Congestive Heart Failure

Congestive heart failure (CHF), sometimes known simply as heart failure, occurs when the heart muscle cannot pump blood well enough to meet the body’s demands.

The purpose of the heart is to pump blood to the body in order to provide oxygen and nutrients. The heart may fail to meet the body’s demands when the heart muscle itself is weaker than normal or when there is a defect in the heart that prevents blood from getting out into the circulation. When the heart does not circulate blood normally, the kidneys receive less blood and filter less fluid out of the circulation into the urine. The extra fluid builds up in the lungs, the liver, around the eyes, and sometimes in the legs. This is called fluid "congestion" and give CHF its name.

Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently. CHF can affect one or both sides of the heart.

Common causes of CHF include coronary artery disease, high blood pressure and diabetes. CHF is more common in people who are 65 years old or older, African Americans, people who are overweight, and people who have had a heart attack. Men have a higher rate of CHF than women.

Not all conditions that lead to CHF can be reversed, but treatments can improve the signs and symptoms of CHF and help you live a longer, better life. Lifestyle changes such as exercising, reducing salt in your diet, managing stress, and losing weight can improve your quality of life.

If lifestyle changes do not control CHF, medicines called diuretics ("water pills") can be used to remove the extra fluid from the body by increasing urination. Medications that relax the blood vessels may also be used to make it easier for the heart to pump, and other medications may help the heart contract with more force.

CHF can be an ongoing (chronic) condition, or CHF may start suddenly (acute). The weakening of the heart's pumping ability causes blood and fluid to back up into the lungs and buildup of fluid in the feet, ankles and legs, a condition called edema.

This fluid buildup leads to the following signs and symptoms of CHF:

• Shortness of breath (dyspnea) when you exert yourself or when you lie down
• Fatigue and weakness
• Swelling (edema) in your legs, ankles, and feet
• Rapid or irregular heartbeat
• Reduced ability to exercise
• Persistent cough or wheezing with white or pink blood-tinged phlegm
• Increased need to urinate at night
• Swelling of your abdomen (ascites)
• Sudden weight gain from fluid retention
• Lack of appetite and nausea
• Difficulty concentrating or decreased alertness
• Sudden, severe shortness of breath and coughing up pink, foamy mucus
• Chest pain if your CHF is caused by a heart attack

CHF often develops after other conditions have damaged or weakened your heart. Eventually, the heart can no longer keep up with the normal demands of pumping blood to the rest of the body.

Any of the following conditions can damage or weaken your heart and can cause CHF.

• Coronary artery disease and heart attack. Coronary artery disease is the most common form of heart disease and the most common cause of CHF. Over time, arteries that supply blood to your heart muscle narrow from a buildup of fatty deposits — a process called atherosclerosis. The buildup of plaques can cause reduced blood flow to your heart. A heart attack occurs if plaques formed by the fatty deposits in your arteries rupture. This causes a blood clot to form, which may block blood flow to an area of the heart muscle, weakening the heart's pumping ability and often leaving permanent damage. If the damage is significant, it can lead to a weakened heart muscle.
• High blood pressure (hypertension). Blood pressure is the force of blood pumped by your heart through your arteries. If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body. Over time, the heart muscle may become thicker to compensate for the extra work it must perform. Eventually, your heart muscle may become either too stiff or too weak to effectively pump blood.
• Faulty heart valves. The valves of your heart keep blood flowing in the proper direction through the heart. A damaged valve — due to a heart defect, coronary artery disease, or heart infection — forces your heart to work harder to keep blood flowing as it should. Over time, this extra work can weaken your heart.
• Damage to the heart muscle (cardiomyopathy). Heart muscle damage (cardiomyopathy) can have many causes, including several diseases, infections, alcohol abuse, and the toxic effect of drugs, such as cocaine or some drugs used for chemotherapy.
• Myocarditis. Myocarditis is an inflammation of the heart muscle. It is most commonly caused by a virus and can lead to CHF.
• Heart defects you are born with (congenital heart defects). If your heart and its chambers or valves have not formed correctly, the healthy parts of your heart have to work harder to pump blood through your heart, which, in turn, may lead to heart failure.
• Abnormal heart rhythms (heart arrhythmias). Abnormal heart rhythms may cause your heart to beat too fast, which creates extra work for your heart. Over time, your heart may weaken, leading to CHF. A slow heartbeat may prevent your heart from getting enough blood out to the body and may also lead to heart failure.
• Other diseases. Chronic diseases such as diabetes, HIV, hyperthyroidism, hypothyroidism, or a buildup of iron or protein may also contribute to heart failure.
• Causes of acute heart failure include viruses that attack the heart muscle, severe infections, allergic reactions, blood clots in the lungs, the use of certain medications or any illness that affects the whole body.

Risk factors for CHF include:

• High blood pressure
• Coronary artery disease
• Heart attack
• Diabetes
• Some diabetes medications
• Sleep apnea
• Congenital heart defects
• Valvular heart disease
• Viruses
• Alcohol use
• Tobacco use
• Obesity
• Irregular heartbeats

To diagnose CHF, your doctor will take a careful medical history, review your symptoms, and perform a physical examination. Your doctor will also check for the presence of risk factors, such as high blood pressure, coronary artery disease, or diabetes.

Your doctor can listen to your lungs with a stethoscope for signs of congestion. The stethoscope also picks up abnormal heart sounds that may suggest heart failure. The doctor may examine the veins in your neck and check for fluid buildup in your abdomen and legs.

The following tests may also be used to diagnose CHF:

• Blood tests. Your doctor may take a sample of your blood to check your kidney, liver, and thyroid function and to look for indicators of other diseases that affect the heart.
• Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. In CHF, your heart may appear enlarged and fluid buildup may be visible in your lungs.
• Electrocardiogram (ECG). An ECG records the electrical activity of your heart. This test helps your doctor diagnose heart rhythm problems and damage to your heart from a heart attack that may be underlying heart failure.
• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart. This test can help doctors see the size and shape of your heart and how well your heart is pumping. It helps distinguish different types of CHF.
• Stress test. Stress tests measure how your heart and blood vessels respond to exertion. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Or you may receive a drug intravenously that stimulates your heart similar to exercise. Sometimes the stress test can be done while wearing a mask that measures the ability of your heart and lungs to take in oxygen and breathe out carbon dioxide.
• Cardiac computerized tomography (CT) scan or magnetic resonance imaging (MRI). These tests can be used to diagnose heart problems, including causes of CHF.
• Coronary angiogram. In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or in your arm and guided through the aorta into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray and the doctor can then identify narrowed arteries to your heart (coronary artery disease) that can be a cause of CHF.
• Myocardial biopsy. In this test, your doctor inserts a small, flexible biopsy cord into a vein in your neck or groin, and small pieces of the heart muscle are taken. This test may be performed to diagnose certain types of heart muscle diseases that cause CHF.

Once CHF is diagnosed, doctors may classify heart failure using 2 systems to determine the cause of your signs and symptoms and develop a program to treat your heart. These scoring systems are not independent of each other. Your doctor often will use them together to help decide your most appropriate treatment options.

• New York Heart Association classification. This symptom-based scale classifies CHF into 4 categories. In Class I heart failure, you do not experience any symptoms. In Class II heart failure, you can perform everyday activities without difficulty but become winded or fatigued when you exert yourself. With Class III, you have trouble completing everyday activities. Class IV is the most severe and you are short of breath even at rest.
• American College of Cardiology/American Heart Association guidelines. This stage-based classification system uses letters A to D to classify CHF. The system includes a category for people who are at risk of developing heart failure. For example, a person who has several risk factors for heart failure but no signs or symptoms of heart failure is Stage A. A person who has heart disease but no signs or symptoms of heart failure is Stage B. Someone who has heart disease and is experiencing or has experienced signs or symptoms of heart failure is Stage C. A person with advanced heart failure requiring specialized treatments is Stage D.

Lifestyle changes can often help relieve signs and symptoms of CHF and prevent the disease from worsening. These changes may be among the most important and beneficial you can make in the treatment of CHF. Lifestyle changes for CHF may include:

• Stop smoking. Smoking damages your blood vessels, raises blood pressure, reduces the amount of oxygen in your blood and makes your heart beat faster.
• Discuss weight monitoring with your doctor. Discuss with your doctor how often you should weigh yourself. Ask your doctor how much weight gain you should notify him or her about. Weight gain may mean that you are retaining fluids and need a change in your treatment plan.
• Check your legs, ankles, and feet for swelling daily. Check for any changes in swelling in your legs, ankles, or feet daily. Talk to your doctor if the swelling worsens.
• Eat a healthy diet. Aim to eat a diet that includes fruits and vegetables, whole grains, fat-free or low-fat dairy products, and lean proteins.
• Restrict salt in your diet. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet.
• Maintain a healthy weight. If you are overweight, a dietitian can help you work toward your ideal weight. Even losing a small amount of weight can help.
• Consider getting vaccinations. If you have heart failure, you may want to get influenza and pneumonia vaccinations. Ask your doctor about these vaccinations.
• Limit fats and cholesterol. In addition to avoiding high-sodium foods, limit the amount of saturated fat, trans fat, and cholesterol in your diet. A diet high in fat and cholesterol is a risk factor for coronary artery disease, which often underlies or contributes to heart failure.
• Limit alcohol and fluids. Your doctor likely will recommend that you do not drink alcohol if you have CHF, since it can interact with medications, weaken your heart muscle, and increase your risk of abnormal heart rhythms.
• If you have severe CHF, your doctor may also suggest you limit the amount of fluids you drink.
• Be active. Moderate aerobic activity helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. Before you start exercising though, talk to your doctor about an exercise program that's right for you. Your doctor may suggest a walking program.
• Reduce stress. When you're anxious or upset, your heart beats faster, you breathe more heavily and your blood pressure often goes up. This can make heart failure worse, since your heart is already having trouble meeting the body's demands. Find ways to reduce stress in your life.
• Sleep easy. If you are experiencing shortness of breath, especially at night, sleep with your head propped up using a pillow or a wedge. If you snore or have had other sleep problems, make sure you get tested for sleep apnea.

Heart failure is a chronic disease that needs lifelong management. However, with treatment, signs and symptoms of heart failure can improve, and the heart sometimes becomes stronger. Treatment may help you live longer and reduce your chance of dying suddenly. Your doctor will use classification systems to identify your risk factors and begin early, aggressive treatment to help prevent or delay heart failure.

Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, the treatment of heart failure involves a balance of the right medications and, in some cases, use of devices that help the heart beat and contract properly.

Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one or more medications, including:

• Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors widen blood vessels to lower blood pressure, improve blood flow, and decrease the workload on the heart. Examples of ACE inhibitors include enalapril (Vasotec), lisinopril (Zestril) and captopril (Capoten).
• Angiotensin II receptor blockers. These drugs have many of the same benefits as ACE inhibitors. They may be an alternative for people who cannot tolerate ACE inhibitors. Examples include losartan (Cozaar) and valsartan (Diovan).
• Beta-blockers. Beta-blockers slow the heart rate and reduce blood pressure, and they limit or reverse some of the damage to your heart in certain types of heart failure. Examples of beta-blockers include carvedilol (Coreg), metoprolol (Lopressor), and bisoprolol (Zebeta).
• Diuretics. Often called “water pills,” diuretics make you urinate more frequently and prevent fluid from accumulating in your body. Diuretics, such as furosemide (Lasix), also decrease fluid in your lungs so you can breathe more easily.
• Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). These are potassium-sparing diuretics, which also have additional properties that may help people with severe systolic heart failure live longer.
• Digoxin (Lanoxin, Digitek). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms.

Your doctor may prescribe other heart medications, including medications to relieve chest pain, medications to lower cholesterol, or medications to help prevent blood clots, along with heart failure medications.

Surgery or implantable devices to help your heart work better may be recommended in severe cases of CHF that are not controlled by medications.