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High-output heart failure


Most patients with heart failure (HF) have systolic dysfunction with a low or normal cardiac output and elevated systemic vascular resistance and/or diastolic dysfunction in which an increase in ventricular stiffness impairs ventricular filling during diastole. In rare circumstances, the cardiac output is elevated and calculated systemic vascular resistance is very low.

High-output HF is characterized by an elevated resting cardiac index beyond the normal range of 2.5 to 4.0 L/min per m2. Ineffective blood volume and pressure, chronic activation of the sympathetic nervous system and renin-angiotensin-aldosterone axis, increased serum vasopressin (antidiuretic hormone) concentrations, and chronic volume overload gradually cause ventricular enlargement, remodeling, and HF.

As will be described in this topic review, a number of conditions lead to an obligatory increase in cardiac output, which can be associated with HF in some patients. However, these conditions are rarely the sole cause of HF; in most such patients, the high cardiac output provokes HF in the setting of reduced ventricular reserve from some underlying cardiac problem. Thus, the presence of high-output HF should prompt a search for another underlying cardiovascular problem.


Several characteristic findings are usually seen on physical examination in patients with high-output HF. The heart rate is typically between 85 and 105 beats per minute, but it may be higher with some causes, eg, thyrotoxicosis. Examination of the systemic veins may reveal a cervical venous hum, heard best over the deep internal jugular veins, particularly on the right side. Less often, a venous hum may be appreciated over the femoral veins.

Examination of the arteries may display signs related to increased left ventricular stroke volume. The pulse is usually bounding with a quick upstroke, and the pulse pressure is typically wide. Pistol-shot sounds may be auscultated over the femoral arteries, and a systolic bruit may be heard over the carotid arteries. Although these findings may be seen in other cardiac conditions, such as aortic regurgitation or patent ductus arteriosus, in the absence of these conditions, these signs are highly suggestive of elevated left ventricular stroke volume due to a hyperdynamic state.


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Literature review current through: Mar 2014. | This topic last updated: Nov 5, 2012.
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  1. Carbillon L, Uzan M, Uzan S. Pregnancy, vascular tone, and maternal hemodynamics: a crucial adaptation. Obstet Gynecol Surv 2000; 55:574.
  2. Nielsen B, Hales JR, Strange S, et al. Human circulatory and thermoregulatory adaptations with heat acclimation and exercise in a hot, dry environment. J Physiol 1993; 460:467.
  3. Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci 2001; 321:225.
  4. Kasper EK, Hruban RH, Baughman KL. Cardiomyopathy of obesity: a clinicopathologic evaluation of 43 obese patients with heart failure. Am J Cardiol 1992; 70:921.
  5. Yun D, Heywood JT. Metastatic carcinoid disease presenting solely as high-output heart failure. Ann Intern Med 1994; 120:45.
  6. Meijer WC, van Veldhuisen DJ, Kema IP, et al. Cardiovascular abnormalities in patients with a carcinoid syndrome. Neth J Med 2002; 60:10.
  7. Velez-Roa S, Neubauer J, Wissing M, et al. Acute arterio-venous fistula occlusion decreases sympathetic activity and improves baroreflex control in kidney transplanted patients. Nephrol Dial Transplant 2004; 19:1606.
  8. Szilagyi DE, Smith RF, Elliott JP, Hageman JH. Congenital arteriovenous anomalies of the limbs. Arch Surg 1976; 111:423.
  9. Chan P, Lee CP, Lee YH. High output cardiac failure caused by multiple giant cutaneous hemangiomas. Jpn Heart J 1992; 33:493.
  10. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med 1998; 158:643.
  11. Pick A, Deschamps C, Stanson AW. Pulmonary arteriovenous fistula: presentation, diagnosis, and treatment. World J Surg 1999; 23:1118.
  12. Montejo Baranda M, Perez M, De Andres J, et al. High out-put congestive heart failure as first manifestation of Osler-Weber-Rendu disease. Angiology 1984; 35:568.
  13. Danchin N, Thisse JY, Neimann JL, Faivre G. Osler-Weber-Rendu disease with multiple intrahepatic arteriovenous fistulas. Am Heart J 1983; 105:856.
  14. Brohée D, Franken P, Fievez M, et al. High-output right ventricular failure secondary to hepatic arteriovenous microfistulae. Selective arterial embolization treatment. Arch Intern Med 1984; 144:1282.
  15. Hisamatsu K, Ueeda M, Ando M, et al. Peripheral arterial coil embolization for hepatic arteriovenous malformation in Osler-Weber-Rendu disease; useful for controlling high output heart failure, but harmful to the liver. Intern Med 1999; 38:962.
  16. Cag M, Audet M, Saouli AC, et al. Successful liver transplantation for Rendu-Weber-Osler disease, a single centre experience. Hepatol Int 2011; 5:834.
  17. Vaksmann G, Rey C, Marache P, et al. Severe congestive heart failure in newborns due to giant cutaneous hemangiomas. Am J Cardiol 1987; 60:392.
  18. Hosono S, Ohno T, Kimoto H, et al. Successful transcutaneous arterial embolization of a giant hemangioma associated with high-output cardiac failure and Kasabach-Merritt syndrome in a neonate: a case report. J Perinat Med 1999; 27:399.
  19. Bennett ML, Fleischer AB Jr, Chamlin SL, Frieden IJ. Oral corticosteroid use is effective for cutaneous hemangiomas: an evidence-based evaluation. Arch Dermatol 2001; 137:1208.
  20. Musumeci ML, Schlecht K, Perrotta R, et al. Management of cutaneous hemangiomas in pediatric patients. Cutis 2008; 81:315.
  21. deLorimier AA, Simpson EB, Baum RS, Carlsson E. Hepatic-artery ligation for hepatic hemangiomatosis. N Engl J Med 1967; 277:333.
  22. Markiewicz-Kijewska M, Kasprzyk W, Broniszczak D, et al. Hemodynamic failure as an indication to urgent liver transplantation in infants with giant hepatic hemangiomas or vascular malformations--report of four cases. Pediatr Transplant 2009; 13:906.
  23. Anderson CB, Codd JR, Graff RA, et al. Cardiac failure and upper extremity arteriovenous dialysis fistulas. Case reports and a review of the literature. Arch Intern Med 1976; 136:292.
  24. Stern AB, Klemmer PJ. High-output heart failure secondary to arteriovenous fistula. Hemodial Int 2011.
  25. Rodgers MV, Moss AJ, Hoffman M, Lipchik EO. Arteriovenous fistulae secondary to renal cell carcinoma. Clinical and cardiovascular manifestations: report of a case. Circulation 1975; 52:345.
  26. Sigler L, Gutiérrez-Carreño R, Martínez-López C, et al. Aortocava fistula: experience with five patients. Vasc Surg 2001; 35:207.
  27. Sy AO, Plantholt S. Congestive heart failure secondary to an arteriovenous fistula from cardiac catheterization and angioplasty. Cathet Cardiovasc Diagn 1991; 23:136.
  28. Santos E, Peral V, Aroca M, et al. Arteriovenous fistula as a complication of lumbar disc surgery: case report. Neuroradiology 1998; 40:459.
  29. Braverman AC, Steiner MA, Picus D, White H. High-output congestive heart failure following transjugular intrahepatic portal-systemic shunting. Chest 1995; 107:1467.
  30. Colombato LA, Spahr L, Martinet JP, et al. Haemodynamic adaptation two months after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients. Gut 1996; 39:600.
  31. Engelberts I, Tordoir JH, Boon ES, Schreij G. High-output cardiac failure due to excessive shunting in a hemodialysis access fistula: an easily overlooked diagnosis. Am J Nephrol 1995; 15:323.
  32. Abushaban L, Uthaman B, Endrys J. Transcatheter coil closure of pulmonary arteriovenous malformations in children. J Interv Cardiol 2004; 17:23.
  33. Hsu CC, Kwan GN, Thompson SA, van Driel ML. Embolisation therapy for pulmonary arteriovenous malformations. Cochrane Database Syst Rev 2010; :CD008017.
  34. Wilson BE, Newmark SR. Thyrotoxicosis-induced congestive heart failure in an urban hospital. Am J Med Sci 1994; 308:344.
  35. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system. N Engl J Med 2001; 344:501.
  36. Lewis BS, Ehrenfeld EN, Lewis N, Gotsman MS. Echocardiographic LV function in thyrotoxicosis. Am Heart J 1979; 97:460.
  37. Riaz K, Forker AD, Isley WL, et al. Hyperthyroidism: a "curable" cause of congestive heart failure--three case reports and a review of the literature. Congest Heart Fail 2003; 9:40.
  38. Buccino RA, Spann JF Jr, Pool PE, et al. Influence of the thyroid state on the intrinsic contractile properties and energy stores of the myocardium. J Clin Invest 1967; 46:1669.
  39. Forfar JC, Muir AL, Sawers SA, Toft AD. Abnormal left ventricular function in hyperthyroidism: evidence for a possible reversible cardiomyopathy. N Engl J Med 1982; 307:1165.
  40. Ho WJ, Chen ST, Tsay PK, et al. Enhancement of endothelium-dependent flow-mediated vasodilation in hyperthyroidism. Clin Endocrinol (Oxf) 2007; 67:505.
  41. Thomas FB, Mazzaferri EL, Skillman TG. Apathetic thyrotoxicosis: A distinctive clinical and laboratory entity. Ann Intern Med 1970; 72:679.
  42. Siu CW, Yeung CY, Lau CP, et al. Incidence, clinical characteristics and outcome of congestive heart failure as the initial presentation in patients with primary hyperthyroidism. Heart 2007; 93:483.
  43. BREWSTER WR Jr, ISAACS JP, OSGOOD PF, KING TL. The hemodynamic and metabolic interrelationships in the activity of epinephrine, norepinephrine and the thyroid hormones. Circulation 1956; 13:1.
  44. Johnson PN, Freedberg AS, Marshall JM. Action of thyroid hormone on the transmembrane potentials from sinoatrial node cells and atrial muscle cells in isolated atria of rabbits. Cardiology 1973; 58:273.
  45. Goodkind MJ, Dambach GE, Thyrum PT, Luchi RJ. Effect of thyroxine on ventricular myocardial contractility and ATPase activity in guinea pigs. Am J Physiol 1974; 226:66.
  46. Di Bello V, Aghini-Lombardi F, Monzani F, et al. Early abnormalities of left ventricular myocardial characteristics associated with subclinical hyperthyroidism. J Endocrinol Invest 2007; 30:564.
  47. Iskandrian AS, Rose L, Hakki AH, et al. Cardiac performance in thyrotoxicosis: analysis of 10 untreated patients. Am J Cardiol 1983; 51:349.
  48. Kahaly GJ, Kampmann C, Mohr-Kahaly S. Cardiovascular hemodynamics and exercise tolerance in thyroid disease. Thyroid 2002; 12:473.
  49. Dalan R, Leow MK. Cardiovascular collapse associated with beta blockade in thyroid storm. Exp Clin Endocrinol Diabetes 2007; 115:392.
  50. Anand IS. Pathophysiology of anemia in heart failure. Heart Fail Clin 2010; 6:279.
  52. Metivier F, Marchais SJ, Guerin AP, et al. Pathophysiology of anaemia: focus on the heart and blood vessels. Nephrol Dial Transplant 2000; 15 Suppl 3:14.
  53. Balfour IC, Covitz W, Davis H, et al. Cardiac size and function in children with sickle cell anemia. Am Heart J 1984; 108:345.
  54. Wooley JA. Characteristics of thiamin and its relevance to the management of heart failure. Nutr Clin Pract 2008; 23:487.
  55. Seligmann H, Halkin H, Rauchfleisch S, et al. Thiamine deficiency in patients with congestive heart failure receiving long-term furosemide therapy: a pilot study. Am J Med 1991; 91:151.
  56. Kitamura K, Yamaguchi T, Tanaka H, et al. TPN-induced fulminant beriberi: a report on our experience and a review of the literature. Surg Today 1996; 26:769.
  57. Shivalkar B, Engelmann I, Carp L, et al. Shoshin syndrome: two case reports representing opposite ends of the same disease spectrum. Acta Cardiol 1998; 53:195.
  58. Lonsdale D, Shamberger RJ. Red cell transketolase as an indicator of nutritional deficiency. Am J Clin Nutr 1980; 33:205.
  59. Akbarian M, Yankopoulos NA, Abelmann WH. Hemodynamic studies in beriberi heart disease. Am J Med 1966; 41:197.
  60. Abelmann WH, Lorell BH. The challenge of cardiomyopathy. J Am Coll Cardiol 1989; 13:1219.
  61. Ikram H, Maslowski AH, Smith BL, Nicholls MG. The haemodynamic, histopathological and hormonal features of alcoholic cardiac beriberi. Q J Med 1981; 50:359.
  62. Jeffrey FE, Abelmann WH. Recovery from proved Shoshin beriberi. Am J Med 1971; 50:123.
  63. Shimon I, Almog S, Vered Z, et al. Improved left ventricular function after thiamine supplementation in patients with congestive heart failure receiving long-term furosemide therapy. Am J Med 1995; 98:485.
  64. Hoffman RS, Goldfrank LR. Ethanol-associated metabolic disorders. Emerg Med Clin North Am 1989; 7:943.
  65. Arroyo V, Bosch J, Gaya-Beltrán J, et al. Plasma renin activity and urinary sodium excretion as prognostic indicators in nonazotemic cirrhosis with ascites. Ann Intern Med 1981; 94:198.
  66. SHUSTER S. High-output cardiac failure from skin disease. Lancet 1963; 1:1338.
  67. Maisch B, Richter A, Sandmöller A, et al. Inflammatory dilated cardiomyopathy (DCMI). Herz 2005; 30:535.
  68. Chiu CY, Huang YC, Wong KS, et al. Poststreptococcal glomerulonephritis with pulmonary edema presenting as respiratory distress. Pediatr Nephrol 2004; 19:1237.
  69. Ozdemir S, Saatçi U, Beşbaş N, et al. Plasma atrial natriuretic peptide and endothelin levels in acute poststreptococcal glomerulonephritis. Pediatr Nephrol 1992; 6:519.
  70. Cichoz-Lach H, Celiński K, Słomka M, Kasztelan-Szczerbińska B. Pathophysiology of portal hypertension. J Physiol Pharmacol 2008; 59 Suppl 2:231.
  71. Milani A, Zaccaria R, Bombardieri G, et al. Cirrhotic cardiomyopathy. Dig Liver Dis 2007; 39:507.
  72. Schrier RW. Water and sodium retention in edematous disorders: role of vasopressin and aldosterone. Am J Med 2006; 119:S47.
  73. Pacca R, Maddukuri P, Pandian NG, Kuvin JT. Echocardiographic detection of intrapulmonary shunting in a patient with hepatopulmonary syndrome: case report and review of the literature. Echocardiography 2006; 23:56.
  74. Park SC, Beerman LB, Gartner JC, et al. Echocardiographic findings before and after liver transplantation. Am J Cardiol 1985; 55:1373.
  75. Su BC, Yu HP, Yang MW, et al. Reliability of a new ultrasonic cardiac output monitor in recipients of living donor liver transplantation. Liver Transpl 2008; 14:1029.
  76. Giustina A, Mancini T, Boscani PF, et al. Assessment of the awareness and management of cardiovascular complications of acromegaly in Italy. The COM.E.T.A. (COMorbidities Evaluation and Treatment in Acromegaly) Study. J Endocrinol Invest 2008; 31:731.
  77. Damjanovic SS, Neskovic AN, Petakov MS, et al. High output heart failure in patients with newly diagnosed acromegaly. Am J Med 2002; 112:610.
  78. Wermers RA, Tiegs RD, Atkinson EJ, et al. Morbidity and mortality associated with Paget's disease of bone: a population-based study. J Bone Miner Res 2008; 23:819.
  79. McBride W, Jackman JD Jr, Grayburn PA. Prevalence and clinical characteristics of a high cardiac output state in patients with multiple myeloma. Am J Med 1990; 89:21.
  80. Inanir S, Haznedar R, Atavci S, Unlü M. Arteriovenous shunting in patients with multiple myeloma and high-output failure. J Nucl Med 1998; 39:1.
  81. Morales-Piga AA, Moya JL, Bachiller FJ, et al. Assessment of cardiac function by echocardiography in Paget's disease of bone. Clin Exp Rheumatol 2000; 18:31.
  82. Kanis JA, Gray RE. Long-term follow-up observations on treatment in Paget's disease of bone. Clin Orthop Relat Res 1987; :99.
  83. Korn TS, Thurston JM, Sherry CS, Kawalsky DL. High-output heart failure due to a renal arteriovenous fistula in a pregnant woman with suspected preeclampsia. Mayo Clin Proc 1998; 73:888.
  84. Gong B, Baken LA, Julian TM, Kubo SH. High-output heart failure due to hepatic arteriovenous fistula during pregnancy: a case report. Obstet Gynecol 1988; 72:440.
  85. Elliott JA, Rankin RN, Inwood MJ, Milne JK. An arteriovenous malformation in pregnancy: a case report and review of the literature. Am J Obstet Gynecol 1985; 152:85.
  86. Swinburne AJ, Fedullo AJ, Gangemi R, Mijangos JA. Hereditary telangiectasia and multiple pulmonary arteriovenous fistulas. Clinical deterioration during pregnancy. Chest 1986; 89:459.
  87. Robson SC, Dunlop W, Moore M, Hunter S. Combined Doppler and echocardiographic measurement of cardiac output: theory and application in pregnancy. Br J Obstet Gynaecol 1987; 94:1014.
  88. Kohrt H, Logan A, Temmins C, et al. Reversible high-output cardiac failure, an unusual marker of disease status in multiple myeloma. Leuk Lymphoma 2008; 49:581.
  89. Aessopos A, Kati M, Farmakis D. Heart disease in thalassemia intermedia: a review of the underlying pathophysiology. Haematologica 2007; 92:658.
  90. Engel PJ, Johnson H, Baughman RP, Richards AI. High-output heart failure associated with anagrelide therapy for essential thrombocytosis. Ann Intern Med 2005; 143:311.
  91. Mehta PA, Dubrey SW. High output heart failure. QJM 2009; 102:235.