Etiology of Congestive Heart Failure

Primary Myocardial Diseases

Ischemic heart disease is the single most common etiology, accounting for approximately 40% of heart failure cases worldwide, though this varies substantially by geographic region 3, 4
In Western populations, ischemic cardiomyopathy causes heart failure in 49-54% of patients with reduced ejection fraction 3, 4
The mechanism of ischemic heart disease involves myocardial scarring, stunning/hibernation, epicardial coronary disease, abnormal coronary microcirculation, and endothelial dysfunction 1, 2
Hypertension represents the underlying cause in 17-31% of heart failure cases, with higher prevalence in preserved ejection fraction phenotypes 3
Long-standing hypertension leads to pathological ventricular remodeling with increased wall thickness and eventual systolic and diastolic dysfunction 5, 6
Idiopathic dilated cardiomyopathy accounts for approximately 30% of heart failure cases in European registries 3
Primary (genetic) cardiomyopathies result from mutations in cytoskeletal, sarcolemmal, sarcomeric, and nuclear envelope proteins, with up to 30% of dilated cardiomyopathy having a genetic cause 5, 6, 7

Recreational substances such as alcohol, cocaine, amphetamines, and anabolic steroids can cause heart failure 1, 2
Medications like anthracycline chemotherapy, immunomodulating drugs, antidepressants, and antiarrhythmics can also contribute to heart failure 1, 2
Heavy metals like copper, iron, lead, and cobalt can cause heart failure 1, 2
Radiation therapy to the chest can increase the risk of heart failure 1, 2
Hormonal abnormalities like hypothyroidism, hyperthyroidism, diabetes mellitus, and metabolic syndrome can contribute to heart failure 1, 2
Nutritional deficiencies like thiamine deficiency, obesity, and malnutrition can also increase the risk of heart failure 1, 2

Viral myocarditis represents a significant cause of heart failure, particularly in younger patients 5, 6, 7
Other infectious agents like bacteria, spirochetes, fungi, protozoa, and parasites can also cause heart failure 1, 2
Chagas disease is a major cause of heart failure in South America 5
Lymphocytic/giant cell myocarditis and systemic lupus erythematosus can also contribute to heart failure 1, 2, 5

Valvular disease accounts for 8-20% of heart failure cases, with higher prevalence in preserved ejection fraction (20%) versus reduced ejection fraction (4%) 3
Rheumatic heart disease remains the greatest global burden of valvular disease, particularly in Sub-Saharan Africa where it causes up to 40% of heart failure cases 3
Acquired and congenital valve abnormalities like mitral, aortic, tricuspid, and pulmonary valve diseases can increase the risk of heart failure 1, 2

Peripartum cardiomyopathy occurs during pregnancy or postpartum period and has an incidence that varies dramatically by region 5, 1, 2, 4
Muscular dystrophies and laminopathies can lead to cardiomyopathy 5, 1, 2

Critical geographic differences exist, with Eastern Europe and Middle East showing highest rates of ischemic etiology (55-57%), Africa showing lowest ischemic rates (12%) but highest rates of rheumatic heart disease and dilated cardiomyopathy, and Sub-Saharan Africa having predominantly non-ischemic causes (75.5%) 3, 4