listenership through this free giveaway, though 300 "Deluxe" CD/vinyl versions have been printed. /ðəˈbæzɪtʃ/ was recorded at the Northcote Social Club on 6 February, "in front of a live studio audience", and like the previous record, was mixed by Peter Cobbin at Abbey Road Studios. Technically a self-titled album, the phonetics spell out the accurate pronunciation of the band’s name. Kris Schroeder: "For years we’ve worked at bringing our live energy into the studio and thus far it’s been a bit hit-and-miss. Our trick this time was to pull a switcheroo and bring the studio to us instead; the result is the best and closest to us we’ve sounded yet."

Melbourne thespian and Dog With Wheels bassist David Bramble - friends with Heath from university days - has occasionally joined the band on tour, playing keys, often while sporting a large moustache. Other guests have included Jake Mason (saxophone), also of Cookin' on 3 Burners and The Bamboos^{[disambiguation needed ]}, Gideon Brazil (saxophone, flute), Simon Imrei (guitar and vocals) and Monty MacKenzie (saxophone).

Covers have often made an appearance from various sources: to date, some of the bands covered have been Cream, The Kinks, The Rolling Stones, The Police, Neil Young, Bob Dylan, New Kids on the Block, Richard Berry, Sonny Curtis and The Crickets, JJ Cale, Harry Nilsson, Bill Scott, Ryan Adams and The Coasters (via The Beatles for their cover of Three Cool Cats).

Members[link]

Current

• Wally De Backer - drums, vocals (2002-present)
• Kris Schroeder - bass, vocals (2002-present)
• Tim Heath - guitar, vocals (2004-present)

Former

• Michael Hubbard - guitar, vocals (2002-2004)

Discography[link]

Albums[link]

• Get Back (15 January 2004)
• Stand Out/Fit In (5 May 2007)
• Keep Your Friends Close (25 September 2009)
• /ðəˈbæzɪtʃ/ (20 August 2010)

EP[link]

• For Girls Like You (11 July 2005)
• Lookin' Over My Shoulder (10 February 2007)
• Like A Brother (5 June 2009)
• Wait For You (21 May 2010)

Singles[link]

• Call It Rhythm & Blues (20 August 2004)
• Just Hold On
• With This Ship (22 February 2009)

Upcoming projects[link]

The band is taking a three year hiatus, with an announced return to the stage together in early 2014. Wally De Backer launched Making Mirrors under his Gotye act in August 2011, Tim Heath will be touring and recording with Blood Red Bird, and Kris Schroeder recorded a solo EP titled, Patience in the Face of Control, before leaving Australia to work with the Red Cross in Kenya for a two year sabbatical.

References[link]

External links[link]

• Official Website
• Myspace Website