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Congestive Heart Failure
Providing the answers for: What is Congestive Heart Failure? What are the symptoms of congestive heart failure? and What is the treatment for congestive heart failure?
Congestive Heart Failure Statistics and so on
Did you know that exacerbations of congestive heart failure are the most common reason for admission to the hospital in patients over the age of 65? Congestive heart failure follows the rules of twos in the United States (and is similar in other Western countries). Two percent of the population has congestive heart failure. Two percent of all admissions to the hospital are because of a congestive heart failure exacerbation. Two percent of all healthcare expenditure in the United States is on congestive heart failure and related diseases, a cost of nearly 40 billion dollars annually. Half a million people are diagnosed with congestive heart failure and 300,000 people die of the disease in the US each year. The cost of and disability from congestive heart failure is truly an epidemic and is getting worse, not better.
Half of all people diagnosed with congestive heart failure will be admitted to the hospital again within six months of discharge. Each time a patient with congestive heart failure is admitted to the hospital the average length of stay is six days. In more advanced disease, more and more time is spent in a cardiac care unit, which is akin to an intensive care unit. Keeping patients with congestive heart failure from entering the hospital not only saves the patient and the healthcare system huge amounts of money, but the quality of life experienced by the patient is much higher outside of the hospital than it is in a cardiac intensive care unit.
There is hope, however. Proper education about congestive heart failure medications and treatments, diet and lifestyle changes can have a profound effect on the course of the disease. Studies have shown that people that are educated about their congestive heart failure have many fewer admissions to the hospital than those that continue to be unaware.1 Those patients that adhere to their treatment plan have much better outcomes than those that do not. Ideally patients would learn about their disease immediately after congestive heart failure diagnosis so that bad habits can be stopped and good habits can be learned from the start.
Like abnormal cholesterol, type 2 diabetes mellitus, COPD (chronic obstructive pulmonary disease) and many other illnesses, how we behave and conduct our lives can predict our success or failure with congestive heart failure.
What is Congestive Heart Failure?
Heart failure is a condition in which the heart cannot move blood through the blood vessels. Because many of the circulatory system’s processes require forward movement of blood, heart failure leads to fluid accumulation in the tissues and in the lungs. In fact, it is this accumulation of fluid that has earned the syndrome the name congestive heart failure. Despite the name congestive heart failure, most people with the syndrome do not have a complete heart failure but rather they suffer from a condition of heart weakening—the heart is not working as well as it needs to be. The heart is failing, but it has not yet failed.
The heart is basically a biological pump in the business of moving blood throughout the body. The right side of the heart is responsible for collecting blood from the veins and pumping blood to the lungs. The left side of the heart collects oxygenated blood from the lungs and pumps that blood everywhere else in the body. In congestive heart failure, one or both sides of the heart perform less well than it should. This poor performance leads to a number of debilitating symptoms.
Symptoms of RIGHT Sided Congestive Heart Failure
In right-sided heart failure, blood collects in the tissues. Since the legs are the farthest extremities from the heart, people with congestive heart failure of the right heart will have fluid accumulation in the body, mostly in the legs. As congestive heart failure progresses, though, patients can experience fluid buildup in the arms and in the abdomen.
Symptoms of LEFT Sided Congestive Heart Failure
In left-sided heart failure, blood is not moving out of the lungs like it should be. This congestion leads to shortness of breath, a feeling of drowning, and frequent coughing. Patients with this type of congestive heart failure cannot lay flat because the fluid that accumulates in the lungs shifts upward if the person reclines. This is why people with congestive heart failure usually sleep on several pillows or reclining in a chair.
Symptoms of Congestive Heart Failure when both sides are implicated
While there is a distinction made between left and right-sided heart failure, in truth, many people suffer from heart failure on both sides of the heart. It is quite common for patients to have breathing troubles as well as swelling in the legs. The distinction is helpful for doctors and for patient education, but in reality, many of the problems and solutions overlap.
Types of Congestive Heart Failure
There are two main types of congestive heart failure. Either the pump is not squeezing like it should or the pipes are not letting blood through them like they should. Sometimes doctors will call “pump” problems systolic heart failure and “pipe” problem diastolic heart failure (you may have heard the these terms related to blood pressure. Systolic is the top number and diastolic is the bottom number in a blood pressure measurement).
The reason that it is important to distinguish between a pump problem and a pipes problem is so that the right treatments can be prescribed. There are medicines that can make the pump squeeze harder and medicines the make the pipes permit more flow. To be sure, people can have both pump and pipe problems, and will need both types of medicine. In general, though, it is important not to treat one type of problem if the congestive heart failure is caused by the other.
Consider if you have a pump problem (systolic) but give a medicine for a pipe problem (diastolic heart failure). The heart is already having trouble pumping but now the pipes have been opened up with a drug. Blood pressure drops and the situation becomes a dangerous. Alternatively, if you have a pipes problem and give a medicine to make the pump squeeze harder, the heart is pumping against faulty pipes and places undue strain on the heart. Management of congestive heart failure requires careful diagnosis and a careful treatment plan.
Diagnosis of congestive heart failure
Diagnosis of congestive heart failure is based on history, physical diagnosis, and specific tests and studies. Patients will often report that they become short of breath with minimal exertion. The body needs more blood during exercise, but the weak pump or constricted pipes do not allow it.
Over time, people may have shortness of breath even at rest. As a result, fluid backs up into the lungs and disrupts breathing. This can become so bad that shortness of breath occurs at rest, too. People’s ability to move and function can become impaired. Patients with congestive heart failure are constantly fatigued and have generalized weakness.
People also have trouble breathing at night when they try to lie flat, as described. Also, the excess fluid tends to cause people with congestive heart failure to urinate frequently at night. When these two symptoms are combined, patients do not often get restful sleep, which further contributes to fatigue.
Congestive heart failure gives doctors many clues that are detected on physical exam. Many patients with congestive heart failure appear ill, tired, and weak. Their skin sometimes appears blue because of a general lack of oxygen in the tissues. Physicians will press on areas of skin to determine if there is fluid (edema) there. Edematous skin will dimple temporarily to the touch as the fluid is pushed out.
In congestive heart failure, the lungs and heart will sound abnormal. A doctor can hear fluid in the lungs with a stethoscope. There may also be a particular murmur in the valves of the heart. The extra fluid and enlarged heart of congestive heart failure disrupt the normal functioning of the heart valves. Excess fluid can sometimes be seen in the veins of the neck, a sign called jugular venous distention. The pulses may feel abnormal, too. Depending on the severity of the congestive heart failure, the liver and abdomen may show signs of fluid congestion.
The main study that is used to diagnose congestive heart failure is the echocardiogram. This study uses the same ultrasound technology that is used to “see” an unborn baby in the womb. In an echocardiogram (routinely called an “echo”) a probe is placed on the chest (or sometimes down the throat in a transesophageal echo) and the way that sounds waves reflect on the structures of the heart allow doctors to look at the size of the heart chambers, the way the heart valves are opening and closing, and how blood moves through the valves of the heart. When congestive heart failure is suspected, an echo is almost always used to learn about the cause and extent of the disease.
An echocardiogram can also provide information about the ejection fraction of the left ventricle. The Left ventricle is the main heart chamber that pumps blood to the body. This ejection fraction is the fraction of blood that is ejected from the heart when it does its big squeeze. In most cases of heart failure, the heart will not pump a full complement of blood with each beat. This means that the fraction that is ejected is abnormally low. This value can be tracked over time to determine that severity of the congestive heart failure.
Other studies can be used to detect congestive heart failure. A chest X-ray can be very helpful because it can show fluid in the lungs. When a previous non-fatal heart attack is thought to be the blame for congestive heart failure, part of the diagnosis and treatment might be a coronary angiogram. In this test, dye is injected into the coronary arteries to determine if there is blockage. A balloon and stent can be used to open the blockage if it exists. This may not necessarily prevent congestive heart failure symptoms but can greatly reduce the likelihood of the disease getting worse.
There is a laboratory test that is used in congestive heart failure that is somewhat controversial and often inappropriately applied. The blood test is called brain natriuretic peptide or BNP. You may hear your physician discussing a BNP value in your case. During heart failure, the heart can release BNP into the blood which is detected by the blood test. When the levels are high, it is fairly good evidence that a person has congestive heart failure. Sadly, though, congestive heart failure is not the only reason that BNP levels can be abnormally elevated. The situation in which BNP testing is an excellent test is when BNP levels are low. If a doctor suspect congestive heart failure but BNP is low or normal, doctors can be confident that symptoms are not being caused by congestive heart failure.
Chronic congestive heart failure versus acute congestive heart failure.
Chronic congestive heart failure
Chronic congestive heart failure is a condition in which the patient has identified their limitations, has perfected and maintains the proper diet, and completes exercises to strengthen the heart and reduce symptoms.
Acute congestive heart failure
Acute congestive heart failure, on the other hand is often a reason for admission to the hospital. In fact, CHF exacerbation (as acute congestive heart failure is often called) is the leading reason for admission to the hospital in the United States and several other countries. It primarily occurs in people with chronic conjestive heart failure who fail to look after themselves properly.
An acute CHF exacerbation can be a life-threatening condition leading to acute respiratory distress because of fluid in the lungs. Also, if the pump and pipes are not delivering enough blood to the tissues and organs, they can begin to fail. In severe cases of CHF exacerbation, the kidneys and liver can enter failure because of poor blood flow. Insufficient blood flow to the brain can lead to confusion and delirium. Lack of proper blood flow to the heart has a snowball effect—a failing heart does not supply blood to the coronary arteries which causes the heart to become even more dysfunctional. Acute congestive heart failure can be a frightening experience for physicians, patients, and their families.
Congestive Heart Failure Treatment
The type of medicine used in congestive heart failure is based on the phase of the disease—acute or chronic. One of the best ways to treat congestive heart failure chronically is through the use of blood pressure lowering agents. If done carefully, you can lower resistance through the pipes, so that the failing heart has an easier time pushing blood to the tissues.
Several classes of blood pressure medications are particularly useful in congestive heart failure. ACE inhibitors, like lisinopril, perform a number of helpful functions on blood vessels including reducing the amount of oxygen that the heart needs to function, and ease the stress on the heart both for blood coming into and going out of the heart. A class of medicines related to ACE inhibitors is angiotensin receptor blockers, like losartan. These newer blood pressure drugs are becoming first-line agents as they are used more by cardiologists and internists.
Beta-blockers reduce blood pressure by slowing down the rate that the heart beats (among other ways). A slow heart rate means there is plenty of the heart to receive blood through the coronary arteries; there is no blood getting to heart through the coronary arteries when it is in full squeeze. The faster the heart beats, the more amount of time is spent in that squeeze, overall. Beta-blockers like metoprolol slow rate and increase the amount of time the heart is in diastole (non-squeeze time).
Angina has been treated with nitrates for decades, but nitrate containing medicine has a primary place in congestive heart failure treatment as well. Long acting nitrates, like Imdur, dilate blood vessels and allow blood to reach organs, especially the heart. Long acting nitrates are good for the treatment of chronic congestive heart failure because they improve blood flow to organs like the heart and kidneys. Nitrates are used in patients that do not have low blood pressure.
The prototypical drug for congestive heart failure is digoxin. While most blood pressure medicines attempt treat the pipes by opening them and reducing resistance, digoxin makes the pump squeeze more strongly. Digoxin (known by some as the related, older medicine digitalis derived from the foxglove plant) actually causes the heart muscle to contract more strongly and push blood more effectively. Digoxin is used sparingly and carefully since it can cause a number of unwanted side effects.
A number of drugs are used in the hospital, especially in the intensive care setting, to make the heart to pump more strongly. These drugs, collectively called pressors, are extremely potent medicines that cause the heart to contract with significant force. They work on the same principle as adrenalin (in fact epinephrine, which is adrenalin, is one pressor). Norepinephrine, dopamine, and dobutamine are other pressors. Pressors are used in the intensive care setting because they require the use of very close blood pressure monitoring, like with an arterial blood pressure line. They are also considered agents of last resort because they have a number of serious side effects and are used to prevent organ failure.
Since congestive heart failure is a disease of fluid overload, medications have been developed to decrease the amount of fluid in the body. These medicines are collectively known as diuretics. While there are some diuretics that are used to treat high blood pressure, like hydrochlorothiazide (HCTZ), the diuretics used in congestive heart failure are fairly specific. The two main diuretics used in congestive heart failure are Lasix (furosemide) and Bumex (bumetanide). These agents can clear the lungs of fluid fairly rapidly and from the tissues over a longer period of time. The fluid moves from the lungs or tissues into the blood vessels and from the blood vessels into the kidneys and is passed as urine. Diuretics are given in pill form to manage fluid in chronic congestive heart failure and intravenously for rapid treatment of acute CHF exacerbation.
What makes the difference between chronic and acute congestive heart failure?
It depends mostly on how well the patient controls their diet and complies with therapy. Successful treatment of congestive heart failure requires several things. First, the precise cause of the congestive heart failure must be known. Is the heart failure right-sided, left-sided, or both? Was it caused by ischemia or some other disease? What is the heart’s ejection fraction? Second, therapy needs to be optimized. Treatment of CHF usually requires a number of medications at the proper doses. Keeping chronic congestive heart failure from becoming acute CHF exacerbation usually requires changes of dosages and types of medications used based on the patients needs and severity of disease. For more advanced cases of congestive heart failure, a cardiologist should be consulted and should follow CHF treatment. Third, patients must understand what each medication is called, what is doing, and be prepared not to miss doses. Missing a dose of two of some CHF medications are enough to put patients in the hospital with acute problems. Fourth, patients must be able to stick to a fairly rigorous diet. A high salt meal can cause a hospital admission. Patients with congestive heart failure should meet with a dietician soon after they receive the diagnosis. The registered dietician can explain what foods are safe in congestive heart failure and what foods will likely lead to a problem. It is then the responsibility of the patient to stick to this diet, as unpalatable as that might be.
Congestive Heart Failure Surgery
There are some surgical treatments for congestive heart failure, but these treatments are usually reserved for late stage, severe CHF. A heart transplant is a possibility in patients with very weak pumps that are also healthy enough for this major surgery. There are also ventricular assist devices that essentially replace most of the heart’s natural pumping function with a machine that pumps blood for it. This is used for more advanced cases, obviously, but can be a successful congestive heart failure treatment in motivated patients.
Congestive Heart Failure in Conclusion
What is obvious from the above, is that congestive heart failure may mean significant alteration to your life style, but if you comply with the prescribed treatments, drugs, foods, and so on, you will achieve a much longer life - but if you don't comply, your congestive heart failure will likely worsen, and then you'll end up in hospital fighting for your life. So take good care of your self. Also, you never know what new treatment may be just round the corner.
Congestive Heart Failure Reference List
(1) Blue L, Lang E, McMurray JJV et al. Randomised controlled trial of specialist nurse intervention in heart failure. BMJ 2001;323:715-718.
ABOUT THE AUTHOR: Michael T. Spako is an M.D. who specializes in medical writing. I am pleased to have him as the principal writer for this congestive heart failure site, and look forward to his further contributions. Donald Urquhart, Psychologist, Editor.