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High-output heart failure

Michael M Givertz, MD
Amir Haghighat, MD, FACC
Section Editor
Stephen S Gottlieb, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


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 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. A number of conditions lead to an obligatory increase in cardiac output, which can be associated with HF in some patients. In most patients with high-output HF, high cardiac output provokes HF in the setting of reduced ventricular reserve from some underlying cardiac problem.

This topic will discuss the clinical manifestations, diagnosis, and management of high-output HF. 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".)


Patients with chronic high output may develop signs and symptoms classically associated with the more common "low-output" HF while an above normal cardiac output is maintained; specifically, they may develop symptoms and signs of pulmonary and/or systemic venous congestion, such as dyspnea and edema.

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.

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Literature review current through: Nov 2017. | This topic last updated: Aug 09, 2016.
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