C O N G E S T I V E   H E A R T  F A I L U R E

What is heart failure?
What causes the weakening of the heart?
What is "cardiomyopathy"?  Is there more than one type?
My doctor says that my heart muscle isn't weak ("diastolic dysfunction").  Why then do I have heart failure?
What are the symptoms of CHF?
Why does the body retain fluids?
What is pulmonary edema?
What are some symptoms I should watch for?
Am I going to have a heart attack?
What tests are done to evaluate CHF?
What is the "ejection fraction"?
I've been told I have "Cardiomegaly".  What is this?
What can be done about CHF?
What can the patient do about it?
I can exercise and make my heart muscle stronger, right?
How can I follow a low-salt diet?
What's the prognosis?
I'm feeling a lot better since my doctor started medications.  I can just stop them now or just take them when I need them, can't I?
What are some of the medications that are used to treat heart failure?
When I start to gain weight or get short of breath, I just take another fluid pill.  That's OK, isn't it?
I hate to take my diuretics before I go on a trip.  That's OK, isn't it?
What are "Heart Failure Clinics"?
What about heart transplantation?
What about the artificial heart?
Will a pacemaker help?
Are there other surgeries that can be done for people with heart failure?


What is heart failure?

The term "Heart Failure" can be scary, and is misleading.  The heart does not "fail" in the sense that it suddenly stops.  It doesn't mean that you're about to die.  It means the heart is not working as efficiently as it should.   Heart "failure"occurs when the heart muscle cannot keep up with the needs the body has for blood flow. It is not a disease itself, but is rather a "syndrome" (a syndrome is a collection of findings which may arise from a number of causes). Most often, it is caused by weakening of the heart muscle ("cardiomyopathy"), leaving it unable to pump enough blood. It is termed "congestive" heart failure (commonly referred to as "CHF") because fluids typically build up in the body, which is then said to be congested.

In addition to heart failure caused from a weakened heart, there are two other major varieties of heart failure. These are CHF secondary to thick "muscle-bound" hearts (this is termed "diastolic dysfunction"), and CHF due to the body having needs which are too high for even a normal heart to keep up with.  This occurs, for example in some cases of thyroid disease in which too much thyroid hormone is produced, in persons with anemia, or several other conditions.

What causes the weakening of the heart?

There are multiple causes to weakening of the muscle. It is not unusual for the physician to be unable to even find a reason. Some reasons include:

What is "cardiomyopathy"?  Is there more than one type?

"Cardiomyopathy" is the name that is used for diseases of the heart muscle.  It is not the same thing as CHF. The heart muscle itself may be normal despite the fact CHF is present in cases caused by thyroid problems, anemia, or some other causes. Additionally, there may not be CHF despite the fact there is weakened heart muscle.


My doctor says that my heart muscle isn't weak ("diastolic dysfunction").  Why then do I have heart failure?

You probably have a disorder of the heart muscle which leads to the symptoms of heart failure because it is "stiff".  In this situation, the heart muscle is also often thick.  The blood which empties into the heart is easily squeezed out, but the problem is that it's hard to get the blood into the pumping chambers because of their thickness and stiffness.  I like to have people think about different types of balloons.  Remember those little balloons that you got as a kid that were so hard to blow up? It made your cheeks stiff trying to get them blown up!  If you let them go after they were blown up, the air came out quickly and the balloon shot quickly across the room.  The point however is that it was hard to blow them up, and you built up a lot of pressure in the chamber behind the balloon (your mouth and cheeks!).  So it is with this type of heart failure . . . pressure builds up behind the heart, and this will cause the fluid from the blood to filter out into the lung tissues.  This is exactly what happens in heart failure from a weak muscle, but by a somewhat different mechanism.

This situation is often referred to as "diastolic dysfunction", referring to the fact that it is a problem which occurs not during muscle contraction ("systole"), but during the part of the cardiac cycle when the heart muscle is supposed to relax ("diastole")

The heart muscle can become thick because of:

The prognosis of this type of heart failure depends on what of the above reasons caused the problem.  In general, the prognosis from this type of heart failure is better than that from weak heart muscle.  Treatment is similar to that described for other forms of heart failure below, but differs from this in the respect that digitalis and other agents which increase the force of muscle contraction are not necessary.  In addition, there is a suggestion that sometimes the "calcium channel blockers" diltiazem and verapamil may be particularly useful since they help "relax" the muscle during diastole.

What are the symptoms of CHF?

The main symptoms of CHF relate to the buildup of fluids which occur for reasons explained in the next section. A substantial amount of extra fluid can build up without a person noticing much change.  The fluid will tend to collect in the "dependant" portions of the body, the feet, and is termed "edema". Fluid also collects in the very fine tissues of the lungs, which increases the work of breathing and decreases the ability to get oxygen into the body.  Shortness of breath with exertion will result. As more fluid builds up, the person may find it difficult to lie down flat, since this places parts of the lung in a more dependant position.  They may be awoken by severe shortness of breath, and need to sit up to get their breath (this is termed "paroxysmal nocturnal dyspnea" or is also termed "PND").  

It is sometimes to difficult to tell whether shortness of breath is due to CHF, diseases of the lung, other diseases of the heart including blockage of the arteries, or other conditions.

People with CHF also may experience weakness with exertion due to the inability to increase the output of the heart.

Not everyone with one or more of these symptoms however has heart failure!

Why does the body retain fluids?

When the heart's output decreases, the body does many things to try and compensate for it. It will release hormones to make the heart beat stronger. The heart will beat faster. Many of these reflexes however, only create a short term gain, and may ultimately hurt the heart's function.

When the kidneys sense a decrease in flow, they release hormones which cause the body to hold sodium and water.  In the short term, this will lead to an increase in the volume of blood which is circulating, and provide the kidneys with the blood volume they are looking for.  However, this extra volume of fluid is more than can be held in the blood vessels, and it will start to exude out into the tissues of the body.  

What is pulmonary edema?

"Pulmonary edema" is water on the lungs.  Fluid is not only in the lung tissues, but actually in the air spaces as well.  This is a severe degree of heart failure, and requires immediate and aggressive management.

What are some symptoms I should watch for?

People with CHF should obviously watch for a return of symptoms that initially led them to seek attention.  

They should call their physician if they have concerns that they might be experiencing worsening of their symptoms -- in perhaps no other medical condition is this rule as important.  CHF is often easy to treat early, and is life-threatening if allowed to go too far.

Symptoms and signs which may be clues to worsening of CHF include:

Am I going to have a heart attack?

Heart attacks ("myocardial infarctions") are usually caused by blockage of the arteries that supply the heart muscle with blood.  A weakened heart muscle does not cause heart attacks.  It should be noted that many people with CHF also have blocked arteries, and indeed heart attacks can cause CHF.

What tests are done to evaluate CHF?
Since heart failure is a syndrome (that is, a collection of findings), there is no single test which will diagnose it ( . . . yet!).  Physician's biggest clue is often obtained simply from talking to the person, the medical history.  There may be very important signs on the physical examination of the patient, including swelling of the ankles (there are several other causes for this, however), and sounds generated in the heart and lungs which are heard with the stethoscope.  The other tests noted below can be helpful in confirming the diagnosis, assessing the cause of heart muscle weakening, and judging the severity.

The electrocardiogram (ECG) does not diagnose heart failure.  That is, a doctor cannot tell whether or not you have heart failure by looking at an ECG.  There may be clues here as to the cause of the process and any associated problems of the heart's rhythm.

The chest x-ray may show that the heart is enlarged, and the particular configuration of the heart's shadow may also give clues as to the cause of the problem.  The chest x-ray is a very useful tool in determining whether there is fluid on the lungs and how much.  Again however, the chest x-ray cannot diagnose heart failure.

A key technique for evaluation today is the echocardiogram.  This sonogram of the heart can reveal the strength of the heart muscle, the size of the chambers, and associated valvular problems.  The procedure, which can be completed in 15-60 minutes in the doctor's office.

Nuclear medicine studies, such as a radionuclide ventriculogram (RVG), which is also known as a "MUGA scan", are useful for assessing heart muscle function, and is particularly useful in assessing the "ejection fraction" (see below).  These tests are also minimally invasive, simply requiring the injection of a very small amount of a radioactive compound into the blood stream through a simple intravenous catheter in the arm.

Cardiac catheterization is accomplished by placing catheters in an artery and/or vein, typically in the groin or at the elbow, and advancing them into the heart to measure pressures and inject dye into heart chambers and arteries.  This may sound scary, and it is certainly more invasive than the other techniques.  It is safer and less painful than perhaps it sounds.  It is often necessary to gain the specific information needed to determine the cause of CHF and treat the person in the most effective manner.

What is the "ejection fraction"?

The "ejection fraction" (also known as the "EF") is the measure of the percentage of blood which is ejected from the main pumping chamber of the heart with each beat.  The heart usually ejects about 45-70% of the blood in its chamber with each contraction.  People with CHF and weak heart muscle and CHF will have an EF less than this.

While it is a useful number in some situations, it is not the "whole story" by any means.  People with EF"s of 40% can be severely disabled, while those with EF's of 15% may hardly have any symptoms at all.  It may be useful for following the course of the problem in some people.

I've been told I have "Cardiomegaly".  What is this?

"Cardiomegaly" is the term for an enlarged heart.  This is not a very exact term, and may be misleading. Sometimes the heart may appear a bit large on a chest x-ray or on another test.  If this is indeed true as borne out on another test such as an echocardiogram, it may indicate a problem with the heart, but often the echo will show normal heart size and function.  The heart may be enlarged, and yet still be normal, in some people who are well-trained athletes.  Some people have slightly enlarged hearts, yet still have good muscle function, and will live normal lives.

What can be done about CHF?

The first principle of the treatment of heart failure is to treat the underlying cause if possible. For example, a defective valve may need to be replaced or a specific disorder of metabolism such as an over-active or under-active thyroid treated.  In many cases however, there is no specific therapy available for the underlying disorder. Fortunately, there are numerous and potent medications available to slow, stop or reverse the process.  See the sections below for more on this topic.

Physicians can do a lot about CHF these days:

What can the patient do about it?

I can exercise and make my heart muscle stronger, right?

No, not really.  Exercise can certainly be important.  It conditions the rest of the body, allowing it to extract oxygen with improved efficiency, and this eases the workload on the heart.  However, the heart muscle is not like the muscle in your arm in terms of its response to exercise -- the muscle itself will not get stronger.  Overwork on the heart muscle is to be avoided.  Again, this is best accomplished by obtaining a specific exercise program from your physician.  Find out how long . . . how hard . . . and how often you should exercise.

General rules about exercise may be useful:

How can I follow a low-salt diet?

The average person takes in about 4,000 milligrams (4 grams) of sodium per day -- you should aim to take in no more than 2,000 milligrams (2 grams) daily.  Your doctor may even recommend less.

Give yourself some time . . . the desire for salt is an acquired one.  Your taste buds will adjust, and you will really enjoy food again.  Check out some of the tips below.  

Fortunately, we have a new food label which is required to clearly list the sodium content of food. Check out the link, and learn to read the label.

Here are some other tips:

What's the prognosis?

This is too wide of an area to discuss with any precision over the Internet.  It must be answered by a physician with knowledge of a number of aspects of your care.  It is important to realize however that CHF is the cause of death of thousands each year, and that it is extremely important to follow the diet, medication and exercise program that is prescribed to help you live as long and as well as possible.  Great improvements have been made, and more will be coming . . . but only you can actually comply with these life-lengthening programs and medications.

I'm feeling a lot better since my doctor started medications.  I can just stop them now or just take them when I need them, can't I?

Well you can guess what we're going to say about that one, can't you?  In all seriousness, CHF is the very worst disease to try and manage yourself.  Many of the medications which are used are designed to help the heart improve its function, and are extremely important to take regardless of whether you feel good or not.  The medications used are potent, require close follow-up, and good judgement in their dosages.  Do not try to do this on your own . . . please.

What are some of the medications that are used to treat heart failure?

Diuretics (fluid medications).  These are medications which increase the kidneys clearance of sodium and water.  They are mainstays of the therapy of CHF.  They decrease swelling, lessen edema, and make the person feel better.  With the extra sodium and water also goes a substantial amount of potassium, and therefore potassium supplements are usually required.  Lasix (furosemide), Demadex (torsemide) and Bumex (butamidine) are the mainstays of diuretic therapy in CHF.  These may be supplemented by agents such as Zaroxolyn (metolazone) to further increase urine volume.

Vasodilators.  Vasodilators are very important to the modern management of CHF.  They not only improve exercise tolerance and decrease the need for diuretics, but more importantly save lives.  Study after study after study has confirmed this, showing improvements in survival up to 40%.  "ACE inhibitors" are the most widely used, but agents such as Apresoline (hydralazine), nitrates, Cardura, Hytrin and "A-2 Blockers" (angiotensin receptor blockers) are used.  They are often given in doses sufficient to lower the systolic blood pressure to 90-110 (link) which is quite satisfactory as long as the patient does not have symptoms such as significant dizziness at these levels of blood pressure.  It appears that a very aggressive approach to their use is justified by an improvement in patients clinical outcomes -- these agents provide the basis for actual improvement in the heart muscle's function in many people treated with them, improvements which are maintained over the long run.

Beta-blockers.  Beta blockers, which block the effects of hormones such as adrenaline, previously were thought to be dangerous with CHF.  Recent studies however have shown promise of improved survival.  It would seem that the heart can be "overstimulated" by the bodies attempts to increase its output, and that these agents restore a more normal state of excitement.  There are numerous beta-blockers which have been around for a long time and may be useful in these situations.  One recent newcomer Coreg (carvedilol) has shown particular promise in early studies.  These agents are being used with increasing frequency, and appear to improve how well the patient feels, as well as survival.

Medications for high blood pressure.  Adequate control of the blood pressure is important to create the best environment for the weakened heart muscle to function.  Those people whose blood pressure is not adequately controlled on diuretics, vasodilators, and beta-blockers often need other medications for control.

Inotropes.  "Inotropes" are medications which increase the strength of the heart muscle's function.  With the exception of digitalis, there are few such agents in routine use today.  Virtually all of the agents may improve the heart's output, and may improve the person's sense of well-being.  However, in the drugs studied to date, these benefits come at a very high price -- decreased survival.  As noted in the section on beta blockers above, "whipping" the heart may work in the short term, but appears to be detrimental to the heart in the long run.  Inotropes are still used on a short term basis when there is decompensation of CHF, and some patients receive agents such as dopamine, dobutamine, amrinone and milrinone on a regular basis in controlled environments.  Digitalis on the other hand has been around for years, and while it has been suspected of being harmful or ineffective, overall appears to be helpful in heart failure, particularly in people who also have certain arrhythmias such as atrial fibrillation.  

Antiarrhythmics.  Medications to control irregular rhythms of the heart are frequently necessary.  These agents are covered in HeartPoint's section on arrhythmias.

Blood thinners.  Another somewhat controversial area is that of anticoagulants or blood thinners.  Patients are often placed on agents such as aspirin when they are in heart failure.  Heparin is often given intravenously or by injections under the skin while one is hospitalized with CHF.  More controversial is the use of agents such as warfarin, a more potent blood thinner, in patients with CHF simply because they have CHF.  This is one area where the studies don't seem to be consistent, and there is variation in practice by individual physicians.

When I start to gain weight or get short of breath, I just take another fluid pill.  That's OK, isn't it?

It's OK if you've discussed it with your doctor.  Many patients who have had heart failure for a long time build up a good sense of their need for diuretics, and after multiple interactions with their physician, all concerned feel comfortable with some adjustment of the diuretic dose.  However, diuretics often lower the serum potassium, a condition that may be dangerous.  Too much diuretic can lower the blood pressure to dangerously low levels, or cause kidney problems.  You must get very specific instructions from your doctor regarding this.

I hate to take my diuretics before I go on a trip.  That's OK, isn't it?

This is not an uncommon complaint among those with CHF who use diuretics.  Diuretics are a mainstay of treatment of CHF to keep fluid from building up to dangerous levels.  Those used for patients with CHF are potent, and generally will lead to frequent urination for several hours.  This, needless to say, can be very inconvenient in a number of situations, such as when travelling.  I advise my patients to wait until they arrive at their destinations, and then take their diuretics. This may keep them up at night -- but the diuretics still need to be taken!

What are "Heart Failure Clinics"?

Heart Failure clinics are relatively new developments in medical care.  They are a response to several problems in people with CHF.  Patients with CHF are admitted to the hospital frequently for episodes of worsening of their heart failure.  These episodes of worsening do not allow the patient to build up his strength, keep him away from loved ones, etc.  Furthermore, in the age of cost-effectiveness, it is very expensive to the health care system as well.  Heart failure clinics have physicians, nurses, and other personnel who concentrate on the care of patients with CHF, checking to make sure they're taking their medications, that they're not gaining weight or showing other evidence of decompensating, providing home visits and a source to call for questions or problems.  This will hopefully lower the frequency, severity and duration of hospitalizations, and benefit the patient and the "system" as well.  They are not the standard of care at this time, but initial experience has been favorable.


What about heart transplantation?

Heart transplantation is a very viable option for people with advanced heart failure who cannot be treated with other means.  This option is limited however, mainly as a result of inadequate availability of donated hearts.  Therefore, transplantations are limited to those not only who are in the greatest need, but those who also stand the greatest chance of benefitting from the procedure.  A "Transplant List" of patients needing hearts is kept in each local area.  Patients on the list receive a heart not only on the basis of need, but they must be a suitable "match" to the donor heart.  This "matching" includes blood typing, as well as other features which indicate whether the person who receives the new heart will have a strong immune response to the donor heart, recognizing it as foreign, and trying to destroy it.

There are no rigid standards for being placed on the transplant waiting list . . . these are set by local transplant programs.  People placed on the list are generally less than 65 years old, without other MAJOR medical problems (cancer, etc.), and who have a life expectancy of about 2-3 years without a heart (this is a difficult thing to estimate!).

Candidates also need to be able to follow the intense post-transplantation regimen of medications and medical re-evaluations. The potential for "rejection", that is the person's body attacking the new heart as "foreign", requires that "immunosuppressive" medicines be taken lifelong.  Heart transplant will be the subject of an upcoming HeartPoint feature.

Of current interest is the Federal Government's interest in maintaining the list of people awaiting transplant, with the intention of trying to provide those in the greatest need available donor hearts (as well as other organs).  This central control, all too common in the rest of our existence, probably causes as many problems as it solves, but does give non-medical bureaucrats the power they crave.

What about the artificial heart?

Progress continues on the artificial heart.  There are several models which are used as a "bridge to transplant".  That is, they are placed with the hope of keeping a person whose heart is otherwise very sick alive until a transplanted heart becomes available.  Some people actually show improvement while on these devices, allowing them to come off of the machine.  Indeed, some of them will go on to improve enough that they can be taken off of the transplant list.  For now, the fully functional artificial heart remains an elusive hope, but a problem which one suspects will be solved in the not-too-distant future.

Will a pacemaker help?

Pacemakers are designed to prevent the heart from going too slow, and this is not the primary problem in CHF.  However, there is substantial evidence to suggest that some patients with severe CHF may benefit from dual-chamber pacemakers.  This is not a standard procedure yet at this point.

Are there other surgeries that can be done for people with heart failure?

Several techniques have been advanced, and are being evaluated.

Cardiomyoplasty, the "Latissimus Dorsi Wrap" takes the large muscle from the back and side of the shoulder and entrains it to contract, with the aid of a pacemaker-like device, after it has been wrapped around the heart.  Thus, the muscle aids the heart muscle in expelling blood.  This is an investigational procedure that has met with mixed results.

A novel procedure, called the "Battista" (after its originator Dr. RVJ Battista, a Brazilian surgeon), is also undergoing substantial investigation in this country.  This procedure seeks to restore a more normal size and function to very large hearts in people who are experiencing heart failure.  The heart chamber generally enlarges as it seeks to provide enough blood to the rest of the body, and this indeed is a very effective mechanism.  However, this advantage is lost in the case of extremely large hearts, which actually begin to lose a great deal of efficiency working under high tensions.  Battista began the procedure of removing substantial parts of these very large hearts, often along with replacing the mitral valve.  Initial results have been encouraging.  This is not yet a "mainstream" procedure, but if proven successful could improve the condition of may people with "end stage" heart failure without requiring transplantation.

Several different procedures are used for the hypertrophic cardiomyopathies. They will be discussed in that section when it is posted.
ęCOPY;1997 HeartPoint   Updated June 1998



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