Norfolk County Cardiologist Association
Congestive Heart Failure
If you don'/t know what it means, medically speaking, "heart failure" sounds pretty scary. But it really isn't. If your doctor says you have congestive heart failure (CHF), it doesn't mean your heart has stopped breathing, or that you're about to die. It just means that your heart isn't pumping as well as it should be.
In cases of congestive heart failure, the heart keeps working, but less efficiently. As a result the body's need for oxygen-rich blood (both during exercise and rest) aren't fully met.
Congestive heart failure is a condition in which a weakened heart exists along with a buildup of fluid in the body. It can be caused by many forms of heat disease.
WHAT'S THE HEART'S NORMAL JOB?
The heart's main job is to pump the right amount of blood to all parts of the body. The circulating blood brings food and oxygen to the body's tissues and helps take away waste products.
How much blood the heat pumps depends on the body's activities. At rest the body needs a relatively small amount of blood; during strenuous exercise the tissues and organs need more oxygen and food so the heart pumps more blood. To meet the varying demands for blood, the heartbeats faster or slower and the vessels expand or relax to distribute the blood properly.
The heart works hard during exercise, but illnesses also can make the heart pump harder to meet the body's needs for extra oxygen and nutrients. Under normal conditions, though, a healthy heart has enormous reserves to draw on to ensure adequate circulation.
WHAT CAUSES CONGESTIVE HEART FAILURE?
Common causes are:
1. Narrowing arteries that supply blood to the heart muscle (coronary artery disease).
2. Past heart attack (myocardial infarction) with scar tissue that interferes with the heat muscle's normal work.
3. High blood pressure.
4. Heart valve disease due to past rheumatic fever or other causes.
5. Primary disease of the heart muscle itself (cardiomyopathy).
6. Defects in the heart present at birth (congenital heart disease).
7. Infection of the heart valves and/or heart muscle itself (endocarditis and/or myocarditis).
Each one of these seven disease processes can lead to congestive heart failure. They can do this
1. By reducing the strength of the muscle contraction,
2. By limiting the ability of the heart chambers to fill with blood because of mechanical problems, or
3. By filling the hearts pumping chambers with too much blood.
Because these disease processes are usually present for years, congestive heart failure typically doesn't occur suddenly. It gradually gets worse over time.
WHAT HAPPENS IN CONGESTIVE HEART FAILURE?
When the heart doesn't pump as efficiently as it should, the blood flow slows down and less blood is pumped. Then blood returning to the heart backs up in the veins. This forces fluid from the blood vessels into tissues of the feet and legs. The swelling that follows is called edema of the feet , ankles, and legs. Sometimes the edema involves the wall of the abdomen and the liver, too. (Not all edema results from congestive heart failure - only a doctor is qualified to make this diagnosis.)
The heart's left side receives oxygenated blood from the lungs, then pumps it to the rest of the body. When the heart's left side isn't pumping as well as it should be, blood backs up in the vessels of the lungs. Sometimes fluid is forced our of the lung vessels into the breathing spaces themselves. When this happens it's called pulmonary edema; shortness of breath and a lack of stamina often follow.
The kidneys' ability to dispose of sodium (salt) and water is also impaired in cases of congestive heart failure. Sodium that normally would be eliminated in the urine stays in the body and holds water. This makes the excess fluid problem that already exists even worse.
A final problem is that a person who has CHF may feel tired. This happens because not enough blood circulates and tissues and organs don't get as much oxygen and food as they need.
When congestive heart failure is present, the body tires to compensate. One way the heart adjusts is by enlarging. When the heart chamber enlarges, it stretches more and can contract more strongly, so it pumps more blood.
A second way the heart compensates is by developing more muscle mass. This increases the total number of muscle fibers able to contract. More heart muscle fibers means the heart can pump more strongly.
One final way the body compensates is by increasing the stimulation of the heart muscle. This causes the heart to pump more often and improves circulation.
At first these ways of compensating help the heart keep working normally or almost normally. However, when the disease processes worsen, compensation starts to make matters worse. Then it contributes to the deterioration of a person's condition over time.
WHAT ARE THE SIGNS OF CONGESTIVE HEART FAILURE?
The most common symptom is shortness of breath caused by fluid in the lungs. Breathlessness is most often a problem during exercise, but it can also occur when a person is resting. Sometimes it may come on suddenly at night, making it extremely hard to breath unless several pillows are used to raise the upper body. Occasionally a person will wake up from sleep.
Although breathing problems are the most common symptoms of congestive heart failure, they aren't the only ones. Sometimes victims cough up pinkish, blood-tinged phlegm. Another sign (already discussed) is the buildup of excess fluid in the body's tissues, causing edema of the legs and sometimes the abdomen. Weight gain often results.
Finally, symptoms that show that blood isn't being pumped efficiently include tiredness, weakness and the inability to exert oneself. Older people with the disease can suffer from confusion and impaired thinking.
Often a doctor can tell from a physical exam that a person has congestive heart failure. By looking at a patient a doctor can see signs of excess body fluid; by listening through a stethoscope to a person's breathing a physician can learn that there's too much fluid in the lungs; and by examining the heart a doctor can learn that it's not working normally.
CAN PEOPLE WITH CONGESTIVE HEART FAILURE EXERCISE?
As a general rule, it's better for people with congestive heart failure to stay active. By exercising regularly and staying in good shape, they'll feel better and be able to do more.
If you have congestive heart failure, it's important to discuss an exercise program with your doctor. In some cases a supervised exercise test ( a so-called stress test) may be necessary before you can start an exercise program at home. Aerobic exercise, such as walking, swimming or biking, is preferable.
Avoid isometric exercises that require holding your breath, bearing down and sudden bursts of energy. Also avoid lifting weights, competitive or contact sports and exercises that cause chest pain, shortness of breath, dizziness, and lightheadedness.
People with the disease shouldn't exercise right after meals, when it's too hot or humid, or when they don't feel good. Extra rest helps during emotional stress or illness, especially when a person has a fever. Often people with CHF complain that they wake up tired because lying flat makes it harder to breath or causes them to cough. Another problem is that their sleep may be interrupted because they need to urinate (pass water).
To improve your sleep at night, use pillows to prop up your head, and avoid naps and big meals right before bedtime. Also discuss with your doctor changing the time for taking medications - especially diuretics. This may keep you from having to urinate often during the night.
HOW IS CONGESTIVE HEART FAILURE TREATED?
Once congestive heart failure has been diagnosed, it can almost always be managed. With the right treatment and some adjustments in daily life, patients usually feel a lot better. The treatment should reduce fatigue, shortness of breath and swelling; maintain a better energy level, well-being and ability to exercise; prevent or slow down the progress of the disease; and allow patients to live longer and more comfortably.
The first way to treat this disease is to limit salt intake, maintain potassium and magnesium at normal levels, and control weight. Salt should always be restricted for people with impaired heart function. The reason is that excess salt contributes to water retention, which makes the heart work harder and causes shortness of breath and swollen ankles. Too much salt also can cause imbalances in important minerals in the body, such as potassium and magnesium.
There are certain things that people with congestive heart failure should and shouldn't do to limit their intake of salt. Things you should do include:
1. Take the salt shaker off the table.
2. Use low-salt seasoning.
3. Substitute fresh vegetables and other low-sodium foods for canned and processed foods.
4. Always read food labels to check on salt content.
5. Discuss the use of salt substitutes with your doctor ( since these may contain extra potassium, which may or may not be appropriate).
Things you should not do are:
1. Don't use seasonings that taste salty.
2. Don't eat foods or snacks with salt on them.
3. Don't take medicines for headaches or heartburn that contain sodium bicarbonate or sodium carbonate.
The usual daily American diet contains up to three teaspoons of salt. People who need to lower their salt intake can reduce it by 30 percent just by taking the salt shaker off the table. Cooking without salt can reduce salt intake by 30 percent more. Good-tasting meals can be prepared using less than one teaspoon of salt a day.
People who have congestive heart failure should weight themselves every morning, because weight gain for several days in a row may be the first sign of fluid buildup that may cause shortness of breath and swelling. They should also talk to their doctor about how much liquid to drink every day and about the weight changes that do occur.
People with CHF usually are given a water pill (diuretic), to help their body get rid of extra water and sodium. This helps their body get rid of extra water and sodium. This helps reduce the heart's workload and makes it easier for the heart to handle the body's demands. But the water pills may have some adverse side effects.
One of the most important and common side effects is potassium loss. Potassium is essential for the body to work properly. It also maintains the electric stability of the heart and nervous system. If patients take a water pill, they must strive to keep their potassium intake high unless their doctor tells them otherwise. Vomiting, diarrhea and using too many laxatives or drugs such as steroids also can cause potassium loss.
Several fruits and vegetables are rich in potassium. Bananas, cantaloupes, orange and grapefruit juice, and potatoes are examples. If a person isn't getting enough potassium in the diet, a doctor may prescribe potassium supplement to help maintain a proper balance. It's important to remember that too much potassium can be harmful and even life-threatening. If a person has kidney failure or the kidneys can't adequately eliminate potassium - or if special drugs are being taken - the doctor should give specific guidelines to avoid potassium buildup.
Often a medication called digitalis (Digoxin) is prescribed to strengthen the heart muscle's pumping action. The level of digitalis in the body can be monitored using a blood test. A doctor may order this test now and then to check if a patient is taking too much, too little or the right amount of the drug. When excess digitalis builds up in the blood, patients may have blurred vision, ringing in their ears, nausea and an irregular heart rhythm. Also, the heart rate may become too fast or too slow.
Often treating congestive heart failure means using special medicines called vasodilators. They cause the blood vessels to expand, making it easier for blood to flow and reducing the heart's work. Some vasodilators, such as nitrates, (Nitroglycerin, Isosorbide, Dinitrate), mainly dilate the veins. Others (Hydralazine) work mostly on the arteries. Still others, such as angiotensin-converting enzyme inhibitors (Captopril, Enalapril, Lisynopril), dilate both veins and arteries. Some vasodilators also work on the heart muscle cells themselves and may keep the heart from getting larger and the disease from getting worse.
Surgical treatment is another option. A diseased heart valve may be surgically replaced with an artificial one. Congestive heart defects that result in congestive heart failure often can be repaired by surgery. Finally, sometimes coronary artery bypass graft surgery is recommended to treat CHF.
Some people have such severe congestive heart failure that they can't be helped by medications or surgery. They may need to have their old, diseased heart replaced with an new one. About 2,000 Americans each year undergo a heart transplant.
This procedure has dramatically improved the survival and quality of life of people with severe CHF. For more information please request the American Heart Association booklet on heart transplantation.
Congestive heart failure isn't a hopeless condition. In most cases medicines can effectively treat it. By getting good medical care, following a doctor's advice, and understanding the disease and its treatment, people with CHF should be able to lead full, active lives.
As the causes of congestive heart failure become better understood, new drugs are being developed at specialized medical centers. These drugs will improve people's lives by stopping or reversing the things that cause this disease to start and progress.
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