Causes of Heart Failure in Adults
Primary Etiologies
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% of all cases. 1, 2
Most Common Causes
Ischemic heart disease represents the single most common etiology globally, responsible for roughly 40% of heart failure cases, with the highest rates observed in Eastern Europe and the Middle East. 2
Hypertension underlies 17-31% of heart failure cases and shows higher prevalence in heart failure with preserved ejection fraction (HFpEF) phenotypes. 2
Idiopathic dilated cardiomyopathy accounts for approximately 30% of cases in European registries, with up to 30% having an identifiable genetic cause. 1, 2
Valvular heart disease remains a common cause, though less prevalent than the three primary etiologies listed above. 1
Secondary and Contributing Causes
Cardiac-Specific Factors
Diabetes mellitus directly damages myocardium and accelerates progression of existing heart failure. 1
Arrhythmias, particularly atrial fibrillation, can precipitate or worsen heart failure. 1
Cardiomyopathies including hypertrophic, restrictive, and peripartum variants contribute to the overall burden. 2, 3
Myocarditis and infections can cause acute or chronic myocardial dysfunction. 4
Systemic and Iatrogenic Factors
Cardiotoxic chemotherapy and mediastinal irradiation cause direct myocardial injury. 1
Illicit drug use (particularly cocaine and amphetamines) damages cardiac tissue. 1
Alcohol abuse leads to toxic cardiomyopathy. 1
Obesity increases hemodynamic burden and metabolic stress. 1
Metabolic and Endocrine Disorders
Thyroid dysfunction (both hyperthyroidism and hypothyroidism) alters cardiac performance. 1
Obstructive sleep apnea causes chronic hypoxemia and increased afterload. 1
Chronic kidney disease creates volume overload and neurohormonal activation. 1
Special Populations and Contexts
Congenital Heart Disease in Adults
For adults with congenital heart disease, specific substrates predispose to late heart failure: 1
- Severe aortic stenosis/regurgitation from bicuspid aortic valve
- Congenital mitral valve disease
- Unoperated atrial septal defects
- Congenitally corrected transposition
- D-transposition after Mustard/Senning operations
- Tetralogy of Fallot with surgical sequelae
- Single-ventricle physiology and Fontan circulation
Pregnancy-Related
- Peripartum cardiomyopathy occurs during pregnancy or the postpartum period, with incidence varying dramatically by geographic region. 2
Pathophysiological Mechanisms
Hemodynamic Overload
Prolonged pressure overload from conditions like aortic stenosis or systemic hypertension causes ventricular hypertrophy and eventual dysfunction. 1
Prolonged volume overload from valvular regurgitation or shunts leads to ventricular dilatation and remodeling. 1
Direct Myocardial Injury
Inadequate coronary blood flow causes ischemic injury and myocyte death. 3
Poor myocardial preservation during cardiac surgery results in perioperative damage, particularly in early-era operations. 1
Large ventricular incisions or patches create scar tissue that impairs contractility. 1
Clinical Pitfalls
Nearly any form of heart disease may ultimately lead to heart failure syndrome, so clinicians must maintain broad differential thinking. 1 The underlying cause must always be identified and documented, as heart failure should never be coded as a sole diagnosis without specifying etiology. 5
Critical geographic differences exist in heart failure etiology, with the lowest rates of ischemic disease in Africa, requiring consideration of regional epidemiology. 2
In elderly patients, multiple concurrent causes often coexist (coronary disease, hypertension, diabetes, valvular disease), making single-cause attribution inappropriate. 6, 7