Circulatory system

What is congestive heart failure?

Affecting more than 1 percent of North Americans over the age of 65, congestive heart failure is the number one reason seniors are admitted to hospital. The term "congestive heart failure" is rather misleading. Although it implies that heart has failed or stopped, congestive heart failure simply means that the heart is not working as efficiently as it should—because it has been weakened by another medical condition, such as coronary artery disease, long-term high blood pressure, or heart attack.

So what does this mean?

Congestive heart failure is not a disease in itself. Rather, it is a collection of symptoms that occur when the heart cannot pump enough blood to satisfy the body's needs. This is because the heart is generally enlarged and the heart muscle is weakened. This condition is called "congestive" because it refers to the build-up of fluids within the body—an accumulation that causes the body to become congested.

Although it is incurable and progressive, becoming worse over a period of several years, congestive heart failure can be managed with medication, a healthy diet, and exercise. Some of its effects are reversible.

What causes congestive heart failure?

As mentioned, congestive heart failure may be caused by long-term high blood pressure, coronary artery disease, or heart attack. Other causes include:

• congenital heart disease—heart defects present from birth
• heart valve damage
• disease and/or inflammation of the heart muscle
• infection of the heart valves and/or of the heart muscle
• excessive alcohol consumption

What are the symptoms of congestive heart failure?

Symptoms of congestive heart failure include, but are not limited to:

• fatigue or weakness
• lightheadedness
• shortness of breath after mild exertion or even while resting
• difficulty breathing while lying flat
• edema (swelling) of the feet, ankles, legs, abdomen, and sometimes of the arms and face
• palpitations (irregular heartbeats); rapid or irregular pulse
• increased urination at night
• a chronic or frothy cough that may show signs of blood
• behavioral changes such as restlessness, confusion, or memory loss
• unexplained rapid weight gain

If you exhibit a worsening of these symptoms, consult your physician or other health care practitioner right away.

Am I going to have a heart attack?

As mentioned above, congestive heart failure is associated with a weakened heart muscle. A weakened heart muscle does not cause heart attack, although heart attacks can lead to congestive heart failure. Heart attacks typically occur when there is a blockage of the arteries that supply blood to the heart.

How is congestive heart failure diagnosed?

Your doctor will be able to diagnose congestive heart failure through a physical examination that includes auscultation. A physical exam will often reveal important signs such as edema. Auscultation, in which your doctor uses a stethoscope to listen to your heart and lungs, allows him or her to hear the sounds generated by fluid in these organs.

Your doctor may also recommend an exercise stress test, a chest x-ray, an echocardiogram, or a nuclear heart scan.

Exercise stress test

An exercise stress tests shows how effectively the heart pumps at higher levels of exertion when the demand for oxygen is high. Readings from blood pressure tests and electrocardiograms are taken before, during, and after exercise to determine how the heart responds to execise. The first blood pressure reading and electrocardiogram are done to get a baseline. Readings are then taken as patients walk on a treadmill, pedal a stationary bicycle, or receive medication that increases heartbeat. The test continues until you reach a predetermined heart rate as set by your doctor. If you experience chest pain or a very sharp rise in blood pressure during the test, the test will end. Monitoring will continue for 10 to 15 minutes after completion of the test or until your heart rate returns to baseline.¹

Chest x-ray

A chest x-ray is a picture of the heart, lungs, blood vessels and other organs and structures inside the chest. A chest x-ray will reveal whether your heart is enlarged and will also reveal any other abnormalities which may indicate heart disease.

Echocardiogram

An echocardiogram uses sound waves to create a picture of the heart. More detailed than an x-ray, the echocardiogram shows how well the heart chambers fill with blood and pump it to the rest of the body. An echocardiogram can also help identify areas of poor blood flow to the heart, areas of the heart muscle that are not contracting normally, and any prior injury to the heart caused by poor blood flow.²

Nuclear heart scan

A nuclear heart scan shows blood flow to the heart and also reveals any damage to the heart muscle. Radioactive dye such as technetium or thallium is injected into the bloodstream. A specialized camera can see the dye and identify areas of low blood flow. Nuclear heart scans are usually conducted while you are at rest and again after exercise. Patients unable to exercise receive medications that increase heart rate. The two nuclear heart scans, before and after, are then compared.³

Cardiac catheterization

Cardiac catheterization is often necessary to gain specific information necessary to determine the cause of congestive heart failure and the most effective course of treatment.

In cardiac catheterization, a thin flexible catheter is passed through an artery in the groin or arm to reach the coronary arteries. This allows the doctor to determine pressure and blood flow to the chambers of the heart. It also allows the doctor to collect blood samples from the heart and to examine the arteries of the heart by x-ray.⁴

How is congestive heart failure treated?

It's important first to address the underlying heart problem that led to congestive heart failure. For instance, treatment for an overactive thyroid gland may be initiated or repair to a diseased or defective heart valve may be necessary. If the underlying cause of congestive heart failure cannot be treated, the focus of treatment becomes therapeutic rather than curative: in other words, the goal is to improve heart function and to help the heart pump more efficiently. Equally important are the prevention of further damage to the heart and the minimization of symptoms.

Treatment for congestive heart failure may include hospitalization, medication, surgery, and changes to diet and lifestyle.

Hospitalization may be necessary if symptoms are quite severe or if a patient does not respond to initial treatments. Surgery may also be necessary to correct congenital defects, to repair or replace defective valves, or to perform bypass procedures. In some cases, a heart transplant may be necessary.

What medications are used to treat congestive heart failure?

Treatment options vary from patient to patient. As such, your doctor will prescribe medication(s) most appropriate to your condition.

Most people with congestive heart failure are prescribed diuretics and angiotensin-converting enzyme (ACE) inhibitors. Many patients are also prescribed digitalis. Below is a list of some of the medications commonly used in the treatment of congestive heart failure:

Diuretics

Diuretics (water pills) are used to help the kidneys expel excess fluid and sodium from the body. Diuretics (examples: indapamide, hydrochlorothiazide) can also improve breathing and may decrease swelling.

Agiotensin converting enzyme (ACE) inhibitors

Agiotensin converting enzyme (ACE) inhibitors block the formation of a powerful enzyme associated with raising blood pressure. This enzyme also narrows blood vessels and leads to salt retention. ACE inhibitors (examples: peridopril, lisinopril) inhibit the production of this enzyme and help prevent the progression of heart failure while improving heart function during exercise. They may also reduce the need for hospitalization.

Nitrates

Nitrates such as isosorbide dintirate and nitroglycerin ointment or spray open up blood vessels and allow blood to flow more easily, thereby bringing more oxygen to the heart muscle and reducing its workload. Nitrates are sometimes combined with angiotensin converting enzyme inhibitors in the treatment of congestive heart failure.

Digitalis

Digitalis (examples: digoxin, digitoxin) helps the heart beat more strongly and is useful in the treatment of severe congestive heart failure.

Hydralazine

An older medication, hydralazine is generally used in combination with nitrates to open up the blood vessels to help lower blood pressure.

Calcium channel blockers

Not commonly prescribed for congestive heart failure, calcium channel blockers such as nifedipine and amlodipine are commonly presribed to patients with high blood pressure and angina.

Beta blockers

Beta blockers such as atenolol and metoprolol are used to prevent the heart from speeding up—something it tends to do in order to compensate for its weakened state. When the heartrate is lowered, so too is blood pressure.

It may be necessary to take more than one medication. It's important to take your medication exactly as instructed by your doctor. Be sure to read the label and to follow all instructions. If you are unclear about when or how to take your medication, be sure to talk to your doctor or pharmacist.

If you miss a dose, take it as soon as you remember, but avoid "doubling up" to catch up. A pill box or dosette, available at most drugstores may help you organize your medications and minimize missed doses.

If you experience what you believe is a side effect, don't simply stop taking your medication. This may do more harm than good. Instead, talk to your doctor. He or she will determine the reason for any ill effects you may be experiencing and will decide what action to take.

Similarly, don't try to manage your condition on your own. Many patients adjust or stop their medications once they start feeling better. Many of the medications prescribed for congestive heart failure are specifically designed to help improve heart function and should be taken regardless of whether you feel well. Medications are potent and require close monitoring and your doctor's expert judgment in their dosages. If you would like to adjust or stop your medications, be sure to talk to your doctor.

Can I take vitamins and over-the-counter medications?

While useful in replacing water-soluble vitamins lost through urination and those affected by your medication, you should know that some over-the-counter products may interfere with or even negate the action of your prescribed medications. Be sure to check with your doctor before taking any multivitamins or over-the-counter products.

What changes will I need to make?

A healthy lifestyle is an integral part of managing congestive heart failure. Your doctor may advise you to make the following changes to your diet and lifestyle:

• reduce salt in your diet
• achieve and maintain a healthy body weight
• limit consumption of alcohol
• avoid extremes in temperature
• avoid smoking
• take time for rest and relaxation
• avoid overexertion and slow down if you become tired
• consult your doctor or health care professional before starting an exercise program
• report any rapid weight gain (2-3 lbs/1kg per day) to your doctor
• report any change in symptoms to your doctor
• take medications as directed
• see your doctor regularly

Although exercise may not necessarily make the heart muscle stronger, it does help condition the rest of the body, allowing it to use oxygen more efficiently. This in turn reduces the load on the heart. Put another way, while the heart muscle itself may not grow stronger, it will directly benefit from exercise. Don't begin an exercise program without consulting your doctor. Your doctor will be able to tell you how much and how often to exercise and will be able to recommend a program that is best suited for you.

Living with congestive heart failure

It's not uncommon for patients with congestive heart failure to become depressed. Try not to let your condition be a source of worry for you. This may be easier said than done, but your doctor, family, friends and community services and support groups are all available to help you. Be sure to discuss your concerns, fears, and frustrations and to maintain a positive attitude. In addition, try to learn as much as you can about congestive heart failure. A positive outlook, as well as an informed and involved approach to managing your condition, will help you live longer and happier.

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1. How is Angina Diagnosed? Diseases and Conditions Index. National Heart, Lung, and Blood Institute. US Department of Health & Human Services.
2. How is Angina Diagnosed? Diseases and Conditions Index. National Heart, Lung, and Blood Institute. US Department of Health & Human Services.
3. How is Angina Diagnosed? Diseases and Conditions Index. National Heart, Lung, and Blood Institute. US Department of Health & Human Services.
4. How is Angina Diagnosed? Diseases and Conditions Index. National Heart, Lung, and Blood Institute. US Department of Health & Human Services.