Congestive Heart Failure
Basics
Congestive heart failure is a condition in which the heart does not pump blood properly.
Congestive heart failure occurs when the heart, due to a defect, injury, or disease, is not able to pump enough blood to meet the body's needs. When this happens, body tissues, which depend on the oxygen and nutrients in blood circulated from the heart, no longer receive enough nourishment. As a result, patients experience shortness of breath when climbing stairs and walking quickly, and tire easily. Because the heart's ability to pump blood is reduced, fluid other than blood builds up in the tissues that were being nourished by a constant flow of blood — this causes the tissues to retain fluid and to swell. Also, because the heart is weakened, it cannot prevent excess fluid from backing up in the lungs, which is why patients have difficulty breathing. The “congestive” in congestive heart failure refers to the buildup of fluid in tissues and the lungs.
Heart failure can occur on the left or right side of the heart, and usually affects either the left or right ventricle Figure 01.
Left ventricle failure is more common. When this happens, fluid backs up into the lungs, and, because the pumping action of the heart slows down, fluid builds up throughout the body. In right ventricle failure, blood backs up in the veins, which often leads to swelling in the ankles and legs. Because the functions of the different parts of the heart are interrelated, failure on the left side often results in failure on the right.
Figure 01. The flow of blood through a healthy heart (animation and audio)
Heart failure is a chronic disease that develops slowly.
Noticeable symptoms may not appear for years, but as the heart gradually loses pumping capacity, it tries to adjust by enlarging, thickening, and beating more often. Blood vessels also begin to narrow, diverting blood away from less important tissues to the major organs of the body. These strategies on the part of the heart hide the problem, and patients may not be aware that they have congestive heart failure until the serious symptoms of chronic fatigue and shortness of breath appear.
Nearly five million Americans live with congestive heart failure.
Congestive heart failure is a growing health problem, and is the most common diagnosis for hospitalized patients aged 65 years and older. Each year 400,000 people learn they have the condition. While most common among older adults, people of any age, including children, can suffer from congestive heart failure. The disease affects men and women in equal numbers. However, prevalence is 25% higher in the African American population than among whites.
A combination of medications and self-care techniques helps patients live longer and more comfortably.
Treatment may include surgery to restore blood supply to the heart, or to replace damaged valves. Transplant surgery is considered only as a last resort.
Causes
Damage to the heart muscle from a heart attack or infection prevents the heart from pumping blood efficiently Figure 02.
If the heart muscle is damaged by heart diseases such as heart attack (myocardial infarction) or coronary artery disease, the risk of a person developing congestive heart failure increases. Heart damage can also be caused by infections, which can injure either the heart muscle or the valves that connect the chambers within the heart. Chronic alcohol and drug abuse also can damage the heart. Once the heart is injured, congestive heart failure often follows.
Figure 02. What happens during a heart attack
Diseases that make the heart work harder, such as chronically high blood pressure and lung disease, may weaken the heart and lead to congestive heart failure Figure 03.
High blood pressure (hypertension) forces the heart to pump harder, eventually causing the chambers of the heart to become larger and weaker. Serious lung disease, such as asthma or emphysema, reduces the amount of oxygen available to the heart, causing the heart to work harder to supply oxygen throughout the body. Diabetes also places an increased strain on the heart, which can lead to congestive heart failure.
Figure 03. Blood pressure chart
Heart damage present at birth can cause congestive heart failure.
Some people are born with abnormalities in the structure of the heart muscle or valves. Because other parts of the heart compensate for the weakness, the heart overall is damaged, making it more likely that the person will develop congestive heart failure.
Symptoms
Fatigue, shortness of breath, and swelling in the legs are common symptoms of congestive heart failure.
Because tissues do not receive enough nourishment if the heart is not pumping adequately, you may tire easily. Shortness of breath may worsen with activity, at night, or when lying down. You may even be awakened from sleep with a feeling of suffocation.
If fluid pools in the lungs, you may experience a persistent cough. You also may cough up a pink, frothy substance, mucus, or blood.
Fluid in the lungs results from the heart’s inability to pump out all the blood it receives. Fluid retention can cause sudden weight gain, and may collect in the lungs over a period of time. Blocked arteries, an irregularly beating heart, stress, or consuming a large amount of salt may increase the risk of your lungs filling with fluid.
Fluid may also back up into the legs, arms, or abdomen, causing swelling and firmness. Other symptoms include irregular heartbeats or palpitations, feeling your heart pounding in your chest, loss of appetite or nausea, and confusion.
The heart beats faster to try to make up for its limited pumping ability. The more rapid heartbeat may be irregular, or cause a feeling in the chest that the heart is racing. When the stomach and digestive system receive less blood, due to the heart’s failure to pump adequately, you may feel nauseous or full. Digestive symptoms also may occur due to swelling of the liver. Changes in blood chemistry levels can lead to confusion, memory loss, and impaired thinking.
Risk Factors
Factors that increase a person’s risk of heart attack, such as high cholesterol levels, obesity, and high blood pressure, also increase risk of congestive heart failure Figure 04.
The same factors that contribute to other heart disease—hardening of the arteries, high cholesterol levels, obesity, high blood pressure, irregular heart rhythm, thyroid problems, diabetes mellitus, and a family history of heart disease or sudden death, increase the risk of congestive heart failure.
Figure 04. BMI calculator
Older people and African-Americans are at increased risk for the heart failure.
People older than 65 are more likely than younger people to suffer from congestive heart failure. The condition is more prevalent among African Americans than whites.
Diagnosis
Congestive heart failure is a condition in which the heart does not pump blood properly.
Congestive heart failure occurs when the heart, due to a defect, injury, or disease, is not able to pump enough blood to meet the body's needs. When this happens, body tissues, which depend on the oxygen and nutrients in blood circulated from the heart, no longer receive enough nourishment. As a result, patients experience shortness of breath when climbing stairs and walking quickly, and tire easily. Because the heart's ability to pump blood is reduced, fluid other than blood builds up in the tissues that were being nourished by a constant flow of blood — this causes the tissues to retain fluid and to swell. Also, because the heart is weakened, it cannot prevent excess fluid from backing up in the lungs, which is why patients have difficulty breathing. The “congestive” in congestive heart failure refers to the buildup of fluid in tissues and the lungs.
Heart failure can occur on the left or right side of the heart, and usually affects either the left or right ventricle Figure 01.
Left ventricle failure is more common. When this happens, fluid backs up into the lungs, and, because the pumping action of the heart slows down, fluid builds up throughout the body. In right ventricle failure, blood backs up in the veins, which often leads to swelling in the ankles and legs. Because the functions of the different parts of the heart are interrelated, failure on the left side often results in failure on the right.Figure 01. The flow of blood through a healthy heart (animation and audio)
Heart failure is a chronic disease that develops slowly.
Noticeable symptoms may not appear for years, but as the heart gradually loses pumping capacity, it tries to adjust by enlarging, thickening, and beating more often. Blood vessels also begin to narrow, diverting blood away from less important tissues to the major organs of the body. These strategies on the part of the heart hide the problem, and patients may not be aware that they have congestive heart failure until the serious symptoms of chronic fatigue and shortness of breath appear.
Nearly five million Americans live with congestive heart failure.
Congestive heart failure is a growing health problem, and is the most common diagnosis for hospitalized patients aged 65 years and older. Each year 400,000 people learn they have the condition. While most common among older adults, people of any age, including children, can suffer from congestive heart failure. The disease affects men and women in equal numbers. However, prevalence is 25% higher in the African American population than among whites.
A combination of medications and self-care techniques helps patients live longer and more comfortably.
Treatment may include surgery to restore blood supply to the heart, or to replace damaged valves. Transplant surgery is considered only as a last resort.
Damage to the heart muscle from a heart attack or infection prevents the heart from pumping blood efficiently Figure 02.
If the heart muscle is damaged by heart diseases such as heart attack (myocardial infarction) or coronary artery disease, the risk of a person developing congestive heart failure increases. Heart damage can also be caused by infections, which can injure either the heart muscle or the valves that connect the chambers within the heart. Chronic alcohol and drug abuse also can damage the heart. Once the heart is injured, congestive heart failure often follows.Figure 02. What happens during a heart attack
Diseases that make the heart work harder, such as chronically high blood pressure and lung disease, may weaken the heart and lead to congestive heart failure Figure 03.
High blood pressure (hypertension) forces the heart to pump harder, eventually causing the chambers of the heart to become larger and weaker. Serious lung disease, such as asthma or emphysema, reduces the amount of oxygen available to the heart, causing the heart to work harder to supply oxygen throughout the body. Diabetes also places an increased strain on the heart, which can lead to congestive heart failure.Figure 03. Blood pressure chart
Heart damage present at birth can cause congestive heart failure.
Some people are born with abnormalities in the structure of the heart muscle or valves. Because other parts of the heart compensate for the weakness, the heart overall is damaged, making it more likely that the person will develop congestive heart failure.
Fatigue, shortness of breath, and swelling in the legs are common symptoms of congestive heart failure.
Because tissues do not receive enough nourishment if the heart is not pumping adequately, you may tire easily. Shortness of breath may worsen with activity, at night, or when lying down. You may even be awakened from sleep with a feeling of suffocation.
If fluid pools in the lungs, you may experience a persistent cough. You also may cough up a pink, frothy substance, mucus, or blood.
Fluid in the lungs results from the heart’s inability to pump out all the blood it receives. Fluid retention can cause sudden weight gain, and may collect in the lungs over a period of time. Blocked arteries, an irregularly beating heart, stress, or consuming a large amount of salt may increase the risk of your lungs filling with fluid.
Fluid may also back up into the legs, arms, or abdomen, causing swelling and firmness. Other symptoms include irregular heartbeats or palpitations, feeling your heart pounding in your chest, loss of appetite or nausea, and confusion.
The heart beats faster to try to make up for its limited pumping ability. The more rapid heartbeat may be irregular, or cause a feeling in the chest that the heart is racing. When the stomach and digestive system receive less blood, due to the heart’s failure to pump adequately, you may feel nauseous or full. Digestive symptoms also may occur due to swelling of the liver. Changes in blood chemistry levels can lead to confusion, memory loss, and impaired thinking.
Factors that increase a person’s risk of heart attack, such as high cholesterol levels, obesity, and high blood pressure, also increase risk of congestive heart failure Figure 04.
The same factors that contribute to other heart disease—hardening of the arteries, high cholesterol levels, obesity, high blood pressure, irregular heart rhythm, thyroid problems, diabetes mellitus, and a family history of heart disease or sudden death, increase the risk of congestive heart failure.Figure 04. BMI calculator
Older people and African-Americans are at increased risk for the heart failure.
People older than 65 are more likely than younger people to suffer from congestive heart failure. The condition is more prevalent among African Americans than whites.
The doctor will perform a physical exam, listen to your heart, and ask about your medical history and that of your immediate family.
Past medical problems and a family history of some heart problems may contribute to congestive heart failure. Knowing your health history helps the doctor figure out what is wrong. The doctor will check for fluid collecting in the legs, the abdomen, and in other parts of the body. The jugular vein in your neck may indicate increased pressure as a result of the heart not pumping blood effectively. This increased pressure provides a visible sign of trouble that may not be otherwise apparent. The doctor will also listen to your heart and lungs. In patients experiencing heart failure, the doctor will often hear an extra heart sound. Normally, the heart emits two sounds with each beat (generated by the closure of the valves). In heart failure, an extra sound is produced which is roughly similar in sound quality, but is characteristic of abnormal heart function. In addition, fluid in the lungs frequently produces abnormal lung sounds.
The evaluation will include an investigation into what might have led to heart failure. Blood tests, urine tests, and other tests will be part of this investigation. In some cases an underlying condition exists that may have been with you for a long time.
The doctor will assess you for hardening of the arteries, kidney and thyroid problems, and other imbalances in the body. Blood tests can check thyroid function, iron levels, and whether you have HIV or other diseases. A urine test helps to assess kidney function.
An electrocardiogram, a simple and painless test that records the heart’s electrical activity on a graph, may aid in identifying underlying heart conditions.
A coronary angiogram may be ordered to assess for blockages or buildup of fatty plaque in the arteries that surround the heart (coronary arteries).
An angiogram is a test that is done by inserting a flexible catheter or tube attached to a guide wire into one of the veins in the groin. The catheter is then advanced through the blood vessels until it reaches the heart. A dye is then injected through the catheter into the bloodstream, and x-rays of the heart and coronary arteries are taken. The dye enables the doctor to identify blockages in the arteries.
An echocardiogram, which uses sound waves to visualize the size, shape, and motion of the heart, assists in diagnosing congestive heart failure.
Echocardiograms are used to examine the internal structures of the heart. The test allows doctors to observe the heart’s chambers and valves, as well as the blood vessels coming to and leaving the heart. An echocardiogram may be used in the future to monitor your response to treatment.
A stress test or x-rays may be ordered to evaluate heart function.
A heart-lung stress test measures oxygen consumption and monitors the heart (with a machine called an electrocardiogram), while a patient is exercising. The test also is helpful in determining if the current impairment is related to the heart or the lungs in patients with disorders in both. Chest x-rays are beneficial in assessing the lungs as well as the size and shape of the heart. A radionuclide ventriculogram, a type of nuclear-medicine test, can help determine how much the blood the heart is pumping.
Preventative measures include taking steps to avoid heart disease and high blood pressure, and adequately treating existing heart conditions.
To prevent heart failure and other cardiac conditions, maintain a healthy weight, eat a low-fat and low-cholesterol diet, stop smoking, limit alcohol intake, and exercise regularly. Take medications ordered by the doctor. Make time to relax and do the things you enjoy.
Patients at risk for congestive heart failure should have their blood pressure checked regularly for possible hypertension (chronic high blood pressure).
High blood pressure puts additional strain on the heart and can lead to congestive heart failure. Prompt detection allows for early treatment and control.
Prevention and Screening
Preventative measures include taking steps to avoid heart disease and high blood pressure, and adequately treating existing heart conditions.
To prevent heart failure and other cardiac conditions, maintain a healthy weight, eat a low-fat and low-cholesterol diet, stop smoking, limit alcohol intake, and exercise regularly. Take medications ordered by the doctor. Make time to relax and do the things you enjoy.
Patients at risk for congestive heart failure should have their blood pressure checked regularly for possible hypertension (chronic high blood pressure).
High blood pressure puts additional strain on the heart and can lead to congestive heart failure. Prompt detection allows for early treatment and control.
Treatment
Seek immediate medical care if you experience severe shortness of breath, profound fatigue, an irregular heartbeat or palpitations, sudden weight gain (three or more pounds in one day), increased swelling of the legs and ankles, or swelling or pain in the abdomen.
Other signs that should be promptly reported to your doctor are loss of appetite, a hacking cough, confusion, and trouble sleeping, including waking up short of breath.
Several self-care techniques, such as losing weight, getting more exercise, and learning to relax improve survival and quality of life.
Patients are encouraged to lose weight, exercise, and to decrease alcohol consumption. Try to restrict the use of salt in cooking and at the table, and to eat a low-fat, low-cholesterol diet that includes lots of fruits and vegetables. Smaller, more frequent meals may help you obtain optimal nourishment. The doctor may also limit your fluid intake. Increasing physical activity helps reduce many of the risk factors for congestive heart failure. Check with your doctor about appropriate forms of exercise.
Following the prescribed diet and taking medications as directed are critical to your well-being.
Salt can cause the body to retain fluid, and excess fluid makes your heart work that much harder. A low-salt diet is extremely important for managing your heart failure. Foods such as bacon, ham, and sausage contain high amounts of salt. Packaged foods, like TV dinners and canned goods, are typically high in sodium, which is found in table salt. Read the labels before purchasing. With canned foods, draining and rinsing helps eliminate some of the sodium. Over-the-counter medications, such as some antacids, may also contain sodium.
Learn as much as you can about your medications and their side effects. Notify the doctor if you start to experience any unusual symptoms that may be related to your heart failure or its treatment.
Pace your activities to allow time for rest and exercise.
Your heart won’t need to work so hard if you give it a chance to rest. Avoid packing the day full of activities or overdoing things.
Once the initial symptoms are under control, check with your doctor about starting an exercise program; then start slowly. Gradually build up to your desired goal. Do not exceed your comfort zone. Physical activity is good for most people. Moderate exercise can help the heart grow stronger. Walking and swimming can be paced to individual tolerance. The doctor may recommend cardiac rehabilitation. Rehab programs allow patients to start increasing physical activity while being carefully monitored. Avoid exercises in which you hold your breath, bear down, or need sudden bursts of energy and competitive contact sports such as football.
Check your blood pressure and weigh yourself every day.
Weigh yourself at the same time each day; first thing in the morning, after using the bathroom but before breakfast, is a good time. Report any increases or significant changes to the doctor. A rapid increase in weight often indicates additional fluid retention. Notify your doctor if you gain more than three pounds in one day, five pounds in a week, or whatever amount your doctor has specified. Alert the doctor to any changes in blood pressure readings.
Emotional stress may aggravate your condition.
Stress increases the demands made on your heart. Blood pressure and heart rate can rise when you are anxious or angry. Learning to manage stress and anger will help you control and more comfortably live with heart failure. American Heart Association tips include:
• Accept the things you cannot change.
• Express your feelings to family and friends.
• Spend 15 to 20 minutes each day relaxing. Breathe deeply and think restful thoughts.
• Look for the good in life, rather than focusing on the negative.
• Exercise according to your doctor’s recommendations. Increased physical activity decreases stress and improves mood. It also increases energy levels, decreases blood pressure, and aids in maintaining a healthy weight.
• Try to avoid situations you know will upset you. For instance, don’t drive on the interstate at rush hour or over-schedule yourself.
• Learn how to say no.
• Join a support group. Talking about your situation with other people with the same condition often proves beneficial. You may even experience the joy of helping someone else.
Propping yourself up on a pillow may improve your ability to sleep at night.
Ask your doctor about receiving flu and pneumonia vaccinations.
Influenza can be more dangerous for people with heart disease. The vaccine helps prevent the infection, and cannot give you the flu. If you catch the flu, your weak heart may make you more susceptible to pneumonia. Flu shots are given annually, the pneumonia shot, generally, once.
You may need to receive antibiotics before having serious dental work done.
These are necessary only if abnormalitites of cardiac structures (such as valves or certain congenital abnormalities) are present.
Always tell all of your health care providers about all of the medications you take, including over-the-counter drugs and dietary supplements.
Drugs can interact with each other. In order to provide the best care, health care providers need to know what medications you are taking.
Your doctor is the best source of information on the drug treatment choices available to you.
Treating any underlying condition is a mainstay of congestive heart failure management.
In addition to treating your primary condition of congestive heart failure, your doctor will also focus on managing other diseases that may be contributing to your heart trouble such as diabetes, thyroid disorders, and anemia.
Procedures to open blocked arteries or replace valves are often helpful in treating the underlying cause of heart failure.
During coronary artery bypass grafting, surgeons reroute blood supply to the heart using other blood vessels. An artificial valve replacement can correct leaking valves. Surgery is also in infants and children to correct congenital (birth) defects in the structure of the heart and valves.
Heart transplants are considered only when all other treatment options have failed.
Candidates for transplant are screened for other serious medical conditions, and patients with cancer, long-term infections, and immune system diseases are usually ineligible for transplants. Transplant candidates often wait for months or years before receiving a new heart. Many do not survive the wait, but others progress and do well enough on medications to be taken off the transplant list. Patients on transplant lists are sometimes kept alive with a mechanical pump, called a left ventricular assist device, which takes over the functions of the heart. However, such devices are not a permanent means of treating heart failure, but are rather temporary solutions to ensure that a patient survives until a transplant is available. Experimental artificial hearts are being tested but are still years away from being in general use.
Ask your doctor about any dietary supplements you may be considering.
Some people recommend herbal remedies for heart conditions. No herbal substance can cure heart failure. Herbs or other remedies may interfere with your regular medications. Always check with the doctor before taking an herb or dietary supplement.
A rare type of heart failure, called peripartum cardiomyopathy, can occur around the time a woman gives birth to a child.
The cause is unknown, but the condition is thought to be associated with an autoimmune process, infection, or a family predisposition. Treatment includes resting in bed, restricting salt intake, and taking prescribed medications. Approximately four in 10,000 women develop this condition.
Congestive heart failure cannot be cured, but it is manageable.
By working with your doctor, following the recommended dietary and medication plan, and making some other lifestyles changes, many patients experience a high quality of life. Still, half will not survive for five years.
The long-term outlook improves when the underlying conditions are treatable.
Patients with congestive heart failure need regular visits to the doctor.
Depending on your medications, you most likely will need regular blood work. Blood tests can measure drug levels in the blood and detect imbalances in normal blood chemistry levels.