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What causes acute heart failure?

ESC Congress 2010

Heart Failure (HF)

Acute heart failure (AHF) implies a rapid onset or change in the signs and symptoms of HF resulting in the need for urgent therapy. The situation may be either new HF or worsening of preexisting HF.

Cardiac dysfunction is always present and may be related to diverse cardiovascular aetiologies and conditions that often interact. Multiple cardiovascular and non-cardiovascular morbidities may precipitate AHF and HF may be aggravated by non-cardiovascular co-morbidities, especially renal dysfunction. In fact, the kidney is always part of the scene and worsening renal function has a strong additive and independent prognostic value in HF.

AHF is complex and is not a single entity but several “syndromes” arising from multiple clinical scenarios linked to different primary physiopathologic problems. Abnormal haemodynamics with fluid retention is an important part of the process, with “congestion” (namely pulmonary congestion) being the most frequent clinical presentation. However, in some patients low cardiac output and tissue hypoperfusion may dominate.

Data from several published registries and surveys indicate that acute coronary syndrome is the most frequent cause of acute new onset HF and in-hospital mortality is particularly high in patients with cardiogenic shock. In contrast, patients with acute hypertensive HF (“vascular failure”) have low in-hospital mortality.

Inflammatory activation is common in both chronic and acute HF and it may be part of the physiopathology of the syndrome. Inflammation increases vascular stiffness and contributes to aggravating systolic and diastolic dysfunction, perpetuating a vicious cycle between endothelial dysfunction and congestion.

In the published AHF trials, most agents improve haemodynamics but none has been shown to reduce mortality. Inflammation may be a new therapeutic target not yet tried in AHF.

A better understanding of the physiopathology of the different subsets of the AHF syndrome is needed. After the “acute” stage, chronic HF may develop and planned management is necessary with individual goals. Inclusion in a HF management programme – structured as a multidisciplinary care approach that coordinates care along the continuum of HF - is recommended.




What causes acute heart failure?
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.