Intended for healthcare professionals

Clinical Review ABC of heart failure


BMJ 2000; 320 doi: (Published 08 January 2000) Cite this as: BMJ 2000;320:104
  1. G Y H Lip,
  2. C R Gibbs,
  3. D G Beevers

    The relative importance of aetiological factors in heart failure is dependent on the nature of the population being studied, as coronary artery disease and hypertension are common causes of heart failure in Western countries, whereas valvar heart disease and nutritional cardiac disease are more common in the developing world. Epidemiological studies are also dependent on the clinical criteria and relevant investigations used for diagnosis, as it remains difficult, for example, to distinguish whether hypertension is the primary cause of heart failure or whether there is also underlying coronary artery disease.

    Causes of heart failure

    Coronary artery disease

    • Myocardial infarction

    • Ischaemia



    • Dilated (congestive)

    • Hypertrophic/obstructive

    • Restrictive—for example, amyloidosis, sarcoidosis, haemochromatosis

    • Obliterative

    Valvar and congenital heart disease

    • Mitral valve disease

    • Aortic valve disease

    • Atrial septal defect, ventricular septal defect


    • Tachycardia

    • Bradycardia (complete heart block, the sick sinus syndrome)

    • Loss of atrial transport—for example, atrial fibrillation

    Alcohol and drugs

    • Alcohol

    • Cardiac depressant drugs (β blockers, calcium antagonists)

    “High output” failure

    • Anaemia, thyrotoxicosis, arteriovenous fistulae, Paget's disease

    Pericardial disease

    • Constrictive pericarditis

    • Pericardial effusion

    Primary right heart failure

    • Pulmonary hypertension—for example, pulmonary embolism, cor pulmonale

    • Tricuspid incompetence

    Coronary artery disease and its risk factors

    Coronary heart disease is the commonest cause of heart failure in Western countries. In the studies of left ventricular dysfunction (SOLVD) coronary artery disease accounted for almost 75% of the cases of chronic heart failure in male white patients, although in the Framingham heart study, coronary heart disease accounted for only 46% of cases of heart failure in men and 27% of chronic heart failure cases in women. Coronary artery disease and hypertension (either alone or in combination) were implicated as the cause in over 90% of cases of heart failure in the Framingham study.

    Recent studies that have allocated aetiology on the basis of non-invasive investigations—such as the Hillingdon heart failure study—have identified coronary artery disease as the primary …

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