Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Pathophysiology and clinical evaluation of acute heart failure

Key Points

  • Acute heart failure (AHF) is a complex syndrome characterized by the worsening of signs and symptoms of heart failure

  • Clinical evaluation of patients with AHF involves a focused history and physical examination, along with ancillary data from laboratory and diagnostic tests

  • New team-based and device-based approaches to the clinical assessment and management of patients with AHF have improved outcomes and reduced hospitalization

  • Neurohormonal activation, venous congestion, endothelial dysfunction, myocardial injury, and renal dysfunction are central to the pathophysiology of AHF

  • Studies are currently underway to investigate the utility of identifying specific AHF phenotypes for targeted therapeutic interventions

Abstract

Acute heart failure (AHF) is a complex syndrome characterized by worsening heart failure (HF) symptoms that requires escalation of therapy. Intrinsic cardiac abnormalities and comorbid conditions, including lung and renal disease, and sleep-disordered breathing, can contribute to the development of AHF. In this Review, we summarize and discuss the literature on the clinical evaluation and underlying pathophysiology of AHF. Important features of AHF evaluation include identification of precipitating factors to the disease, and assessment of circulatory–renal limitations associated with use of HF medications, prior HF hospitalizations, congestion and perfusion profiles, and end-organ dysfunction. The pathophysiological contributions of endothelial dysfunction, neurohormonal activation, venous congestion, and myocardial injury to the development of AHF are also discussed. These potential causative mechanisms provide a framework for clinicians to evaluate and manage patients with AHF and highlight possible future targets for therapies designed to improve clinical outcomes.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Figure 1: Assessment of haemodynamic profile using a colour gradient chart involving haemodynamic signs of patients presenting with heart failure.
Figure 2: Mechanisms of acute heart failure.

References

  1. Ambrosy, A. P. et al. The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. J. Am. Coll. Cardiol. 63, 1123–1133 (2014).

    Article  PubMed  Google Scholar 

  2. Gheorghiade, M. & Pang, P. S. Acute heart failure syndromes. J. Am. Coll. Cardiol. 53, 557–573 (2009).

    Article  PubMed  Google Scholar 

  3. Mentz, R. J. & Felker, G. M. Noncardiac comorbidities and acute heart failure patients. Heart Fail. Clin. 9, 359–367 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  4. Mentz, R. J. et al. Decongestion in acute heart failure. Eur. J. Heart Fail. 16, 471–482 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  5. Mentz, R. J. et al. Learning from recent trials and shaping the future of acute heart failure trials. Am. Heart J. 166, 629–635 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ramirez, A. & Abelmann, W. H. Cardiac decompensation. N. Engl. J. Med. 290, 499–501 (1974).

    Article  CAS  PubMed  Google Scholar 

  7. Mentz, R. J. et al. International differences in clinical characteristics, management, and outcomes in acute heart failure patients: better short-term outcomes in patients enrolled in Eastern Europe and Russia in the PROTECT trial. Eur. J. Heart Fail. 16, 614–624 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ambrosy, A. P., Gheorghiade, M., Chioncel, O., Mentz, R. J. & Butler, J. Global perspectives in hospitalized heart failure: regional and ethnic variation in patient characteristics, management, and outcomes. Curr. Heart Fail. Rep. 11, 416–427 (2014).

    Article  PubMed  Google Scholar 

  9. Fonarow, G. C. et al. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Arch. Intern. Med. 168, 847–854 (2008).

    Article  PubMed  Google Scholar 

  10. Kittleson, M. et al. Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality. J. Am. Coll. Cardiol. 41, 2029–2035 (2003).

    Article  CAS  PubMed  Google Scholar 

  11. Solomon, S. D. et al. Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure. Circulation 116, 1482–1487 (2007).

    Article  PubMed  Google Scholar 

  12. O'Connor, C. M. et al. Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Am. Heart J. 156, 662–673 (2008).

    Article  PubMed  Google Scholar 

  13. O'Connor, C. M. et al. Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. J. Am. Coll. Cardiol. 55, 872–878 (2010).

    Article  PubMed  Google Scholar 

  14. Mentz, R. J. et al. Noncardiac comorbidities in heart failure with reduced versus preserved ejection fraction. J. Am. Coll. Cardiol. 64, 2281–2293 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  15. Mentz, R. J. et al. Relation of dyspnea severity on admission for acute heart failure with outcomes and costs. Am. J. Cardiol. 115, 75–81 (2015).

    Article  PubMed  Google Scholar 

  16. Thibodeau, J. T. et al. Characterization of a novel symptom of advanced heart failure: bendopnea. JACC Heart Fail. 2, 24–31 (2014).

    Article  PubMed  Google Scholar 

  17. Mentz, R. J. et al. Comparison of clinical characteristics and long-term outcomes of patients with ischemic cardiomyopathy with versus without angina pectoris (from the Duke Databank for Cardiovascular Disease). Am. J. Cardiol. 109, 1272–1277 (2012).

    Article  PubMed  Google Scholar 

  18. Mentz, R. J., Broderick, S., Shaw, L. K., Fiuzat, M. & O'Connor, C. M. Heart failure with preserved ejection fraction: comparison of patients with and without angina pectoris (from the Duke Databank for Cardiovascular Disease). J. Am. Coll. Cardiol. 63, 251–258 (2014).

    Article  PubMed  Google Scholar 

  19. Mentz, R. J. & Fiuzat, M. Sleep-disordered breathing in patients with heart failure. Heart Fail. Clin. 10, 243–250 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  20. Gheorghiade, M. et al. Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure. JAMA 296, 2217–2226 (2006).

    Article  CAS  PubMed  Google Scholar 

  21. Ambrosy, A. P. et al. Clinical profile and prognostic value of low systolic blood pressure in patients hospitalized for heart failure with reduced ejection fraction: insights from the Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan (EVEREST) trial. Am. Heart J. 165, 216–225 (2013).

    Article  CAS  PubMed  Google Scholar 

  22. Bohm, M. et al. Heart rate as a risk factor in chronic heart failure (SHIFT): the association between heart rate and outcomes in a randomised placebo-controlled trial. Lancet 376, 886–894 (2010).

    Article  PubMed  Google Scholar 

  23. Swedberg, K. et al. Ivabradine and outcomes in chronic heart failure (SHIFT): a randomised placebo-controlled study. Lancet 376, 875–885 (2010).

    Article  CAS  PubMed  Google Scholar 

  24. Greene, S. J. et al. The prognostic significance of heart rate in patients hospitalized for heart failure with reduced ejection fraction in sinus rhythm: insights from the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) trial. JACC Heart Fail. 1, 488–496 (2013).

    Article  PubMed  Google Scholar 

  25. Mohammed, S. F. et al. Resting ventricular-vascular function and exercise capacity in heart failure with preserved ejection fraction: a RELAX trial ancillary study. Circ. Heart Fail. 7, 580–589 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  26. Nohria, A., Lewis, E. & Stevenson, L. W. Medical management of advanced heart failure. JAMA 287, 628–640 (2002).

    Article  PubMed  Google Scholar 

  27. Nohria, A. et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J. Am. Coll. Cardiol. 41, 1797–1804 (2003).

    Article  PubMed  Google Scholar 

  28. Ambrosy, A. P. et al. Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial. Eur. Heart J. 34, 835–843 (2013).

    Article  PubMed  Google Scholar 

  29. Rame, J. E., Dries, D. L. & Drazner, M. H. The prognostic value of the physical examination in patients with chronic heart failure. Congest. Heart Fail. 9, 170–178 (2003).

    Article  PubMed  Google Scholar 

  30. Drazner, M. H., Rame, J. E., Stevenson, L. W. & Dries, D. L. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N. Engl. J. Med. 345, 574–581 (2001).

    Article  CAS  PubMed  Google Scholar 

  31. McGee, S. R. Physical examination of venous pressure: a critical review. Am. Heart J. 136, 10–18 (1998).

    Article  CAS  PubMed  Google Scholar 

  32. Stevenson, L. W. & Perloff, J. K. The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. JAMA 261, 884–888 (1989).

    Article  CAS  PubMed  Google Scholar 

  33. O'Connor, C. M. et al. The PROTECT in-hospital risk model: 7-day outcome in patients hospitalized with acute heart failure and renal dysfunction. Eur. J. Heart Fail. 14, 605–612 (2012).

    Article  CAS  PubMed  Google Scholar 

  34. Felker, G. M. et al. Risk stratification after hospitalization for decompensated heart failure. J. Card. Fail. 10, 460–466 (2004).

    Article  PubMed  Google Scholar 

  35. Mentz, R. J. et al. Clinical profile and prognostic value of anemia at the time of admission and discharge among patients hospitalized for heart failure with reduced ejection fraction: findings from the EVEREST trial. Circ. Heart Fail. 7, 401–408 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  36. van Kimmenade, R. R. et al. Red blood cell distribution width and 1-year mortality in acute heart failure. Eur. J. Heart Fail. 12, 129–136 (2010).

    Article  CAS  PubMed  Google Scholar 

  37. Ambrosy, A. P. et al. Clinical course and predictive value of liver function tests in patients hospitalized for worsening heart failure with reduced ejection fraction: an analysis of the EVEREST trial. Eur. J. Heart Fail. 14, 302–311 (2012).

    Article  CAS  PubMed  Google Scholar 

  38. Maisel, A. S. & Daniels, L. B. Breathing not properly 10 years later: what we have learned and what we still need to learn. J. Am. Coll. Cardiol. 60, 277–282 (2012).

    Article  PubMed  Google Scholar 

  39. Mentz, R. J. & Felker, G. M. Natriuretic peptide-guided therapy for heart failure. Circ. J. 75, 2031–2037 (2011).

    Article  CAS  PubMed  Google Scholar 

  40. Ahmad, T., Fiuzat, M., Felker, G. M. & O'Connor, C. Novel biomarkers in chronic heart failure. Nat. Rev. Cardiol. 9, 347–359 (2012).

    Article  CAS  PubMed  Google Scholar 

  41. Yancy, C. W. et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J. Am. Coll. Cardiol. 62, e147–e239 (2013).

    Article  PubMed  Google Scholar 

  42. Greig, D. et al. Ischemic electrocardiographic abnormalities and prognosis in decompensated heart failure. Circ. Heart Fail. 7, 986–993 (2014).

    Article  PubMed  Google Scholar 

  43. Wang, N. C. et al. Clinical implications of QRS duration in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction. JAMA 299, 2656–2666 (2008).

    Article  CAS  PubMed  Google Scholar 

  44. Douglas, P. S. et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Endorsed by the American College of Chest Physicians. J. Am. Coll. Cardiol. 57, 1126–1166 (2011).

    Article  PubMed  Google Scholar 

  45. Patel, A. R. et al. 3D echocardiography to evaluate right atrial pressure in acutely decompensated heart failure correlation with invasive hemodynamics. JACC Cardiovasc. Imaging 4, 938–45 (2011).

    Article  PubMed  Google Scholar 

  46. Verhaert, D. et al. Right ventricular response to intensive medical therapy in advanced decompensated heart failure. Circ. Heart Fail. 3, 340–346 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  47. Cooper, L. T. et al. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology. J. Am. Coll. Cardiol. 50, 1914–1931 (2007).

    Article  PubMed  Google Scholar 

  48. Bennett, M. K. et al. Evaluation of the role of endomyocardial biopsy in 851 patients with unexplained heart failure from 2000–2009. Circ. Heart Fail. 6, 676–684 (2013).

    Article  PubMed  Google Scholar 

  49. Smith, C. E. et al. Multidisciplinary group clinic appointments: the Self-Management and Care of Heart Failure (SMAC-HF) trial. Circ. Heart Fail. 7, 888–894 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  50. Abraham, W. T. et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: a randomised controlled trial. Lancet 377, 658–666 (2011).

    Article  PubMed  Google Scholar 

  51. Hernandez, A. F. et al. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA 303, 1716–1722 (2010).

    Article  CAS  PubMed  Google Scholar 

  52. Jehn, M. et al. Association of daily physical activity volume and intensity with COPD severity. Respir. Med. 105, 1846–1852 (2011).

    Article  PubMed  Google Scholar 

  53. Shoemaker, M. J. et al. Longitudinal daily activity patterns in individuals with heart failure: derivation and association with prognosis and clinical characteristics. Cardiopulm. Phys. Ther. J. 24, 25–33 (2013).

    Article  Google Scholar 

  54. Whellan, D. J., Adams, S. & Bowerman, L. Review of advanced heart failure device diagnostics examined in clinical trials and the potential benefit from monitoring capabilities. Prog. Cardiovasc. Dis. 54, 107–114 (2011).

    Article  PubMed  Google Scholar 

  55. US National Library of Medicine. ClinicalTrials.gov [online], (2015).

  56. Braunwald, E. Heart failure. JACC Heart Fail. 1, 1–20 (2013).

    Article  PubMed  Google Scholar 

  57. Swedberg, K., Eneroth, P., Kjekshus, J. & Snapinn, S. Effects of enalapril and neuroendocrine activation on prognosis in severe congestive heart failure (follow-up of the CONSENSUS trial). CONSENSUS Trial Study Group. Am. J. Cardiol. 66, 40D–45D (1990).

    Article  CAS  PubMed  Google Scholar 

  58. Aronson, D. & Burger, A. J. Neurohormonal prediction of mortality following admission for decompensated heart failure. Am. J. Cardiol. 91, 245–248 (2003).

    Article  CAS  PubMed  Google Scholar 

  59. Aronson, D. & Burger, A. J. Neurohumoral activation and ventricular arrhythmias in patients with decompensated congestive heart failure: role of endothelin. Pacing Clin. Electrophysiol. 26, 703–710 (2003).

    Article  PubMed  Google Scholar 

  60. Reudelhuber, T. L., Bernstein, K. E. & Delafontaine, P. Is angiotensin II a direct mediator of left ventricular hypertrophy? Time for another look. Hypertension 49, 1196–1201 (2007).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  61. Milo-Cotter, O. et al. Neurohormonal activation in acute heart failure: results from VERITAS. Cardiology 119, 96–105 (2011).

    Article  CAS  PubMed  Google Scholar 

  62. Chin, B. S. et al. Interleukin-6, tissue factor and von Willebrand factor in acute decompensated heart failure: relationship to treatment and prognosis. Blood Coagul. Fibrinolysis 14, 515–521 (2003).

    Article  CAS  PubMed  Google Scholar 

  63. Kalogeropoulos, A. P. et al. High-sensitivity C-reactive protein in acute heart failure: insights from the ASCEND-HF trial. J. Card. Fail. 20, 319–326 (2014).

    Article  CAS  PubMed  Google Scholar 

  64. Mueller, C., Laule-Kilian, K., Christ, A., Brunner-La Rocca, H. P. & Perruchoud, A. P. Inflammation and long-term mortality in acute congestive heart failure. Am. Heart J. 151, 845–850 (2006).

    Article  PubMed  Google Scholar 

  65. Mann, D. L. Inflammatory mediators and the failing heart: past, present, and the foreseeable future. Circ. Res. 91, 988–998 (2002).

    Article  CAS  PubMed  Google Scholar 

  66. Girerd, N. et al. Serum aldosterone is associated with mortality and re-hospitalization in patients with reduced ejection fraction hospitalized for acute heart failure: analysis from the EVEREST trial. Eur. J. Heart Fail. 15, 1228–1235 (2013).

    Article  CAS  PubMed  Google Scholar 

  67. Francis, G. S. et al. Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis. Ann. Intern. Med. 103, 1–6 (1985).

    Article  CAS  PubMed  Google Scholar 

  68. Francis, G. S. et al. Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. A substudy of the Studies of Left Ventricular Dysfunction (SOLVD). Circulation 82, 1724–1729 (1990).

    Article  CAS  PubMed  Google Scholar 

  69. Ronco, C., Cicoira, M. & McCullough, P. A. Cardiorenal syndrome type 1: pathophysiological crosstalk leading to combined heart and kidney dysfunction in the setting of acutely decompensated heart failure. J. Am. Coll. Cardiol. 60, 1031–1042 (2012).

    Article  PubMed  Google Scholar 

  70. Mentz, R. J. et al. Decongestion strategies and renin-angiotensin-aldosterone system activation in acute heart failure. JACC Heart Fail. 3, 97–101 (2015).

    Article  PubMed  Google Scholar 

  71. Felker, G. M. et al. Heart failure therapeutics on the basis of a biased ligand of the angiotensin-2 type 1 receptor: rationale and design of the BLAST-AHF study (Biased Ligand of the Angiotensin Receptor Study in Acute Heart Failure). JACC Heart Fail. 3, 193–201 (2015).

    Article  PubMed  Google Scholar 

  72. Schiff, G. D., Fung, S., Speroff, T. & McNutt, R. A. Decompensated heart failure: symptoms, patterns of onset, and contributing factors. Am. J. Med. 114, 625–630 (2003).

    Article  PubMed  Google Scholar 

  73. Fallick, C., Sobotka, P. A. & Dunlap, M. E. Sympathetically mediated changes in capacitance: redistribution of the venous reservoir as a cause of decompensation. Circ. Heart Fail. 4, 669–675 (2011).

    Article  PubMed  Google Scholar 

  74. Burchell, A. E., Sobotka, P. A., Hart, E. C., Nightingale, A. K. & Dunlap, M. E. Chemohypersensitivity and autonomic modulation of venous capacitance in the pathophysiology of acute decompensated heart failure. Curr. Heart Fail. Rep. 10, 139–146 (2013).

    Article  CAS  PubMed  Google Scholar 

  75. Gheorghiade, M. et al. Pathophysiologic targets in the early phase of acute heart failure syndromes. Am. J. Cardiol. 96, 11g–17g (2005).

    Article  PubMed  Google Scholar 

  76. Mullens, W. et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J. Am. Coll. Cardiol. 53, 589–596 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  77. Nohria, A. et al. Cardiorenal interactions: insights from the ESCAPE trial. J. Am. Coll. Cardiol. 51, 1268–1274 (2008).

    Article  PubMed  Google Scholar 

  78. ter Maaten, J. M. et al. Diuretic response in acute heart failure—pathophysiology, evaluation, and therapy. Nat. Rev. Cardiol. 12, 184–192 (2015).

    Article  CAS  PubMed  Google Scholar 

  79. Ronco, C., Haapio, M., House, A. A., Anavekar, N. & Bellomo, R. Cardiorenal syndrome. J. Am. Coll. Cardiol. 52, 1527–1539 (2008).

    Article  PubMed  Google Scholar 

  80. Mentz, R. J. & Lewis, E. F. Epidemiology of cardiorenal syndrome. Cardiol. Clin. 29, 301–314 (2011).

    Article  PubMed  Google Scholar 

  81. Colombo, P. C. & Jorde, U. P. The active role of venous congestion in the pathophysiology of acute decompensated heart failure. Rev. Esp. Cardiol. 63, 5–8 (2010).

    Article  PubMed  Google Scholar 

  82. Gutierrez, E. et al. Endothelial dysfunction over the course of coronary artery disease. Eur. Heart J. 34, 3175–3181 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  83. Marti, C. N. et al. Endothelial dysfunction, arterial stiffness, and heart failure. J. Am. Coll. Cardiol. 60, 1455–1469 (2012).

    Article  CAS  PubMed  Google Scholar 

  84. Colombo, P. C., Onat, D. & Sabbah, H. N. Acute heart failure as “acute endothelitis”—interaction of fluid overload and endothelial dysfunction. Eur. J. Heart Fail. 10, 170–175 (2008).

    Article  PubMed  Google Scholar 

  85. Colombo, P. C. et al. Peripheral venous congestion causes inflammation, neurohormonal, and endothelial cell activation. Eur. Heart J. 35, 448–454 (2014).

    Article  CAS  PubMed  Google Scholar 

  86. Hillege, H. L. et al. Renal function as a predictor of outcome in a broad spectrum of patients with heart failure. Circulation 113, 671–678 (2006).

    Article  PubMed  Google Scholar 

  87. Dries, D. L., Exner, D. V., Domanski, M. J., Greenberg, B. & Stevenson, L. W. The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction. J. Am. Coll. Cardiol. 35, 681–689 (2000).

    Article  CAS  PubMed  Google Scholar 

  88. Heywood, J. T. et al. High prevalence of renal dysfunction and its impact on outcome in 118,465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database. J. Card. Fail. 13, 422–430 (2007).

    Article  PubMed  Google Scholar 

  89. Damman, K. et al. Worsening renal function and prognosis in heart failure: systematic review and meta-analysis. J. Card. Fail. 13, 599–608 (2007).

    Article  PubMed  Google Scholar 

  90. Owan, T. E. et al. Secular trends in renal dysfunction and outcomes in hospitalized heart failure patients. J. Card. Fail. 12, 257–262 (2006).

    Article  PubMed  Google Scholar 

  91. Smith, G. L. et al. Worsening renal function: what is a clinically meaningful change in creatinine during hospitalization with heart failure? J. Card. Fail. 9, 13–25 (2003).

    Article  CAS  PubMed  Google Scholar 

  92. Forman, D. E. et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J. Am. Coll. Cardiol. 43, 61–67 (2004).

    Article  PubMed  Google Scholar 

  93. Aronson, D. & Burger, A. J. The relationship between transient and persistent worsening renal function and mortality in patients with acute decompensated heart failure. J. Card. Fail. 16, 541–547 (2010).

    Article  PubMed  Google Scholar 

  94. Testani, J. M., Chen, J., McCauley, B. D., Kimmel, S. E. & Shannon, R. P. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation 122, 265–272 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  95. Kazory, A. & Elkayam, U. Cardiorenal interactions in acute decompensated heart failure: contemporary concepts facing emerging controversies. J. Card. Fail. 20, 1004–1011 (2014).

    Article  PubMed  Google Scholar 

  96. Schrier, R. W. & Abraham, W. T. Hormones and hemodynamics in heart failure. N. Engl. J. Med. 341, 577–585 (1999).

    Article  CAS  PubMed  Google Scholar 

  97. Aronson, D., Abassi, Z., Allon, E. & Burger, A. J. Fluid loss, venous congestion, and worsening renal function in acute decompensated heart failure. Eur. J. Heart Fail. 15, 637–643 (2013).

    Article  CAS  PubMed  Google Scholar 

  98. Kociol, R. D. et al. Troponin elevation in heart failure: prevalence, mechanisms, and clinical implications. J. Am. Coll. Cardiol. 56, 1071–1078 (2010).

    Article  CAS  PubMed  Google Scholar 

  99. O'Connor, C. M. et al. Impact of serial troponin release on outcomes in patients with acute heart failure: analysis from the PROTECT pilot study. Circ. Heart Fail. 4, 724–732 (2011).

    Article  CAS  PubMed  Google Scholar 

  100. Peacock, W. F. et al. Cardiac troponin and outcome in acute heart failure. N. Eng. J. Med. 358, 2117–2126 (2008).

    Article  CAS  Google Scholar 

  101. Felker, G. M. et al. Troponin I in acute decompensated heart failure: insights from the ASCEND-HF study. Eur. J. Heart Fail. 14, 1257–1264 (2012).

    Article  CAS  PubMed  Google Scholar 

  102. Metra, M. et al. Effect of serelaxin on cardiac, renal, and hepatic biomarkers in the Relaxin in Acute Heart Failure (RELAX-AHF) development program: correlation with outcomes. J. Am. Coll. Cardiol. 61, 196–206 (2013).

    Article  CAS  PubMed  Google Scholar 

  103. Biolo, A. et al. Episodes of acute heart failure syndrome are associated with increased levels of troponin and extracellular matrix markers. Circ. Heart Fail. 3, 44–50 (2010).

    Article  CAS  PubMed  Google Scholar 

  104. Paulus, W. J. & Tschöpe, C. A novel paradigm for heart failure with preserved ejection fraction: comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. J. Am. Coll. Cardiol. 62, 263–271 (2013).

    Article  PubMed  Google Scholar 

  105. Smith, B. M. et al. Impaired left ventricular filling in COPD and emphysema: is it the heart or the lungs? The multi-ethnic study of atherosclerosis COPD study. Chest 144, 1143–1151 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  106. Barr, R. G. The epidemiology of vascular dysfunction relating to chronic obstructive pulmonary disease and emphysema. Proc. Am. Thorac. Soc. 8, 522–527 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  107. Ahmad, T. et al. Clinical implications of chronic heart failure phenotypes defined by cluster analysis. J. Am. Coll. Cardiol. 64, 1765–1774 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  108. Ahmad, T. et al. Phenotypes of heart failure identified via cluster analysis do not recapitulate hemodynamic profiles: insights from the ESCAPE trial [abstract 11924]. Circulation 130, A11924 (2014).

    Google Scholar 

  109. Ahmad, T. et al. Charting a roadmap for heart failure biomarker studies. JACC Heart Fail. 2, 477–488 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Contributions

Both authors researched data for the article, discussed its content, and wrote, reviewed, and edited the manuscript before submission.

Corresponding author

Correspondence to Robert J. Mentz.

Ethics declarations

Competing interests

R.J.M. declares that he has received research support from Amgen, AstraZeneca, Bristol-Myers Squibb, Gilead, GlaxoSmithKline, Novartis, Otsuka, and ResMed. He has also received honoraria from Thoratec and has served on an advisory board for Luitpold Pharmaceuticals, Inc. C.M.O. receives research support from Astellas, Gilead, Otsuka, and Roche Diagnostics, and is a consultant for HeartWare.

PowerPoint slides

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Mentz, R., O'Connor, C. Pathophysiology and clinical evaluation of acute heart failure. Nat Rev Cardiol 13, 28–35 (2016). https://doi.org/10.1038/nrcardio.2015.134

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrcardio.2015.134

This article is cited by

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing