Heart Failure

Heart failure, also called congestive heart failure, is a life-threatening condition in which the heart can no longer pump enough blood to the rest of the body.

Causes

Heart failure is almost always a chronic, long-term condition, although it can sometimes develop suddenly. This condition may affect the right side, the left side, or both sides of the heart.

As the heart's pumping action is lost, blood may back up into other areas of the body, including the:

• Gastrointestinal tract, arms, and legs (right-sided heart failure)
• Liver
• Lungs (left-sided heart failure)

Heart failure results in a lack of oxygen and nutrition to organs, which damages them and reduces their ability to function properly. Most areas of the body can be affected when both sides of the heart fail.

The most common causes of heart failure are:

• Coronary artery disease
• High blood pressure

Other structural or functional causes of heart failure include:

• Cardiomyopathy
  • Dilated cardiomyopathy
  • Hypertropic cardiomyopathy
  • Restrictive cardiomyopathy
• Congenital heart disease
• Heart valve disease
• Heart tumor
• Lung disease

Heart failure becomes more common with advancing age. You are also at increased risk for developing heart failure if you are overweight, have diabetes, smoke cigarettes, abuse alcohol, or use cocaine.

Symptoms

• Cough
• Decreased alertness or concentration
• Decreased urine production
• Difficulty sleeping
• Fatigue, weakness, faintness
• Irregular or rapid pulse
• Loss of appetite, indigestion
• Nausea and vomiting
• Neck veins that stick out
• Need to urinate at night
• Sensation of feeling the heart beat (palpitations)
• Shortness of breath with activity, or after lying down for a while
• Swelling of the abdomen
• Swelling of feet and ankles
• Weight gain

Infants may sweat during feeding (or other activity).

Some patients with heart failure have no symptoms. In these people, the symptoms may develop only with these conditions:

• Abnormal heart rhythm (arrhythmias)
• Anemia
• Hyperthyroidism
• Infections with high fever
• Kidney disease

Exams and Tests

A physical examination may reveal the following:

• Fluid around the lungs (pleural effusion)
• Irregular heartbeat
• Leg swelling (edema)
• Neck veins that stick out (are distended)
• Swelling of the liver

Listening to the chest with a stethoscope may reveal lung crackles or abnormal heart sounds. Blood pressure may be normal, high, or low.

The following tests may reveal heart swelling or decreased heart function:

• Cardiac MRI
• Chest CT scan
• Chest x-ray
• ECG, which may also show arrhythmias
• Echocardiogram
• Heart catheterization
• Nuclear heart scans

This disease may also alter the following test results:

• Blood chemistry
• BUN
• Complete blood count
• Creatinine
• Creatinine clearance
• Liver function tests
• Serum uric acid
• Serum sodium
• Urinalysis
• Urinary sodium

Treatment

If you have heart failure, your doctor will monitor you closely. You will have follow up appointments at least every 3 to 6 months and tests every now and then to check your heart function. For example, an ultrasound of your heart (echocardiogram) will be done once in awhile to see how well your heart pumps blood with each beat.

You will need to carefully monitor yourself and help manage your condition. One important way to do this is to track your weight on a daily basis. Weight gain can be a sign that you are retaining fluid and that the pump function of your heart is worsening. Make sure you weigh yourself at the same time each day and on the same scale, with little to no clothes on.

Other important measures include:

• Take your medications as directed. Carry a list of medications with you wherever you go.
• Limit salt intake.
• Don’t smoke.
• Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan based on your degree of heart failure and how well you do on tests that check the strength and function of your heart. DO NOT exercise on days that your weight has gone up from fluid retention or you are not feeling well.
• Lose weight if you are overweight.
• Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest as well. Keep your feet elevated to decrease swelling.

Here are some tips to lower your salt and sodium intake:

• Look for foods that are labeled “low-sodium,” “sodium-free,” “no salt added,” or “unsalted.” Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels.
• Don’t cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG).
• Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese.
• Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese.
• Use oil and vinegar, rather than bottled dressings, on salads.
• Eat fresh fruit or sorbet when having dessert.

Your doctor may consider prescribing the following medications:

• ACE inhibitors such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart
• Diuretics including thiazide, loop diuretics, and potassium-sparing diuretics to help rid your body of fluid and sodium
• Digitalis glycosides to increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances
• Angiotensin receptor blockers (ARBs) such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors
• Beta-blockers such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease

If you have sudden (acute) heart failure, you may be admitted to the hospital. Treatment may involve:

• Oxygen
• Medicines given through a vein, including dobutamine or milrinone, which help the heart pump blood
• A medication called nesiritide (Natrecor) to help dilate blood vessels

Swan-Ganz catheterization may be needed in some cases. If excessive fluid has gathered around the sac surrounding the heart (pericardium), pericardiocentesis will be done.

Severe heart failure may require the following treatments:

• Thoracentesis to remove excess fluid
• Implanted devices such as the intra-aortic balloon pump (IABP) and the left ventricular assist device (LVAD)

These devices can be life-saving, but they are not permanent solutions. Patients who become dependent on circulatory support will need a heart transplant.

Heart failure symptoms may be improved with biventricular pacemaker or cardiac resynchronization therapy. Ask your provider if you are a candidate for this type of treatment.

Outlook (Prognosis)

Heart failure is a serious disorder. It is usually a chronic illness, which may get worse with infection or other physical stress.

Many forms of heart failure can be controlled with medication, lifestyle changes, and treatment of any underlying disorder.

Possible Complications

• Irregular heart rhythms (can be deadly)
• Pulmonary edema
• Total heart failure (circulatory collapse)

Possible side effects of medications include:

• Cough
• Digitalis toxicity
• Gastrointestinal upset (such as nausea, heartburn, diarrhea)
• Headache
• Light-headedness and fainting
• Low blood pressure
• Lupus reaction
• Muscle cramps

When to Contact a Medical Professional

Call your health care provider if weakness, increased cough or sputum production, sudden weight gain or swelling, or other new or unexplained symptoms develop.

Go to the emergency room or call the local emergency number (such as 911) if you experience severe crushing chest pain, fainting, or rapid and irregular heartbeat (particularly if other symptoms accompany a rapid and irregular heartbeat).

Prevention

Follow your health care provider's treatment recommendations and take all medications as directed.

Keep your blood pressure, heart rate, and cholesterol under control as recommended by your doctor. This may involve exercise, a special diet, and medications.

Other important treatment measures:

• Do not smoke.
• Do not drink alcohol.
• Reduce salt intake.
• Exercise as recommended by your health care provider.

References

Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. J Am Coll Cardiol. 2005;46:1-82.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 25.

Hess OM and Carroll JD. Clinical assessment of heart failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 23.