From the Guidelines
High output heart failure is recognized by the European Society of Cardiology (ESC) as a condition that mimics the signs and symptoms of heart failure, but is caused by specific medical conditions leading to increased cardiac output. According to the ESC guidelines 1, high output heart failure refers to conditions where the primary abnormality is not disease of the heart, but rather other medical conditions such as anaemia, thyrotoxicosis, septicaemia, liver failure, arteriovenous shunts, Paget’s disease, and beri-beri. These conditions lead to a clinical picture that mimics the signs and symptoms of heart failure, but with increased cardiac output.
Key Characteristics
- The ESC guidelines 1 emphasize that these conditions are treatable and should be excluded when diagnosing heart failure.
- Common causes of high output states mimicking heart failure include anaemia, thyrotoxicosis, septicaemia, liver failure, arteriovenous shunts, Paget’s disease, and beri-beri.
- Management of high output heart failure focuses on treating the underlying cause rather than the standard heart failure medications.
Diagnosis and Treatment
- Echocardiography showing increased cardiac output with normal or increased ejection fraction is key to diagnosis.
- Patients typically present with warm extremities, bounding pulses, and wide pulse pressure, distinguishing them from classic heart failure presentations.
- Treatment options include addressing the underlying cause, such as blood transfusions for anaemia, surgical correction of arteriovenous fistulas, antithyroid medications for thyrotoxicosis, or thiamine supplementation for beriberi.
From the Research
Definition and Recognition of High Output Heart Failure
- High output heart failure is a condition where the heart's output is normal or increased, but the patient still experiences symptoms of heart failure, such as dyspnea and congestion 2.
- This condition can be caused by various factors, including chronic severe anemia, large arteriovenous fistula, and severe hepatic or renal disorders 2, 3.
Etiologies and Pathophysiology
- The most common etiologies of high-output heart failure include obesity, liver disease, arteriovenous shunts, lung disease, and myeloproliferative disorders 3.
- High-output heart failure is characterized by eccentric left ventricular remodeling, greater natriuretic peptide activation, higher filling pressures, pulmonary hypertension, and increased cardiac output, despite similar ejection fraction 3.
Acceptance by ESC
- The European Society of Cardiology (ESC) recognizes advanced heart failure, which includes high-output heart failure, as a condition that requires timely referral to advanced heart failure centers 4.
- However, there is no direct statement from the ESC on the acceptance of high-output heart failure as a specific condition, but it is mentioned as a type of heart failure that can be caused by various conditions, such as anemia and iron deficiency 5.
Treatment and Outcomes
- Treatment of high-output heart failure depends on the underlying cause and may include vasodilator therapy, iron supplementation, and other supportive measures 2, 6.
- Mortality is increased in high-output heart failure compared to controls, and hemodynamics and outcomes are poorest amongst patients with the lowest systemic vascular resistance 3.