Congestive Heart Failure Overview

The heart is a pump that works together with the lungs. It pumps blood in 2 ways.

 It pumps blood from the heart to the lungs to pick up oxygen. The oxygenated blood returns to
the heart.

 It then pumps blood out into the circulatory system of blood vessels that carry blood through the
body.

The heart consists of 4 chambers.

 The upper chambers are called atria, and the lower chambers are calledventricles.

 The right atrium and ventricle receive blood from the body through the veins and then pump the
blood to the lungs.

 The left atrium and ventricle receive blood back from the lungs and pump it out the aorta into the
arteries, feeding all organs and tissues of the body.

 Because the left ventricle has to pump blood through the entire body, it is a stronger pump than
the right ventricle.

Heart failure sounds frightening because it sounds like the heart just stops working. Do not be
discouraged by the term heart failure-the heart has not stopped beating or pumping. Heart failure means
the tissues of the body are temporarily not receiving enough blood and oxygen. With advancements in
diagnosis and therapy for heart failure, patients are feeling better and living longer.

 Although heart failure is a serious medical condition, the heart does not just stop abruptly.

 Heart failure may develop gradually over several years, or move quickly after aheart attack or a
disease of the heart muscle.

Heart failure is an illness in which the pumping action of the heart becomes less and less powerful. That
is, the heart does not pump blood as well as it should. When this happens, blood does not move
efficiently through the circulatory system and starts to back up, increasing the pressure in the blood
vessels and forcing fluid from the blood vessels into body tissues.

 When the left side of the heart starts to fail, fluid collects in the lungs (pulmonary edema). This
extra fluid in the lungs (congestion) makes it more difficult for the airways to expand as you inhale.
Breathing becomes more difficult, and you may feel short of breath, particularly with activity or lying
down.

 When the right side of the heart starts to fail, fluid collects in the feet and lower legs. As the heart
failure becomes worse, the upper legs swell and eventually the abdomen collects fluid (ascites).
Weight gain accompanies the fluid retention and is an excellent measure of how much fluid is being
retained. Puffy swelling (edema) is a sign of right heart failure, especially if the edema ispitting edema.
With pitting edema, a finger pressed on the swollen leg leaves a finger imprint. Nonpitting edema is not
caused by heart failure.

Congestive heart failure (CHF) is generally classified as systolic or diastolic heart failure and becomes
progressively more common with increasing age. 

Systolic heart failure: The pumping action of the heart is reduced or weakened. A common clinical
measurement is the ejection fraction (EF). The ejection fraction is a calculation of how much blood is
ejected out of the left ventricle (stroke volume), divided by the maximum volume remaining in the left
ventricle at the end of diastoleor relaxation phase. A normal ejection fraction is greater than 50%. Systolic
heart failure has a decreased ejection fraction of less than 50%. 

Diastolic heart failure: The heart can contract normally but is stiff, or less compliant, when it is relaxing
and filling with blood. This impedes blood filling into the heart and produces backup into the lungs and
CHF symptoms. Diastolic heart failure is more common in patients older than 75 years, especially in
women withhigh blood pressure. In diastolic heart failure, the ejection fraction is normal.

 Heart failure affects 1% of people aged 50 years, about 5% of those aged 75 years or older, and
25% of those aged 85 years or older.

 Heart failure is the most common reason for Medicare patients to be admitted to the hospital.

 As the number of elderly people continues to rise, the number of people diagnosed with this
condition will continue to increase.

In the United States, nearly 5 million people have heart failure.

 Each year about 550,000 new cases are diagnosed.

 The condition is more common among African Americans than whites.

 The rate of death from heart failure is about 10% after 1 year. About half of those with CHF die
within 5 years after their diagnosis. These statistics vary widely by a patient's exact diagnosis and
therapy. Advances in research are providing more options and improving outcomes for people with
CHF.

Congestive Heart Failure Causes

Congestive heart failure (CHF) is a syndrome, not a disease, that can be brought about by several
causes. CHF is a weakening of the heart brought on by an underlying heart or blood vessel problem,
often a combination of several different problems, including the following: 

 Weakened heart muscle

 Damaged heart valves

 Blocked blood vessels supplying the heart muscle (coronary arteries), leading to a heart attack
 Toxic exposures, like alcohol or cocaine

 Infections

 High blood pressure that results in thickening of the heart muscle (left ventricular hypertrophy)

 Pericardial disease, such as pericardial effusion (a large collection of fluid around the heart in the
space between the heart muscle and the thick layer of pericardiumsurrounding the heart) and/or a
thickened pericardium, which does not allow the heart to fill properly

 Congenital heart diseases

 Prolonged, serious arrhythmias  

While these conditions often combine to produce CHF, sometimes the causes of diseased heart muscles
are not known; this is called idiopathic cardiomyopathy or heart muscle disease of unknown cause.
CHF is often a result of the following lifestyle habits:

 Unhealthy habits, such as smoking and excessive use of alcohol, are often to blame.

 Obesity and lack of activity may contribute to CHF, either directly or indirectly through
accompanying high blood pressure, diabetes, and coronary artery disease.

 Years of uncontrolled high blood pressure damages both heart and blood vessels.

Along with lifestyle risk factors, a number of diseases (for example, diabetes, heart attack [myocardial
infarction], and congenital heart disease) can damage the heart and lead to congestive heart failure. Over
a hundred other, less common, causes of CHF include a variety of infections, exposures, complications of
other diseases, toxic effects, and genetic predisposition.

Whether through disease or lifestyle choices, the pumping action of the heart can be impaired by several
mechanisms:

 Heart muscle damage (cardiomyopathy): The heart muscle can become weak because of
damage or disease and thus does not contract or squeeze as forcefully as it should. This damage to
the muscle can occur from coronaryheart disease (coronary artery disease) leading to a heart attack,
or long-standing high blood pressure, viral infection, alcohol abuse, diabetes, or many other less
common causes. Sometimes, the cause is not known.

 Heart attack (myocardial infarction): A heart attack commonly causes severe pain in the chest,
shortness of breath, nausea, sweating, and/or a feeling of impending doom. Heart attack may rapidly
lead to either cardiac arrest (no heartbeat) or permanent damage of the left ventricle. If this damage is
bad enough, that part of the heart will not work properly, which leads to heart failure.

 High blood pressure (hypertension): Abnormally high blood pressure increases the amount of
work the left ventricle has to do to pump blood out into the circulatory system. Over time, this greater
workload can damage and weaken the heart. This can lead to heart failure if this damage is allowed to
go on unchecked. Proper treatment of high blood pressure can prevent left ventricular hypertrophy and
heart failure.
 Heart valve problems: The valves of the heart normally keep the blood flowing in the right
direction through the heart. Abnormal heart valves impede this forward flow in 1 of 2 ways.

o An incompetent valve is a valve that does not close properly when it should and allows
blood to flow backward in the heart, "against the current." When blood flows the wrong way across
a valve, the heart has to work harder to keep up its output. Eventually, this backed up blood
accumulates in the lungs and the body.

o A stenotic valve is a valve that does not open properly when it should. Blood flow
through the narrowed opening is blocked, creating an increased workload on the heart.
 
 Abnormal rhythm or irregular heartbeat: Abnormal heart rhythms lower the heart's effectiveness
as a pump. The rhythm may be too slow or too fast, or irregular. The heart has to pump harder to
overcome these rhythm disorders. If this excessively slow or fast heartbeat is sustained over hours,
days, or weeks, the heart can weaken, which can cause heart failure.

 Other conditions may have injured the heart such as thyroid disorders (too much or too
little thyroid hormone) or treatments for cancer (radiation or certain chemotherapy drugs).

Congestive Heart Failure Symptoms

People with congestive heart failure (CHF) sometimes do not suspect a problem with their heart. 

 The early symptoms are often shortness of breath, cough, or a feeling of not being able to get a
deep breath.

 If you have a known breathing problem, such as asthma, chronic obstructive pulmonary

disease (COPD), oremphysema, you may think you are having an "attack" or worsening of that
condition.

 If you usually do not have breathing problems, you may think you have a cold,flu, or bronchitis.

 To make matters worse, any or several of these conditions may coexist along with congestive
heart failure.

Congestive heart failure has the following 3 major symptoms: 

  Exercise intolerance

o A person may be unable to tolerate exercise or even mild physical exertion that he or
she may have been able to do in the past. The body needs oxygen and other nutrients during
physical activity. A failing heart cannot pump enough blood to provide these nutrients to the body.

o The ability to exercise, even to walk at a normal pace, may be limited by feeling tired
(fatigue) and having shortness of breath.

o Ordinary activities, such as sweeping, vacuuming, pushing a lawnmower, or even

walking about the house, may be difficult or impossible.
The shortness of breath that accompanies these activities usually gets better with rest. 

 Shortness of breath

o If a person has CHF, he or she may have difficulty breathing (dyspnea), especially
when he or she is active.

o When CHF worsens, fluid backs up into the lungs and interferes with oxygen getting
into the blood, causing dyspnea at rest and at night (orthopnea). 

o If a person has CHF, he or she may awaken at night short of breath and have to sit or
stand up to get relief. This is called paroxysmal nocturnal dyspnea.

o Several pillows may help with a more comfortable sleep. A person may also prefer
sleeping in a recliner rather than in a bed.

o As the buildup of fluid in the lungs becomes very severe, a frothy, pink liquid may be
coughed up.   
 
 Fluid retention and swelling

o Puffy swelling (edema) in the legs, the feet, and the ankles may occur, particularly at
the end of the day or after prolonged sitting or standing.  

o Often, the swelling is more noticeable in the ankles or on the lower leg in the front
where the bone is close to the skin.

o Press down on the skin in the puffy areas; the indentation where the finger pressed may
be visible for a few minutes. This is called pitting edema. Nonpitting edema is not caused by heart
failure. Pitting edema is not synonymous with heart failure; it can have other causes,
includingliver and kidney failure.

o Swelling may be so severe as to reach up to the hips, scrotum, abdominal wall, and

eventually the abdominal cavity (ascites).

o Daily weight checks are mandatory in persons with heart failure because the amount of
fluid retention is usually reflected by the amount of increasing shortness of breath and weight gain.
Persons with heart failure should know what their dry weight is or what they weigh when they feel
good with no pitting edema.

Congestive heart failure usually does not cause chest pain. Remember, though, that other serious
conditions that do cause chest pain, such as angina and myocardial infarction, can coexist with heart
failure.

Exams and Tests

Congestive heart failure (CHF) can be confused with other illnesses that cause breathing difficulties, such
as bronchitis, pneumonia, emphysema, and asthma. Talking to a medical professional, along with a
physical exam and tests available only at a medical office or hospital, is necessary to make an exact
diagnosis.

Chest x-ray film: This is very helpful in identifying the buildup of fluid in the lungs. Also, the heart usually
enlarges in CHF, and this may be visible on the x-ray film.

Electrocardiogram (ECG): This painless test measures the electrical activity (rhythm) of the heart.

 It can reveal several different heart problems that can cause heart failure, including heart
attacks, rhythm disorders, long-standing strain on the heart from high blood pressure, and certain
valve problems.

 The ECG gives clues as to the underlying cause of heart failure.

 For this test, which takes just a few minutes, you lie on a table with electrodes fastened to the
skin of your chest, arms, and legs.

 The ECG result may, however, be normal in heart failure.

Blood tests: You may have blood drawn for lab tests. 

 Blood cell counts: Low blood cell counts (anemia) may cause symptoms much like CHF or
contribute to the condition.

 Sodium, potassium, and other electrolyte levels, especially if the person has been treated with
diuretics and/or has kidney disease

 Tests of kidney function

 B-type natriuretic peptide (BNP)

o This is a hormone produced at higher levels by the failing heart muscle. This is a good
screening test; the levels of this hormone generally increase as the severity of heart failure
worsens.

o Interestingly, BNP has been produced by recombinant DNA technologyand can be used
as a treatment for heart failure in the hospital (seeMedications).

Echocardiogram: This is a type of ultrasound that shows the beating of the heart and the various cardiac
structures. 

 An echocardiogram can be useful in determining the cause of heart failure (such as muscle,
valves, or pericardium), and it provides an accurate measurement of ejection fraction.

 This very safe, painless technique is similar to that used to look at a fetusduring pregnancy.

MUGA scan: This stands for multiple-gated acquisition scanning. 

 A small amount of a mildly radioactive dye is injected into a vein and travels to the heart.

 As the heart pumps the blood with the dye in it, pictures are taken. The pumping performance of
the left and right ventricles can be determined.

 People with an allergy to iodine or shellfish have special considerations and may not be able to
have this test because the dye contains iodine.

Stress test: A treadmill or medication (nonwalking) stress test is used to help evaluate the cause or
causes of heart failure, in particular, regarding coronary artery disease. This test is frequently combined
with nuclear imaging orechocardiography to improve accuracy.

Congestive Heart Failure Treatment

The treatment of heart failure depends on the exact cause, but it can usually be treated effectively. The
overall goals of treatment are to correct underlying causes, to relieve symptoms, and to prevent
worsening of the condition. Symptoms are relieved by removing excess fluid from the body, improving
blood flow, improving heart muscle function, and increasing delivery of oxygen to the body tissues. 

Medical Treatment

If no underlying correctible cause of heart failure is established, medical treatment is composed of lifestyle
changes and medications. 

 Lifestyle changes recommended by your health care provider can help relieve symptoms, slow
the progression of heart failure, and improve one's quality of life. Lifestyle changes that may be helpful
in preventing or relieving heart failure include those recommended by the American Heart
Association and other organizations as part of a heart-healthy lifestyle. See Self-Care at Home for
more information.

 Medications help control both the underlying causes of heart failure and the symptoms.
Medications are the most critical part of therapy for heart failure. Usually, several types of medications
are required to address as many of thephysiologic imbalances as possible.

Procedures

Other treatment or procedures, such asangioplasty or a pacemaker, may be offered, depending on the
underlying cause of the heart failure.

Angioplasty: This is an alternative to coronary bypass surgery for some people whose heart failure is
caused by coronary artery disease and is compounded by heart damage/heart attack. Angioplasty is used
to treat narrowing or blockage of a coronary artery that supplies the left ventricle with blood.

 A long, thin tube called a catheter is inserted through the skin, into a blood vessel, and threaded
into the affected artery. This procedure is performed while the person is under local anesthesia.
 At the point of the atherosclerotic narrowing or blockage, a tiny balloon and/or an expandable
metal stent, attached to the end of the catheter, is inflated/deployed.

 The inflated catheter pushes aside the cholesterol deposits (plaque) that are blocking the artery
so that blood can flow through in a more normal manner.

Pacemaker: This device controls the rhythm of the heartbeats. 

 A pacemaker is an electrode on the tip of a wire, usually implanted inside the heart by an
electrophysiologist or specialized cardiologist in the cardiac cath lab. This wire goes to the right
ventricle, frequently with a second wire to the right atrium (dual chamber pacemaker).

 A pacemaker can stimulate a heart that is beating too slowly to beat faster, or it can control an
irregular heartbeat (sometimes, this requires medications in addition to the pacemaker). In certain
circumstances, a device called an intracardiac defibrillator (ICD) may be implanted as part of a
pacemaker device. This defibrillator can detect and electrically shock a life-threateningarrhythmia back
to normal.

 The pacemaker may also be used to synchronize the pumping action of the left and right
ventricles (cardiac resynchronization therapy). This approach requires an extra lead placed behind the
heart in a coronary vein overlying the left ventricle. Synchronization improves the effectiveness of the
heart as a pump.

Medications

People with heart failure usually take several different medications that work in different ways to lessen
heart failure symptoms, to prevent worsening of the underlying disease, and to prolong life.  

Diuretics (water pills): The buildup of fluid is usually treated with a diuretic.

 Diuretics cause the kidneys to remove excess salt and accompanying water from the
bloodstream, thereby reducing the amount of blood volume in circulation. With a lower volume of
blood, your heart does not have to work so hard. The number of red and white blood cells is not
changed.

 The end result is an improvement of the ability to breathe (clear out water in the lungs) and a
lessening of the swelling in the lower body.

 Most of these drugs tend to remove potassium from the body, but some drugs, such as diuretics
containing triamterene orspironolactone, can increase potassium levels, so potassium levels have to
be watched carefully.

 Diuretics commonly used in heart failure

include furosemide (Lasix), bumetanide(Bumex), hydrochlorothiazide(HydroDIURIL), spironolactone (A
ldactone),eplerenone (Inspra), triamterene (Dyrenium), torsemide (Demadex),
ormetolazone (Zaroxolyn), or a combination agent (for example, Dyazide).
 Spironolactone and eplerenone are not only mild diuretics when used with stronger diuretics
like furosemide (Lasix), but when used in small doses, (not diuretic doses), they have been shown to
prolong life when used in combination with angiotensin-converting enzyme (ACE) inhibitors. This
suggests they have additional effects on the myocardium to prevent progression of myocardial
scarring and enlargement.

Inotropes: IV inotropes are stimulants, such as dobutamine and milrinone, that increase the pumping
ability of the heart. These are used as a temporary support of a very weak left ventricle that is not
responding to standard CHF therapy.

Digoxin (Lanoxin): This drug improves the pumping ability of the heart, causing it to pump more
forcefully, a so-called positive inotrope. However, digoxin is a very weak inotrope and is now only an add-
on therapy to ACE inhibitors and beta-blockers. 

 Although commonly used, not all people receive digoxin because it is less effective than several
of the other classes of medications discussed in this article.

 Digoxin helps relieve symptoms after vasodilators and diuretics have been tried, but it does not
prolong life.

 Digoxin is an old medicine, used for more than 200 years, that is derived from the foxglove plant.

 This medication can also be used to control the rhythm of the heart (in atrial fibrillation).

 Excessive digoxin can build up in the blood and cause potentially dangerous abnormal heart
rhythms (arrhythmias). The risk of developing arrhythmias is enhanced if the dose is excessive, the
kidneys are impaired and do not excrete digoxin from the body properly, or the potassium in the body
is too low (low potassium may result from taking diuretics).

Vasodilators: These medications enlarge the small arteries or arterioles, which relieve the systolic
workload of the left ventricle. The heart has to work less to pump blood through the arteries. This also
generally lowers blood pressure. 

 ACE inhibitors are the most widely used vasodilators for CHF. They block the production
of angiotensin II, which is abnormally high in congestive heart failure. Angiotensin II
causes vasoconstriction with increased workload on the left ventricle, and it is directly toxic to the left
ventricle at excessive levels.

 ACE inhibitors are important because they not only improve symptoms, but they also
have been proven to significantly prolong the lives of people with heart failure. They do this by
slowing progression of the heart damage and in some cases improving heart muscle function.

 Some common examples of ACE inhibitors

are captopril (Capoten),enalapril (Vasotec), lisinopril (Zestril/Prinivil), benazepril (Lotensin),quinapril 
(Accupril), fosinopril (Monopril), and ramipril (Altace).
 
 Angiotensin II receptor blockers (ARBs) work by preventing the effect of angiotensin II at the
tissue level. Examples of ARB medications
includecandesartan (Atacand), irbesartan (Avapro), olmesartan (Benicar), losartan(Cozaar), valsartan 
(Diovan), telmisartan (Micardis), and eprosartan (Teveten). These medications are usually prescribed
for people who cannot take ACE inhibitors because of side effects. Both are effective, but ACE
inhibitors have been used longer with a greater number of clinical trial data and patient information.

 ACE inhibitors and ARBs may cause the body to retain potassium, but this is generally only a
problem in people with significant kidney disease, or in people who are also taking a potassium-
sparing diuretic, such as triamterene or spironolactone.

 Calcium channel blockers are arterial vasodilators that are not used for treatment of heart failure
per se because clinical trials have proven no benefit for prolongation of life. Calcium channel blockers
are useful for lowering blood pressure if the cause of the CHF is high blood pressure and the patient is
not responding to ACE inhibitors or ARBs.

 Isosorbide dinitrate and hydralazine (BiDil) is a fixed dose combination of isosorbide dinitrate (20

mg/tablet) and hydralazine (37.5 mg/tablet). This drug is indicated for heart failure in black individuals
based in part on results of the African American Heart Failure Trial. Two previous trials in the general
population of people with severe heart failure found no benefit but suggested a benefit in black
patients. Compared with a placebo, this drug showed a 43% reduction in mortality rate, a 39%
decrease in hospitalization rate, and a decrease in symptoms from heart failure in black patients.

Nitrates are venous vasodilators that include isosorbide mononitrate (Imdur) and isosorbide dinitrate

(Isordil). They are weaker than the ACE inhibitors and ARBs and are primarily used in combination with
an arterial vasodilator, such as hydralazine. 
  
Hydralazine (Apresoline) is a pure smooth muscle arterial vasodilator that may be used for CHF. Recent
trial data have shown hydralazine to be especially effective in African Americans, but it does not replace
ACE inhibitors or ARBs. Hydralazine is especially valuable in patients who have poor kidney function
and/or are intolerant to ACE inhibitors and ARBs.  

Beta-blockers: These drugs slow down the heart rate, lower blood pressure, and have a direct affect on
the heart muscle to lessen the workload of the heart. Specific beta-blockers, such as carvedilol (Coreg)
and long-acting metoprolol(Toprol XL), have been shown to decrease symptoms, hospitalization due to
CHF, and deaths. 

 Beta-receptors are in the heart muscle and in the walls of arteries. Thesympathetic nervous
system produces a chemical called norepinephrine that is toxic to the heart muscle in prolonged, high
doses.

 Beta-blockers work by blocking the action of norepinephrine on the heart muscle. In the past,
doctors treating heart failure thought that blocking norepinephrine was bad and would make the heart
worse because norepinephrine is a stimulant that makes the heartbeat stronger. However, clinical
trials have proven that beta-blockers gradually improve the systolic function of the left ventricle,
thereby improving symptoms and prolonging life.

 The foundation of modern therapy of systolic heart failure is a combination of ACE inhibitors and
beta-blockers. If at all possible, every patient should be on both drugs for improvement of left
ventricular function and prolongation of life.
Natriuretic peptides: Nesiritide (Natrecor), or B-type natriuretic peptide (BNP), is a new medication
produced by recombinant DNA technology. BNP is normally produced by the heart muscle. When the left
and/or right ventricle are under excessive workload, excess BNP is excreted into the bloodstream. 

 Because the natural BNP is already increased with heart failure, why additional BNP works is not
totally understood. However, giving additional BNP intravenously lowers the pressure in the lungs and
is a mild diuretic, so lung water is removed and excreted through the kidneys, resulting in relief
ofpulmonary congestion.

 Nesiritide is given into the vein (intravenously [IV]) to help stabilize people whose heart failure is
suddenly worse. Commonly used in the emergency department, nesiritide is used to more rapidly
stabilize the patient. Some people may not need to be admitted to the hospital.

Getting the most out of your medications involves the following: 

 Other medications may be prescribed, depending on the underlying cause of the heart failure or
on the medical condition.

 Keep a diary of daily weight, and bring it to the doctor every follow-up visit.

 Since people with heart failure are often on many drugs, the likelihood of drug interactions
increases. The medications taken for other medical problems may affect what drugs are prescribed for
heart failure. Because of this, people are advised to always bring a current list of medications and any
other supplements or nonprescription drugs with them every time they visit a doctor. Note that many of
these medications come in combination pills under different marketing names.

 Take your medication as directed by your health care provider. If he or she does not tell you how
to take your medication, ask.

 Follow the recommendations of your health care provider about diet, exercise, and other lifestyle
issues.

 Be sure you are informed about the side effects of your medications.

 Develop an action plan with your doctor so you and your family know what to do promptly if your
symptoms worsen.

Surgery

Surgery can repair some underlying causes of heart failure, such as blockage of the coronary arteries, a
valve problem, a congenital heart defect, or too thick of a pericardium. However, once the heart's ability to
pump blood is severely, permanently, and irreversibly impaired, no surgery can repair the damage. The
only alternative is a heart transplant. This option is for patients who are not elderly and who do not have
other medical conditions that would make it unlikely for a heart transplant to be successful. Heart
transplant evaluations are done in specialized centers. 

 Intra-aortic balloon pump is used as a temporary support of left ventricle function, such as in a
large heart attack, waiting for the heart to recover.
 Left ventricle assist device (LVAD) is surgically implanted to mechanicallybypass the left
ventricle. A clinical trial showed that complications are too high and the device did not significantly
prolong life if used on a long-term basis. This device is used as a temporary left ventricle support to
get the patient awaiting a heart transplant out of bed.

 Left ventricle volume reduction surgery, which removes a piece of dead heart muscle, is
considered experimental at this time.

 Totally implantable artificial hearts are being developed for patients with severe, end-stage heart
failure.  

o These devices are most commonly used as a temporary bridge to heart transplantation.

o This technique is constantly improving but is still limited to specialized centers and is
considered experimental at this time.