CONGESTIVE HEART FAILURE

The words "heart failure" sound alarming, but they do not mean that the heart has suddenly stopped working. Instead, heart failure means that the heart is not pumping as well as it should to deliver oxygen-rich blood to the body. Congestive heart failure (CHF) happens when the heart's pumping action becomes so weak that fluid begins to accumulate in the lungs and other body tissues. This fluid buildup is the “congestion” part of congestive heart failure.

CHF usually develops slowly. Patients may be symptom-free for years, but the symptoms tend to get worse with time. This slow onset and progression of CHF is due to the heart's efforts to accommodate for its gradual weakening. The heart attempts to make up for its weakening by enlarging and by pumping faster.

Who is at risk for developing CHF, and what are its causes?

According to the American Heart Association, people 40 and older have a 1 in 5 chance of developing CHF during their lifetime. Nearly 5 million people in the United States—mostly older adults—already have CHF, and the number of people with CHF is rising. Approximately 400,000 people develop CHF each year. People are living longer and surviving heart attacks and other medical conditions that put them at risk for CHF. People who have other types of heart and vessel disease are also at risk for CHF.

Risk factors for CHF include:

• Previous heart attack
• Coronary artery disease
• High blood pressure (hypertension)
• Irregular heartbeat (arrhythmia)
• Heart valve disease (especially of the aortic and mitral valves)
• Cardiomyopathy (disease of the heart muscle)
• Congenital heart defects (inborn defects)
• Alcohol and drug abuse

Symptoms

Symptoms help doctors determine which side of the heart is not working properly.

If the left side of the heart is not working properly (left-sided heart failure), blood and fluid back up into the lungs. Patients feel short of breath, are very tired, and have a cough (especially at night). In some cases, patients may begin to cough up pinkish, blood-tinged sputum.

If the right side of the heart is not working properly (right-sided heart failure), the slowed blood flow causes a buildup of fluid in the veins. The patient’s feet, legs, and ankles begin to swell. This swelling is called edema. Sometimes edema spreads to the lungs, liver, and stomach. Because of the fluid buildup, patients may need to go to the bathroom more often, especially at night. Fluid buildup is also hard on the kidneys. It affects their ability to dispose of salt (sodium) and water, which can lead to kidney failure. After CHF is treated, the kidneys' function usually returns to normal.


As heart failure progresses, the heart becomes weaker and symptoms begin. In addition to those listed above, here are some other symptoms of CHF:

• Trouble breathing or lying flat due to shortness of breath
• Feeling tired, weak, and unable to exercise or perform physical activities
• Weight gain from excess fluid
• Chest pain
• Poor appetite or indigestion
• Swollen neck veins
• Cold and sweaty skin
• Fast or irregular pulse
• Feeling restless or confused
• Decreased attention span and memory


Diagnosis

Tests that doctors use to diagnose CHF include taking a history and physical examination, listening for the crackling sounds of fluid in the lungs, the distinct sound of faulty valves (heart murmur), or the presence of a very quick heartbeat, tapping on the chest to determine fluid buildup, ordering blood tests, taking a chest x-ray, performing electrocardiography (ECG) and exercise testing, and using echocardiography and other imaging techniques, such as nuclear ventriculography or multiple-gated acquisition scanning (MUGA), and angiography.

Treatment

The goals of treatment include reducing the heart's workload, controlling excess salt and water retention, and improving the heart's function. In some cases, heart failure can be treated by correcting the underlying cause. For example, controlling a fast heart rhythm may reverse structural heart abnormalities. In many cases structural abnormalities cannot be corrected, but treatment can usually markedly decrease symptoms and increase life expectancy and quality of life. Treatment may include lifestyle changes, medicines, transcatheter interventions, and surgery.

Lifestyle Changes

The best way to prevent heart failure from progressing is to practice healthy lifestyle habits. It is also important to address any risk factors that contribute to heart failure, such as high blood pressure or coronary artery disease. Lifestyle habits to implement include:

• Quitting smoking
• Maintaining a healthy weight
• Controlling high blood pressure, cholesterol levels, and diabetes
• Eating a sensible diet that is low in calories, saturated fat, and salt
• Limiting alcohol consumption
• Limiting liquid consumption and caffeine
• Weighing daily to monitor fluid buildup
• Participating a doctor-approved aerobic exercise program
• Reducing stress

Medicines

Studies show that medicines help improve heart function and make it easier to exercise or do physical activity. The following medicines are often given to patients with CHF: diuretics, inotropics, blood-thinning medicines, vasodilators, calcium channel blockers, beta blockers, ACE inhibitors, and angiotensin II receptor blockers.

Percutaneous Coronary Interventions

CHF may be improved with the use of angioplasty, a procedure to open arteries narrowed by fatty plaque buildup. It is performed in a cardiac catheterization laboratory. Stenting is sometimes used along with balloon angioplasty. It involves placing a mesh-like metal device into an artery at a site narrowed by plaque. Inotropic drug therapy is a percutaneous intervention that can increase the heart's ability to beat. This medicine is given through a small catheter placed directly into an artery.

Surgical Procedures

The conditions underlying CHF may be improved with surgery. Surgical procedures that are often considered, depending on the individual patient, may include heart valve repair or replacement, pacemaker or ICD implantation, correction of congenital heart defects, coronary artery bypass surgery, mechanical assist devices, myectomy, and heart transplantation.

Patients who carefully follow their doctors' advice continue to live full and productive lives.



Resources

Texas Heart Institute www.texasheartinstitute.com/HIC/Topics/Cond/CHF.cfm

Mayo Clinic www.mayoclinic.org/congestive-heart-failure/index.html

American Heart Association www.americanheart.org/presenter.jhtml?identifier=4585