Congestive Heart Failure (CHF)

• Heart failure sounds frightening because it sounds like the heart just stops working. Do not be discouraged by the term heart failure. Heart failure means the tissues of the body are temporarily not receiving as much blood and oxygen as needed.
• There are two types of heart failure, systolic and diastolic.
  • Systolic heart failure: This condition occurs when the pumping action of the heart is reduced or weakened. A common clinical measurement is ejection fraction (EF). The ejection fraction is a calculation of how much blood is ejected out of the left ventricle (stroke volume) divided by the maximum volume remaining in the left ventricle at the end of diastole, or when the heart is relaxed after filling with blood. A normal ejection fraction is greater than 55%. Systolic heart failure is diagnosed when the ejection fraction has significantly decreased below the threshold of 55%.
  • Diastolic heart failure: This condition occurs when the heart can contract normally but is stiff, or less compliant, when it is relaxing and filling with blood. The heart is unable to fill with blood properly, which produces backup into the lungs and heart failure symptoms. Diastolic heart failure is more common in patients older than 75 years of age, especially in patients with high blood pressure, and it is also more common in women. In diastolic heart failure, the ejection fraction is normal or increased.
• About 5.7 million people in the United States have heart failure. The condition is more common among African Americans than Caucasians.
• About 5 million people in the United States have heart failure.
• About half of those with congestive heart failure die within five years after their diagnosis. These statistics vary widely, as a patient's exact diagnosis and response to therapy play a large role in patient survival. Any questions about diagnoses and therapy should be discussed with the treating doctor or other health care professional.
• With advancements in diagnosis and therapy for heart failure, patients are feeling better and living longer.
• Advances in research are providing more options and improving outcomes for people with congestive heart failure.

• The heart is fundamentally a blood pump. It pumps blood from the right side of the heart to the lungs to pick up oxygen. The oxygenated blood returns to the left side of the heart. The left side of the heart then pumps blood into the circulatory system of blood vessels that carry blood throughout the body.
  • The heart consists of four chambers.
  • The two upper chambers are called atria and the two lower chambers are called ventricles.
  • The right atrium and right ventricle receive blood from the body through the veins and then pump the blood to the lungs.
  • The left atrium and left ventricle receive blood from the lungs and pump it out through the aorta into the arteries, which feed all organs and tissues of the body with oxygenated blood.
• Because the left ventricle has to pump blood to the entire body, it is a stronger pump than the right ventricle.

Picture of congestive heart failure. The heart is a pump that works together with the lungs. The heart pumps blood from the veins through the lungs where oxygen is added and then moves it on to the arteries. This pumping action creates relatively high pressure in the arteries and low pressure in the veins. Image courtesy of Bryan Moss at Scott and White Hospital, and David A. Smith, MD.
 

• Heart failure is an illness in which the pumping action of the heart becomes less and less powerful. When this happens, blood does not move efficiently through the circulatory system and starts to back up, increasing the pressure in the blood vessels and forcing fluid from the blood vessels into body tissues. Symptoms depend on which area of the body is most involved in the reduced pumping action.
  • When the left side of the heart (left ventricle) starts to fail, fluid collects in the lungs (edema). This extra fluid in the lungs (pulmonary congestion) makes it more difficult for the airways to expand as a person inhales. Breathing becomes more difficult and the person may feel short of breath, particularly with activity or when lying down.
  • When the right side of the heart (right ventricle) starts to fail, fluid begins to collect in the feet and lower legs. Puffy leg swelling (edema) is a sign of right heart failure, especially if the edema is pitting edema. With pitting edema, a finger pressed on the swollen leg leaves an imprint. Non-pitting edema is not caused by heart failure.
  • As the right heart failure worsens, the upper legs swell and eventually the abdomen collects fluid (ascites). Weight gain accompanies fluid retention and is a reliable measure of how much fluid is being retained.
• Although heart failure is a serious medical condition, there are many causes and the outcome can vary from person to person. Heart failure may develop gradually over several years, or more quickly after a heart attack or a disease of the heart muscle. Congestive heart failure (CHF) is generally classified as systolic or diastolic heart failure and becomes progressively more common with increasing age. In addition, patients with risk factors for heart disease are more likely to develop congestive heart failure.

People with congestive heart failure sometimes do not suspect a problem with their heart or have symptoms that may not obviously be from the heart.

• Early symptoms may include shortness of breath, cough, or a feeling of not being able to get a deep breath, especially when lying down.
• If a person has a known breathing problem, such as asthma, chronic obstructive pulmonary disease (COPD), or emphysema, they may they are having an "attack" or worsening of that condition.
• If a person usually does not have breathing problems, they may think they have a cold, flu, or bronchitis.
• Any or several of these above conditions may coexist along with congestive heart failure.

Congestive heart failure can have the following major symptoms and signs.

Exercise intolerance

• A person may be unable to tolerate exercise or even mild physical exertion that he or she may have been able to do before. The body needs oxygen and other nutrients during physical activity. A failing heart cannot pump enough blood to provide these nutrients to the body.
• The ability to exercise, or even to walk at a normal pace, may be limited by feeling tired (fatigue) and having shortness of breath.

Shortness of breath

• If a person has congestive heart failure, he or she may have difficulty breathing (dyspnea), especially when he or she is active. Ordinary activities, such as sweeping or even walking around the house, may be difficult or impossible. The shortness of breath that accompanies these activities usually gets better with rest.
• When congestive heart failure worsens, fluid backs up into the lungs and interferes with oxygen getting into the blood, causing dyspnea at rest and at night (orthopnea). If a person has congestive heart failure, he or she may awaken at night short of breath and have to sit or stand up to get relief. This condition is known as paroxysmal nocturnal dyspnea. Several pillows may help with a more comfortable sleep. A person may also prefer sleeping in a recliner rather than in a bed. As the buildup of fluid in the lungs becomes very severe, a frothy, pink liquid may be coughed up.

Fluid retention and swelling

• Puffy swelling (edema) in the legs, the feet, and the ankles may occur, particularly at the end of the day or after prolonged sitting. Often, the swelling is more noticeable in the ankles or on the lower leg in the front where the bone, the tibia, is close to the skin.
• Pitting edema can occur when pressing down on the skin in the puffy areas. The indentation where the finger pressed may be visible for a few minutes. Pitting edema is not synonymous with heart failure; it can have other causes, including liver and kidney failure. Nonpitting edema is generally not caused by heart failure.
• Swelling may be so severe as to reach up to the hips, scrotum, abdominal wall, and eventually, the abdominal cavity (ascites).
• Daily weight checks are necessary in persons with heart failure because the amount of fluid retention is usually reflected by the amount of weight gain and increasing shortness of breath. Persons with heart failure should know their dry weight, which is what they weigh when they feel good with no pitting edema.

Congestive heart failure (CHF) is a syndrome that can be brought about by several causes. Congestive heart failure is a weakening of the heart caused by an underlying heart or blood vessel problem, or a combination of several different problems, including the following:

• Weakened heart muscle (cardiomyopathy)
• Damaged heart valves
• Blocked blood vessels supplying the heart muscle (coronary arteries), which may lead to a heart attack (This is known as ischemic cardiomyopathy. If there are other, noncoronary causes, these are collectively termed nonischemic cardiomyopathy.)
• Toxic exposures, such as alcohol or cocaine
• Infections, commonly viruses, which for unknown reasons affect the heart in only certain individuals
• High blood pressure that results in thickening of the heart muscle (left ventricular hypertrophy)
• Congenital heart diseases
• Certain genetic diseases involving the heart
• Prolonged, serious arrhythmias
• A variety of less common disorders in which the heart muscle is infiltrated by a disease process

There are over a hundred other less common causes of heart failure, which include a variety of infections, exposures (such as radiation or chemotherapy), endocrine disorders (including thyroid disorders), complications of other diseases, toxic effects, and genetic predisposition. However, the cause of congestive heart failure is often idiopathic, or unknown. People who have diabetes are at increased risk for both ischemic and nonischemic heart failure.

Congestive heart failure may be exacerbated by the following lifestyle habits:

• Unhealthy habits, such as smoking and excessive use of alcohol
• Obesity and lack of exercise (May contribute to congestive heart failure, either directly or indirectly through accompanying high blood pressure, diabetes, and coronary artery disease.)
• High salt intake, which may cause more fluid retention
• Noncompliance with medications and other therapies

Whether through disease and/or complicating lifestyle choices, the pumping action of the heart can be impaired by several physiologic mechanisms:

• Direct heart muscle damage (cardiomyopathy): The heart muscle can become weak because of damage or disease and thus does not contract or squeeze as forcefully as it should. This damage to the muscle can occur from any of the diseases mentioned above, but sometimes, the cause is unknown.
• Damage to heart muscle due to blockage: When the coronary blood supply is blocked, this results in a heart attack (myocardial infarction). A heart attack commonly causes severe pain in the chest, shortness of breath, nausea, sweating, and/or a feeling of impending doom. A heart attack may rapidly lead to either cardiac arrest (no heartbeat) or permanent damage to the left ventricle. If this damage is bad enough, that part of the heart will not work properly, which leads to heart failure. Prompt (emergency) medical attention is critical for all heart attacks.
• High blood pressure (hypertension): Abnormally high blood pressure increases the amount of work the left ventricle has to do to pump blood out to the circulatory system. Over time, this greater workload can damage and weaken the heart, leading to heart failure. Proper treatment of high blood pressure can prevent left ventricular failure.
• Heart valve problems: The valves of the heart normally keep the blood flowing in the proper direction through the heart. Abnormal heart valves impede this forward flow in one of two ways:
  • An incompetent valve is a valve that does not close properly when it should and allows blood to flow backward in the heart, "against the current." When blood flows the wrong way across a valve, the heart has to work harder to keep up its output. Eventually, this backed up blood accumulates in the lungs and the body and the heart muscle weakens.
  • A stenotic valve is a valve that does not open properly. Blood flow through the narrowed opening is blocked, creating an increased workload on the heart that can also lead to heart failure.
• Abnormal rhythm or irregular heartbeat: Abnormal heart rhythms can lower the heart's effectiveness as a pump. The rhythm may be too slow or too fast, or irregular. The heart has to pump harder to overcome these rhythm disorders. If this excessively slow or fast heartbeat is sustained over hours, days, or weeks, the heart can weaken, which may lead to heart failure.

Once a diagnosis of heart failure is established, evaluation of heart failure is important. Providing a complete and accurate history of symptoms is essential. Two major groups have established various stages of congestive heart failure.

The American College of Cardiology/American Heart Association stages patients according to the progression of their heart failure. The stages are as follows:

• Stage A: High risk for developing heart failure
  • Patient has one or more risk factors for developing heart failure.
• Stage B: Asymptomatic heart failure
  • This stage includes patients who have an enlarged or dysfunctional left ventricle from any cause, but are asymptomatic.
• Stage C: Symptomatic heart failure
  • Patient experiences heart failure symptoms -- shortness of breath, fatigue, inability to exercise, etc.
• Stage D: Refractory end-stage heart failure
  • Patient has heart failure symptoms at rest in spite of medical treatment.
  • Cardiac transplantation, mechanical devices, more aggressive medical therapy, or end-of-life care may be necessary.

The New York Heart Association classifies patients based on their physical limitations. Classifications are as follows:

• Class I: No limitations of physical activity, no symptoms with ordinary activities
• Class II: Slight limitation, symptoms with ordinary activities
• Class III: Marked limitation, symptoms with less than ordinary activities
• Class IV: Severe limitation, symptoms of heart failure at rest

Based on a clinical study, it was determined that one in every five people will develop heart failure in his or her lifetime. Some of the most common risk factors for heart failure include the following:

• Age
• Hypertension
• Physical inactivity
• Diabetes
• Obesity
• Smoking
• Metabolic syndrome
• Family history of heart failure
• Enlargement of the left ventricle
• Some types of valvular heart disease, including infection
• Coronary artery disease
• High cholesterol and triglycerides
• Excessive alcohol consumption
• Prior heart attack
• Certain exposures, such as radiation and some types of chemotherapy
• Infection of the heart muscle (usually viral)

Often cardiologists, who specialize in heart failure, can work together with primary care doctors and other health care providers to diagnose and treat congestive heart failure. Certain symptoms need to be checked by a doctor. If a person has any of the symptoms listed below, they should call their health care provider for an appointment. If symptoms listed below are severe or of sudden onset, seek immediate emergency care.

• Shortness of breath that seems to be getting worse or causes difficulty sleeping
• Waking up at night with shortness of breath
• Sleep is better in a semi-upright position in a chair or recliner than flat in bed.
• Shortness of breath develops with mild exertion and is worse than usual.
• Unusual fatigue that is not relieved with rest
• A dry cough that will not go away or seems otherwise unusual
• Swelling in the ankles, feet, or legs that does not go away

Other, more subtle symptoms of heart failure that are also seen in other diseases warrant a visit to a health care provider, especially if linked to any of the symptoms already listed above. These include:

• Abdominal bloating or discomfort
• Persistently pale skin
• Poor appetite

Always take chest pain seriously. Congestive heart failure, per se, usually does not cause chest pain. However, remember other serious conditions that cause chest pain, such as angina and myocardial infarction, can coexist with heart failure.

If these symptoms develop quickly or worsen rapidly, seek emergency treatment.

• Shortness of breath
• Severe, unrelieved chest pain
• Swelling in the legs that becomes painful, even in one leg
• Fainting or near-fainting

Congestive heart failure CHF can be confused with other illnesses that cause breathing difficulties, such as bronchitis, pneumonia, emphysema, and asthma. Talking to a medical professional, along with receiving a physical exam and tests available only at a medical office or hospital, are necessary to make an definitive diagnosis. Some of the most useful tests are mentioned below.

Chest X-ray: This is very helpful in identifying the buildup of fluid in the lungs. Also, the heart usually enlarges in congestive heart failure, and this may be visible on the X-ray film. In addition, other disorders may be diagnosed.

• An electrocardiogram (ECG, EKG) is a painless test that measures the electrical activity (rhythm) of the heart. For this test, which takes just a few minutes, one lies on a table with electrodes attached to the skin of the chest, arms, and legs. The ECG can reveal several different heart problems that can cause heart failure, including heart attacks, rhythm disorders, long-standing strain on the heart from high blood pressure, and certain valve problems.
• However, the ECG result may be normal in heart failure.

Blood tests: People may have blood drawn for lab tests.

• Low blood cell counts (anemia) may cause symptoms much like congestive heart failure or contribute to the condition.
• Sodium, potassium, magnesium, and other electrolyte levels may be abnormal, especially if the person has been treated with diuretics and/or has kidney disease.
• Tests for kidney function.
• B-type natriuretic peptide (BNP) can be measured. This is a hormone produced at higher levels by the failing heart muscle. This is a good screening test; the levels of this hormone generally increase as the severity of heart failure worsens.

Echocardiogram (echo): This is a type of ultrasound that shows the beating of the heart and the various cardiac structures. It is safe, painless, and one of the most important tests for diagnosing and following patients with heart failure over time.

• An echocardiogram can be useful in determining the cause of heart failure (such as problems with the muscle, valves, or pericardium) and it provides an accurate measurement of the left ventricle's ejection fraction, an important measure of the heart's pumping function.
• In multiple-gated acquisition scanning (MUGA scan), a small amount of a mildly radioactive dye is injected into a vein and travels to the heart. As the heart pumps, pictures are taken. The pumping performance of the left and right ventricles can then be determined from these pictures. This test is used far less often than echocardiography.

Stress testing: A treadmill or medication (nonwalking) stress test is used to help evaluate the cause or causes of heart failure, in particular, regarding coronary artery disease. This test is frequently combined with nuclear imaging or echocardiography to improve accuracy. Stress testing is commonly performed and is a cornerstone of diagnostic cardiology.

MRI (Magnetic resonance imaging):

• Magnetic fields are used to provide images of the structure of the heart and its ability to pump blood to the body.
• If used with a special MRI contrast agent (gadolinium), it can provide information about inflammation, injury, and blood flow to the heart.

Cardiac catheterization (cath): During this procedure, a small tube is inserted into and artery in the leg or arm. The catheter is moved to the heart to measure pressures inside the heart and to put contrast into the coronary arteries to look for blockages.

• Although this test is invasive, it is common and considered the “gold standard” for diagnosing coronary artery disease as well as for measuring various pressures in the heart and diagnosing certain disorders of the heart valves.

The treatment of heart failure depends on the exact cause, but it can usually be treated effectively. The overall goals are to correct underlying causes, to relieve symptoms, and to prevent worsening of the condition. Symptoms are relieved by removing excess fluid from the body, improving blood flow, improving heart muscle function, and increasing delivery of oxygen to the body tissues. This can be done by the various congestive heart failure treatments listed in this sections.

If the underlying cause of heart failure is not correctable by surgery or catheterization procedures, medical treatment is composed of lifestyle changes and medications.

Lifestyle changes recommended by your doctor or other health care professional can help relieve symptoms, slow the progression of heart failure, and improve one's quality of life. Lifestyle changes that may be helpful in preventing or relieving heart failure include those recommended by the American Heart Association and other organizations as part of a heart-healthy lifestyle.

• Once diagnosed and under the care of a qualified medical professional, patients can and should do several things at home to increase their comfort and reduce the chance of the condition getting worse.
• In fact, the more active role patients take in managing heart failure, the more likely they are to do well.
• Making the lifestyle changes described here will make a real difference. Not only will patients feel better, but they will increase their chances of a longer, healthier life.

Treat swelling with the following measures:

• Elevate the feet and legs if they are swollen.
• Eat a reduced-salt diet.
• Weigh in every morning before breakfast and record it in a diary that can be shown to a health care provider.

Avoid the following:

• Not taking prescribed medications
• Smoking (in all forms)
• Alcohol (up to one drink per day is usually fine, unless prone to excessive intake/alcoholism)
• Excessive emotional stress and/or depression (seek professional help)
• High altitude (breathing is more difficult because of the lower level of oxygen in the atmosphere; pressurized cabin air travel is usually fine)
• Herbal or other complementary medicine without first consulting a doctor to see if they are safe

Patients with congestive heart failure should know the following information that may apply to their disease:

• Keep walking or doing some form of aerobic exercise. Join a cardiac rehabilitation program (this program can monitor a person's exercise capacity).
• People with diabetes must control their blood sugar level every day. Patients should know their HbA1C level. It should be less than 7.0%, and preferably less than 6.5%.
• People with high blood pressure should measure it regularly, and make sure they know the value, (systolic pressure should be below 140 mm Hg in everyone and even below 130 in many individuals).
• People with elevated lipid levels (cholesterol and triglycerides) can take medications to get the bad cholesterol (LDL) below 70 optimally (or at least below 100), good cholesterol (HDL) above 40 for men and 50 for women, and the triglycerides below 150.

Medications help control both the underlying causes of heart failure and the symptoms. Medications are the most critical part of therapy for heart failure. Usually, several types of medications are required to address as many of the physiologic imbalances as possible.

People with heart failure usually take several different medications that work in different ways to lessen heart failure symptoms, to prevent worsening of the underlying disease, and to prolong life.

Diuretics (water pills): The buildup of fluid is usually treated with a diuretic.

• Diuretics cause the kidneys to remove excess salt and accompanying water from the bloodstream, thereby reducing the amount of blood volume in circulation. With a lower volume of blood, the heart does not have to work so hard. The number of red and white blood cells is not changed.
• The end result is an improvement in the ability to breathe (clear out water in the lungs) and a lessening of the swelling in the lower body.
• Most of these drugs tend to remove potassium from the body, but some drugs, such as diuretics containing triamterene or spironolactone, can increase potassium levels, so either way potassium levels need to be monitored carefully.
• Diuretics commonly used in heart failure include furosemide (Lasix), bumetanide (Bumex), hydrochlorothiazide (HCTZ), spironolactone (Aldactone), eplerenone (Inspra), triamterene (Dyrenium), torsemide (Demadex), or metolazone (Zaroxolyn), or a combination agent (for example, Dyazide).
• Spironolactone and eplerenone are not only mild diuretics but can also be used with stronger diuretics like furosemide (Lasix). They have been shown to prolong life in certain types of heart failure patients when used in combination with angiotensin-converting enzyme (ACE) inhibitors. The patient's physician will know what medication or combinations should be best for each individual; however, it is not uncommon for dosages and medications to be changed by the physician as the disease changes or if better medication becomes available.
• Digoxin (Lanoxin): Digoxin is a mild inotrope and, in some cases, is beneficial as an add-on therapy to ACE inhibitors and beta-blockers. Digoxin is an old medicine, used for more than 200 years; it is derived from the foxglove plant. It is the most common form of digitalis.
• Digoxin can reduce heart failure symptoms and hospitalizations, but it does not prolong life.
• Digoxin is mainly used as an antiarrhythmic to control the rate of the heart in atrial fibrillation and flutter. In contrast, excessive digoxin in the blood can cause life-threatening arrhythmias.
• Although commonly used in the past, digoxin has moved far down the list of recommended drugs for treatment of heart failure. It is still considered for patients who are taking ACE inhibitors, ARBs, beta-blockers and/or diuretics and are still experiencing heart failure symptoms.

Vasodilators: These medications enlarge the small arteries or arterioles, which relieve the systolic workload of the left ventricle. Therefore, the heart has to work less to pump blood through the arteries. This also generally lowers blood pressure. Just as importantly, they reduce the levels of certain deleterious hormones and signals that can worsen heart failure.

• ACE inhibitors are the most widely used vasodilators for congestive heart failure. They block the production of angiotensin II, which is abnormally high in congestive heart failure. Angiotensin II causes vasoconstriction with increased workload on the left ventricle, and it is directly toxic to the left ventricle at excessive levels.
  • ACE inhibitors are important because they not only improve symptoms, but they also have been proven to significantly prolong the lives of people with heart failure. They do this by slowing progression of the heart damage and in some cases improving heart muscle function.
  • Some common examples of ACE inhibitors are captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril/Prinivil), benazepril (Lotensin), quinapril (Accupril), fosinopril (Monopril), and ramipril (Altace). Many times the individual drugs are used together as part of a combination pill (for example, Vaseretic, a combination pill containing enalapril and hydrochlorothiazide).
• Angiotensin II receptor blockers (ARBs) work by preventing the effect of angiotensin II at the tissue level. Examples of ARB medications include candesartan (Atacand), irbesartan (Avapro), olmesartan (Benicar), losartan (Cozaar), valsartan (Diovan), telmisartan (Micardis), and eprosartan (Teveten). These medications are usually prescribed for people who cannot take ACE inhibitors because of side effects. Both are effective, but ACE inhibitors have been used longer with a greater number of clinical trial data and patient information.

Nitrates are venous vasodilators that include isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil). They are commonly used in combination with an arterial vasodilator, such as hydralazine (see below).

• Nitroglycerin is a nitrate preparation that is administered to treat acute chest pain, or angina.

Hydralazine (Apresoline) is a smooth muscle arterial vasodilator that may be used for congestive heart failure. Clinical trial data has shown hydralazine plus nitrates to be especially effective in African-Americans with heart failure, when used in addition to ACE inhibitors or ARBs.

• Isosorbide dinitrate and hydralazine (BiDil) is a fixed dose combination of isosorbide dinitrate (20 mg/tablet) and hydralazine (37.5 mg/tablet). This drug is indicated for heart failure in African-Americans based in part on results of the African American Heart Failure Trial (A-HeFT).
• Hydralazine is also especially valuable in patients who have poor kidney function and/or are intolerant to ACE inhibitors and ARBs.

Beta-blockers: These drugs slow down the heart rate, lower blood pressure, and have a direct effect on the heart muscle to lessen the workload of the heart. Specific beta-blockers, such as carvedilol (Coreg) and long-acting metoprolol (Toprol XL), have been shown to decrease symptoms, hospitalization due to congestive heart failure, and deaths. Other beta-blockers include bispropolol (Zebeta), atenolol (Tenormin), propranolol (Inderal), and bystolic (Nebivolol), but they are generally not used with significant congestive heart failure.

• Beta-blockers work in part by blocking the action of norepinephrine on the heart muscle. They prevent norepinephrine from binding to beta-receptors in the heart muscle and arterial walls. Norepinephrine may be toxic to the heart in prolonged, high doses. Clinical trials have proven that beta-blockers gradually improve the systolic function of the left ventricle, thereby improving symptoms and prolonging life.
• The foundation of modern therapy of systolic heart failure is a combination of ACE inhibitors and beta-blockers. If at all possible, every patient should be on both drugs for improvement of left ventricular function and prolongation of life.

Inotropes: IV inotropes are stimulants, such as dobutamine and milrinone, which increase the pumping ability of the heart. These are used as a temporary support of a very weak left ventricle that is not responding to standard congestive heart failure therapy. Commonly used inotropes are dobutamine (Dobutex) and milrinone (Primacor). Phenylephrine (Neo-Synephrine) may be used when a patient is suffering with severe low blood pressure.

ACE inhibitors and ARBs may cause the body to retain potassium, but this is generally only a problem in people with significant kidney disease, or in people who are also taking a potassium-sparing diuretic, such as triamterene or spironolactone. Potassium levels can be monitored with lab testing.

Calcium channel blockers (CCBs) are arterial vasodilators that are not used for treatment of heart failure because clinical trials have proven no specific benefit. However, calcium channel blockers are useful for lowering blood pressure. If the cause of the congestive heart failure is high blood pressure and the patient is not responding to ACE inhibitors or ARBs, a CCB may be considered. Some CCBs include diltiazem (Cardizem), verapamil (Calan, Isoptin), nifedipine (Procardia, Adalat), and amlodipine (Norvasc).

These above-mentioned medications can be very effective in treatment of patients with systolic heart failure. There are not many successful therapies proven with clinical trial results available for patients with diastolic heart failure. Patients with diastolic heart failure are often prescribed these medications to treat their underlying conditions, such as hypertension or coronary disease, and as an extrapolation of favorable results, in the treatment of systolic heart failure. Several clinical trials are ongoing.

The medications listed above are very commonly used, but other mediations may be prescribed depending on the underlying cause of the heart failure or medical condition.

Getting the most out of congestive heart failure medications involves the following:

• Keep a diary of daily weight, and bring it to the doctor every follow-up visit.
• Since people with heart failure are often on many drugs, the likelihood of drug interactions increases. The medications taken for other medical problems may affect what drugs are prescribed for heart failure. Because of this, people are advised to always bring a current list of medications and any other supplements or nonprescription drugs with them every time they visit a doctor. Note that many of these medications come in combination pills under different marketing names.
• Take medication as directed by the health care provider. If he or she does not tell the patient how to take their medication or the patient does not understand how to dose the medication, ask the doctor or medical caregiver to explain the medication treatment in detail to the patient.
• Follow the recommendations of the health care provider about diet, exercise, and other lifestyle issues.
• Be informed about the side effects of medications.
• Develop an action plan with the doctor so the patient and their family know what to do promptly if congestive heart failure symptoms worsen.

Other treatments or procedures may be offered, depending on the underlying cause of the heart failure.

Angioplasty: This is an alternative to coronary bypass surgery for some people whose heart failure is caused by coronary artery disease and may be compounded by heart damage or a previous heart attack. Angioplasty is performed to treat narrowing or blockage of a coronary artery that supplies the left ventricle with blood. The narrowing or blockage is caused by cholesterol deposits.

• Angioplasty begins with the cardiac catheterization procedure during which a long, thin tube called a catheter is inserted through the skin, into a blood vessel, and threaded into the affected artery. This procedure is performed while the person is under local anesthesia.
• At the point of the atherosclerotic narrowing or blockage, a tiny balloon and/or an expandable metal stent, attached to the end of the catheter, is inflated and/or deployed.
• The expanded stent pushes aside the cholesterol deposits (plaque) that are blocking the artery so that blood can flow through in a more normal manner.

Pacemaker: This device controls the rate of the heartbeat. A pacemaker may keep the heart from going too slow, increasing heart rate when the heart is not increasing enough with activity. It also helps sustain regular rates when the heart is not beating in a coordinated way. Or, the pacemaker performs some combination of these.

• A pacemaker is an electrode on the tip of a wire, usually implanted inside the heart by an electrophysiologist or specialized cardiologist in the cardiac cath lab. This wire goes to the right ventricle, frequently with a second wire to the right atrium (dual-chamber pacemaker).
• A pacemaker can stimulate a heart that is beating too slowly to beat faster; sometimes, this requires medications in addition to the pacemaker.

Implantable cardioverter defibrillator (ICD): This device returns the heart to a normal rhythm by pacing or delivering an electrical shock, with a life-threatening arrhythmia.

• ICDs are indicated for ischemic or nonischemic cardiomyopathy patients with slight or marked physical limitations and low left ventricular ejection fractions (<30% to 35%) since these patients are at higher risk for serious ventricular arrhythmias. In these circumstances, an ICD may be implanted as part of a pacemaker device. This defibrillator can detect and electrically shock a life-threatening arrhythmia back to normal.

Cardiac resynchronization therapy (CRT): This involves a biventricular pacemaker that is used to synchronize the pumping action of the left and right ventricles. Synchronization improves the effectiveness of the heart as a pump since with heart failure the pumping action is sometimes uncoordinated.

• One pacer lead is placed in a coronary vein on the back side of the heart, overlying the left ventricle. The other pacer is placed in the usual right ventricular position. This improves the coordination of contraction between the left and right ventricle, especially if the patient has a left bundle branch block (LBBB). In LBBB, the electrical signal to the left ventricle is delayed.
• Biventricular pacing has been shown to improve exercise capacity, prevent the progression of heart failure symptoms, and prolong life in certain patients.
• Cardiac resynchronization therapy is frequently combined with an ICD to shock a person out of life-threatening arrhythmias, such as ventricular tachycardia or ventricular fibrillation. The worse the function of the left ventricle, the higher the risk for sudden death secondary to these arrhythmias.

Temporary cardiac support: An intra-aortic balloon pump is used as temporary support for left ventricle function, such as in a large heart attack, waiting for the heart to recover. There are other similar devices that can be used to temporarily support the heart if there is something that can be done for the underlying heart failure.

Surgery can repair some underlying causes of heart failure, such as blockage of the coronary arteries, a valve problem, a congenital heart defect, or thickened pericardium. For patients with severe coronary artery disease, coronary artery bypass graft (CABG) surgery can be conducted to circumvent blockages in vessels and ensure that the heart muscle maintains its blood supply. Valve replacement surgery can also be performed to repair malfunctioning heart valves. However, once the heart's ability to pump blood is severely, permanently, and irreversibly impaired, no surgery can repair the damage. The only alternative is a heart transplant. This option is for patients who are not elderly and who do not have other medical conditions that would make it unlikely for a heart transplant to be successful. Heart transplant evaluations are done in specialized centers. Over the years there have been new innovations in the field of cardiac surgery and if a heart transplant is not available, a left ventricular assist device (LVAD) may be implanted to help prolong life.

Left ventricle assist device (LVAD): This device is surgically implanted to mechanically bypass the left ventricle. It can be used as a “bridge to transplant” until a heart transplant is available.

• Alternatively, LVADs are also being used as “destination therapy” in patients who are not eligible for a transplant, but only at approved specialized medical centers.

Total artificial heart (TAH): For patients with severe, end-stage heart failure.

• These devices are most commonly used as a temporary bridge to heart transplantation, but can be used as destination therapy in patients who are not eligible for a transplant and have a high chance of mortality within 30 days.
• This technique is constantly improving, but is still limited to specialized centers and is considered experimental at this time.

Congestive Heart Failure Follow-up

If a patient has congestive heart failure, he or she will need frequent, regular medical attention to adjust medications and watch for side effects. Keep scheduled regular visits with the health care provider, as he or she recommends, because congestive heart failure is a serious medical condition that requires constant monitoring. Patients need to educate themselves as much as possible about this life-threatening condition and follow the suggestions below:

• Establish a daily routine for taking medication properly and on schedule.
• Weigh in daily. Every morning, record the weight in a diary, and take it to the health care provider every visit. An accurate bathroom scale is helpful in monitoring weight gain or loss from day to day in order to detect fluid retention.
• Keep a list of all medications, with the exact name and dose, and know why each one is taken. Bring them to each follow-up visit so the doctors can double check to make sure patients are on the correct medication and dose.
• Reminder boxes for medications are helpful.
• Be sure to keep all these medications away from small children who may accidentally swallow them. Many of the drugs prescribed for congestive heart failure are more dangerous in overdose than other medications.

Congestive heart failure can be the ultimate result of a number of diseases, or lifestyle choices, that damage the heart. Some of these can be prevented. Others cannot be prevented but can be treated successfully.

Some examples of illnesses or lifestyle choices that can lead to congestive heart failure are as follows:

• Coronary heart disease (coronary artery disease), including heart attack
• Uncontrolled high blood pressure (hypertension)
• Uncontrolled high cholesterol
• Diabetes
• Congenital heart disease (a heart condition that one is born with)
• Infection (particularly some common viruses that can rarely severely affect the heart and cannot be reliably predicted or prevented)
• Damage to the heart valves
• Alcoholism
• Smoking

In some cases, a family history of heart failure can be present. Many cases are a combination of factors, and in other cases, the cause is unknown.

If a person has congestive heart failure, they are at increased risk of developing pneumonia. They probably should receive both the pneumonia vaccination and annual flu shots. Patients should ask their doctor or other health care professional to be sure.

Heart failure is a major health problem that comes with the aging of America. Today, many more people are surviving heart attacks and other heart diseases. Enduring these heart conditions allows them many more years of quality life, but can eventually lead to the development of heart failure.

In recent years, more effective medications have been developed that improve the outlook of heart failure. Medications are the mainstay of therapy with congestive heart failure.

• New and sophisticated treatments are allowing people to live longer. These results are proven by clinical trials in which patients volunteer to take new therapies under strict ethical and scientific monitoring.
• Pacemakers and implantable defibrillators have improved and now offer the ability to control rare, but life-threatening, disturbances of heart rhythm in some people.
• Some people may even benefit from sophisticated treatments such as heart transplants and newer forms of temporary mechanical hearts and LVADs.

Having the support of doctors and other health care professionals, family, friends, and caregivers is essential to effectively coordinate all of the needs of a person with heart failure.

People with severe heart failure have special needs beyond standard medical care.

• Advance directives are legal documents that tell doctors and hospitals what treatments you might not want, should you become unable to speak for yourself.
• A living will provides instructions while you are still alive, for example, if you have specific wishes if your heart or breathing stops.
• A medical durable power of attorney allows someone you designate to make medical decisions on your behalf, if you become unable to make these decisions.
• pulmonary edema care may be required when you and your physicians agree that your prognosis for survival is poor. Professional hospice caregivers emphasize pain control and emotional support.