Congestive Heart Failure

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 called ventricles.



• 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 a heart 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 is pitting 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 diastole or 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 with high 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 (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 pericardium surrounding 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 coronary heart 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.
  
  
  • 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.
  
  
  
  • 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).

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), or emphysema, 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
  
  
  • 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.
  
  
  
  • The ability to exercise, even to walk at a normal pace, may be limited by feeling tired (fatigue) and having shortness of breath.
  
  
  
  • 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
  
  
  • If a person has CHF, he or she may have difficulty breathing (dyspnea), especially when he or she is active.
  
  
  
  • 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). 
  
  
  
  • 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.
  
  
  
  • Several pillows may help with a more comfortable sleep. A person may also prefer sleeping in a recliner rather than in a bed.
  
  
  
  • As the buildup of fluid in the lungs becomes very severe, a frothy, pink liquid may be coughed up.   
     
• Fluid retention and swelling
  
  
  • 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.  
  
  
  
  • 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.
  
  
  
  • 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, including liver and kidney failure.
  
  
  
  • Swelling may be so severe as to reach up to the hips, scrotum, abdominal wall, and eventually the abdominal cavity (ascites).
  
  
  
  • 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.

Often cardiologists who specialize in heart failure can work together with primary care doctors and other health care providers. Certain symptoms need to be checked by a doctor. If you have any of these symptoms, call your health care provider for an appointment. If the symptoms are severe or of sudden onset, seek immediate emergency care.

• You have shortness of breath that seems to be getting worse or causes difficulty sleeping.



• You fall asleep in bed but wake up at night with shortness of breath.



• You sleep better in a semi-upright position in a chair or recliner than flat in bed.



• Your shortness of breath develops with mild exertion and is worse than usual.



• You have unusual fatigue that is not relieved with rest.



• You have a dry cough that will not go away or seems otherwise unusual.



• You have swelling in your ankles, feet, or legs that does not go away.

Other, more subtle symptoms of heart failure warrant a visit to your health care provider, especially if linked to any of the symptoms already listed.

• Abdominal bloating or discomfort



• Persistently pale skin



• Poor appetite

Other than childbirth, congestive heart failure is the most common reason for hospital admission in the United States, especially for people older than 65 years. This highlights the fact that many people with heart failure will have to go to the hospital, either at the beginning of their illness or from time to time because of it.

Always take chest pain seriously. Although failure of the heart does not cause pain, several important conditions associated with congestive heart failure do.

If these symptoms develop quickly or worsen rapidly, seek emergency treatment.

• Shortness of breath



• Severe, unrelieved chest pain



• Swelling in the legs that becomes painful, even in one leg, especially if associated with signs of an infection (redness, warmth to the touch, fever)



• Fainting

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)
  
  
  • 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.
  
  
  
  • Interestingly, BNP has been produced by recombinant DNA technology and can be used as a treatment for heart failure in the hospital (see Medications).

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 fetus during 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 or echocardiography to improve accuracy.

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.

|Self-Care at Home|

Congestive heart failure is a serious medical condition that requires professional medical help.

• Once diagnosed and under the care of a qualified medical professional, you can and should do several things at home to increase your comfort and reduce the chance of your condition getting worse.



• In fact, the more active role you take in managing your heart failure, the more likely you are to do well.



• Making the lifestyle changes described here will make a real difference. Not only will you feel better, but you will be increasing your chances of a longer, healthier life.

Treat swelling with the following measures:

• Elevate the feet and legs if they are swollen.  



• Eat a reduced-salt diet.



• Weigh in every morning before breakfast and record it in a diary that can be shown to a health care provider.

Avoid the following:

• Not taking prescribed medications



• Smoking (in all forms)



• Alcohol (up to 1 drink per day is usually fine, unless prone to excessive intake/alcoholism)



• Keep walking or join a cardiac rehabilitation program (this program can monitor increasing or decreasing exercise capacity)



• Excessive emotional stress and/or depression (Moderate-to-severe mental depression has been shown to double mortality risk.)



• High altitude (Breathing is more difficult because of the lower level of oxygen in the atmosphere; pressurized cabin air travel is usually fine.)



• Herbal or other complementary medicine without first consulting a doctor to see if they are safe  

Know the following:

• People with diabetes must control their blood sugar level every day. Know the HbA1C level. It should be less than 7.0, preferably less than 6.5.



• People with high blood pressure should measure it regularly, and make sure they know the value, (systolic pressure should be below 140 mm Hg in everyone and even below 130 if the person has diabetes).



• People with elevated lipid levels (cholesterol and triglycerides) can take medications to get the bad cholesterol, or LDL, below 100, and the triglycerides below 150.

|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 the physiologic imbalances as possible.

Procedures

Other treatment or procedures, such as angioplasty 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-threatening arrhythmia 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 or spironolactone, 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 (Aldactone), eplerenone (Inspra), triamterene (Dyrenium), torsemide (Demadex), or metolazone (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 include candesartan (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. The sympathetic 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 of pulmonary 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 mechanically bypass 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. 
  
  
  • These devices are most commonly used as a temporary bridge to heart transplantation.
  
  
  
  • This technique is constantly improving but is still limited to specialized centers and is considered experimental at this time.

|Other Therapy|

A rapidly growing newer therapy is called cardiac resynchronization therapy and involves a biventricular pacemaker. 

• One pacer is placed in a coronary vein on the back side of the heart, overlying the left ventricle. The other pacer is placed in the usual right ventricle position. This improves the coordination of contraction between the left and right ventricle, especially if the patient has left bundle branch block.



• Biventricular pacing has been shown to improve exercise capacity, and, in a recent clinical trial, it has been found to prolong life.



• Cardiac resynchronization therapy is frequently combined with an ICD to shock a person out of life-threatening arrhythmias, such as ventricular tachycardia or ventricular fibrillation. The worse the left ventricle, the higher the risk for sudden death secondary to these arrhythmias.



• Whether biventricular pacing will work so well as to prevent deterioration of the left ventricle and the need for heart transplantation is unknown.

|Follow-up|

If you have congestive heart failure, you will need frequent, regular medical attention to adjust your medications and watch for side effects. Schedule regular visits with your health care provider as he or she recommends because congestive heart failure is a serious medical condition that requires constant monitoring. Educate yourself as much as possible about this life-threatening condition.

• Establish a daily routine for taking medication properly and on schedule.



• Weigh in daily. Every morning, record the weight in a diary, and take it to the health care provider every visit. An accurate bathroom scale is helpful in monitoring weight gain or loss from day to day. This will help to see fluid retention.



• Keep a list of all medications, with the exact name and dose, and know why each one is taken. Bring them to each follow-up visit so the doctor can double check to make sure you are on the correct medication and dose.



• Reminder boxes for medications are helpful.



• Be sure to keep all these medications away from small children who may accidentally swallow them. Many of the drugs prescribed for congestive heart failure are more dangerous in overdose than other medications.

|Prevention|

Congestive heart failure can be the ultimate result of a number of diseases, or lifestyle choices, that damage the heart. Some of these can be prevented. Others cannot be prevented but can be treated successfully.

Some examples of illnesses or lifestyle choices that can lead to congestive heart failure are as follows:

• Coronary heart disease (coronary artery disease), including heart attack



• Uncontrolled high blood pressure (hypertension)



• Uncontrolled high cholesterol



• Diabetes



• Congenital heart disease (a heart condition that one is born with)



• Infection (particularly some common viruses that can rarely severely affect the heart and cannot be reliably predicted or prevented)



• Damage to the heart valves (possibly from IV drug use)



• Alcoholism



• Smoking

In some cases, a family history of heart failure can be present. Many cases are a combination of factors, and in other cases, the cause is unknown. 

If you have congestive heart failure, you are at increased risk of developing pneumonia. You probably should receive both the pneumonia vaccination and annual flu shots. Ask your health care provider to be sure.

|Outlook|

Heart failure is a major health problem that comes with the graying of America. Today, many more people are surviving heart attacks and other heart diseases. This allows them many more years of quality life but can eventually lead to the development of heart failure.

In recent years, more effective medications have been developed that improve the outlook of heart failure. Medications are the mainstay of therapy with congestive heart failure. 

• New and sophisticated treatments are allowing people to live longer. These results are proven by clinical trials where patients volunteer to take new therapies under strict ethical and scientific monitoring.



• Pacemakers and implantable defibrillators have improved and now offer the ability to control rare but life-threatening disturbances of heart rhythm in some people.



• Some people may even benefit from sophisticated treatments such as heart transplants and newer forms of temporary mechanical hearts.

|Support Groups and Counseling|

Having the support of health care providers, family, and friends is essential to effectively coordinate all of the needs of a person with heart failure. 
 
People with severe heart failure have special needs beyond standard medical care.  

• Advance directives are legal documents that tell doctors and hospitals what treatments you might not want, should you become unable to speak for yourself.



• A living will provides instructions while you are still alive, for example, if you have specific wishes if your heart or breathing stops. 



• A medical durable power of attorney allows someone you designate to make medical decisions on your behalf, if you become unable to make these decisions.



• Hospice care may be required when you and your physicians agree that your prognosis for survival is poor. Professional hospice caregivers emphasize pain control and emotional support. 

American Heart Association
National Center
7272 Greenville Avenue
Dallas, TX 75231
(800) 242-8721

National Heart, Lung, and Blood Institute
PO Box 30105
Bethesda, MD 20824-0105
(301) 592-8573

|Web Links|

American Heart Association 

National Heart, Lung, and Blood Institute (NHLBI)

Heart Rhythm Society

Media file 1: Congestive heart failure. Heart Lung Pump-Oxygenator. The right lung (appears to the left in the graphic) is the normal dry lung. The left (or wet) lung shows congestive heart failure's effect on the lung. Image courtesy of Bryan Moss at Scott and White Hospital, and David A. Smith, MD.

Media type:  Image

Media file 2: Congestive heart failure. The heart is a pump that works together with the lungs. The heart pumps blood from the veins through the lungs where oxygen is added and then moves it on to the arteries. This pumping action creates a relatively high pressure in the arteries and a low pressure in the veins. Image courtesy of Bryan Moss at Scott and White Hospital, and David A. Smith, MD.

Media type:  Image

congestive heart failure, abnormal heart rhythm, arrhythmias, cardiomyopathy, CHF, coronary artery disease, coronary heart disease, enlarged heart, heart attack, heart rhythm disorders, heart valve stenosis, high blood pressure, hypertension, incompetent heart valve, myocardial infarction, pulmonary edema, weak heart, ankle swelling, edema, fluid retention, puffy ankles, swollen ankles, leg swelling, lung congestion, systolic heart failure, diastolic heart failure, diuretics, vasodilators,ACE inhibitors, beta-blockers, pacemaker, defibrillator, heart failure, echocardiogram, electrocardiogram, ECG

Author: Terrence X O'Brien, MD, FACC, Office of Research and Development, Ralph H Johnson Veterans Affairs Medical Center; Associate Professor, Department of Medicine, Division of Cardiology, Medical University of South Carolina.

Coauthor(s): David A Smith, MD, Assistant Professor, Department of Emergency Medicine, Scott and White Hospital and Clinic, Texas A&M University; Kathryn L Hale, MS, PA-C, Medical Writer, .com, Inc.

Editors: Alan D Forker, MD, Program Director of Cardiovascular Fellowship, Professor of Medicine, Department of Internal Medicine, University of Missouri at Kansas City School of Medicine; Mary L Windle, Pharm D, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, .com, Inc; Michael E Zevitz, MD, Clinical Assistant Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science, Chicago.