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Congestive Heart Failure

What is Congestive Heart Failure?

Congestive Heart Failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body. Congestive Heart Failure can be caused by:

Diseases that weaken the heart muscleDiseases that cause stiffening of the heart musclesDiseases that increase oxygen demand by the body tissue beyond the capability of the heart to deliver adequate oxygen-rich blood

Congestive Heart Failure Symptoms and Signs
The symptoms of Congestive Heart Failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensated" for the heart muscle weakness. The early symptoms are often shortness of breath, cough, or a feeling of not being able to get a deep breath.

Exercise intolerance (a person may be unable to tolerate exercise or even mild physical exertion that he or she may have been able to do in the past)

Shortness of breath (you may have difficulty breathing (dyspnea), especially when active, or even at rest)

Fluid retention and swelling (edema in the legs, feet, and ankles)

How it can affect many organs of the body:
The weakened heart muscles may not be able to supply enough blood to the kidneys, which then begin to lose their normal ability to excrete salt (sodium) and water.

This diminished kidney function can cause the body to retain more fluid.

The lungs may become congested with fluid (pulmonary edema) and the person's ability to exercise is decreased.

Fluid may likewise accumulate in the liver, thereby impairing its ability to rid the body of toxins and produce essential proteins.

The intestines may become less efficient in absorbing nutrients and medicines.

Fluid also may accumulate in the extremities, resulting in edema (swelling) of the ankles and feet.

What causes Congestive Heart Failure?

Many disease processes can impair the pumping efficiency of the heart to cause Congestive Heart Failure in the United States, and the most common causes of congestive heart failure are:

  • Coronary Artery Disease
  • High blood pressure (Hypertension)
  • Longstanding alcohol abuse
  • Disorders of the heart valves

Less common causes include viral infections of the stiffening of the heart muscle, thyroid disorders, disorders of the heart rhythm, and many others.

How is Congestive Heart Failure diagnosed?

The diagnosis of congestive heart failure is most often a clinical one that is based on knowledge of the patient's pertinent medical history, a careful physical examination, and selected laboratory tests.

A thorough patient history may disclose the presence of one or more of the symptoms of congestive heart failure described above. In addition, a history of significant coronary artery disease, prior heart attack, hypertension, diabetes, or significant alcohol use can be clues. The physical examination is focused on detecting the presence of extra fluid in the body (breath sounds, leg swelling, or neck veins) as well as carefully characterizing the condition of the heart (pulse, heart size, heart sounds, and murmurs).

Useful diagnostic tests include the electrocardiogram (ECG) and chest X-ray to detect previous heart attacks, arrhythmia, heart enlargement, and fluid in and around the lungs. Perhaps the single most useful diagnostic test is the echocardiogram, in which ultrasound is used to image the heart muscle, valve structures, and blood flow patterns. The echocardiogram is very helpful in diagnosing heart muscle weakness. In addition, the test can suggest possible causes for the heart muscle weakness (for example, prior heart attack, and severe valve abnormalities). Virtually all patients in whom the diagnosis of congestive heart failure is suspected should ideally undergo echocardiography early in their assessment.

Nuclear Medicine Studies assess the overall pumping capability of the heart and examine the possibility of inadequate blood flow to the heart muscle. Heart catheterization allows the arteries to the heart to be visualized with angiography (using dye inside of the blood vessels that can be seen using X-ray methods). During catheterization the pressures in and around the heart can be measured and the heart's performance assessed. In rare cases, a biopsy of the heart tissue may be recommended to diagnose specific diseases. This biopsy can often be accomplished through the use of a special catheter device that is inserted into a vein and maneuvered into the right side of the heart.

Another helpful diagnostic test is a blood test called a BNP or brain natriuretic peptide level. This level can vary with age and gender but is typically elevated from heart failure and can aid in the diagnosis, and can be useful in following the response to treatment of congestive heart failure.

The choice of tests depends on each patient's case and is based on the suspected diagnosis.

What is the treatment of Congestive Heart Failure?

After Congestive Heart Failure is diagnosed, treatment should be started immediately. Perhaps the most important and yet most neglected aspect of treatment involves lifestyle modifications. Sodium causes an increase in fluid accumulation in the body's tissues. Because the body is often congested with excess fluid, patients become very sensitive to the levels of intake of sodium and water. Restricting salt and fluid intake is often recommended because of the tendency of fluid to accumulate in the lungs and surrounding tissues. An American "no added salt" diet can still contain 4 to 6 grams (4000 to 6000 milligrams) of sodium per day. In individuals with congestive heart failure, an intake of no more than 2 grams (2000 milligrams) of sodium per day is generally advised. Reading food labels and paying close attention to total sodium intake is very important.

Likewise, the total amount of fluid consumed must be regulated. Although many people with congestive heart failure take diuretics to aid in the elimination of excess fluid, the action of these medications can be overwhelmed by an excess intake of water and other fluids. The maxim that "drinking eight glasses of water a day is healthy" certainly does not apply to patients with congestive heart failure. In fact patients with more advanced cases of congestive heart failure are often advised to limit their total daily fluid intake from all sources to 2 quarts. The above guidelines for sodium and fluid intake may vary depending on the severity of congestive heart failure in any given individual and should be discussed with their physician.

An important tool for monitoring an appropriate fluid balance is the frequent measurement of body weight. An early sign of fluid accumulation is an increase in body weight. This may occur even before shortness of breath or swelling in the legs and other body tissues (edema) is detected. A weight gain of two to three pounds over two to three days should prompt a call to the physician who may order an increase in the dose of diuretics or other methods designed to stop the early stages of fluid accumulation before it becomes more severe.

Aerobic exercise, once discouraged for congestive heart failure patients, has been shown to be beneficial in maintaining overall functional capacity, quality of life, and perhaps even improving survival. Each person's body has its own unique ability to compensate for the failing heart. Given the same degree of heart muscle weakness, individuals may display widely varying degrees of limitation of function. Regular exercise, when tailored to the person's tolerance level, appears to provide significant benefits and should be used only when the individual is compensated and stable.

Medications:
Until recently, the selection of medications available for the treatment of congestive heart failure was frustratingly limited and focused mainly on controlling the symptoms. Medications have now been developed that both improve symptoms, and importantly, prolong survival.

The success of today's heart failure programs is based upon educating, educating, and re-educating our patients to become heart failure experts, and then monitoring, monitoring, and re-monitoring their progress to give them feedback on their success. Doctors treating heart failure simply cannot succeed without active help from their patients. In short, your doctor will not be successful in controlling your heart failure without you.

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