Introduction: High output heart failure (HOHF) can be caused by chronic conditions, including severe anemia, hypoxia, obesity, acutely by septic shock, and hemorrhage. Basically, the heart is normal and there’s no “pump” failure. The main problem is the underlying decrease in systemic vascular resistance ,that drives low blood pressure, and activation of neurohormonal mechanisms, favoring salt and water retention. Case Description: A 58-year-old male presents after developing shortness-of-breath at rest for two days. He reported diet and medications compliance. Patient noticed to have a lower extremity edema. He was hypotensive with BP 83/57. Chest x-ray revealed vascular congestion with cephalization. BNP was found to be elevated. EKG and troponin were unremarkable. 2D echocardiography revealed hyper-dynamic left ventricular systolic function with ejection fraction of 84 %. Patient has been admitted five times over the past four months with similar presentations. Following each admission, he underwent aggressive diuresis and subsequently discharged home on Frusemide, conferring a diagnosis of diastolic heart failure. It was noted, that patient had those frequent admissions after developing chronic anemia, as low as Hgb of 6.8 mg/dl. He had rick factors for HOF including anemia, chronic hypoxemia secondary to tobacco abuse, and obesity. His estimated cardiac output was 7.6 L/min and estimated mixed venous oxygen saturation was 10.7%, all speaks for HOHF. Patient cautiously diuresed. Hematology was involved to address the anemia. Conclusion: This case illustrates patients with HOHF are overlooked and sometimes aggressively diuresed, which could be deleterious. It is recommended that HOHF patients should be diuresed cautiously because preload is needed to avoid functional outflow obstruction. Management should focus on treating the underlying causes
