CONGESTIVE HEART FAILURE

A person with congestive heart failure has a weakened heart that is unable to pump enough blood to meet
the needs of the tissues in the body. Common causes of congestive heart failure include diabetes,
hypertension, cardiac arrhythmia, and coronary artery disease. Congestive heart failure may affect the
right ventricle, left ventricle, or both ventricles of the heart. Symptoms of congestive heart failure include
cough, difficulty breathing with exertion, and swelling in both legs. Other symptoms include wheezing,
shortness of breath lying flat, and waking up with shortness of breath. Treatment depends on the
underlying cause for the heart failure. Treatment options for congestive heart failure include stop
smoking, heart diet, low cholesterol diet, low salt diet, exercise plan, weight reduction, fluid restriction,
diuretics, beta-blockers, ACE inhibitors, aspirin, and potassium supplements. Other options include
surgery and heart pacemaker
To better understand congestive heart failure, it helps to understand the anatomy of the heart.
The heart is a muscular pump that contains four chambers: right atrium, left atrium, right ventricle and
left ventricle. The two small atria make up the top of the heart, and the two large ventricles make up the
bottom of the heart. The right atrium pumps blood to the right ventricle, and the left atrium pumps blood
to the left ventricle. A wall, called the septum, separates the right atrium and right ventricle, from the left
atrium and left ventricle.
Blood flows through the heart in the following manner:

The right atrium receives oxygen-poor blood from the body, and then pumps the blood through
the tricuspid valve and into the right ventricle.

The right ventricle pumps the blood through the pulmonic valve and to the lungs, where it picks
up more oxygen.

The left atrium receives the oxygen-rich blood from the lungs, and then pumps the blood through
the mitral valve and into the left ventricle.

The left ventricle pumps blood through the aortic valve and to the rest of the body.

The blood supplies oxygen to the body and the cycle starts again.

TYPES
Congestive heart failure can be described as right ventricular, left ventricular, or both: this distinction
indicates which ventricle of the heart is weak.
Right ventricular congestive heart failure
Right ventricular congestive heart failure leads to a back up of blood into the liver, gastrointestinal tract,
and the lower extremities. Severe right ventricular heart failure can lead to condition called cor
pulmonale.
Left ventricular congestive heart failure
Left ventricular heart failure leads to a build-up of fluid within the lungs. This condition is referred to as
pulmonary edema. Isolated left ventricular congestive heart failure is more common than isolated right
ventricular disease. Untreated and severe left ventricular congestive heart failure can eventually lead to
right
ventricular
heart
failure.
Bi-ventricular congestive heart failure
Both the right and left ventricles are affected. Severe left-sided heart failure can lead to bi-ventricular
heart failure over time. Some conditions, such as a cardiomyopathy, often cause bi-ventricular heart
failure.

SYMPTOMS
Symptoms of mild congestive heart failure include:

Loss of appetite

Mild fatigue:
o

Fatigue during exercise

Urinary frequency

Increased urination at night

Rapid pulse

Indigestion

Rapid weight gain

Due to fluid retention

Obesity

Malaise

Symptoms of moderate congestive heart failure include:

Moderate fatigue:
o

Worse with exercise

Nighttime cough

Difficulty breathing:

Shortness of breath when lying flat

Shortness of breath with exercise

Waking at night with shortness of breath

Leg swelling (bilateral):

o

Ankle swelling (bilateral)

Foot swelling (bilateral)

Hand swelling (bilateral)

Wheezing

Anorexia

Symptoms of serious congestive heart failure include:

Distension of the veins in the neck

Chest pain

Palpitations:
o

Abnormal heart beats

Ascites:
o

An abnormal collection of fluid inside the abdomen

Scrotum swelling

Fainting

Chest congestion

Severe difficulty breathing:

Shortness of breath at rest

Severe shortness of breath with exertion

Severe shortness of breath when lying flat

Waking up with shortness of breath

Severe leg swelling (bilateral):

o

Severe ankle swelling (bilateral)

Severe foot swelling (bilateral)

Severe fatigue

Worsening wheezing

Decreased urination

Rapid breathing rate

CAUSES

The most common cause of congestive heart failure is a heart attack.

Additional causes of congestive heart failure include:

Valvular heart disease:

Aortic stenosis

Aortic regurgitation

Mitral stenosis

Mitral regurgitation

Alcoholism

Anemia

Arrhythmias

Diabetes

High blood pressure

Hyperthyroidism

Medication side effects Myocarditis

Radiation

Rheumatic fever

DIAGNOSIS

The evaluation of congestive heart failure begins with a medical history and physical examination.
Physical findings in those with congestive heart failure may include:

Irregular heartbeat

Rapid pulse

Mild or moderate leg swelling (bilateral)

Distension of the veins in the neck

High blood pressure

Abnormal lung sounds:

o

During examination with a stethoscope

Less common findings in those with congestive heart failure include:

Jaundice
o

Yellow skin

Yellow eyes

Brown urine

Ascites

Severe leg swelling

Testing is usually required to confirm the diagnosis of congestive heart failure and to determine the
underlying cause.
Tests that may be used to evaluate congestive heart failure include:

Complete blood count

BNP testing

Electrolyte profile

Kidney profile

Liver profile

Thyroid profile

Urinalysis

Chest x-ray:
o

May be normal or show heart enlargement

Normal chest x-rays

Enlarged heart

Heart failure

Electrocardiogram

MUGA scan

Thallium heart scan

Thallium stress test

Echocardiography

Cardiac catheterization

Heart biopsy:
o

May be necessary to determine the underlying cause.

Less commonly performed tests that may be used to evaluate congestive heart failure include:

MRI scan of the heart:

o

Shows detailed images of the heart and coronary arteries

Detects structural abnormalities of the heart

SPECT scanning of the heart:

o

Detects blood flow abnormalities to heart muscle

Coronary artery CT scanning:

o

Checks for possible obstructions in the coronary arteries

Can show a build-up of calcium in a coronary artery

MORTALITY

Facts about congestive heart failure:

More than 5 million people in the US have congestive heart failure.

Nearly a half a million people develop congestive heart failure in the US each year.

COMPLICATIONS

Ascites

Cardiac arrhythmias:
o

Atrial fibrillation

Digoxin toxicity

Low potassium

Fainting

Low blood pressure

Mesenteric ischemia

Heart attack

Pleural effusion:
o

A collection of fluid within the chest cavity

Renal failure

RISK FACTORS

Atherosclerosis

Congenital heart disease

Diabetes

Genetics

High cholesterol

Prior myocardial infarction

Heart valve disease

High blood pressure

Lifestyle

can

also

play

an

important

role

in

Lifestyle risk factors for congestive heart failure include:

Alcohol abuse

Depression

Emotional stress

High fat diet

increasing

congestive

heart

failure

risk.

High sodium diet

Inactive or sedentary lifestyle

Obesity

Smoking

TREATMENT
Treatment for heart failure depends on the underlying cause for the heart failure and the severity of the
symptoms. Sudden, severe symptoms of congestive heart failure require urgent treatment in the hospital
for oxygen therapy and intravenous (IV) medications. Medications are the main form of treatment for
heart failure, but it is important to treat underlying causes, such as diabetes, hypertension, congenital heart
disease, coronary artery disease, arrhythmia, and valvular heart disease. Common medications used for
the treatment of congestive heart failure include nitroglycerin, diuretics, beta-blockers, ACE inhibitors,
and potassium supplements. Additional procedures include angioplasty, cardiac surgery, heart pacemaker
placement, and kidney dialysis. Lifestyle changes that can help reduce symptoms of congestive heart
failure include smoking cessation, a heart-healthy diet, a low cholesterol diet, a low salt diet, an exercise
plan, and weight reduction. A person with congestive heart failure, who has damage to the heart from an
underlying illness, requires life-long treatment. However, a person can recover completely if the
symptoms of heart failure are caused by an illness that does not damage the heart.
General treatment for congestive heart failure usually includes:

Healthy heart diet:

o

Low cholesterol diet

Low fat diet

Low salt diet for CHF

Fluid restriction for congestive heart failure

Elastic support stockings fro swollen lower legs

Exercise plan developed by a doctor

Smoking cessation

Medications for the treatment of congestive heart failure may include:

Beta-blocker medications

ACE inhibitor medications

Angiotensin receptor blocker medications

Long acting nitroglycerin

o

Isosorbide mononitrate (Imdur)

Isosorbide dinitrate (Isordil)

Diuretics:
o

Furosemide (Lasix)

Metolazone (Mykrox, Zaroxolyn)

High dose nitrates:

o

Nitroglycerin (Nitro-Bid, Nitrol, Nitrostat)

Nitroprusside sodium (Nitropress)

Morphine sulfate (Duramorph, Astramorph)

Digoxin

Medications for low blood pressure:

Dopamine (Intropin)

Dobutamine (Dobutrex)

Human B-type natriuretic peptides:

o

Nesiritide (Natrecor)

Additional treatment for congestive heart failure may include:

Oxygen therapy

Surgery:
o

Heart valve surgery

Coronary artery bypass surgery for coronary artery disease

Angioplasty for coronary artery disease

Pacemaker therapy for cardiac arrhythmias

Automatic implantable cardioverter defibrillator

Cardiac resynchronization therapy:

o

Uses a special biventricular pacemaker that allows the right and left ventricle to be
stimulated automatically.

Also has defibrillator capability

Mechanical ventilation:

Use of a ventilator to support breathing in severe heart failure

Kidney dialysis
o

Effective in the presence of end stage renal disease

Congestive Heart Failure Angioplasty

Congestive heart failure due to coronary artery disease may benefit from correcting blocked coronary
vessels.
Angioplasty is a procedure that involves the passage of a balloon-tipped catheter into a narrowed
coronary artery. When the balloon is inflated, it widens the artery by cracking plaques.
There are newer variations of this procedure that remove plaque with a rotating blade or laser.
Examples:

Balloon angioplasty

Laser angioplasty

Angioplasty tool

After angioplasty, a stent is used to help hold the artery open. Stents are tiny struts that expand against the
inside wall of the artery. They prop open the blood vessel after it has been opened.

Congestive Heart Failure Drugs

Congestive heart failure is often treated with a combination of medications. There is no standard
combination: what
works for
one person may not work well
for
another.
Congestive heart failure medications may include:

ACE inhibitors:
o

Help the heart work more efficiently

AR2 blockers:

Beta blockers:
o

Human B-type natriuretic peptide

Hydralazine

Minoxidil

Digoxin:
Improves the pumping ability of the heart

Nitrate medicines:
o

Remove excess fluid from the body

Vasodilators:

Reduce the work the heart must perform

Diuretics:
o

Reduce blood pressure in those with heart failure and hypertension.

Reduce the work the heart must perform

Blood thinners:
o

Coumadin

Plavix

Aspirin

Dipyridamole

Congestive Heart Failure ACE Inhibitors

The chronic management of congestive heart failure usually includes the use of an ACE inhibitor
medication. ACE inhibitors dilate the arteries and allow blood to flow with less resistance. This has the
effect of reducing the pumping work of the heart.These drugs have clearly been shown to reduce
mortality and delay the progression of congestive heart failure. Other studies have shown that ACE
inhibitors improve life expectancy in patients who have suffered a heart attack. Higher doses of ACE
inhibitors appear to be more effective than lower doses without additional side effects.
ACE inhibitors:

Accupril (quinapril)

Altace (ramipril)

Capoten (captopril)

Lotensin (benazepril)

Mavik (trandolapril)

Monopril (fosinopril)

Prinivil (lisinopril)

Univasc (moexipril)

Vasotec (enalapril)

Congestive Heart Failure AR2 Blockers

A newer class of drugs similar to ACE inhibitors is known as angiotensin II receptor blockers. These
medications are usually prescribed for people who cannot take ACE inhibitors because of side effects.
Most patients may benefit from a drug in this class or an ACE inhibitor, but will seldom need both.
These drugs work by blocking the binding of angiotensin II to type 1-angiotensin II receptors in the body.
The effect is a reduction in the effects of the hormone angiotensin II. Angiotensin II plays a major role in
the maintenance of blood pressure in the human body.
Common AR2 blockers:

Candesartan (Atacand)

Irbesartan (Avapro)

Losartan (Cozaar)

Telmisartan (Micardis)

Valsartan (Diovan)

Eprosartan (Teveten)

Olmesartan (Benicar)

Congestive Heart Failure Beta-Blockers

Beta-blocker drugs have also been shown to slow the progression of chronic congestive heart failure.
Metoprolol (Lopressor) is one of three beta-blockers that have been shown to help some people with heart
failure. The other two that have been shown to be beneficial are carvedilol (Coreg) and bisoprolol
(Zebeta).

Beta-blockers:

Atenolol

Carvedilol (Coreg)

Inderal

Kerlone

Labetalol

Lopressor

Metoprolol (Toprol XL)

Nadolol

Pindolol

Propranolol

Timolol

Toprol

Visken

Ziac

Congestive Heart Failure Blood Thinners

Congestive heart failure patients who regularly take anti-platelet agents such as aspirin, dipyridamole, and
Plavix have better survival, and a reduced risk of death or hospital admission for heart failure. More
aggressive anticoagulation may need to be undertaken in those who are at risk for deep venous
thrombosis and pulmonary embolism.
Blood thinners:

Heparin

Warfarin (Coumadin)

Congestive Heart Failure Cardiac Glycosides

Cardiac glycosides are a group of medications that can improve the pumping ability of the heart. Options
include digoxin and digitoxin.

Digoxin may decrease symptoms and increase exercise tolerance in some congestive heart failure
patients. These drugs work by helping the heart to contract more forcefully. They help clear excess fluid
from the lungs and eliminate salt from the body.
Cardiac glycosides can be very effective but must be closely regulated. It can easily cause side effects and
toxicity. Blood levels are routinely measured to make sure they remain within a normal level.

Congestive Heart Failure Diuretics

Diuretics, such as furosemide (Lasix), bumetanide (Bumex), or torsemide (Demadex), help to reduce
excess fluid in the body by increasing urination and eliminating salt. The effect is reduced strain on the
heart and more effective pumping.
Diuretics:

Furosemide (Lasix)

Metolazone (Mykrox, Zaroxolyn)

Bumetanide (Bumex)

Torsemide (Demadex)

Hydrochlorothiazide (HydroDIURIL)

Chlorothiazide

Indapamide

Congestive Heart Failure Nesiritide

Nesiritide is a purified, natural hormone called human B-type natriuretic peptide, which is produced in the
ventricles of the heart. Nesiritide causes veins and arteries to dilate and promotes renal excretion of
sodium and water. These actions reduce stress on the weakened heart seen in patients with congestive
heart failure. This allows the weakened heart to function more efficiently and improves patient symptoms.
Concurrent administration with ACE inhibitors and other vasodilators may cause low blood pressure.

Congestive Heart Failure Nitrates

These drugs are useful in the care of congestive heart failure due to coronary artery disease. A regular
schedule of nitrates can help to decrease the incidence of anginal attacks and control blood pressure.
Nitrates dilate the veins encouraging blood to more readily return to the heart. They also open up the
arteries that supply the heart itself. Both of these effects work together to reduce the heart muscles
demand for oxygen and increase its supply.
Nitrates:

Isosorbide mononitrate (Imdur)

Isosorbide dinitrate (Isordil)

Surgical options for the treatment of congestive heart failure include:

eart valve replacement or repair:
Valvular surgery can help many patients with severe aortic stenosis, aortic regurgitation, mitral stenosis, and mitral
regurgitation.
Coronary artery bypass grafting:
In this procedure, vein grafts are taken from the patient's leg and then used to reconstruct a new coronary vessel. In
certain patients, surgery can remove scarred heart tissue to improve overall pumping action.
Heart transplantation:
Some individuals with severe heart failure and pulmonary hypertension may be candidates for heart lung
transplantation. Heart transplantation is becoming more and more effective with the advent of chemical agents that
suppress the immune response and inhibit organ rejection.
Biventricular pacemaker:
Also referred to as cardiac resynchronization therapy, it involves the placement of two pacemaker electrodes in the
heart: one in the front and one in the back of the heart. This procedure has been shown to improve exercise capacity
as well as prolong life.
PATIENT CARE

for congestive heart failure includes:

Measure your weight daily.

o

Keep a log of the results.

Stop smoking

Avoid exposure to secondary smoke

Eat a healthy heart diet:

o

Limit your intake of fat to 30% of your total calories.

10% to 15% of your total calories should be in the form of monounsaturated fats, such as
olive oil, canola oil and peanut oil.

Low cholesterol diet.

Low salt diet.

Eat foods rich in omega-3 fats

If you have been prescribed medications to control high cholesterol, so not skip doses.

Follow an exercise plan developed with your doctor

Weight loss if you are overweight.

Take any prescribed heart medications as directed:

Don't skip doses of your heart medication

Avoid running out of your prescribed heart medications

Don't stop your medication when you feel better

Talk to your doctor before stopping your heart medication if you feel worse.

Be aware of potential drug side effects

Learn how to take your blood pressure.

o

Check your blood pressure every day:

o

If you have high blood pressure, don't skip doses of your medication

Keep a log of your results.

If you have diabetes:

o

Check your blood sugar every day.

Keep a log of your results.

Take your diabetes medication as directed

Learn how to take your own pulse.

o

Notify your doctor if your heart rate is high or irregular

Control chronic stress and anxiety

Let your doctor know if you are suffering from severe or prolonged depression.

Avoid alcohol, or drink alcohol in moderation:

o

For men: no more than 2 alcoholic beverages per day

For women: no more than 1 alcoholic beverage per day

Learn everything you can about congestive heart failure:

o

The more you know about your condition, the easier it will be to participate with your
doctor in making treatment decisions.

Ask your doctor about good sources for information.

Write down questions to ask your doctor

Congestive Heart Failure Diet

Dietary changes for people with congestive heart failure include:

Control dietary salt: Lower dietary sodium by following a special diet that is low in salt. All
heart failure patients should limit salt intake to 1,000-1,500 mg of sodium per day. Foods that are
high in salt should be avoided.
o

Fluid restriction: Ask your doctor what degree you need to restrict fluid consumption. Ask your
doctor how many 8 ounce cups (240 ml) of water you allowed to drink per day.
o

Remember 2 cups (1 pint or about 500 ml) of retained fluid will equal one pound (2.2 kg)
of fluid weight gain.

Heart healthy diet: Follow a proper heart diet, which is low in saturated fats and cholesterol.
Most people with heart failure taking a diuretic medication need to eat potassium rich foods.
o

Do not use table salt; consider a salt substitute with your doctor's consent. Season foods
with dried herbs, garlic, onion, or lemons.

Potassium rich foods include bananas, apricots, raisins, oranges, grapefruit, and peas.

Magnesium: Eat foods rich in magnesium. Heart failure drugs can deplete the body's stores of
magnesium. This has been correlated with more severe symptoms and a higher death rate.
o

Foods high in magnesium include wheat germ, soybeans, oatmeal, nuts, seeds, low-fat
diary items, and seafood.

A generally healthy diet for people with heart disease should include:

Control calories:
o

Eat just enough calories to achieve and maintain a healthy weight.

Eat quality fats:

Eat the right amount of fats, carbohydrates and protein:

o

Limit your fat intake to 20 or 30 percent, but don't substitute simple carbohydrates for fat.

Less than 7% of the day's total calories from saturated fat.

Up to 10% of the day's total calories from polyunsaturated fat.

Up to 20% of the day's total calories from monounsaturated fat

Avoid fad diets:

o

Eat a well-rounded diet instead.

Eat small, frequent meals.

Avoid large and heavy meals.

Limit cholesterol in diet:

o

To less than 200 milligrams a day.

Limit iron intake:

o

Use virgin olive oil and other unsaturated, low-cholesterol fats.

Too much iron can increase atherosclerosis.

Eat enough dietary fiber:

o

Whole grains are best.

Eat plenty of fresh fruit and vegetables

Reduce salt in your diet

o

Optimal: no more than 1,500 milligrams per day.

Check with your doctor about supplementing your diet with B vitamins:
o

Vitamin B1 (thiamine)

Vitamin B2 (riboflavin)

Vitamin B3 (niacin)

Vitamin B5 (pantothenic acid)

Vitamin B6 (pyridoxine)

Vitamin B12 (cobalamin)