Congestive Heart Failure
A weak pump
Despite the confusing terminology, congestive heart failure (CHF) is not the same as cardiac arrest. In other words, congestive heart failure doesn't mean the heart has stopped pumping, but it does mean that the heart isn't able to pump enough blood to supply the body's oxygen needs.
Although the condition usually worsens over time, people with heart failure can live for years with proper treatment, including drug therapy and lifestyle modifications.
People with congestive heart failure often have shortness of breath and feel tired and weak because their muscles aren't getting enough blood. The heart keeps working but doesn't work as efficiently as it should. As blood flows more slowly out of the heart, the blood returning to the heart through the veins backs up in the tissues. This plumbing problem often causes swelling most commonly in the legs and ankles. Heart failure also affects the ability of the kidneys to dispose of sodium and water. The extra water increases blood volume and therefore the swelling.
Congestive heart failure can cause a buildup of fluid in the lungs, called pulmonary edema, that results in extreme shortness of breath and can be life-threatening. Many people experience this shortness of breath while lying down because the fluid moves into the lungs. People with congestive heart failure may have to sleep sitting up to allow the fluid to drain from the lungs and make breathing easier.
How Common Is Congestive Heart Failure?
According to the American Heart Association, about 4,600,000 Americans (2,200,000 males and 2,300,000 females) have CHF and are alive today. About 400,000 new cases of CHF occur each year, and the incidence of CHF approaches 10 per 1,000 people after age 65.
Goals of Treatment
Treatment options depend on the underlying cause. In many cases, lifestyle changes to help lower blood pressure, lose weight, and improve overall cardiovascular function are sufficient. Medication is available to strengthen the heart's pumping action. Surgery is also used to treat rarer cases of congenital (from birth) heart defects or a diseased heart valve. Treatment for congestive heart failure has four goals:
- Improve the heart's ability to pump
- Reduce the heart's workload
- Remove excess salts and fluids
- Relieve symptoms such as shortness of breath, fatigue, and weakness
The only way to cure congestive heart failure is to treat its cause, but for most patients, no cure exists, and the best approach is to improve the quality of life, prolong life, and make physical activity more comfortable. Depending on the severity of the underlying cause, congestive heart failure can be managed effectively for some time.
There are three main approaches to treating congestive heart failure:
- Treat the underlying cause, such as heart valve problems or coronary artery disease: surgery can correct narrowed or leaking heart valves, abnormal connections between heart chambers, or coronary artery blockage. Antibiotics can cure infection. Drugs, surgery, or radiation therapy can correct an overactive thyroid gland. Drugs can reduce and control high blood pressure. Lifestyle modifications such as dietary restrictions and gradual exercise programs treat the underlying causes such as high blood pressure and coronary artery disease.
- Remove contributing factors, such as smoking and obesity: doctors may recommend smoking and/or alcohol cessation programs and dietary counseling.
- Treat the heart failure itself with medication and sometimes surgery: Medications include diuretics, digoxin, vasodilators, and beta-blockers. In extreme causes of CHF, heart transplantation may be recommended.
Treatment for CHF includes:
- If CHF is caused by severe coronary artery disease:
- Angioplasty: A catheter with a balloon tip is inserted into a narrowed artery and then inflated, widening the artery by cracking plaques. In one newer variation, a rotating blade shaves the plaque into tiny particles, and in another, a laser beam vaporizes the plaque.
- Coronary bypass surgery: A section of vein or artery is removed from elsewhere in the body and reconnected to detour blood around the diseased vessel.
- Transmyocardial revascularization: A laser cuts a series of channels in the heart muscle to increase blood flow. A surgeon makes an incision on the left side of the chest and inserts a laser into the chest cavity. With the laser, the surgeon shoots from 15 to 30 holes, each a millimeter in diameter, through the heart's left ventricle, in between heartbeats. (The laser is fired when the chamber is full of blood so the blood can protect the inside of the heart.) Then the surgeon seals the outer openings but lets the inner channels stay open, allowing oxygen-rich blood to flow through the heart muscle. This is a new procedure and is still considered experimental.
- Cardiomyoplasty: A procedure in which a large muscle from the back is wrapped around the heart and stimulated by an artificial pacemaker to contract rhythmically.
- Myocardial wall resection: Flabby, nonfunctioning heart muscle is simply cut out.
- Heart transplant
Appropriate Healthcare Setting
The appropriate health care is outpatient, unless the condition requires surgery, or otherwise becomes severe enough to warrant hospitalization.
Healthcare Professionals Who May Be Involved in Treatment
Health professionals who participate in managing this disorder:
- Family practitioners
- Cardiac surgeons
- Thoracic surgeons
- Transplant surgeons
Activity & Diet Recommendations
During severe stages of congestive heart failure, bed rest is recommended. You should sit up in bed to prevent fluid buildup in the lungs. Avoid unnecessary exertion, such as climbing stairs, until the condition is under control. Talk to your doctor about gradually increasing your activity to improve overall cardiovascular strength.
Low salt intake reduces fluid accumulation, which in turn decreases the heart's workload. Research suggests that a low-fat, high-fiber diet rich in fruit and vegetables benefits patients with coronary artery disease in addition to helping with weight control. Here are some general guidelines:
- Avoid foods high in saturated fats, such as meats, eggs, cheeses, and other dairy products
- Eat plenty of whole grains, breads, and cereals instead of white and refined grains
- Eat lots of fresh fruits and vegetables with meals and as snacks
- Eat legumes such as beans, peas, and lentils in soups and salads
Because some diuretic medications increase potassium excretion, eating foods high in potassium is advised if you're taking these drugs. Potassium-rich fruits include oranges, orange and grapefruit juice, bananas, melons, nectarines, prunes, peaches, pears, and avocados. Vegetables high in potassium include collard greens, cucumbers, potatoes, sweet potatoes, cabbage, beans, peas, winter squash, and tomatoes.
A sudden accumulation of fluid in the lungs is called acute pulmonary edema. It causes the person with CHF to gasp for breath and is a life-threatening condition requiring immediate hospitalization.
Other possible complications of CHF include the following:
- Electrolyte imbalances
- Digitalis intoxication characterized by cardiac arrhythmias, gastrointestinal upset, and central nervous system effects such as visual disturbances, weakness, dizziness, and headache
- Heart arrhythmias
- Protein intestinal disease
Quality of Life
Depending on the severity and stage of congestive heart failure, available treatments range from lifestyle adjustments and drug therapy to major surgery. Which treatment is right for you depends on your individual situation. Congestive heart failure can lead to difficulties with basic daily living activities, causing frustration and anxiety. Try relaxation techniques to help reduce anxiety and improve your mood.
Considerations for Women
Certain medications prescribed for congestive heart failure (such as ACE inhibitors) cannot be taken during pregnancy.
Likewise, ACE inhibitors can be excreted into breast milk, so you should either avoid these medications or refrain from nursing.
Considerations for Older People
Older people are more likely to have congestive heart failure, because they're at higher risk for its underlying causes. In general, older people have less efficient heart functions. With age, the heart muscle becomes thicker, but not stronger. While congestive heart failure reduces life expectancy, some cases are well-controlled with medication.
Instead of shortness of breath, some older people with congestive heart disease will first experience insomnia, fatigue, weakness, agitation, or confusion. Also, older people are more likely to experience the toxic effects of the medication digoxin, which can include dizziness, confusion, weakness, and depression. Any symptoms should be reported promptly. Also, older people are especially sensitive to blood-pressure-lowering medications, so start with small doses.
Considerations for Children and Adolescents
Some cases of congestive heart failure are caused by a congenital (from birth) heart defect.
Last updated 25 May 2012
- Heart failure
- Congestive cardiac failure
- Circulatory failure
- Cardiac decompensation
- Myocardial decompensation
- Left ventricular diastolic dysfunction
- Left ventricular systolic dysfunction
Heart failure has many causes, including a number of diseases. Any disease that affects the heart and circulation can lead to heart failure. The most common cause of CHF is coronary artery disease. Other causes include diabetes, high blood pressure, and extreme obesity.
These conditions can cause the heart to work harder, and over a period of months or years, the heart gets larger, just as any muscle gets larger with exercise. At first, the enlargement provides a stronger contraction, but eventually an enlarged heart may result in decreased pumping ability and heart failure.
Risk factors for congestive heart failure include the following:
- Coronary artery disease
- High blood pressure
- Extreme obesity
- Infection of the heart muscle (myocarditis)
- Severe lung diseases like emphysema
- Heart-valve and heart rhythm abnormalities
- Certain high-output metabolic states, including hyperthyroidism
- Physical, emotional, or environmental stress
- Conditions that increase metabolic demand (such as pregnancy)
- Drinking alcohol
- Idiopathic cardiomyopathy caused by a viral illness
Symptoms & Diagnosis
The signs and symptoms of congestive heart failure include the following:
- Engorged neck veins
- Shortness of breath (dyspnea)
- Awakening from sleep due to dyspnea
- Irregular or rapid heartbeat
- Inability to lie flat in bed
- Rapid weight gain
- Swelling of the feet and ankles
- Coughing and wheezing
- Low blood pressure
Conditions That May Be Mistaken for Congestive Heart Failure
Certain similar conditions that may confuse the diagnosis of congestive heart failure:
- Right heart failure
- Left heart failure
- Kidney disorders
- Bronchial asthma
- Severe anemia
How Is Congestive Heart Failure Diagnosed?
Your symptoms, along with the results of a physical exam, will help your doctor make a preliminary diagnosis. Your doctor will check for a weak and often-rapid pulse rate, certain abnormalities in heart sounds, fluid in your lungs, low blood pressure, and an enlarged liver.
Your doctor will likely order additional tests to support the diagnosis.
Laboratory tests include the following:
- Blood cell counts and blood chemistries
- Thyroid function tests
- Electrocardiogram (EKG): measures electrical activity of the heart, which may be abnormal if there is diminished blood flow to the heart.
- Heart-catheterization studies
Imaging techniques include the following:
- X-rays can show if your heart is enlarged or if there is fluid in your lungs. Further imaging can be obtained through the use of positron-emission tomography (PET) scans.
- Echocardiogram uses sound waves to create an image of the heart.
- Magnesium: If your diet does not supply enough, supplementation can help. A multivitamin is a good start, but people with congestive heart failure should consult a clinical nutritionist or naturopath for an individualized supplementation program.
- Vitamin E: helps prevent heart attack. It also helps preserve heart function in congestive heart failure.
- Carnitine: helps power the heart. Carnitine deficiency is associated with congestive heart failure, and carnitine supplementation helps treat it. In a study in Naples, Italian researchers gave either a placebo or carnitine (1 g twice a day) for six months. In the carnitine group, heart strength and exercise ability improved significantly without side effects.
- Coenzyme-Q10: helps strengthen the heart. Italian scientists measured the heart function and shortness of breath among 2,600 people with congestive heart failure, and then gave them coenzyme-Q10 (100 mg/day for three months). The participants' breathing and heart function improved significantly. Shortness of breath decreased an average of 53% and arrhythmias subsided 63%
Hawthorn: This herb has been used for centuries to treat congestive heart failure (known long ago as "dropsy"). German studies show that hawthorn extracts (160 to 600 mg/day) improve heart function
Emotional stress increases the risk and severity of all forms of heart disease, including congestive heart failure. Stress management programs can help. Different techniques include meditation, biofeedback, visualization, and hypnotherapy.
Self care & Prevention
Preventing Congestive Heart Failure
Preventing congestive heart failure focuses on addressing the underlying causes:
- Hypertension: early detection with blood pressure screenings, and long-term control with medication and lifestyle modifications
- Coronary artery disease: early detection and reduction of risk factors; prevention of heart attack
- Diabetes: early detection and control of blood-sugar levels
- Avoid the following: tobacco, excessive alcohol, an excessive salt, high-fat, or high-cholesterol diet, a sedentary lifestyle, and high stress
Once congestive heart disease has developed, adhering to your treatment plan can prevent or delay the onset of further symptoms. In addition, following these lifestyle modification suggestions can help reduce strain on your heart:
- If you smoke, stop. It taxes the heart.
- Avoid alcohol.
- If you are overweight, shed some pounds. Extra weight taxes the heart and it also raises blood pressure, which can aggravate congestive heart failure.
- Get regular exercise. Congestive heart failure precludes strenuous exercise, but regular, light exercise can improve heart function and help build stamina. In a study in Finland, 27 people with congestive heart failure engaged in 30 minutes of low-impact exercise (walking, swimming, bike riding) three times a week. After three to six months, the participants had less shortness of breath and more stamina. Consult your doctor about an appropriate exercise program.
- Avoid strenuous exercise. Rest in bed when symptoms worsen.
- Eat a low-salt diet. Salt actually, the sodium in salt causes fluid retention, which can be a big problem for people with congestive heart failure because it makes the damaged heart strain even more. Salt may also raise blood pressure, which aggravates this condition.
- Eat foods rich in magnesium. Some drugs used to treat congestive heart failure deplete magnesium from the body. As blood magnesium level declines, symptoms grow worse and death rate increases, according to a study at the Mt. Sinai School of Medicine in New York City that tracked magnesium levels and survival in 199 people with congestive heart failure. Foods high in magnesium include wheat germ, soybeans, oatmeal, nuts, seeds, low-fat diary items, and seafood.
Also, look out for and report early signs of pulmonary edema (fluid buildup in the lungs), a serious complication of congestive heart failure. Such signs include coughing, difficulty breathing, fatigue, restlessness, and anxiety.