Congestive Heart Failure

The heart is a complex, vital organ. At its simplest, it is a pump—a pump we cannot live without. Each day, the average heart moves over 6000 quarts of blood throughout the body. And like all pumps, it can run into problems and eventually fail. When this occurs, it is called heart failure, but the term heart failure doesn’t actually mean that the heart has stopped entirely. After a lifetime of strenuous work, a failing heart is simply no longer strong enough to keep up with the demands of the body. This article focuses on congestive heart failure (CHF)—what causes it, its risk factors and how it is treated. 

The Normal, Healthy Heart

The heart is an amazing organ; each day, it beats nearly 100,000 times to provide our bodies with a steady flow of blood. When the heart pumps, its left and right sides contract, or squeeze, in unison. The left side of the heart pumps blood out to the body while the right side pumps blood to the lungs. The heart typically functions as follows: The heart’s main pumping chamber, the left ventricle, is located on the left side of the heart. It pumps blood to the body, delivering nutrients and oxygen to all of our organs. After reaching the smallest of blood vessels in our bodies—called capillaries—and delivering its cargo of oxygen and nutrients, it returns via a large vessel (called the vena cava) to the right side of the heart. The right ventricle then pumps this blood to the lungs, where the red blood cells pick up more oxygen and gets rid of carbon dioxide, that we exhale as we breathe out. The oxygenated blood then returns to the left side of the heart to begin this cycle all over again.

The Failing Heart

Heart failure is typically a chronic (meaning long-standing), progressive (meaning it gets worse) condition that causes the heart to weaken. Chronic means that the condition is long-standing, and progressive means that it gets worse over time. The weakened heart either is not strong enough to pump enough oxygen-rich blood to the body or does not fill with enough blood. Heart failure can affect the left, the right, or both sides of the heart. Left-sided heart failure is the most common type of heart failure, and there are two sub-types:

• In Systolic heart failure, the left ventricle of the heart cannot contract with enough force to push adequate blood into circulation;
• In Diastolic heart failure, the left ventricle loses its ability to relax and so it cannot fill with sufficient blood in between heartbeats.

Heart failure can also affect the right side of the heart. When this occurs, the right ventricle loses its pumping function, leading to excess fluid accumulation in the body. Right-sided failure often develops after failure has started in the left side of the heart.

Causes and Risk Factors

Heart failure is the end point of many conditions that damage or weaken the heart muscle. The most common cause of heart failure is coronary artery disease, also called hardening of the arteries. This is due to a process called atherosclerosis, whereby fatty deposits, or plaques, build up in the walls of the arteries that supply the heart with blood.  Over time, coronary artery disease can weaken heart muscle. If a blockage in the artery actually leads to a heart attack, the heart muscle is not only starved of oxygen but actually dies, leading to heart failure. Other common causes of heart failure include:

• Hypertension, or high blood pressure, which puts pressure on the heart to pump and work harder;
• Cardiomyopathy, a general term that refers to abnormal changes in the heart muscle Caused by a range of conditions such as infections or drug or alcohol abuse;
• Valvular heart disease, whereby one or more of the valves in the heart do not work properly;
• Congenital heart defects, or conditions that are present at birth
• Arrhythmias, or irregular heart rhythms; 
• Myocarditis, an inflammation of the heart that may be caused by a virus; or
• Other diseases, such as diabetes (and the medications used to treat it), thyroid disorders, emphysema, lupus, or kidney conditions.

Symptoms of Heart Failure

Heart failure is typically a chronic, or ongoing, condition that develops slowly over time. Some patients with heart failure may not have noticeable symptoms. Others may have multiple symptoms ranging from mild to severe—and these may come and go over time.

Some people with heart failure experience fatigue and difficulty completing daily activities. So activities that once seemed easy—like walking the dog, climbing the stairs or even carrying a bag of groceries—may make bring on a feeling of exhaustion or shortness of breathe. If you notice that you are having trouble completing daily tasks like these, you should speak to your doctor.

Other people notice swelling—also called edema—in the legs, feet, and abdomen. This congestion occurs because blood flow out of the heart slows, and therefore blood returning to the heart backs up. As a result, fluid builds up in the tissues of the body, usually first noticed in the feet and legs. Eventually, this accumulated fluid can cause weight gain. Weight gain is common symptom of congestive heart failure. Other symptoms typically include rapid pulse, cough, loss of appetite, increase in the size of the abdomen, and frequent urination.  Less common symptoms include decreased alertness and nausea and vomiting.

Although heart failure is often a chronic condition, it is possible for sudden heart failure to occur, even in people without heart disease. The symptoms of sudden heart failure are often more severe and can worsen quickly, even within a few hours. Usually, patients notice a sudden shortness of breath due to fluid accumulation in the lungs.

If you feel you are experiencing any of these symptoms, you should contact your doctor immediately.

Diagnosing Heart Failure  

Since there is no single test to diagnose heart failure, your doctor will ask you about your medical history, perform a physical exam and see whether you have any risk factors for heart failure, such as high blood pressure. In addition, the doctor may order the following:

• Blood tests to determine how your heart and other organs are functioning, including the hormone BNP, which is made by the heart and shows how well it is working.
• A stress test, which entails walking on a treadmill or pedal on a stationary bike while your doctor assesses how well your heart responds to activity.
• A chest x-ray will show the size of your heart and whether there is fluid in your lungs. In heart failure, the heart may be larger than normal. An x-ray can sometimes also rule out other conditions that may be causing your symptoms.
• An electrocardiogram or E-C-G can uncover problems with your heart rhythm and help your doctor determine whether your heart failure is due to heart rhythm problems or a heart attack.
• An echocardiogram uses sound waves to create a video of the heart’s motion.
• Other imaging studies, like an MRI, may be used to determine the cause of heart failure. 

These tests will help your doctor assess the extent of your heart failure in order to design a treatment program just for you.

Preventing and Treating Heart Failure: Lifestyle Changes

The best way to prevent heart failure is to reduce risk factors for developing it. Improving your lifestyle plays a key role in both the prevention and the treatment of CHF. 

If you have been diagnosed with heart failure, your doctor will ask you to pay close attention to your symptoms and make some lifestyle changes.  These may include:

• Losing weight. This will help reduce blood pressure and relieve strain on the heart.  You can work with a nutritionist to get excess weight off.
• Exercising.  This has been shown to strengthen the heart and help to relieve symptoms.  But you should talk to your doctor about what is safe for you. Although you should stay active, also make sure to get plenty of rest so that your heart can rest as well. A structured heart rehabilitation program may be the best way to get the appropriate type and amount of exercise you need.
• Improving your diet.  Eat food that is low in saturated fat, trans fat and cholesterol. Reach for fresh fruits and vegetables, complex carbs, and lean protein.
• Watching salt intake. Salt can cause fluid retention, which can lead to even more swelling and overall congestion.   So, look for “low-sodium” foods, do not add extra salt to your food, and, be sure to pay special attention to what you order when you eat out. 
• Knowing your blood pressure and making sure it is  controlled.
• Avoiding alcohol.
• And last but not least, if you smoke, quitting!

You should plan on seeing your doctor every three to six months to make sure that your condition is not worsening.  Decrease your chances of a respiratory illnesses by getting your flu and pneumococcal vaccines. And remember, regardless of the cause of your heart failure or how severe it is, you can take steps immediately to improve your lifestyle, which will help you manage this disease.

Preventing and Treating Heart Failure: Medications

Your doctor may prescribe medication to treat congestive heart failure, or other conditions that put you at risk for heart failure. These drugs perform different functions:

• Diuretics rid the body of excess fluid and salt. They may also help to relieve the symptoms of shortness of breath and swelling.
• ACE inhibitors open blood vessels, reducing blood pressure and the workload of the heart.
• Angiotensin receptor blockers (ARBs) also reduce the workload of the heart and are good for patients who cannot tolerate ACE inhibitors.
• Beta blockers can help to slow the heart and increase the amount of blood it pumps.
• Digitalis glycosides help strengthen the contraction of the heart muscle and slow the heart rate, helping to make the heart more effective as it pumps.
• Some patients, particularly African Americans, may benefit from a combination of two drugs, hydralazine and nitrate, if ACE inhibitors and beta-blockers do not help to relieve symptoms.

One of the most important things you can do to manage heart failure is to take your medications exactly as prescribed. Never stop taking them without first speaking to your doctor. And, if you have side effects, don’t be afraid to speak up! Your doctor can make adjustments if necessary.

Preventing and Treating Heart Failure: Procedures, Devices and Surgery

If lifestyle changes or medications are not effective in controlling your heart failure, surgery may be recommended.

Nearly 50 percent of people with CHF have defects in their hearts’ ability to maintain a normal rhythm of beats. Two devices are used to help the heart maintain a normal rhythm:

• An implantable cardioverter-defibrillator, or ICD, is a device that monitors heart rhythm. If your heart develops an abnormal rhythm or stops beating, the ICD kicks in to help return it to a normal rhythm.
• A pacemaker can help drive the pumping of your heart by sending a small electrical signal to the heart muscle and is often used along with an ICD.

Surgery can both prevent further damage to the heart and improve its function:     

• If you have a narrow or blocked artery, a doctor may perform angioplasty to open the artery and improve blood flow to the heart. In some instances, a stent—a small hollow tube—may need to be placed in the artery at the point it is narrowed to keep it open.
• If you have a blockage that cannot be treated with angioplasty, your doctor may recommend coronary bypass surgery, which reroutes blood around the clogged artery.
• If a defective valve is the cause of your heart failure, a cardiovascular surgeon may be able to repair or replace it. For more advanced heart failure, your doctor may recommend the use of a device called a left ventricular assist device, or LVAD, that helps the heart perform its work. A cardiovascular surgeon implants that LVAD in the abdomen or chest and connects the pump to the heart. This device may be used in people who are waiting for a heart transplant or for those who are not eligible for a transplant. The LVAD is reserved for those with severe heart failure. If the hear failure progress or a patient becomes dependent on a LVAD device for support, the doctor may consider a heart transplant.