Congestive Heart Failure

Congestive heart failure is a devastating disease as it increases the incidence of depression and hospital/nursing home admission. It decreases the ability to care for oneself and increases disability and death.

Congestive heart failure is an inability of the heart to pump out enough blood to meet the needs of the body. As a result of a poor pumping heart, the cells of the body are unable to get adequate oxygen resulting in many of the symptoms of heart failure. As heart failure progresses it activates the nervous and endocrine system. The activation of these systems results in a progression of the disease. Treatment options are focused on stopping the negative impact of the activated nervous and endocrine system.


Systolic versus Diastolic

Congestive heart failure is classified in two different ways – systolic or diastolic. A picture of the heart called an echocardiogram, can help determine which type of heart failure is present.

The echocardiogram detects ejection fraction, which is normally 50-65%. Ejection fraction is the measure of the amount of blood ejected from the heart with each beat. When the heart is unable to eject a normal percentage of blood the ejection fraction is less than 40-45% and heart failure is classified as systolic.

When the heart does not fill properly with blood, but the percentage of blood ejected with each beat is normal than diastolic blood heart failure is diagnosed. Patients with clinical signs and symptoms of heart failure and a normal ejection fraction are classified as diastolic heart failure. Diastolic heart failure is associated with lower death rates than systolic heart failure though its affect on quality of life is similarly dire.
 
Causes  

Congestive heart failure has multiple causes but often the exact cause in any individual is unknown. The common causes of heart failure include:

• High blood pressure
• Heart disease
• Heart attacks
• Viral infections that damage the heart muscle
• Excessive alcohol
• Problems with one of the valves in the heart
• Abnormal heart rhythms
• Diabetes
• Thyroid problems
• Anemia
• Lifestyle factors such as eating too much salt

Free Health Ebook: Understanding Medical Treatment of Heart Failure

Signs and symptoms

The signs and symptoms of heart failure are related to the increased amount of fluid in the body. The main symptoms of heart failure include: shortness of breath, swelling of the legs, fatigue and difficulty breathing when lying on your back.

The heart is responsible for pushing the blood out of the heart. In heart failure the blood backs up and overloads the lungs and the veins. The malfunctioning heart allows extra fluid to back up into the lungs contributing to the breathing problems. When the doctor listens to the lungs of a heart failure patient the lungs make a distinct sound. As the fluid fills the venous system, fluid leaks out of the blood vessels and cause swelling in the legs or abdomen. A combination of fluid in the lungs and the heart’s inability to pump out enough oxygen to the working muscles result in fatigue. Gradual weight gain is another common sign of heart failure. Other symptoms of heart failure include cough at night, intolerance to cold, cough, wheeze and poor appetite.

When examined by the doctor hallmark signs of heart failure include abnormal lung sounds, abnormal heart sounds, swelling in the legs, bulging neck veins, weight gain, decreased oxygen levels and increased breathing and heart rate. Those with other medical problems that mimic heart failure make the diagnosis more difficult.



Diagnosis

When heart failure is suspected the first thing that needs to occur is an exam by your doctor. The doctor finds many of the signs and symptoms listed above and performs further testing.

Blood tests are one such test and include: complete blood counts, kidney and liver function tests, electrolytes, thyroid test, B-type natriuretic peptide, and blood tests to rule out heart attacks. Blood tests can rule help determine if anything else is contributing to, causing or complicating heart failure.

Diagnostic testing can further define heart failure. Chest x-rays help determine if there is any fluid in the lungs or if the heart size is increased, which are both markers of heart failure. Electrocardiograms, a test that measures the electrical activity of the heart, may convey any irregular heart rhythms, enlargement of the heart or damage to the heart. Echocardiogram is an ultrasound of the heart, which evaluates how effective the heart is beating and if there are any problems with the heart valves. Stress tests or cardiac catheterizations are done if lack of blood flow to the heart is suspected, as this is a common causes or contributing factor to heart failure.

Treatment

Heart failure can be broken down into two different categories in terms of treatment: acute and chronic. Acute heart failure is a sudden onset of signs and symptoms where the heart is not pumping out enough blood to supply the body with oxygen. Many of these patients are seen in the emergency room with the complaint of difficulty breathing and swollen legs.

The under functioning heart does supply adequate blood flow to the vital organs of the body which, overtime, damages the body. In response to the underperformance of the heart, the body tries to compensate by excreting chemicals called hormone and activating the nervous system. Exposure to the hormones and the activated nervous system given off by the body of a failing heart, cause the heart to change in a negative ways, in a process called remodeling. Treatment of chronic heart failure, which includes normalizing the hormones and nervous system, is essential to prevent permanent damage. Acute Heart Failure

The first step in treating heart acute heart failure is to rid the body of extra fluid, which is causing the majority of distress. Diuretics clear the body of extra fluid by increasing urine output. Diuretics are the most common treatment but sometimes nitroglycerin and morphine are used.

Hospitalization is usually required to provide oxygen, monitoring of blood chemistries and heart rhythm. Aggressive workup is sometimes undertaken to determinate the underlying cause of heart failure including a work up to rule out lack of blood flow to the heart, high blood pressure, thyroid disease, kidney disease, anemia, and infections.Chronic Heart Failure

The main goals for older adults with chronic HF includes relief of symptoms, improved quality of life, maintaining independence, improving ability to function, preventing hospitalization, prolonging life and preventing the negative effects of an under performing heart. Those with chronic heart failure are at risk to develop bouts of acute heart failure and another goal of the treatment of chronic heart failure is to reduce exacerbations of acute heart failure. Non-Drug Treatment

The main components of non-drug treatment for treating heart failure include exercise, salt restriction, stop smoking, weight loss, monitoring body weight and limiting alcohol.

Many products are available for help improve function of life in those with heart failure.  If you are intereested in checking out prouducts check out products available at Full of Life. 

Dietary changes can have a profound impact on heart failure. Ingestion of sodium increases fluid retention so it is important that those with heart failure limit the amount of sodium in the diet. Heart failure patients may notice that the day after ingestion of a large sodium meal, body weight increases. Eating high quantities of salt over consecutive days results in an exacerbation of heart failure. Talk to your doctor about how much sodium should be in your diet. Most doctors will recommend 2-3 grams of sodium a day.

Toxic habits can have negative effects on the heart. Smoking cigarettes initiates a chemical cascade that leads to constriction of the blood vessels, elevated blood pressure and worsening of heart function. Not smoking is a key component to treating heart failure. Alcohol can have dire effects on the heart. Certain types of heart failure are directly related to the alcohol ingestion. Not all heart failure is caused by alcohol, but its intake should be limited in anyone with heart failure. Speak with your doctor about the amount of alcohol you should consume in a given day.

Monitoring weight is a very subtle way to observe heart function. When the heart is not functioning optimally, fluid backs up in the body instead of being urinated out. Consequently, body weight increases. Therefore, checking your weight daily helps you and your doctor know when an extra dose of diuretics, to help your body get rid of the extra fluid and potential decrease the risk of hospitalization and death, is needed

Drug treatment

Great advances in medical therapy for heart failure have been made over the last few years. Some drugs treat the acute signs and symptoms of heart failure and other medicines control the long-term outcomes of the disease. Water pills, also known as diuretics, are common drugs used in heart failure to rid the body of extra fluid.

The mainstay of treatment in chronic, systolic HF are angiotensin converting enzyme inhibitors (ACE-I) and beta-blockers. Diuretics are primarily used to prevent excessive fluid build up and may not be needed by all patients. Digoxin, which was once the main treatment option for systolic heart failure, is now used in patients who still have signs and symptoms of disease despite treatment with ACE-I and beta-blockers. Aldosterone antagonists such as spironolactone should also be considered in patients with severe symptoms.


Diuretics Diuretics are a first-line treatment for acute heart failure and are used in some patients in chronic heart failure to prevent fluid buildup. Diuretics are often only used during an acute attack and some patients do not require them for long-term treatment. It is best to avoid the use of diuretics in chronic heart failure because they may negatively affect the chemicals cascade that leads to progression of heart failure. Although, many patients with chronic heart failure need them to prevent fluid from building up.

Side effects of diuretics include dehydration, dizziness, abnormal electrolytes and incontinence. Most troubling is that diuretics increase hormones that are associated with disease progression. When the doctor decides that it is safe to discontinue or reduce the dose of the diuretics, daily weights should be monitored to assure fluid is not accumulating. While on diuretics blood tests need to be checked to assure electrolytes remain normal. Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers

Angiotensin II is an important hormone that causes progression of the heart failure. Lowering the levels of angiotensin II slows the progression of heart failure and profoundly affects the natural course of the disease. Angiotensin II constricts blood vessels resulting in elevated blood pressure. Constricted blood vessels make the heart work harder as it is working against more pressure. Therefore, high blood pressure leads to a faster progression of the disease.

Two drugs that affect angiotensin are angiotensin converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARBS). ACE-I prevent the formation of angiotensin II and therefore dilate the blood vessels and lower blood pressure. While ACE-I are considered the gold standard drug for heart failure ARBS are a good alternative for those not able to tolerate ACE-I.

Patients with HF have high levels of angiotensin circulating in their bodies. By using ACE-I the levels of angiotensin are reduced, which decrease the negative effects angiotensin has on the progression of the disease ARBS work very similarly to ACE-I. They directly block the effect of angiotensin on the blood vessel walls and result in lower blood pressure.

ACE-I end in the "pril" suffix. Examples of ACE-I are lisinopril (Zestril), quinapril (Accupril), fosinopril (Monopril), captopril (Capoten), and ramipril (Altace). ARBS end in the suffix "sartan", common ARBS, include candesartan (Atacand), losartan (Cozaar), and valsartan (Diovan).

Side effects of ACE-I include: low blood pressure, dizziness, high potassium, cough, stomach upset, headache and renal impairment. Reasons exist not to be on ACE-I including certain kidney problems and propensity to side effects (e.g., worsening electrolyte imbalance, low blood pressure, and cough). Cough is a very common side effect of ACE-I, which at times makes the drug unbearable. ARBS are commonly substituted for ACE-I when cough becomes bothersome.

Side effects of ARBS are similar to ACE-I except they lack cough as a significant side effect. Beta Blockers (BB)

BB, such as metoprolol and Coreg® (carvedilol), are another class of drug used to treat both high blood pressure and heart failure. BB improve heart function, blood flow to the heart, symptoms and exercise tolerance. They also decrease death rates in those with heart failure. One mechanism that they decrease death rates is by reducing life threatening abnormal heart rhythms that are common in heart failure.

These drugs should be started at a very low dose and the dose should be advanced slowly. This reduces the incidence of severe side effects. While BB have a profound impact on the disease close monitoring is essential. Blood pressure and weights should be monitored closely as some patients develop very low blood pressures or worsening heart failure while on these drugs.

Common side effects of BB include fatigue, dizziness, depression, stomach upset, slow heart rate and low blood pressure. Caution should be used with BB when certain diseases are present including diabetes, peripheral vascular disease, depression, asthma and chronic obstructive lung disease. Spironolactone

Spironolactone has recently become a standard drug in the armamentarium of heart failure. Recent studies have shown that it prolongs the life in those with advanced heart failure. The drug works by blocking the effects of a hormone called aldosterone. Aldosterone, when present in high quantities for a long period of time, changes the structure of the heart and accelerates the process of heart failure. High levels of potassium (which has the potential to cause fatal heart rhythms) and low blood pressure are the most common side effects. While this drug is a diuretic and helps remove fluid its main effect is through the effect it has on the hormone aldosterone.

Digoxin

This was once the number one prescribed drug for heart failure but has fallen out of favor with recent medical research. Digoxin works by helping the heart beat more effectively. This drug has shown not to prolong life, but can be effective in reducing hospitalizations and helping the patient feel better, especially patients with systolic heart failure.

Digoxin can be very dangerous and needs to be monitored. Blood levels are drawn to assure they are in the prescribed range, as fatal heart rhythm disturbances can develop when the level of this drug becomes toxic. Side effects include loss of appetite, nausea, vomiting, diarrhea and blurred vision.

Diastolic heart failure

Diastolic heart failure treatment is not as well defined as therapy for systolic heart failure. Treatment involves treating any underlying heart conditions such as high blood pressure, coronary heart disease or any problems with the valves in the heart. Diuretics are often used in these patients because they are commonly afflicted with extra fluid. Treatment of high blood pressure is a cornerstone of treatment and can be accomplished with a variety of medications and should include salt restriction.

Device therapy

Device therapy is a new approach to treating heart failure, which is often implemented after failure of medical therapy to adequately control the disease. Patients with heart failure are at high risk for experiencing heart rhythm disturbances that can lead to death. If these arrhythmias are not treated, death will ensue. Treatment is accomplished with either pacemakers, internal cardiac defibrillators (ICD) or both.

Pace makers are helpful because they help the two sides of the heart contract more efficiently together. Patients with heart failure often have conduction disturbances that cause the right and left side of the heart to not beat together effectively. Pacemakers help the heart eject more blood out of its left ventricle, reduce the amount of strain that is placed on the heart, and may even slow down the changes that occur in the heart caused by heart failure.

Patients with heart failure are at high risk for developing fatal arrhythmias. ICD shock the heart back into rhythm if they develop a fatal arrhythmias.Prognosis

Heart failure is a very serious disease, especially in the older patient. It is especially severe if heart failure is complicated with other factors such as a very low ejection fraction, older age, renal failure, disabling symptoms and inability to care for oneself. In those with severe heart failure, 50% will die within five years.

Your Responsibility

1. Know your disease. Be able to answer all of the questions listed below utilizing the worksheet. Asking your doctor the questions listed below assures that he or she thinks through all the necessary steps to appropriately manage heart failure.
2. Track your weight, blood pressure and heart rate using the form in the Appendix. Talk to your doctor about a plan if you notice a weight gain. Weighing yourself is a useless task unless you know what to do when you gain weight.

   Questions to ask you health care provider

   What type of heart failure do I have? The two main types of heart failure are systolic heart failure and diastolic heart failure.What is my ejection fraction?

   When am I going to have my next echocardiogram? Ejection fraction is the percentage of blood beat out with each beat. Patients with systolic heart failure have an ejection fraction less than 40-50%. Physicians frequently monitor the progression of the disease in patients with serial echocardiograms. There are other ways to determine ejection fraction, but the echocardiogram is the easiest way to do this.

   What caused my heart failure? There are a number of causes of heart failure. It is important that you know what caused your heart to fail so it can be avoided in the future.

   How often should I weight myself? What should I do if I gain X pounds? Keep the weight form above your scale. Heart failure patients are prone to fluid overload and should weigh themselves everyday. This is to determine the degree of fluid overload that may occur on a day-to-day basis. If you gain a certain amount of weight your doctor will want you to call, come to the office or take an extra water pill. Talk to your doctor about the specific plan he/she wants for you.

   Should I restrict the amount of salt and/or fluid in my diet? Most people with heart failure should restrict the amount of salt they consume. Binges of high salt foods may lead to an acute exacerbation of heart failure. Talk to your doctor about how much salt you should eat in a given day. Avoid large quantities of food containing a lot of salt including processed food, canned foods and bagged snack food. Some individuals with heart failure benefit from a restriction of the amount of fluid that they take in. Talk to your doctor if a fluid restriction is important for you.

   If you have systolic heart failure; should I be on an ACE-I, ARBS, and/or BB? You will unlikely be on all three medicines but aggressive treatment would likely put you on at least two of these drugs.If you have systolic heart failure; should I be on an aldosterone agonist (spironolactone) or digoxin?

   Spironolactone is a drug that has been shown to improve outcomes in those with severe heart failure. Digoxin may be helpful in some patients with heart failure. Should I pay to attention to how much I urinate?

   Not urinating enough may indicate that you are retaining more fluid and may be at risk for going into acute heart failure. Do I have any evidence of lack of blood flow to any area of my heart? Have you checked for it?

   Many patients with heart failure have evidence of coronary heart disease, which can make their heart failure worse, and should be evaluated. It can be evaluated by a number of different means including a stress test or cardiac catheterization.

   Are my risk factors controlled? Blood pressure, cholesterol, diabetes. It is important in patients with heart failure and other risk factors to control them to prevent progression of heart failure.

   Should I see a cardiologist? Many patients especially those with severe heart failure, see a cardiologist. Cardiologists are doctors that specialize in treating patients with heart problems.

   Should I exercise? The answer to this is almost always yes. Special precautions are often taken prior to and during exercise. Talk to your doctor about any testing that should take place prior to exercise such as a stress test. Talk to your doctor about any precautions that you should during exercise. Some health care systems are associated with a cardiac rehabilitation program or and exercise facility that specializes in congestive heart failure.

   1. American Heart Association. Heart Disease and Stroke Statistics – 2006 Update. http://circ.ahajournals.org/cgi/content/short/113/6/e85#SEC8. Accessed 6/16/2009.
   2. National Heart, Lung and Blood Institute. What is Heart Failure? Accessed on May 20, 2009 from: http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_WhatIs.html.