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Congestive Heart Failure (CHF)
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Why is the Heart Important?

the heartThe heart is one of the most important organs in the human body. It is a specialized muscle that pumps continuously, without rest, throughout your lifetime. Delivering oxygenated blood and nutrients, such as glucose, to all of the vital organs and body's cells, the heart beats about 72 times per minute.

The heart muscle contracts and relaxes with each heartbeat. The contraction part of of a heartbeat is called systole (SIS'to-le), whereas the relaxation phase of each heartbeat is called diastole (di-AS'to-le).

Read more about cardiac anatomy.

Illustration courtesy of the National Institute of Arthritis and Musculoskeletal and Skin Diseases

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What is Congestive Heart Failure (CHF)?

CHF is a medical condition in which the heart's ability to pump is weaker than normal, thus the heart cannot pump enough oxygen and nutrients to meet the body's needs. Heart failure does not mean the heart has stopped working or is about to stop.

Congestive heart failure is a common condition; it's the leading cause of hospitalization in people older than 65. Although it is more common in older people, it can occur at any age.

CHF can affect the left side, the right side, or both sides of the heart. Most cases involve the left side where the heart can’t pump enough oxygen-rich blood to the rest of the body. With right-sided failure, the heart can’t effectively pump blood to the lungs where the blood picks up oxygen.

As a result of the heart muscle's weak pumping action, blood backs up in the blood vessels and fluid may seep out into the tissues throughout the body and around the lungs. Also, the other organs in the body may not get adequate blood supply which can cause them to lose their normal function. For instance, without adequate blood supply, the kidneys begin to lose their normal ability to excrete salt (sodium) and water. As a result, the body retains more fluid than it needs. Fluid accumulates in the body's tissues resulting in swelling (edema) in the legs, ankles and feet. The lungs also may become congested with fluid (pulmonary edema) which can result in shortness of breath, wheezing, or coughing, especially with exertion. Fluid may also accumulate in the liver, thus impairing its ability to rid the body of toxins and produce proteins. The intestines may become less efficient in absorbing nutrients and medication. If left untreated, CHF will eventually affect every organ in the body and may ultimately result in death.

Diastolic Heart Failure
Another type of heart failure is called Diastolic Heart Failure.

In some people with heart failure, the contraction function is normal but there's impaired relaxation of the heart. This condition affects the heart's lower pumping chamber, the left ventricle specifically. This condition is called diastolic (di"as-TOL'ik) dysfunction. Because the ventricle doesn't relax normally, the pressure within the left ventricle increases abnormally as it fills. This prevents adequate filling. A lower filling volume results in lower cardiac output. (It's harder for all of the blood to get into the ventricle, and then less is pushed out into the body) As a result, the cells and vital organs are not receiving an adequate supply of blood and nutrients. This results in fatigue and lowered endurance.

Another problem with diastolic heart failure is that abnormally increased pressures within the left ventricle can transmit back to the lungs and result in increased fluid back up (congestion) within the lungs. This increased fluid within the lungs limits the lungs capacity to adequately oxygentate the blood. This results in increased shortness of breath, especially during exercise.

Symptoms

The symptoms of CHF vary between individuals. A person with congestive heart failure may have several of these symptoms or only one:

  • Fatigue or weakness are early symptoms of CHF but may also be caused by many other conditions as well.
  • Decreased exercise tolerance is another early symptom. Early on, patients may not even sense this decrease and they may subconsciously limit their activities to minimize their symptoms.
  • As the body becomes overloaded with fluid, the following can occur:
    • Shortness of breath, especially with exercise and when lying flat. In some instances, patients are awakened at night, gasping for air. Some may be unable to sleep unless sitting upright. These symptoms are caused by accumulation of fluid in the lungs.
    • Edema (swelling) of the ankles, feet and legs. This is caused by fluid in the body's tissues. In CHF it usually occurs in the feet, ankles and legs, but it can involve the entire body. Edema is commonly seen in the feet and ankles, because of the effect of gravity. Although edema can be a symptom of CHF, it can also be simply caused by prolonged standing, prolonged sitting, pregnancy, being overweight, or aging.
    • Increased urination, particularly at night, is caused by extra fluid in the body
    • Nausea, abdominal pain, and decreased appetite can be caused by accumulation of fluid in the liver and intestines

Congestive heart failure is classified into four levels of increasing severity:

  • Class I: Physical activity is unaffected, and the patient has no unusual fatigue, shortness of breath, palpitations, or pain during normal activities.
  • Class II: The patient may experience mild fatigue, shortness of breath, palpitations, or pain during normal activities; slight limitations on normal activities.
  • Class III: The patient experiences fatigue, shortness of breath, palpitations, or pain during normal activities; activities are dramatically limited.
  • Class IV: The patient is uncomfortable even at rest. Discomfort increases with any physical activity.

Causes of Congestive Heart Failure

Heart failure can occur as a result of coronary artery disease , a previous heart attack, high blood pressure, heart valve disease, damage to the heart muscle (cardiomyopathy), congenital heart defects, infection of the heart valves or muscle (endocarditis or myocarditis), diabetes, chronic kidney disease or longterm alcohol abuse. There are many other less common causes such as viral infections of the heart muscle, thyroid disorders, heart rhythm disorders, etc.

An adverse reaction to certain medications has also been thought to cause CHF in people who already have an underlying heart disease. Commonly used nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Motrin, Advil and others) and naproxen (Aleve and others) have been implicated in causing or exacerbating CHF.

Diagnosis of Congestive Heart Failure

Early diagnosis and treatment are very important in people with congestive heart failure. Anyone who suspects that they may have a heart condition or be at risk for heart failure, should see their health care provider as soon as possible.

A complete medical history and physical exam will provide significant information about your condition. Go to this visit prepared to make the most of this office visit.

Diagnostic tests that may be ordered to diagnose heart failure include:

  • Blood tests will help identify a wide range of abnormalities. Most specifically, BNP may be ordered to help diagnose heart failure and to grade the severity of the failure. BNP levels can also help doctors differentiate between heart failure and other problems, such as lung disease.
  • Electrocardiogram (ECG) and chest x-ray These tests will help identify any arrhythmias, previous heart attacks, heart enlargement, or fluid in and around the lungs.
  • Echocardiogram, is an ultrasound which is used to take a picture of the heart muscle, valvular structures, and blood flow patterns. The echocardiogram is painless, does not expose the patient to radiation, and is very helpful in diagnosing heart muscle weakness. Also, the test can detect possible causes for the heart muscle weakness such as prior heart attack or severe valvular abnormalities. In addition to a resting echocardiogram, there are other types as well:
    • Stress echocardiogram: is performed while the patient walks on a treadmill or exercises on stationary bicycle. This test can visualize the motion of the heart's walls and pumping action of the muscle during the time when the heart is stressed due to exercise. This test is used to detect any lack of blood flow that isn't always apparent on other heart tests. The echocardiogram is performed just before and just after the exercise.
    • Chemical stress echocardiogram: is another form of stress echocardiogram. In this test, instead of exercising to stress the heart, the stress is obtained by giving an intravenous drug that stimulates the heart and makes it "think" it is exercising. This test might be used in a person who is physically unable to exercise.

  • Heart catheterization During cardiac catheterization, a very small catheter (hollow tube) is advanced from an artery or vein in the groin through the aorta into the heart. Once the catheter is in place, pressure within the chambers can be measured, a dye can be injected into the arteries (coronary angiography or arteriography) and with a special type of x-ray, the physician can tell where any blockages in the coronary arteries are located as the dye moves through the arteries. Also, a small sample of heart tissue can be obtained during the procedure to be examined later under the microscope for abnormalities (this is called a biopsy).

Treatment

In some cases, medication and lifestyle changes enable patients to live nearly normal lives. Advances in treatment of heart failure has led to improved survival rates, but if left untreated, heart failure can worsen and may prevent the heart from pumping enough blood to keep the person alive.

Your doctor will continue to treat the underlying diseases or conditions that caused the heart failure. The treatment for heart failure includes:

  • Medications will need to be closely monitored by your physician. Some, or all, of these medications may be prescribed for you:
    • Diuretics (water or fluid pills) to minimize fluid retention in your lungs and control swelling in your feet and ankles.
    • ACE inhibitors and/or ARBs are used to control blood pressure and reduce the strain on your heart.
    • Beta blockers are used to slow heart rate and lower blood pressure in order to decrease cardiac workload.
    • Digoxin is used to make the heart beat stronger and pump more blood.
  • Low salt diet is prescribed to minimize the fluid retention. A build up of fluid will make heart failure worse.
  • Follow a diet rich in fruits, vegetables, low-fat dairy products, and low in saturated fat
  • Limit the amount of fluids that you drink
  • Weigh yourself every day, and let your doctor know right away if you have a sudden weight gain. This could mean you have extra fluid building up in your body.
  • Daily exercise as directed to help build your fitness level and ability to be more active.
  • Lose weight if overweight
  • Quit smoking if you smoke
  • Limit alcohol if you drink

Video Tutorials

  • Congestive Heart Failure from Medline Plus, A service of the National Library of Medicine and the National Institute of Health
  • Understanding Heart Failure from Largo Medical Center.com. This is an excellent well-illustrated animated video of blood flowing through the atria & ventricles.
  • Animated illustrations of the heart from the American Heart Association. View excellent animations of the beating heart, clot formation and stroke.
  • Managing Cholesterol from Medline Plus, A service of the Nat'l Library of Medicine and the Nat'l Institute of Health
  • Smoking - The Facts from Medline Plus, A service of the Nat'l Library of Medicine and the Nat'l Institute of Health

References

1) "Heart Failure" from the American Heart Association
2) "Simple Steps to Reduce Your Risk" from the National Heart, Lung, and Blood Institute
3) "Heart Failure" from the National Heart, Lung, and Blood Institute
4) Heart Attack, Stroke and Cardiac Arrest Warning Signs from the American Heart Association
5) Diastolic Dysfunction from the American Heart Association
--Written by N Thompson, ARNP and Michael Thompson, MD, Internal Medicine, Last updated June 2012

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