From the Guidelines
Right heart failure, particularly when it leads to increased pressure in the venous system, is the type of congestive heart failure (CHF) that typically causes ascites. Ascites develops when fluid accumulates in the peritoneal cavity due to elevated hydrostatic pressure in the hepatic veins and portal system. This occurs because the failing right ventricle cannot effectively pump blood forward, causing blood to back up in the venous system, increasing pressure in the liver and portal circulation. The increased hydrostatic pressure forces fluid out of blood vessels into the peritoneal space.
Causes of Right Heart Failure Leading to Ascites
- Advanced left heart failure that progresses to biventricular failure
- Pulmonary hypertension
- Tricuspid valve disease
- Constrictive pericarditis
- Restrictive cardiomyopathy
According to the 2013 ACCF/AHA guideline for the management of heart failure 1, patients with HF can be categorized into different profiles based on their clinical status, with Profile 4 including patients who have symptoms of congestion at rest or with activities of daily living, such as disabling ascites.
Management of Ascites in CHF
- Treating the underlying heart failure with diuretics like furosemide or spironolactone
- Sodium restriction
- Addressing the primary cardiac condition
- In severe cases, therapeutic paracentesis may be necessary to relieve symptoms by directly removing the accumulated fluid
The assessment of volume status is crucial in managing HF, as stated in the 2005 ACC/aha guideline update for the diagnosis and management of chronic heart failure in the adult 1 and the 2009 focused update incorporated into the ACC/aha 2005 guidelines for the diagnosis and management of heart failure in adults 1. However, the most recent and highest quality study, the 2013 ACCF/AHA guideline 1, provides the most relevant information for managing ascites in CHF.
Key Points in Management
- Limiting fluid intake to around 2 L/d is usually adequate for most hospitalized patients
- Strict fluid restriction may best be used in patients who are either refractory to diuretics or have hyponatremia
- Fluid restriction, especially in conjunction with sodium restriction, enhances volume management with diuretics
From the Research
Causes of Ascites in Congestive Heart Failure (CHF)
- Ascites in CHF is often associated with refractory CHF, as seen in patients treated with regular at-home abdominal paracentesis via Tenckhoff catheter 2
- The development of ascites in CHF can be due to increased pressure in the hepatic veins, leading to fluid accumulation in the peritoneal cavity 3
- In some cases, ascites in CHF can be hemorrhagic, as reported in a case study of a 64-year-old woman with recurrent large bloody ascites secondary to heart failure 3
- Culture-negative neutrocytic ascites (CNNA) can also occur in patients with cardiac ascites from end-stage heart failure, as seen in a 46-year-old male with end-stage biventricular heart failure 4
Types of CHF that Cause Ascites
- Refractory CHF, which requires treatment with regular at-home abdominal paracentesis via Tenckhoff catheter, can cause ascites 2
- End-stage heart failure, particularly biventricular heart failure, can lead to the development of ascites, including CNNA 4
- CHF with congestion, which is characterized by increasing symptoms and signs of congestion with volume overload, can also cause ascites 5
Key Findings
- The serum albumin-ascites gradient (SAAG) can be used to determine the etiology of ascites, with a high gradient indicating portal hypertension 4
- The total protein level in ascitic fluid can also help differentiate between cirrhosis and heart failure as the cause of ascites 4
- Early diagnosis and treatment of ascitic fluid infections, such as CNNA, are crucial in preventing patient mortality 4