Congestive Heart Failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood through to meet the body’s needs for blood and oxygen. It is the inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide adequate blood flow to other organs such as the brain, liver, and kidneys. Heart failure may be due to failure of the right or left or both ventricles.
At first, the heart tries to make up for this by
- Enlarging – The heart stretches to contract more strongly and keep up with the demand to pump more blood. Over time this causes the heart to become enlarged.
- Developing more muscle mass – The increase in muscle mass occurs because the contracting cells of the heart get bigger. This lets the heart pump more strongly, at least initially.
- Pumping faster – This helps to increase the heart’s output.
The body also tries to compensate in other ways
- The blood vessels narrow to keep blood pressure up, trying to make up for the heart’s loss of power.
- The body diverts blood away from less important tissues and organs (like the kidneys), and towards the heart and brain.
These temporary measures mask the problem of heart failure, but they don’t solve it. Heart failure continues and worsens until these substitute processes no longer work.
Types of Heart Congestive Heart Failure
Systolic heart failure – This happens when your heart muscle doesn’t squeeze with enough force. When that’s the case, it pumps less oxygen-rich blood through your body.
Diastolic heart failure – Your heart squeezes normally, but the ventricle — the main pumping chamber — doesn’t relax properly. This lowers the amount of blood that can enter your heart and raises blood pressure in your lungs. When that happens, you get fluid in your lungs, legs, and belly.
Heart failure can involve the left side (left ventricle), right side (right ventricle) or both sides of your heart. Generally, heart failure begins with the left side, specifically the left ventricle — your heart’s main pumping chamber.
Stages of Congestive Heart Failure
The American Heart Association and American College of Cardiology have put out a list of heart failure stages that helps you understand how the condition changes over time and the kinds of treatments that are used in each phase.
Stage A – This is the period when you are at risk for heart failure. You may be in this stage if you have:
- High blood pressure
- Coronary artery disease
- Metabolic syndrome
You may also be at risk if you have a history of:
- Cardiotoxic drug therapy
- Alcohol abuse
- Rheumatic fever
- Family members with cardiomyopathy
If you’re in stage A, your doctor may suggest lifestyle changes and treatment such as:
- Regular exercise
- If you smoke, quit.
- Treat high blood pressure or high cholesterol.
- Stop drinking alcohol or using illegal drugs.
- Take an ACE inhibitor or an angiotensin II receptor blocker (ARB) if you’ve had coronary artery disease or if you have diabetes, high blood pressure, or other heart and blood vessel conditions.
- Take beta-blockers if you have high blood pressure or you’ve had a heart attack.
Stage B – You’re in this phase if you never had symptoms of heart failure but you’re diagnosed with systolic left ventricular dysfunction, which means the left chamber of your heart doesn’t pump well. You may be in this group if you had or have:
- Heart attack
- Valve disease
Treatments for Stage B – Depending on your situation, your doctor may suggest treatments such as
- ACE inhibitor or angiotensin II receptor blocker (ARB)
- Beta-blockers after a heart attack
- Aldosterone inhibitor if the symptoms continue while you are taking beta-blockers and ACE/ARB medications
- Surgery for coronary artery repair and valve repair or replacement
- Implantable cardiac defibrillator (ICD)
Stage C – You’re in this phase if you have systolic heart failure along with symptoms such as:
Treatments for Stage C – Your doctor may suggest treatments like these, depending on your specific condition:
- ACE inhibitors and beta-blockers
- Hydralazine/nitrate combination for some people if symptoms persist
- Diuretics (water pills) and digoxin if you continue to have symptoms
- Aldosterone inhibitor when your symptoms stay severe with other treatments
- Angiotensin receptor blocker and neprilysin inhibitors
- Biventricular pacemaker
- Implantable cardiac defibrillator (ICD)
- Eat less salt.
- Lose weight if you’re overweight.
- Drink fewer fluids if necessary.
- Stop drugs that make your condition worse.
Stage D – You’re in this phase if you have systolic heart failure and advanced symptoms after you get medical care.
Treatments for Stage D – Your doctor may suggest some of the treatments from stages A, B, and C. You may also talk with your doctor about some other kinds of treatments, like:
- Heart transplant
- Ventricular assist devices
- Surgery options
- Continuous infusion of intravenous inotropic drugs
Classification of Congestive Heart Failure
There are many different ways to categorize heart failure, including
- The side of the heart involved (left heart failure versus right heart failure). Right heart failure compromises pulmonary flow to the lungs. Left heart failure compromises aortic flow to the body and brain. Mixed presentations are common; left heart failure often leads to right heart failure in the longer term.
- Whether the abnormality is due to insufficient contraction (systolic dysfunction), or due to insufficient relaxation of the heart (diastolic dysfunction), or to both.
- Whether the problem is primarily increased venous back pressure (preload), or failure to supply adequate arterial perfusion (afterload).
- Whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high-output heart failure).
- The degree of functional impairment conferred by the abnormality (as reflected in the New York Heart Association Functional Classification)
- The degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/kidney failure, etc.
Functional classification generally relies on the New York Heart Association functional classification. The classes (I-IV) are:
- Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
- Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
- Class III: marked limitation of any activity; the patient is comfortable only at rest.
- Class IV: any physical activity brings on discomfort and symptoms occur at rest.
This score documents the severity of symptoms and can be used to assess response to treatment. While its use is widespread, the NYHA score is not very reproducible and does not reliably predict the walking distance or exercise tolerance on formal testing.
In its 2001 guidelines, the American College of Cardiology/American Heart Association working group introduced four stages of heart failure
- Stage A: Patients at high risk for developing HF in the future but no functional or structural heart disorder.
- Stage B: a structural heart disorder but no symptoms at any stage.
- Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment.
- Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.
The ACC staging system is useful in that Stage A encompasses “pre-heart failure” – a stage where intervention with treatment can presumably prevent progression to overt symptoms. ACC Stage A does not have a corresponding NYHA class. ACC Stage B would correspond to NYHA Class I. ACC Stage C corresponds to NYHA Class II and III, while ACC Stage D overlaps with NYHA Class IV.
Causes of Congestive Heart Failure
Heart failure is caused by any conditions that damage the heart muscle. These include:
- Coronary artery disease– the coronary arteries supply the heart muscle with blood. If these are blocked or the flow is reduced, the heart does not receive the blood supply it needs.
- Heart attack – a sudden block of the coronary arteries; this causes scars in the heart’s tissues and decreases how effectively it can pump.
- Cardiomyopathy – damage to the heart muscle other than by artery or blood flow problems; for instance caused by drug side effects or infections.
- Conditions that overwork the heart – for instance, valve disease, hypertension (high blood pressure), diabetes, kidney disease, or heart defects present from birth.
The following are risk factors for congestive heart failure; they may make it more likely:
- Diabetes – especially diabetes type 2.
- Obesity – people who are both obese and have diabetes type 2 have an increased risk.
- Smoking – people who smoke regularly run a significantly higher risk of developing heart failure.
- Anemia– a deficiency of red blood cells.
- Hyperthyroidism– overactive thyroid gland.
- Hypothyroidism– underactive thyroid gland.
- Myocarditis– inflammation of the heart muscle, usually caused by a virus, leading to left-sided heart failure.
- Heart arrhythmias – abnormal heart rhythms, may cause the heart to beat too fast, creating more work for the heart. Eventually, the heart may weaken, leading to heart failure. If the heartbeat is too slow not enough blood may get out from the heart to the body, leading to heart failure.
- Atrial fibrillation – an irregular, often rapid heartbeat; patients with atrial fibrillation have a higher risk of hospitalization due to heart failure, a study found.
- Emphysema– a chronic disease that makes it hard for the patient to breathe.
- Lupus – the patient’s immune system attacks healthy cells and tissues.
- Hemochromatosis – a condition where iron accumulates in the tissues.
- Amyloidosis – one or more organ systems in the body accumulate deposits of abnormal proteins.
Symptoms of Congestive Heart Failure
Heart failure signs and symptoms may include
- Shortness of breath (dyspnea) when you exert yourself or when you lie down
- Fatigue and weakness
- Swelling (edema) in your legs, ankles, and feet
- Rapid or irregular heartbeat
- Reduced ability to exercise
- excessive fatigue
- sudden weight gain
- a loss of appetite
- persistent coughing
- irregular pulse
- heart palpitations
- abdominal swelling
- shortness of breath
- leg and ankle swelling
- protruding neck veins
- Persistent cough or wheezing with white or pink blood-tinged phlegm
- Increased need to urinate at night
- Swelling of your abdomen (ascites)
- Very rapid weight gain from fluid retention
- Lack of appetite and nausea
- Difficulty concentrating or decreased alertness
- Sudden, severe shortness of breath and coughing up pink, foamy mucus
- Chest pain if your heart failure is caused by a heart attack
Diagnosis of Congestive Heart Failure
Your doctor may also order other tests to determine the cause and severity of your heart failure. These include
- Blood tests – Blood tests are used to evaluate kidney and thyroid function as well as to check cholesterol levels and the presence of anemia. Anemia is a blood condition that occurs when there is not enough hemoglobin (the substance in red blood cells that enables the blood to transport oxygen through the body) in a person’s blood.
- B-type Natriuretic Peptide (BNP) blood test – BNP is a substance secreted from the heart in response to changes in blood pressure that occur when heart failure develops or worsens. BNP blood levels increase when heart failure symptoms worsen, and decrease when the heart failure condition is stable. The BNP level in a person with heart failure — even someone whose condition is stable — is higher than in a person with normal heart function. BNP levels do not necessarily correlate with the severity of heart failure.
- Chest X-ray – A chest X-ray shows the size of your heart and whether there is fluid build-up around the heart and lungs.
- Echocardiogram –This test is an ultrasound which shows the heart’s movement, structure, and function.
- Blood and urine tests– these will check the patient’s blood count and liver, thyroid, and kidney function. The doctor may also want to check the blood for specific chemical markers of heart failure.
- An ECG (electrocardiogram)– this device records the electrical activity and rhythms of the patient’s heart. The test may also reveal any damage to the heart from a heart attack. Heart attacks are often the underlying cause of heart failure.
- An echocardiogram– this is an ultrasound scan that checks the pumping action of the patient’s heart. The doctor measures the percentage of blood pumped out of the patient’s left ventricle (the main pumping chamber) with each heartbeat – this measurement is called the ejection fraction.
- The Ejection Fraction (EF) – is used to measure how well your heart pumps with each beat to determine if systolic dysfunction or heart failure with preserved left ventricular function is present. Your doctor can discuss which condition is present in your heart.
- Electrocardiogram (EKG or ECG)-An EKG records the electrical impulses traveling through the heart.
- Cardiac catheterization – This invasive procedure helps determine whether coronary artery disease is a cause of congestive heart failure.
- Stress Test –Noninvasive stress tests provide information about the likelihood of coronary artery disease.
- Cardiac MRI (magnetic resonance imaging) or CT (computed tomography) scan – they can measure ejection fraction as well as the heart arteries and valves. They can also determine whether the patient had a heart attack.
- B-type natriuretic peptide (BNP) blood test– BNP is released into the blood if the heart is overfilled and struggling to function properly.
- Angiogram (coronary catheterization) – a catheter (thin, flexible tube) is introduced into a blood vessel until it goes through the aorta into the patient’s coronary arteries. The catheter usually enters the body at the groin or arm. A dye is injected through the catheter into the arteries.
- Coronary angiogram – In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or in your arm and guided through the aorta into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray, helping doctors spot blockages.
- Myocardial biopsy – In this test, your doctor inserts a small, flexible biopsy cord into a vein in your neck or groin, and small pieces of the heart muscle are taken. This test may be performed to diagnose certain types of heart muscle diseases that cause heart failure.
Treatment of Heart Failure
ACE inhibitors (inhibitors of Angiotensin-Converting Enzyme)
- These drugs help the arteries relax, lower blood pressure, making it easier for the heart to pump blood around the body – they lower the heart’s workload. Ace inhibitors generally boost the performance of the heart and invariably improve the quality of life of the heart failure patient. These drugs are unsuitable for some patients, though. They can cause an irritating cough in some people.
Angiotensin II receptor blockers
- These drugs, which include losartan and valsartan , have many of the same benefits as ACE inhibitors. They may be an alternative for people who can’t tolerate ACE inhibitors.
- These drugs make it harder for the blood to clot; they help thin the blood and help prevent a stroke. The most commonly used anticoagulant is Warfarin. However, it has to be carefully monitored by the doctor to ensure the blood thinning effect is not excessive, and it will only be used if you have another reason to thin your blood. There have been a lot of studies on this discussion point. Most point toward no anticoagulation in patients without a diagnosis of afibrilation with or without another indication.
Angiotensin-converting enzyme inhibitors
- (ACE inhibitors) open up narrowed blood vessels to improve blood flow. Vasodilators are another option if you cannot tolerate ACE inhibitors.
You may be prescribed one of the following
- Thiazide diuretics can cause an additional decrease in blood pressure.
- Potassium-sparing diuretics, such as triamterene , eplerenone , and spironolactone , can cause potassium buildup in the blood. This may lead to abnormal heart rhythms.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, and naproxen, can cause sodium and water retention. This may reduce the ACE inhibitor’s effect on your blood pressure.
Can reduce blood pressure and slow a rapid heart rhythm.
This may be achieved with
Beta-blockers should be taken with caution with the following medications, as they may cause an adverse reaction
- Antiarrhythmic medications, such as amiodarone , can increase cardiovascular effects, including reduced blood pressure and slowed heart rate.
- Antihypertensive medications, such as lisinopril , candesartan , and amlodipine , may also increase the likelihood of cardiovascular effects.
- The effects of albuterol on bronchodilation may be cancelled out by beta-blockers.
- Fentora may cause low blood pressure.
- Antipsychotics, such as thioridazine , may also cause low blood pressure.
- Clonidine may cause high blood pressure.
Reduce your body’s fluid content. CHF can cause your body to retain more fluid than it should.
- Thiazide diuretics – These cause blood vessels to widen and help the body remove any extra fluid. Examples include metolazone , indapamide , and hydrochlorothiazide .
- Loop diuretics – These cause the kidneys to produce more urine. This helps remove excess fluid from your body. Examples include furosemide ethacrynic acid , and torsemide .
- Potassium-sparingdiuretics –These help get rid of fluids and sodium while still retaining potassium. Examples include triamterene , eplerenone ,
Diuretics should be taken with caution with the following medications, as they may cause an adverse reaction:
- Tricyclics, such as amitriptyline and desipramine , may cause low blood pressure.
- Anxiolytics, such as alprazolam , chlordiazepoxide , and diazepam, may cause low blood pressure.
- Hypnotics, such as zolpidem and triazolam , may cause low blood pressure.
- Beta-blockers, such as acebutolol and atenolol , may cause low blood pressure.
- Calcium channel blockers, such as amlodipine and diltiazem may cause a drop in blood pressure.
- Nitrates, such as nitroglycerin and isosorbide-dinitrate , may cause low blood pressure.
- NSAIDS, such as ibuprofen, aspirin, and naproxen, may cause toxicity of the liver.
This is an abbreviated list containing only the most common drug interactions. You should always talk to your doctor before taking any new medications.
- A drug for patients with a fast irregular heart rhythm. Digoxin slows down the heartbeat.
- These stop the blood platelets from forming clots in the blood Aspirin is an antiplatelet drug and can be considered in certain patient populations. Patients who take low-dose aspirin for heart failure will need to continue taking it for the rest of their life.
These drugs include spironolactone and eplerenone . These are potassium-sparing diuretics, which also have additional properties that may help people with severe systolic heart failure live longer.
- Unlike some other diuretics, spironolactone and eplerenone can raise the level of potassium in your blood to dangerous levels, so talk to your doctor if increased potassium is a concern, and learn if you need to modify your intake of food that’s high in potassium.
Surgery of Heart Failure
In some cases, doctors recommend surgery to treat the underlying problem that led to heart failure. Some treatments being studied and used in certain people include
- Coronary bypass surgery – If severely blocked arteries are contributing to your heart failure, your doctor may recommend coronary artery bypass surgery. In this procedure, blood vessels from your leg, arm or chest bypass a blocked artery in your heart to allow blood to flow through your heart more freely.
- Heart valve repair or replacement – If a faulty heart valve causes your heart failure, your doctor may recommend repairing or replacing the valve. The surgeon can modify the original valve to eliminate backward blood flow. Surgeons can also repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly. Sometimes repairing the valve includes tightening or replacing the ring around the valve (annuloplasty).Valve replacement is done when valve repair isn’t possible.
- Implantable cardioverter-defibrillators (ICDs) – An ICD is a device similar to a pacemaker. It’s implanted under the skin in your chest with wires leading through your veins and into your heart.The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm. An ICD can also function as a pacemaker and speed your heart up if it is going too slow.
- Cardiac resynchronization therapy (CRT), or biventricular pacing – A biventricular pacemaker sends timed electrical impulses to both of the heart’s lower chambers (the left and right ventricles) so that they pump in a more efficient, coordinated manner.Many people with heart failure have problems with their heart’s electrical system that cause their already-weak heart muscle to beat in an uncoordinated fashion. This inefficient muscle contraction may cause heart failure to worsen. Often a biventricular pacemaker is combined with an ICD for people with heart failure.
- Ventricular assist devices (VADs) – A VAD, also known as a mechanical circulatory support device, is an implantable mechanical pump that helps pump blood from the lower chambers of your heart (the ventricles) to the rest of your body. A VAD is implanted into the abdomen or chest and attached to a weakened heart to help it pump blood to the rest of your body.Doctors first used heart pumps to help keep heart transplant candidates alive while they waited for a donor heart. VADs may also be used as an alternative to transplantation. Implanted heart pumps can enhance the quality of life of some people with severe heart failure who aren’t eligible for or able to undergo heart transplantation or are waiting for a new heart.
- Heart transplant – Some people have such severe heart failure that surgery or medications don’t help. They may need to have their diseased heart replaced with a healthy donor heart.
- Heart valve surgery– Diseased heart valves can be treated both surgically (traditional heart valve surgery) and non-surgically (balloon valvuloplasty).
Risk factors of Heart Failure
A single risk factor may be enough to cause heart failure, but a combination of factors also increases your risk.
- High blood pressure – Your heart works harder than it has to if your blood pressure is high.
- Coronary artery disease – Narrowed arteries may limit your heart’s supply of oxygen-rich blood, resulting in weakened heart muscle.
- Heart attack – A heart attack is a form of coronary disease that occurs suddenly. Damage to your heart muscle from a heart attack may mean your heart can no longer pump as well as it should.
- Diabetes – Having diabetes increases your risk of high blood pressure and coronary artery disease.
- Some diabetes medications – The diabetes drugs rosiglitazone and pioglitazone (Actos) have been found to increase the risk of heart failure in some people. Don’t stop taking these medications on your own, though. If you’re taking them, discuss with your doctor whether you need to make any changes.
- Certain medications – Some medications may lead to heart failure or heart problems. Medications that may increase the risk of heart problems include nonsteroidal anti-inflammatory drugs (NSAIDs); certain anesthesia medications; some anti-arrhythmic medications; certain medications used to treat high blood pressure, cancer, blood conditions, neurological conditions, psychiatric conditions, lung conditions, urological conditions, inflammatory conditions and infections; and other prescription and over-the-counter medications.Don’t stop taking any medications on your own.
- Sleep apnea – The inability to breathe properly while you sleep at night results in low blood oxygen levels and increased risk of abnormal heart rhythms. Both of these problems can weaken the heart.
- Congenital heart defects – Some people who develop heart failure were born with structural heart defects.
- Valvular heart disease – People with valvular heart disease have a higher risk of heart failure.
- Viruses – A viral infection may have damaged your heart muscle.
- Alcohol use– Drinking too much alcohol can weaken heart muscle and lead to heart failure.
- Tobacco use – Using tobacco can increase your risk of heart failure.
- Obesity – People who are obese have a higher risk of developing heart failure.
- Irregular heartbeats – These abnormal rhythms, especially if they are very frequent and fast, can weaken the heart muscle and cause heart failure.
- Coronary artery disease and heart attack – Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. The disease results from the buildup of fatty deposits (plaque) in your arteries, which reduce blood flow and can lead to heart attack.
- High blood pressure (hypertension) – If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body. Over time, this extra exertion can make your heart muscle too stiff or too weak to effectively pump blood.
- Faulty heart valves – The valves of your heart keep blood flowing in the proper direction through the heart. A damaged valve — due to a heart defect, coronary artery disease or heart infection — forces your heart to work harder, which can weaken it over time.
- Damage to the heart muscle (cardiomyopathy) – Heart muscle damage (cardiomyopathy) can have many causes, including several diseases, infections, alcohol abuse and the toxic effect of drugs, such as cocaine or some drugs used for chemotherapy. Genetic factors also can play a role.
- Myocarditis – Myocarditis is an inflammation of the heart muscle. It’s most commonly caused by a virus and can lead to left-sided heart failure.
- Heart defects you’re born with (congenital heart defects) – If your heart and its chambers or valves haven’t formed correctly, the healthy parts of your heart have to work harder to pump blood through your heart, which, in turn, may lead to heart failure.
- Abnormal heart rhythms (heart arrhythmias) – Abnormal heart rhythms may cause your heart to beat too fast, creating extra work for your heart. A slow heartbeat also may lead to heart failure.
- Other diseases – Chronic diseases — such as diabetes, HIV, hyperthyroidism, hypothyroidism, or a buildup of iron (hemochromatosis) or protein (amyloidosis) — also may contribute to heart failure.Causes of acute heart failure include viruses that attack the heart muscle, severe infections, allergic reactions, blood clots in the lungs, the use of certain medications or any illness that affects the whole body.