CONDITIONS

Congestive Heart Failure

What Is Congestive Heart Failure

Congestive Heart failure occurs when your heart can no longer pump the necessary blood to deliver oxygen and nutrients to the body. Heart failure does not mean that the heart has stopped working entirely, only that it is not pumping as much blood as it should be. It is called “congestive” because blood returns to the heart in greater volumes than it can pump out, resulting in a congestion of liquids in the heart chambers. Congestive heart failure is most common in individuals above the age of 60. It is also linked to obesity, high blood pressure, and diabetes.

What Causes Congestive Heart Failure

Heart disease and other cardiovascular conditions are the preeminent cause of congestive heart failure. But there are actually many other less common causes that can include: a number of infections, chemotherapy or radiation exposure, endocrine and thyroid disorders, complications from other diseases, and genetic predisposition.

Truth is, however, that the cause of congestive heart failure is often idiopathic, or unknown.

Risk Factors For Congestive Heart Failure

The following are risk factors for coronary artery disease:

  • Coronary artery disease. The narrowing and hardening of the arteries that is seen in coronary artery disease can lead to a decrease in blood flow to the heart and ultimately heart failure.
  • Cardiomyopathy, chronic weakening of the heart muscle, causes the heart to contract improperly, leading to heart failure.
  • Lung disease. Serious lung conditions such as chronic obstructive pulmonary disease (COPD) decrease the lung’s ability to deliver oxygen to the body, putting extra stress on the heart.
  • High blood pressure. About 75% of patients with congestive heart failure have previously been diagnosed with high blood pressure.
  • Congenital heart defects. Defects in heart structure during development can lead to an inability of the heart to circulate blood. The risk of heart failure depends on which defect(s) affect the heart.
  • Arrhythmias, or irregular heartbeat, can interfere with the heart’s ability to pump an adequate amount of blood. For example, if a heart is beating too fast, its chambers do not have enough time to fill completely and deliver necessary blood to the body.
  • Metabolic Syndrome. People with metabolic syndromes are more likely to have high blood pressure and cholesterol, and are more likely to be diabetic or overweight. All of these factors increase the risk of heart failure.
  • In hyperthyroidism, high levels of thyroid hormone signal the heart to beat faster, putting it under excess stress.
  • With deficient levels of red blood cells, the heart is forced to work harder to pump a larger volume of blood to the body.
  • Kidney Disease. Malfunctioning of the kidney can lead to increased blood pressure and additional stress on the heart.
  • The exact effects of depression on heart health are unknown, however studies have shown that a large portion of patients with heart failure also are experiencing depressive symptoms. A 2011 study found that 35% of heart failure patients experienced depressive symptoms, 14% of which qualified for a major depressive disorder diagnosis.

Diagnosing Congestive Heart Failure

If your doctor suspects you may be suffering from congestive heart failure, he or she may conduct the following diagnostic tests:

  • Medical history. Your doctor will ask about your previous history of heart and other medical conditions, as well as previously experienced symptoms of heart failure.
  • Physical examination. Your doctor will examine the physical condition of the heart through pulse, heartbeat, etc., as well as look for signs of excess fluid in the body. Swelling in the legs, appearance of neck veins, and abnormal breathing sounds can all be signs of heart failure.
  • Electrocardiogram (ECG). An ECT uses small sensors (electrodes) attached to your chest and arms to record electrical signals as they travel through your heart. According to the National Heart, Blood and Lung Institute (NHLBI), the electrical signals originate in a group of cells called the sinus node or sinoatrial (SA) node. The SA node is located in the right atrium, the upper right chamber of the heart. In a normal adult heart at rest, the SA node sends an electrical signal to begin a heartbeat 60 to 100 times a minute. Individuals
  • Echocardiogram. An echocardiogram uses sound waves to create detailed images of your heart and can help detect arrhythmias, structural defects, and areas of poor blood flow.
  • Angiogram (coronary catheterization). In this test, a liquid dye is injected into the arteries through a long tube known as a catheter. The dye settles on plaque buildup in the artery and reveals the buildup on an x-ray image.
  • BNP test. This test measures levels of B-type natriuretic peptide, a protein that is secreted by the heart when it is under extreme stress or is damaged. High levels of BNP can indicate heart failure.
  • Blood tests. While cholesterol and blood sugar levels are not enough to make a diagnosis alone, high levels of either can help identify the factors that lead up to heart failure.

Symptoms of Congestive Heart Failure

Symptoms of congestive heart failure are dependent on which side of the heart has failed.


Symptoms of left-sided failure include:

  • Shortness of breath and wheezing after limited physical exertion
  • Fatigue and weakness
  • Dry cough or cough with frothy or bloody sputum
  • Loss of appetite
  • Nausea and/or vomiting
  • Anxiety and/or mental confusion
  • Irregular heartbeat

Symptoms of right-sided failure include:

  • Frequent urination during the night
  • Swelling in the ankles and feet (or in the lower back, if bed ridden)
  • Rapid weight gain due to fluid retention
  • Abdominal pain and a feeling of fullness
  • Loss of appetite
  • Swelling of neck veins
  • Irregular heartbeat
  • Anxiety and/or mental confusion
  • Nausea and/or vomiting

Prognosis

Mortality rates can be as high as 20% at the one-year mark for congestive heart failure, meaning that 20% of patients will die within one year of diagnosis. Patients with congestive heart failure who have not experienced severe symptoms and have not been hospitalized have a much higher chance of living a long life with heart failure if they receive proper treatment.

Living With Congestive Heart Failure

No matter what is causing your heart’s health to be compromised, there are things you can do to improve it:

  • Stop smoking. An estimated 20% of all deaths due to heart disease are directly linked to smoking.
  • Keep your blood pressure and cholesterol under control. People with high blood pressure and cholesterol are at an elevated risk for heart disease. About 50% of ischemic strokes (caused by a blockage of the artery to the brain) are caused by high blood pressure.
  • Manage your weight. About one in three American adults is obese (weighing at least 20 percent above the “suggested” weight for their height), which doubles their risk for coronary artery disease (CAD) at a given age.
  • Engage in regular cardiovascular exercise. Exercise helps the heart work more efficiently, reducing blood pressure, raising HDL cholesterol, decreasing the tendency of blood to form clots, moderating stress, helping the body use insulin, and helping people maintain a healthy weight. Sedentary people who begin a regular program of exercise reduce their risk of a heart attack by 35 to 55 percent. Low-intensity activities, such as gardening or walking, if done regularly and over the long term, can decrease the risk of heart attack. Speak with your doctor about the right routine for you.
  • If you have diabetes, keep your blood sugar levels under control. People with diabetes are twice as likely to have a heart attack or stroke.
  • Eat a healthy diet. Opt for high fiber foods such as fruits, vegetables, and whole grains, as well omega-3 rich foods, like coldwater fish like salmon, and mono- and polyunsaturated fats such as those found in nuts and avocadoes. But limit saturated fats and avoid trans fats, often found in fried foods, processed foods, and commercial baked goods.
  • Limit salt. The American Heart Association recently reduced the amount of salt recommended for everyone to just 1,500 mg a day, which is about two-thirds of a teaspoon.
  • Control stress.
  • Tame alcohol intake. There’s a growing consensus that light to moderate alcohol consumption–that is, two drinks or less a day for a man, one drink for a woman (a drink is defined as 12 oz. of beer, 4 oz. of wine, or 1.5 oz. of 80-proof spirits) can help prevent heart attacks. However, drinking more than that can increase the risk of heart attack and stroke.
  • Educate yourself about your condition so that you can know as much as you can about heart disease. This will help ensure you are getting the best treatment available, as well as train you to recognize any potentially harmful side effects or disease progression.

Screening

Most heart diseases and risk factors contributing to heart failure are screened for at regular physicals. The American Heart Association stresses the importance of regular screening for cardiovascular disease. American heart association volunteer and director of William Beaumont Hospital in Royal Oak, Michigan, Barry A. Franklin, Ph. D., said on the matter, “Regular cardiovascular screening is important because it helps you detect risk factors in their earliest stages. This way, you can treat the risk factor with lifestyle changes and pharmacotherapies, if appropriate, before it ultimately leads to the development of cardiovascular disease.”

Your doctor will most likely check the following:

  • Blood pressure. High blood pressure is one of the most common precursors to cardiovascular disease. If it is found early, appropriate medications can help reduce the risk of cardiovascular disease due to high blood pressure
  • Body mass index (BMI). A BMI of 25 or above is considered to be overweight, and a BMI above 30 indicates obesity.
  • Waist circumference. A large waist circumference is indicative of fat accumulation around the midsection, which significantly raises an individual’s risk of heart disease.
  • Your doctor will most likely ask you about your diet. If your diet is high in red meats, fats, and processed foods, he or she will most likely recommend a change to include more whole grains, fatty fish, and vegetables. A diet high in red meat, fats, and processed foods can cause high cholesterol and eventually atherosclerosis (hardening of the arteries).
  • Exercise. Your doctor will ask about your exercise regimen and may suggest more or less activity based on the limitations of your heart and body.
  • Smoking and drug use. Your doctor will ask about smoking and drug use, which can add significantly to the risk of heart disease. If you do smoke or use drugs, your doctor will be able to help you find the right pathway to quit.
  • Heart rate/heartbeat. Your doctor will conduct a physical exam, listening to your heart beat and taking your heart rate. Some doctors may wish to perform a regular electrocardiogram (ECG), which can help detect irregularities in the heart’s electrical activity. ECGs are recommended

If your doctor suspects you have a heart disease after a thorough examination, he or she may conduct several diagnostic tests to arrive at a diagnosis.

Prevention

For healthy people, the following steps have been shown to help prevent or reduce the risk factors for heart failure. Keep in mind that reducing one risk factor may help reduce others:

  • Quit smoking. An estimated 20% of deaths due to heart disease in the United States are linked directly to smoking.
  • Reduce your blood cholesterol. For every 1 percent reduction in high blood cholesterol, there’s a 2 to 3 percent decline in the risk of heart attack.
  • Avoid or control hypertension. For every one-point reduction in diastolic blood pressure, there’s a 2 to 3 percent decline in the risk of heart attack.
  • Stay active. Exercise helps the heart work more efficiently, reducing blood pressure, raising HDL cholesterol, decreasing the tendency of blood to form clots, moderating stress, helping the body use insulin, and helping people maintain a healthy weight. Sedentary people who begin a regular program of exercise reduce their risk of a heart attack by 35 to 55 percent. Low-intensity activities, such as gardening or walking, if done regularly and over the long term, can decrease the risk of heart attack.
  • Maintain a healthy weight. About one in three American adults is obese (weighing at least 20 percent above the “suggested” weight for their height), which doubles their risk for CAD at a given age. Obesity also increases the risk for hypertension, and high blood cholesterol.
  • Avoid or control diabetes. Type 2 diabetes (non-insulin-dependent), is an important risk factor for heart disease. According to the American Heart Association, heart disease and stroke are the number one cause of death for patients with type 2 diabetes, and adults with type 2 diabetes are two to four times more likely to have heart disease than those who do not.
  • Consider a drink a day. There’s a growing consensus that light to moderate alcohol consumption–that is, two drinks or less a day for a man, one drink for a woman (a drink is defined as 12 oz. of beer, 4 oz. of wine, or 1.5 oz. of 80-proof spirits) can help prevent heart attacks. However, drinking more than that can increase the risk of heart attack and stroke.
  • Take low-dose aspirin. The recommended regimen–a baby aspirin (81 milligrams) daily or half a regular aspirin (160 milligrams) very other day–can lower the risk of heart attack by about one-third by reducing the ability of platelets in the blood to stick together and thus form a clot. Aspirin can have side effects and isn’t right for everyone, so consult with your doctor.

Common Treatment

There are a number of medical and other treatments used for congestive heart failure.


MEDICATIONS

The following medications are used to treat congestive heart failure:

Beta blockers, which work by lowering the heart rate, thereby reducing the stress on the heart and preventing future heart attacks. These include:

  • Acebutolol (Sectral)
  • Atenolol (Tenormin)
  • Bisoprolol (Monocor)
  • Carvedilol (Coreg)
  • Labetalol (Trandate)
  • Metoprolol (Lopressor, Toprol)
  • Penbutolol (Levatol)
  • Pindolol
  • Propanolol (Inderal)

Side effects of beta-blockers include:

  • Nausea
  • Vomiting
  • Diarrhea
  • Stomach cramps
  • Rash
  • Blurred Vision
  • Muscle cramps
  • Headache
  • Confusion
  • Depression

*** Beta blockers can cause angina (chest pain) or heart attack if suddenly withdrawn. Never stop taking beta blockers without first talking to your doctor.


ACE (Angiotensin-converting enzyme) inhibitors make your heart work less hard by lowering your blood pressure. Some ACE inhibitors are:

  • Benazepril hydrochloride (Lotensin)
  • Captopril (Capoten)
  • Enalapril maleate (Vasotec)
  • Fosinopril sodium (Monopril)
  • Lisinopril ( Prinivil, Zestril)
  • Moexpiril (Univasc)
  • Quinapril hydrochloride (Accupril)
  • Ramipril (Altace)
  • Trandolapril (Mavik).

Side effects of ACE inhibitors include:

  • Cough
  • Elevated blood potassium levels
  • Weakness
  • Drowsiness
  • Rash
  • Headache
  • Low blood pressure

Angiotensin-receptor blockers (ARBs) blocks angiotensin II, a substance in the body, from constricting the blood vessels and stimulating salt and water retention. They include:

  • Azilsartan (Edarbi)
  • Candesartan (Atacand)
  • Eprosartan (Teveten)
  • Irbesartan (Avapro)
  • Losartan (Cozaar)
  • Olmesartan (Benicar)
  • Telmisartan (Micardi)
  • Valsaartan (Diovan)

Side effects of ARBs include:

  • Dizziness
  • Insomnia
  • Vomiting/Diarrhea
  • Muscle cramps
  • Dehydration
  • Irregular heartbeat
  • Upper respiratory tract infection

Digoxin, which helps to slow heart rate.

Side effects of digoxin include:

  • Nausea
  • Headache
  • Vomiting/Diarrhea
  • Breast enlargement in men

Diuretics help the kidneys eliminate sodium and water from the body. This process decreases blood volume, so your heart has less to pump with each beat, which in turn lowers blood pressure. Among the most popular are:

  • Chlorthalidone (Hygroton)
  • Hydrochlorothiazide (Hydrodiuril, Microzide, Esidrix)
  • Indapamide (Lozol)
  • Metolazone (Mykrox, Zaroxolyn).

Side effects of diuretics include:

  • Frequent urination
  • Arrhythmia (irregular heartbeat)
  • Weakness
  • Muscle cramps
  • Dehydration
  • Dizziness/confusion
  • Nausea/loss of appetite

Hydralazine and Nitrates, which are used in combination to dilate blood vessels and allow for blood to be pumped more easily. These include:

  • Apresoline
  • Nitrobid
  • Imdur
  • Isordil

Side effects of hydralazine and nitrate combination therapy include:

  • Headache
  • Dizziness
  • Irregular heartbeat
  • Loss of appetite
  • Nausea
  • Vomiting
  • Diarrhea
  • Chest pain
  • Swelling in the hands, legs, or feet.

Aldosterone Antagonists, which work by preventing the body from producing hormones that are harmful to the heart. These include:

  • Spironolactone
  • Eplerenone

Side effects of aldosterone antagonists include:

  • Headache
  • Dizziness
  • Abdominal pain/gas
  • Skin rash
  • Confusion
  • Muscle pain or weakness
  • Drowsiness
  • Difficulty breathing


SURGERY AND MEDICAL DEVICES

Surgical options and medical devices are also available to help the heart pump and receive blood. These include:


Coronary bypass surgery. During this procedure, the surgeon bypasses the blocked artery by making a graph with a vessel from another part of the body. This is an invasive open-heart surgery that is only recommended if the patient has multiple serious blockages. Success rates for coronary bypass surgery are between 95 and 98%.

Patients will typically need 1-2 days of close monitoring in an intensive care unit, followed by a hospital stay of 3-5 days. A fully recovery varies from person to person, but typically takes 6-12 weeks. Physical activity should be incorporated gradually to prevent discomfort and complications. Side effects of the surgery typically go away within 4-6 weeks of the procedure and may include:

  • Discomfort and itching of incisions
  • Swelling
  • Muscle pain
  • Fatigue
  • Mood swings
  • Insomnia
  • Loss of appetite
  • Constipation
  • Chest pain

Heart valve repair or replacement. Valvuloplasty can help to stop backflow from a damaged valve or restore a damaged seal. Valves that are damaged beyond repair can be replaced with a prosthetic valve.

Patients who undergo valvuloplasty will typically return home after an overnight stay in the hospital where they will monitor themselves for complications and return to physical activity within a span of several weeks as instructed by the doctor. Patients who undergo valve replacement surgery have a longer hospital stay (at least 2 days in intensive care and 3-5 in less intensive) and have a longer estimated time of recovery. Valve replacement patients should expect to spend at least 8-12 weeks recovering.

Valve replacement surgery has a very high success rate – only 1% of patients under 70 experience fatal complications from valve replacement surgery. Valvuloplasty has a success rate of 80-90% with a very low rate of post-procedure complications.


Implantable cardioverter-defibrillators (ICDs). ICDs are devices implanted under the skin that are connected to the heart and detect heartbeat abnormalities. In the event of an abnormal or rapid heartbeat, the CDI can attempt to shock the heart back into rhythm. Rates of ICD implementation success are high and recovery time is short (typically several weeks), though there is a 2-3% chance of potentially lethal infection. Patients with ICDs should be mindful of possible device interference with magnetic security systems, cell phones, medical equipment and headphones.


Cardiac resynchronization therapy (CRT) or biventricular pacing. This involves the installation of a pacemaker that sends electric signals to the left and right ventricles, convincing them to work in a more synchronized ,efficient manner. CRTs are placed under the skin on the upper chest in a minimally invasive procedure that often only requires local anesthesia. A one or two day hospital stay in an intensive care until is necessary to monitor potential complications. Following their hospital stay, patients require several weeks of recovery at home during which they make a gradual return to physical activity. One year survival rates following CRT insertion are between 88-92%. Five year survival rates are between 65-50%.


Heart pumps. Heart pumps are used either as an alternative to heart transplant or as a way to keep patients alive while they wait for a heart transplant. Pumps are inserted into the abdomen or chest and help a weakened heart pump the necessary amount of blood to the body. Studies have shown that quality of life, survival, and overall health is greater in patients with severe congestive heart failure than those without. Survival rates can vary dramatically depending on the severity of the patient’s condition – anywhere from 30-80% after one year.


Heart transplant. Heart transplants are for patients who are no longer responsive to other treatment methods. According to the University of Maryland Medical Center, patients must meet the following criteria:

  • An estimated life expectancy of less than one year without transplant
  • Objective evidence of advanced physical incapacity due to heart disease
  • Solid agreement that previous medical therapy has been optimal and that no medical therapy or surgical procedure other than transplantation offers realistic expectation of extension of life and functional improvement.
  • Strong family support to help the patient emotionally before and after the surgery.

The wait for a donor match on the transplant list can take weeks, months, or sometimes years. As with all transplant surgeries, there is the risk of transplant rejection, though there are medications available to lower this risk. Survival rates for heart transplant surgery are 87% after one year and about 50% after five.

Talk to your doctor about which treatment is right for you.

Complementary and Alternative Treatment

The following list of supplements is offered by the University of Maryland Medical Center. Always check with your cardiologist or primary doctor before adding supplements to your regimen for treating and preventing heart failure.


SUPPLEMENTS

Many people with heart conditions take multiple medications, including blood-thinning medications, blood pressure medications, and others. The supplements below may interact with these (and other medications) and may not be right for people with certain medical conditions.

  • Magnesium is particularly important for maintaining a normal heart rhythm and is often used by physicians to treat irregular heartbeat (arrhythmia). People with heart failure are often at risk for developing an arrhythmia. In addition, some diuretics (water pills) may cause your body to lose too much magnesium.
  • Carnitine. Early studies show L-carnitine supplements may reduce your chances of developing heart failure after a heart attack and improve exercise capacity if you already have heart failure.
  • Coenzyme Q-10. Several research studies suggest that CoQ10 supplements can help reduce swelling in the legs, enhance breathing by reducing fluid in the lungs, and increase exercise capacity in people with heart failure.
  • Creatine is a naturally occurring amino acid (protein building block) found mainly in muscles. In a few studies of people with heart failure, injections of creatine (in addition to standard medical care) provided improvement in heart function and ability to exercise compared to those who received placebo.
  • Vitamin B1 (Thiamine may be related to heart failure in several ways. First, low levels of thiamine can contribute to the development of heart failure. On the flip side, people with severe heart failure can lose a significant amount of weight, including muscle mass (called cachexia), and become deficient in many nutrients, including thiamine. In addition, diuretics (water pills) can cause your body to lose too much thiamine..
  • Amino acids. A few small studies suggest these amino acids might be helpful for heart failure, but more research is needed:
    • Arginine (needed for the body to make nitric oxide, which helps blood flow)
    • Taurine (helps heart muscle contract)

STRESS REDUCTION PRACTICES

Since stress is associated with heart disease, it’s prudent to try techniques to help reduce it. The following methods have been shown to reduce stress in some people:

  • Meditation
  • Yoga, Tai’ Chi, and other forms of moderate exercise such as walking
  • Deep breathing
  • Visualization
  • Biofeedback

Care Guide

Being diagnosed with heart failure can be difficult for you and your family, but there are things you can do to make your life easier and healthier.

  • If you smoke, quit. Tobacco has direct and damaging effects on the cardiovascular system.
  • Avoid salt. Sodium promotes fluid retention. Avoid high-sodium foods, heavily processed foods and unnecessary salt.
  • Don’t forget to take your prescribed medications. Wearing a watch with an alarm, setting your       smart phone alert, or keeping a labeled pill box on your dining table are helpful methods to remember.
  • Check other meds for potential side effects and interactions. Over-the-counter NSAIDS, such as aspirin, Motrin (ibuprofen) and Aleve (Naproxen) may increase fluid retention. Tell your doctor about any remedies you are taking.
  • Control risk factors. Work with your doctor to address high blood pressure, diabetes and atherosclerosis or other heart problems.
  • Reduce stress. The hormones released by the body in response to stress, anxiety and depression make the heart work harder. Practice relaxation techniques, volunteer, and seek positive social interactions. The relaxing breath exercise can improve the oxygenation of blood and take workload off the heart.
  • Be open with your family and friends about your condition and consider joining a support group or on-line forum.

When To Contact A Doctor

Call 911 if you are experiencing any of the following symptoms, which may be a sign of a HEART ATTACK:

  • Chest pain or pressure, or a strange feeling in the chest.
  • Sweating.
  • Shortness of breath.
  • Nausea or vomiting.
  • Pain, pressure, or a strange feeling in the back, neck, jaw, or upper belly, or in one or both shoulders or arms.
  • Lightheadedness or sudden weakness.
  • A fast or irregular heartbeat.

Questions For Your Doctor

You may wish to include the following doctors in your care team:

  • Primary care physician
  • Cardiologist (heart specialist)
  • Lipidologist (Cholesterol management specialist)
  • Vascular surgeon (surgeon specializing in cardiovascular procedures)
  • Dietitian (nutritional expert)

Questions For A Doctor

You will probably have different questions to ask your doctor depending on your heart condition. Be open about all your concerns. If you’re having difficulty focusing, bring along a friend or family member. Below you’ll find general questions you might want to ask your doctor about heart disease as suggested by the American Heart Association.


QUESTIONS ABOUT MEDICATION

  • What is the name of the medicine?
  • Is this the brand or generic name?
  • What is the medicine supposed to do?
  • What happens if I miss a dose of my medicine?
  • How will I know that my medication is working?
  • What are the risks of taking this medication?
  • What are the risks of NOT taking this medication?

QUESTIONS ABOUT DIET

  • What kinds of foods should I eat?
  • What kinds of foods should I avoid?
  • Should I restrict my calories or fat intake to a certain level?
  • What are some cooking tips that I should follow?
  • What do I need to know about eating out?
  • Do I need to see a nutritionist or dietitian?
  • Are there any groups in the community that can help me with my nutrition goals?
  • How can I control the portions? How much salt may I eat?

QUESTIONS ABOUT EXERCISE

  • Can I exercise?
  • Can I play sports?
  • What are the best types of activities for me?
  • How much activity do I need?
  • Can I have sex?

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