3. What are the causes of acute heart failure exacerbations?

The etiology of a heart failure exacerbation is crucial to determine in order to direct medical therapy in the right direction not only to improve the current heart failure symptoms, but to prevent recurrence. Every heart failure patient presenting to the emergency room or the hospital ward should be evaluated for the following:

1. Dietary non-compliance: Consuming large amounts of fluids and/or sodium can result in volume overload causing symptoms of heart failure and eventual pulmonary edema.

2. Medication non-compliance: Frequently, diuretics are not taken as prescribed due to the urinary side-effects. Also, uncontrolled hypertension from not taking other cardiovascular medications can contribute.

3. Ischemia: Acute coronary syndromes or progression of ischemic heart disease can cause heart failure exacerbations. All heart failure patients in the hospital should have at least one ECG performed as well as cardiac enzymes.

4. Arrhythmia: Multiple different arrhythmias can occur in heart failure patients resulting in volume overload from reduced cardiac output. These include atrial fibrillation and ventricular tachycardia.

5. Progression of the heart failure: Worsening of the cause of the patients heart failure, such as progression of valvular heart disease or further LV systolic decline in ischemic or non-ischemic cardiomyopathies cause trigger heart failure exacerbations.

6. Non-cardiac illness: Pneumonia, severe sepsis, and gastrointestinal bleeding are examples of conditions that require a higher cardiac output. In patients with already reduced heart function, these can trigger clinical heart failure.

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