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Upon completion of the chapter, the reader will be able to:

  1. Classify heart failure (HF) syndrome types into HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), HF with mid-range ejection fraction (HFmrEF), and HF with recovered ejection fraction (HFrecEF).

  2. Differentiate between the common underlying etiologies of HF, including ischemic, nonischemic, and idiopathic causes.

  3. Describe the pathophysiology of HF as it relates to neurohormonal activation of the renin-angiotensin-aldosterone system, sympathetic nervous system, and endogenous counterregulatory vasodilatory peptide systems.

  4. Identify signs and symptoms of HF and classify a given patient by New York Heart Association Functional Classification and American College of Cardiology/American Heart Association Heart Failure Stage.

  5. Discuss and modify the goals of therapy for a patient with acute and/or chronic HF.

  6. Create a strategy for the nonpharmacologic management of a patient with HF that includes patient education.

  7. Develop an evidence-based pharmacologic treatment and monitoring plan for a patient with chronic HFrEF.

  8. Design a pharmacologic treatment and monitoring plan for a patient with acute HF.

  9. Formulate a therapeutic management plan for a patient with HFpEF.


Heart failure (HF) is a syndrome defined as the inadequate ability of the heart to pump enough blood to meet the blood flow and metabolic demands of the body.1 HF is most commonly a result of low cardiac output (CO) secondary to impaired cardiac function. High-output HF is characterized by an inordinate increase in the body’s metabolic demands that outpaces an increase in CO of a generally normally functioning heart. The term heart failure refers to low-output HF for the purposes of this chapter.

HF can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to eject or fill with blood.1 Apart from the clinical syndrome, it is commonly characterized by assessment of left ventricular (LV) function. Impairment in ventricular contraction (systolic dysfunction) and/or ventricular filling (diastolic dysfunction) can result in a similar decrease in CO. Ejection fraction (EF) is the fraction of the volume present at the end of diastole that is pushed into the aorta during systole. When the primary defect is LV systolic dysfunction, evidenced by a left ventricular ejection fraction (LVEF) of 40% (0.40) or less, and is accompanied by symptoms, it is referred to as HF with reduced ejection fraction (HFrEF). HFrEF can occur with or without a component of diastolic dysfunction, which coexists in up to two-thirds of patients. When the primary defect is LV diastolic dysfunction, evidenced by an LVEF of 50% (0.50) or greater along with other criteria to document impaired ventricular filling, and symptoms are present, it is referred to as HF with preserved ejection fraction (HFpEF). HFpEF occurs in approximately one-third to one-half of patients with HF, with long-standing hypertension being the leading cause. Patients with symptoms of HF and an LVEF between 41% and 49% (0.41 and 0.49) are termed ...

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