Heart Information Center

What is heart failure ? How is heart failure treated? Symptoms of heart failure Common heart failure medications What causes heart failure? How often should I see my Doctor ? How common is heart failure ? Glossary (definition of medical terms ) How is heart failure diagnosed? Other sites

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Congestive heart failure (or heart failure) is a condition in which the heart can't pump enough blood to meet the needs of the body's other organs. Despite the way it sounds, the term "heart failure" doesn't mean your heart has stopped working. Heart failure usually develops slowly, often over years, as the heart gradually loses its pumping ability and works less efficiently. Some people may not become aware of their condition until symptoms appear years later.

Initially the heart attempts to compensate for pumping problems in several ways. Like skeletal muscle that must work harder the heart enlarges (dilatation); this allows more blood into the heart. Heart muscle fibers may thicken (hypertrophy) to allow more forceful contraction and pumping of blood and the heart may beat more frequently (faster heart rate) to improve blood flow to the body's tissues. If factors causing heart failure are not corrected compensatory mechanisms eventually fail and signs of heart failure appear.

How serious the condition is depends on how much pumping capacity the heart has lost. Nearly everyone loses some pumping capacity as he or she ages. But the loss is significantly more in heart failure and often results from a heart attack or other disease that damages the heart. The "failing" heart keeps working but doesn't work as efficiently as it should. People with heart failure can't exert themselves because they become short of breath and tired.

As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Often swelling (edema) results, most commonly in the legs and ankles, but possibly in other parts of the body as well. Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down.

Heart failure also affects the ability of the kidneys to dispose of sodium and water. The retained water increases edema in various parts of the body.

The severity of the condition determines the impact it has on a person's life. Mild forms of heart failure may have little effect on a person's life; at the other end, severe heart failure can interfere with even simple activities and prove fatal.

But all forms of heart failure, even the mildest, are a serious health problem, which must be treated. To improve their chance of living longer, patients must take care of themselves, see their physician regularly, and closely follow treatments.

Heart failure is also called congestive heart failure. "Congestive" means fluid is building up in the body because the heart isn't pumping properly. This is only one feature of heart failure and does not occur in all patients.

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A number of symptoms are associated with heart failure but none are specific for it. For people who are symptomatic the following frequently occur:

• Shortness of breath (dyspnea) with exertion such as walking or climbing stairs or when resting
• Shortness of breath when lying flat (orthopnea)
• Waking up at night suddenly short of breath (paroxysmal nocturnal dyspnea or PND)
• Swelling of the feet or ankles in the presence of other symptoms
• General weakness and easily fatigued
• Rapid weight gain (1 to 2 pounds a day for more than several days in a row)
• Persistent coughing or wheezing (especially if sputum appears "frothy" or blood tinged)

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Any factor that causes either abnormal thickening / swelling of the heart or narrowing of the coronary arteries supplying blood (oxygen) to the heart is a risk factor for heart failure. A number of factors contribute to heart failure including:

• Myocardial Ischemia (insufficient blood flow to the heart muscle)- people with heart failure have often had either long standing angina or a heart attack in the past. This is most often due to coronary artery disease (causing narrowing of the heart's blood vessels). Coronary artery disease is the single biggest risk for heart failure. Any risk factor for coronary artery disease is a risk factor for heart failure. [Discussed in more detail in topics about Angina and about Heart attacks]
  
  
• Cardiomyopathies are problems with the heart muscle itself not due to heart blood vessel narrowing. These conditions can be caused by infections (viral, bacterial or parasitic), chemical exposures (toxic metals, therapeutic drugs), or hereditary factors. Cardiomyopathies can occur with "normal" coronary arteries. [Visit Cardiomyopathies for more information]
  
  
• High blood pressure [Visit High Blood Pressure for more information]
  
  
• Metabolic problems- Thyroid disorders are an uncommon but not infrequent cause of heart failure. Thyroid hormone is needed by all cells in the body to work optimally. Too little thyroid hormone may cause the heart to work too sluggishly while too much thyroid hormone may cause the heart to beat too fast and work too hard thus not pumping blood efficiently. Both conditions may cause heart failure.
  
  
• Heart valve problems - A leaky heart valve may allow blood to be pushed backward into the lung vessels with each heart contraction. [Visit Valvular Heart Disease for more information].
  
  
• Toxic substances (alcohol abuse is the most common toxin)
  
  
• Inhaled tobacco products- Cigarette smoke (second hand smoke too) directly contribute to coronary artery disease and thus are a strong risk factor (although not direct cause) of heart failure.
  
  
• Arrhythmia's are heart beats that occur abnormally. They may be too fast, slow or irregular. The end result is the heart does not pump enough blood to the body's organs and tissues. Special parts (conduction system) of the heart conduct electrical impulses that signal the heart muscle to contract. Parts of the conduction system may be damaged from prior heart attacks or other problems with the surrounding heart muscle. [Visit Arrhythmias for more information]
  
  
• Diabetes- poor blood sugar control is associated with other risk factors for heart failure ( high blood pressure, obesity, and high cholesterol) as well as directly contributing to heart failure by causing stiffing and narrowing of the coronary arteries (as well as arteries throughout the body). People with diabetes are 2 to 10 times more likely to experience heart failure than those without diabetes. Female diabetics are at greater risk than male diabetics.

Although a single risk factor may cause heart failure, a combination of risk factors greatly increases the risk.

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Between 2 to 3 million Americans have heart failure, and almost 400,000 new cases are diagnosed each year. The condition is slightly more common among men than women and is twice as common among African Americans as whites. Heart failure causes 39,000 deaths a year and is a contributing factor in another 225,000 deaths. The death rate attributed to heart failure rose by 64 percent from 1970 to 1990, while the death rate from coronary heart disease dropped by 49 percent during the same period. Heart failure mortality is about twice as high for African Americans as whites for all age groups.

Heart failure's growing presence as a health problem reflects the Nation's changing population: More people are living longer. People age 65 and older represent the fastest growing segment of the population, and the risk of heart failure increases with age. The condition affects 1 percent of people age 50, but about 5 percent of people age 75 years and older.

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Your doctor will ask you questions about your symptoms (shortness of breath, cough, chest pain, ankle or foot swelling, abnormal weight gain), your risk factors for heart failure (high blood pressure, diabetes, obesity, high cholesterol, smoking, prior heart problems), and perform a physical examination. The physical exam will include listening to your heart and lungs with a stethoscope; the stethoscope may detect abnormal heart and lung sounds associated with heart failure. Likewise, signs of edema such as swelling of your ankles or feet and neck vein swelling may be present.

Your doctor may also order the following tests:

• Blood tests
  • blood count (to check for anemia)
  • electrolyte panel (to check blood sugar, sodium, potassium, BUN and creatanine) BUN and creatanine are a rough indicator of kidney function.
  • Thyroid panel- Thyroid disorders are an increasing common cause of heart problems in persons over 60 years of age. This test is not ordered for all patients.
    
    
• Urine tests- a urinalysis will check for protein and sugar in the urine. If present this may indicate underlying kidney problems or diabetes.
  
  
• Chest x-ray- may show fluid or congestion in the lungs or abnormal enlargement of the heart.
  
  
• Electrocardiogram (EKG or ECG)- demonstrates the electrical activity of different areas of the heart. Certain patterns may indicate prior heart attack, conduction system problems, or abnormal heart enlargement.

The above tests are used in addition to history and physical exam findings. They give indirect information in that they may provide useful information but can not directly show how your heart is working. Two additional tests may "see" how well the heart is pumping. Most patients are referred to a specialist in radiology or nuclear medicine to perform these tests.

• Echocardiogram- uses ultrasonic type sound waves that are converted to a movie picture of your heart that can show how it is beating. This test is painless and noninvasive.
  
  
• Radionuclide Ventriculography- very low doses of a radioactive substance are injected into the blood stream. A rapid series of pictures (movie) are taken as it passes through your heart. This movie can show how well your heart is pumping.

Both echocardiogram and radioventriculography are capable of measuring the ejection fraction (EF) of the left ventricle. This may be very useful in knowing how severe heart failure is as well as telling what type of heart failure is present. The left ventricle is a heart chamber that pumps oxygenated blood to the entire body. Ejection fraction is the percent of blood present in the left ventricle at the very beginning of a heart beat that is actually pumped out with each beat. Ejection fractions of less than 40% suggest heart failure.

Some causes of heart failure, such as high output heart failure and diastolic dysfunction, do not have low ejection fractions. The problem in these cases is that the left ventricle does not adequately fill with blood during the relaxation period between heart beats. These conditions may be treated with different medications than low output heart failure. The reader is encouraged to review medical reference books or contact their doctor for further information.

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Treatment of heart failure may depend on the underlying cause. Potentially treatable causes of heart failure include:

• Hyperthyroidism
• Hypothyroidism
• Anemia
• Heart valve problems

Heart failure due to heart muscle damage (most common type) is not currently curable. However, medical treatment and risk factor modification can be very successful in improving heart function and quality of life. The following are often very beneficial:

• Stopping smoking
• Losing excess weight
• Modest exercise (under a doctor's supervision)
• Reduction of alcohol intake (if heavy)
• Salt restriction is extremely important in controlling excess body fluid accumulation for persons with moderate to severe heart failure. Daily weights are very important in monitoring fluid accumulation.

Even with life style modifications many people with heart failure will need to take medication. Specific medications are discussed in the next section.

When heart failure is severe and life threatening, despite lifestyle modifications and optimal use of medications, heart transplantation may be required. However, patients must often wait months or years before a suitable donor is found. During this time some patients improve and no longer need a transplant while others die.

Transplant candidates who do not improve sometimes need mechanical pumps, which are attached to the heart. Called left ventricular assist devices (LVADs), the machines take over part or virtually all of the heart's blood-pumping activity. However, current LVADs are not permanent solutions for heart failure.

Studies are currently being done at selected centers using a specialized procedure (Batista procedure) that removes an elliptical shaped portion of the left ventricular wall of the heart and then stitches the heart muscle back together. First performed by a Brazilian surgeon several years ago this procedure has shown great promise for some patients but had a high mortality rate (30%) when performed on Brazilian patients. The Batista procedure is used for patients whose heart muscles have been stretched or weakened by disease, such as infection or inflammation which have led to congestive heart failure. Chargas disease, due to a parasitic infection, is a very frequent cause of heart failure in third world countries. (Weakened heart muscle that results from heart attack does not seem to respond as well.) Because of their weakened condition, these hearts can't pump enough blood to sustain themselves and the body. By removing part of the left ventricle (the heart's main pumping chamber), the heart's chamber is made smaller and it can contract more effectively to pump more blood.

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Many different medicines are used to treat heart failure. You may need one or more medicines, depending on your symptoms. Your doctor will talk about these medicines with you. It may take a while to find the best medicine for you and the best amount of it.

The various drugs used to treat congestive heart failure perform different functions.

• ACE inhibitors and vasodilators expand blood vessels and decrease resistance, allowing blood to flow more easily and making the heart's work easier or more efficient.
  
  
• Beta blockers can improve the function of the left ventricle .
  
  
• Digitalis increases the pumping action of the heart
  
  
• Diuretics help the body eliminate excess salt and water.

Listed below are some of the medications prescribed for heart failure. Not all medications are suitable for all patients, and more than one drug may be needed.

All medications have potential side effects. The most frequently encountered side effects are included for each class of medicine. Most patients will tolerate medications reasonably well. A side effect does not mean you are allergic to a medicine. Not all patients will develop these side effects. If you suspect that you are having a side effect, tell your physician.

• ACE Inhibitors.
  These prevent the production of a chemical that causes blood vessels to narrow. As a result, blood pressure drops and the heart does not have to work as hard to pump blood. Also protective effect on kidneys and beneficial in patients with diabetes.
  • Side effects may include coughing, skin rashes, fluid retention, excess potassium in the bloodstream, kidney problems, and an altered or lost sense of taste.
    
    
• Digitalis.
  Increases the force of the heart's contractions. It also slows certain fast heart rhythms. As a result, the heart beats less frequently but more effectively, and more blood is pumped into the arteries.
  • Side effects may include nausea, vomiting, loss of appetite, diarrhea, confusion, and new heartbeat irregularities.
    
    
• Diuretics.
  These decrease the body's retention of salt and water. Diuretics are commonly prescribed to reduce high blood pressure. Diuretics come in many types, with different periods of effectiveness. Diuretics are often called "water pills" because they make you urinate more often and help keep fluid from building up in your body. They can also decrease fluid that collects in your lungs, which helps you breathe easier.
  • Side effects may include loss of too much potassium, weakness, muscle cramps, joint pains, and impotence.
    
    
• Hydralazine.
  This drug widens blood vessels, easing blood flow. Not as frequently used as diuretics and ACE inhibitors. Often combined with other medications.
  • Side effects may include headaches, rapid heartbeat, and joint pain.
    
    
• Nitrates.
  These drugs are used mostly for chest pain, but may also help diminish heart failure symptoms. They relax smooth muscle and widen blood vessels. They act to lower primarily systolic blood pressure. Usually combined with other medications.
  • Side effects may include headaches. Tolerance quickly developed to nitrates.
    
    
• Beta blockers. Beta blockers can improve blood flow and may help prevent some heart rhythm problems. Used more commonly in heart failure with normal ejection fraction. However, recent studies show them to be effective in low output heart failure as well. Under utilized.
  • May cause abnormally slow heart rate in patients with already slow heart rates, may worsen some types of heart block, may hide symptoms of low blood sugar in diabetics, may exacerbate depression, asthma and cause impotence.

You might need to take other medicines if you have other problems or if you have side effects with any of these medicines.

When you're taking medicine for heart failure, you'll need to have blood tests to check your potassium level and kidney function. How often you need blood tests depends on the type and strength of medicine you are taking. Many patients take these medicines without any problems. However, if you have concerns about the medicine or think you may be having side effects, talk to your doctor. It's very important that you take your medicine exactly as your doctor says.

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At first, you may need to be seen as often as every week to check how you're reacting to the medicine. After your doctor has adjusted your medicine and you're feeling better, you may need to be seen less often.

Here are some points you may want to discuss with your doctor. Don't hesitate to ask questions to clarify points. Also, ask your doctor to rephrase a reply you cannot understand. You may want to take a family member or friend to the appointment with you to help you better understand and remember what's said.

• Briefly describe your symptoms, even those you feel may not be important. You may want to keep a list so you will remember them.
  
  
• Tell the doctor all of the medications you take--including over-the-counter drugs--and any problems you may be having with them.
  
  
• Be sure you understand all of the doctor's instructions--especially for medications. Know what drug to take when, how often, and in what amount.
  
  
• Find out what side effects are possible from any drug the doctor prescribes for you.
• Ask the meaning of any medical term you don't understand.
  
  
• If, after your appointment, you still have questions or are uncertain about your treatment, call the doctor's office to get the information you need.

You should call your doctor if:

• you are short of breath
  
  
• you have swelling in your ankles or feet
  
  
• You should also call if you gain 3 to 5 pounds in 1 or 2 days. (To keep track of your weight, weigh yourself each morning after urinating but before you eat anything.)

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