Causes of Heart Failure
Coronary artery disease, hypertension, and dilated cardiomyopathy are the primary causes of heart failure in the Western world, with valvular heart disease remaining a common etiology 1, 2.
Primary Etiologies
Most Common Causes
The three dominant causes account for the substantial majority of heart failure cases:
- Coronary artery disease/Ischemic heart disease - Including myocardial infarction with subsequent myocardial fibrosis and ventricular remodeling, or ischemia with hibernating/stunned myocardium 3, 4
- Hypertension - Chronic pressure overload leading to cardiac remodeling 4
- Dilated cardiomyopathy - Up to 30% have a genetic cause 2
- Valvular heart disease - Remains a common cause despite advances in treatment 1, 2
Additional Cardiac Structural Causes
Heart failure can result from disorders affecting multiple cardiac structures 1, 2:
- Pericardial disease
- Myocardial disorders (most common source of symptoms)
- Endocardial abnormalities
- Great vessel disorders
Secondary and Specific Etiologies
Cardiomyopathies
Familial/genetic cardiomyopathies warrant three-generation family history assessment 4:
- Predisposition to atherosclerotic disease
- Sudden cardiac death history
- Myopathy
- Conduction system disease
- Tachyarrhythmias
Cardiotoxic Exposures
Critical to identify through detailed history 2:
- Anthracyclines - Can cause heart failure years after exposure
- Trastuzumab (Herceptin)
- High-dose cyclophosphamide
- Mediastinal irradiation - Effects may manifest years later
- Alcohol - Current and past consumption patterns
- Cocaine and methamphetamine 4
- Ephedra
Metabolic and Endocrine Causes 4
- Diabetes mellitus
- Thyroid disorders
- Hemochromatosis (iron overload)
- Hypocalcemia
- Pheochromocytoma
Inflammatory and Infiltrative Causes 4
- Myocarditis - Including viral and autoimmune
- Amyloidosis - Requires specific disease-directed management
- Sarcoidosis
- Collagen vascular disease
Other Important Causes 4
- Peripartum cardiomyopathy
- Tachycardia-induced cardiomyopathy
- Right ventricular pacing-induced cardiomyopathy
- Stress-induced (Takotsubo) cardiomyopathy
- Atrial fibrillation
- Obesity
Essential Historical Elements for Cause Identification
When evaluating heart failure etiology, specifically inquire about 2:
Cardiovascular risk factors:
- Hypertension, diabetes, dyslipidemia
- Tobacco use
- Coronary, valvular, or peripheral vascular disease
Specific exposures:
- Rheumatic fever
- Sleep-disordered breathing
- Sexually transmitted diseases (for myocarditis risk)
Family history must include 2:
- Myocardial infarctions, strokes, peripheral arterial disease
- Sudden cardiac death
- Unexplained heart failure
- Skeletal myopathy
- Need for pacemaker
Clinical Pitfalls
Critical consideration: Many patients have more than one cardiac abnormality contributing to heart failure development 2. A comprehensive evaluation is essential because identifying potentially treatable or reversible conditions directly impacts management 2.
Important caveat: In many patients, the underlying cause may not be discernible or amenable to treatment 2. However, clinicians should focus diagnostic efforts on conditions with therapeutic implications rather than exhaustive testing for untreatable etiologies.
Novel risk factors emerging in contemporary practice include electronic nicotine delivery systems (ENDS), cannabis, high-dose caffeine, and psychostimulants 5, though these represent evolving rather than established major causes.
The pathophysiological mechanisms—endothelial dysfunction, oxidative stress, neurohormonal activation, and direct myocardial toxicity—represent common final pathways regardless of initial etiology 5.