Primary Causes of Congestive Heart Failure
Coronary artery disease, hypertension, and dilated cardiomyopathy are the three dominant causes of heart failure in Western populations, with ischemic heart disease alone accounting for approximately 40-54% of cases. 1, 2
Major Etiologic Categories
Ischemic Heart Disease (Most Common)
- Ischemic cardiomyopathy represents the single most common cause, responsible for 40% of heart failure cases globally and 49-54% in Western populations with reduced ejection fraction. 2, 3
- The pathophysiology involves myocardial scarring, stunning/hibernation, epicardial coronary disease, abnormal coronary microcirculation, and endothelial dysfunction. 2
- In the United States specifically, coronary artery disease underlies approximately two-thirds of cases with left ventricular systolic dysfunction. 1
Hypertension (Second Most Common)
- Hypertension causes 17-31% of heart failure cases, with higher prevalence in patients with preserved ejection fraction phenotypes. 2, 3
- Long-standing hypertension produces pathological ventricular remodeling with increased wall thickness, eventually leading to both systolic and diastolic dysfunction. 2
Cardiomyopathies
- Idiopathic dilated cardiomyopathy accounts for approximately 30% of heart failure cases in European registries. 2, 3
- Up to 30% of dilated cardiomyopathy cases have a genetic cause, resulting from mutations in cytoskeletal, sarcolemmal, sarcomeric, and nuclear envelope proteins. 1, 2
Valvular Heart Disease
- Valvular disease causes 8-20% of heart failure cases, with significantly higher prevalence in preserved ejection fraction (20%) versus reduced ejection fraction (4%). 2
- Rheumatic heart disease remains the greatest global burden of valvular disease, particularly in Sub-Saharan Africa where it causes up to 40% of heart failure cases. 2
Toxic and Metabolic Causes
- Recreational substances including alcohol, cocaine, amphetamines, and anabolic steroids can directly cause heart failure. 2
- Cardiotoxic medications such as anthracycline chemotherapy, immunomodulating drugs, antidepressants, and antiarrhythmics contribute to myocardial dysfunction. 2
- Heavy metals including copper, iron, lead, and cobalt are recognized causes. 2
- Endocrine disorders such as hypothyroidism, hyperthyroidism, diabetes mellitus, and metabolic syndrome increase heart failure risk. 2
- Nutritional deficiencies including thiamine deficiency, as well as obesity and malnutrition, can precipitate heart failure. 2
Infectious and Immune-Mediated Causes
- Viral myocarditis represents a significant cause, particularly in younger patients. 2
- Chagas disease is a major cause of heart failure in South America. 2
- Other infectious agents including bacteria, spirochetes, fungi, protozoa, and parasites can cause myocarditis leading to heart failure. 2
- Lymphocytic/giant cell myocarditis and systemic lupus erythematosus are immune-mediated causes. 2
Important Geographic Variations
- Eastern Europe and Middle East show the highest rates of ischemic etiology (55-57%). 2
- Africa shows the lowest ischemic rates (12%) but highest rates of rheumatic heart disease and dilated cardiomyopathy. 2
- Sub-Saharan Africa has predominantly non-ischemic causes (75.5%). 2
Special Population Considerations
- Peripartum cardiomyopathy occurs during pregnancy or the postpartum period, with incidence varying dramatically by geographic region. 2, 3
- Muscular dystrophies and laminopathies can lead to progressive cardiomyopathy. 2
Clinical Pitfall
Heart failure is not equivalent to cardiomyopathy or left ventricular dysfunction—these terms describe structural or functional abnormalities that may cause heart failure, but heart failure itself is a clinical syndrome defined by specific symptoms (dyspnea, fatigue) and signs (edema, rales). 1 This distinction is critical because patients may have significant left ventricular dysfunction without heart failure symptoms, or conversely, may have heart failure symptoms with preserved ejection fraction.