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Causes and pathophysiology of high-output heart failure

Michael M Givertz, MD
Amir Haghighat, MD, FACC
Section Editor
Barry A Borlaug, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


While most patients with heart failure (HF), with either reduced or preserved ejection fraction, have low or normal cardiac output accompanied by elevated systemic vascular resistance, a minority of patients with HF present with a high-output state with low systemic vascular resistance.

This topic will discuss the causes and pathophysiology of high-output HF. Clinical manifestations, diagnosis, and management of high-output HF are discussed separately. The diagnosis and management of HF with reduced ejection fraction and HF with preserved ejection fraction are discussed separately. (See "Determining the etiology and severity of heart failure or cardiomyopathy" and "Overview of the therapy of heart failure with reduced ejection fraction" and "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)


High-output HF is an uncommon type of HF. The prevalence of this disorder is uncertain, particularly since the potential contributory role of high-output syndromes to HF may not be appreciated in many cases. Although high-output states are uncommon as a sole cause of HF, they may more commonly contribute to HF in patients with underlying cardiovascular disease and reduced myocardial reserve. (See 'Role of concurrent cardiac conditions' below.)

In a Mayo Clinic series of 120 consecutive patients with high-output HF diagnosed between 2000 and 2014, the most common causes were morbid obesity (31 percent), liver disease (22.5 percent), arteriovenous shunts (22.5 percent), lung disease (16 percent), and myeloproliferative disorders (8 percent) [1]. This study excluded patients with physiologic (eg, pregnancy, fever, infection), iatrogenic (pulmonary vasodilator or inotrope administration), or congenital causes of high output, as well as patients with severe anemia (hemoglobin <8 mg/dL), hyperthyroidism, valvular heart disease, constrictive pericarditis, left ventricular systolic dysfunction (left ventricular ejection fraction <45 percent), cardiomyopathy, or heart transplantation.


High-output HF is characterized by elevated cardiac output, low systemic vascular resistance (due to peripheral vasodilation or arteriovenous shunting), and low arterial-venous oxygen content difference; some types are associated with increased oxygen consumption (reflecting increased metabolic demand). In the setting of high-output HF, the elevation in cardiac output is greater than that required to meet metabolic demand [1].

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Literature review current through: Dec 2017. | This topic last updated: Jan 11, 2018.
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