What is congestive heart failure ?

What is congestive heart failure ?

Your body depends on the heart’s pumping action to deliver oxygen- and nutrient-rich blood to the body’s cells. When the cells are nourished properly, the body can function normally. Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn’t pump blood as well as it should and the heart can’t pump enough blood to meet the body’s needs ¹. With heart failure, the weakened heart can’t supply the cells with enough blood. This results in fatigue and shortness of breath and some people have coughing. Everyday activities such as walking, climbing stairs or carrying groceries can become very difficult. This inability may also result in fluid retention, which causes swelling, for example, in the legs, feet, or abdomen.

The term “heart failure” makes it sound like the heart is no longer working at all and there’s nothing that can be done, but that is not the case at all. Heart failure also doesn’t mean that your heart has stopped or is about to stop working.

Congestive heart failure is a serious medical condition in which the heart cannot pump enough blood to meet the body’s needs. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the body’s tissues. Often swelling (edema) results. Most often there’s swelling in the legs and ankles, but it can happen in other parts of the body, too ².

Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down. This is called pulmonary edema and if left untreated can cause respiratory distress ².

Heart failure also affects the kidneys’ ability to dispose of sodium and water. This retained water also increases swelling in the body’s tissues (edema) ².

Congestive heart failure is often caused by hypertension, diabetes, or coronary heart disease, gradually leave your heart too weak or stiff to fill and pump efficiently.

It is estimated that 5.8 million people in the United States have congestive heart failure ¹ and at least 10 million in Europe ³. Congestive heart failure is one of the most common reasons those aged 65 and over are hospitalized ⁴.

• There were 1 million hospitalizations for congestive heart failure in 2000 and in 2010.
• About half of people who develop heart failure die within 5 years of diagnosis ⁵.
• Most congestive heart failure hospitalizations were for those aged 65 and over, but the proportion under age 65 increased significantly from 23% in 2000 to 29% in 2010.
• The overall rate of congestive heart failure hospitalization per 10,000 population did not change significantly from 2000 to 2010 (35.5 compared with 32.8), but the trends were different for those under and over age 65.
• From 2000 to 2010, the rate of congestive heart failure hospitalization for males under age 65 increased significantly while the rate for females aged 65 and over decreased significantly.
• In both 2000 and in 2010, a greater share of inpatients under age 65, compared with those aged 65 and over, were discharged to their homes.

Other names for Heart Failure

• Congestive heart failure.
• Left-side heart failure. This is when the heart can’t pump enough oxygen-rich blood to the body.
• Right-side heart failure. This is when the heart can’t fill with enough blood.
• Cor pulmonale. This term refers to right-side heart failure caused by high blood pressure in the pulmonary arteries and right ventricle (lower right heart chamber).

In some cases of heart failure, the heart can’t fill with enough blood. In other cases, the heart can’t pump blood to the rest of the body with enough force. Some people have both problems.

Not all conditions that lead to heart failure can be reversed, but treatments can improve the signs and symptoms of heart failure and help you live longer. Lifestyle changes — such as exercising, reducing salt in your diet, managing stress and losing weight — can improve your quality of life.

One way to prevent heart failure is to control conditions that cause heart failure, such as coronary artery disease, high blood pressure, diabetes or obesity.

How the normal heart works

The normal healthy heart is a strong, muscular pump a little larger than a fist. It pumps blood continuously through the circulatory system. Watch an animation of blood flow through the heart.

The heart has four chambers, two on the right and two on the left:

• Two upper chambers called atria (one is an atrium)
• Two lower chambers called ventricles

The right atria takes in oxygen-depleted blood from the rest of the body and sends it back out to the lungs through the right ventricle where the blood becomes oxygenated.

Oxygen-rich blood travels from the lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body.

The heart pumps blood to the lungs and to all the body’s tissues by a sequence of highly organized contractions of the four chambers. For the heart to function properly, the four chambers must beat in an organized way.

Types of Heart Failure

Heart failure can involve the heart’s left side, right side or both sides. However, it usually affects the left side first.

Left-sided heart failure

The heart’s pumping action moves oxygen-rich blood as it travels from the lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body. The left ventricle supplies most of the heart’s pumping power, so it’s larger than the other chambers and essential for normal function. In left-sided or left ventricular heart failure, the left side of the heart must work harder to pump the same amount of blood.

There are two types of left-sided heart failure. Drug treatments are different for the two types.

• Heart failure with reduced ejection fraction, also called systolic failure: The left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.
• Heart failure with preserved ejection fraction, also called diastolic failure (or diastolic dysfunction): The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can’t properly fill with blood during the resting period between each beat.

Right-sided heart failure

The heart’s pumping action moves “used” blood that returns to the heart through the veins through the right atrium into the right ventricle. The right ventricle then pumps the blood back out of the heart into the lungs to be replenished with oxygen.

Right-sided or right ventricular heart failure usually occurs as a result of left-sided failure. When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the lungs, ultimately damaging the heart’s right side. When the right side loses pumping power, blood backs up in the body’s veins. This usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the gastrointestinal tract and liver (causing ascites).

Congestive heart failure

Congestive heart failure is a type of heart failure which requires seeking timely medical attention, although sometimes heart failure and congestive heart failure, the two terms are used interchangeably.

As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the body’s tissues. Often swelling (edema) results. Most often there’s swelling in the legs and ankles, but it can happen in other parts of the body, too.

Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down. This is called pulmonary edema and if left untreated can cause respiratory distress.

Heart failure also affects the kidneys’ ability to dispose of sodium and water. This retained water also increases swelling in the body’s tissues (edema).

Figure 1. Congestive Heart Failure

What causes congestive heart failure

Conditions that damage or overwork the heart muscle can cause heart failure ⁶. Over time, the heart weakens. It isn’t able to fill with and/or pump blood as well as it should. As the heart weakens, certain proteins and substances might be released into the blood. These substances have a toxic effect on the heart and blood flow, and they worsen heart failure.

Causes of heart failure include:

• Coronary heart disease
• Diabetes
• High blood pressure
• Other heart conditions or diseases
• Other factors

Coronary Heart Disease

Coronary heart disease is a condition in which a waxy substance called plaque builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart muscle.

Plaque narrows the arteries and reduces blood flow to your heart muscle. The buildup of plaque also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow. Coronary heart disease can lead to chest pain or discomfort called angina, a heart attack, and heart damage.

Diabetes

Diabetes is a disease in which the body’s blood glucose (sugar) level is too high. The body normally breaks down food into glucose and then carries it to cells throughout the body. The cells use a hormone called insulin to turn the glucose into energy.

In diabetes, the body doesn’t make enough insulin or doesn’t use its insulin properly. Over time, high blood sugar levels can damage and weaken the heart muscle and the blood vessels around the heart, leading to heart failure.

High Blood Pressure

Blood pressure is the force of blood pushing against the walls of the arteries. If this pressure rises and stays high over time, it can weaken your heart and lead to plaque buildup.

Blood pressure is considered high if it stays at or above 140/90 mmHg over time. (The mmHg is millimeters of mercury—the units used to measure blood pressure.) If you have diabetes or chronic kidney disease, high blood pressure is defined as 130/80 mmHg or higher.

Other Heart Conditions or Diseases

Other conditions and diseases also can lead to heart failure, such as:

• Arrhythmia. Happens when a problem occurs with the rate or rhythm of the heartbeat.
• Cardiomyopathy. Happens when the heart muscle becomes enlarged, thick, or rigid.
• Congenital heart defects. Problems with the heart’s structure are present at birth.
• Heart valve disease. Occurs if one or more of your heart valves doesn’t work properly, which can be present at birth or caused by infection, other heart conditions, and age.

Other Factors

Other factors also can injure the heart muscle and lead to heart failure. Examples include:

• Alcohol abuse or cocaine and other illegal drug use
• HIV/AIDS
• Thyroid disorders (having either too much or too little thyroid hormone in the body)
• Too much vitamin E
• Treatments for cancer, such as radiation and chemotherapy.

Complications of heart failure

If you have heart failure, your outlook depends on the cause and the severity, your overall health, and other factors such as your age. Complications can include:

• Kidney damage or failure. Heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment.
• Heart valve problems. The valves of your heart, which keep blood flowing in the proper direction through your heart, may not function properly if your heart is enlarged or if the pressure in your heart is very high due to heart failure.
• Heart rhythm problems. Heart rhythm problems (arrhythmias) can be a potential complication of heart failure.
• Liver damage. Heart failure can lead to a buildup of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for your liver to function properly.

Some people’s symptoms and heart function will improve with proper treatment. However, heart failure can be life-threatening. People with heart failure may have severe symptoms, and some may require heart transplantation or support with a ventricular assist device.

Who is at Risk for Heart Failure ?

About 5.7 million people in the United States have heart failure ⁷. The number of people who have this condition is growing.

Heart failure is more common in:

• People who are age 65 or older. Aging can weaken the heart muscle. Older people also may have had diseases for many years that led to heart failure. Heart failure is a leading cause of hospital stays among people on Medicare.
• Blacks are more likely to have heart failure than people of other races. They’re also more likely to have symptoms at a younger age, have more hospital visits due to heart failure, and die from heart failure.
• People who are overweight. Excess weight puts strain on the heart. Being overweight also increases your risk of heart disease and type 2 diabetes. These diseases can lead to heart failure.
• People who have had a heart attack. Damage to the heart muscle from a heart attack and can weaken the heart muscle.

Children who have congenital heart defects also can develop heart failure. These defects occur if the heart, heart valves, or blood vessels near the heart don’t form correctly while a baby is in the womb. Congenital heart defects can make the heart work harder. This weakens the heart muscle, which can lead to heart failure. Children don’t have the same symptoms of heart failure or get the same treatments as adults.

How to prevent heart failure

The key to preventing heart failure is to reduce your risk factors. You can control or eliminate many of the risk factors for heart disease — high blood pressure and coronary artery disease, for example — by making lifestyle changes along with the help of any needed medications.

Lifestyle changes you can make to help prevent heart failure include:

• Not smoking
• Controlling certain conditions, such as high blood pressure and diabetes
• Staying physically active
• Eating healthy foods
• Maintaining a healthy weight
• Reducing and managing stress

Signs and symptoms of congestive heart failure

The most common signs and symptoms of heart failure are ⁸:

• Shortness of breath (dyspnea) or trouble breathing when you exert yourself or when you lie down
• Fatigue, tiredness and weakness
• Swelling (edema) in your legs, ankles and feet
• Rapid or irregular heartbeat
• Reduced ability to exercise
• Persistent cough or wheezing with white or pink blood-tinged phlegm
• Increased need to urinate at night
• Swelling of your abdomen (ascites)
• Sudden 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
• Prominent veins in the neck

All of these symptoms are the result of fluid buildup in your body. When symptoms start, you may feel tired and short of breath after routine physical effort, like climbing stairs.

As your heart grows weaker, symptoms get worse. You may begin to feel tired and short of breath after getting dressed or walking across the room. Some people have shortness of breath while lying flat.

Fluid buildup from heart failure also causes weight gain, frequent urination, and a cough that’s worse at night and when you’re lying down. This cough may be a sign of acute pulmonary edema. This is a condition in which too much fluid builds up in your lungs. The condition requires emergency treatment.

Figure 2. Signs and symptoms of congestive heart failure

[Source ⁹]

Diagnosing Heart Failure

To diagnose heart failure, your doctor will take a careful medical history, review your symptoms and perform a physical examination. Your doctor will also check for the presence of risk factors, such as high blood pressure, coronary artery disease or diabetes.

Using a stethoscope, your doctor can listen to your lungs for signs of congestion. The stethoscope also picks up abnormal heart sounds that may suggest heart failure. The doctor may examine the veins in your neck and check for fluid buildup in your abdomen and legs.

After the physical exam, your doctor may also order some of these tests:

• Blood tests

Your doctor may take a sample of your blood to check your kidney, liver and thyroid function and to look for indicators of other diseases that affect the heart.

A BNP blood test to check for a chemical called N-terminal pro-B-type natriuretic peptide (NT-proBNP) may help in diagnosing heart failure if the diagnosis isn’t certain when used in addition to other tests.

• Chest X-ray

Chest X-ray images help your doctor see the condition of your lungs and heart. In heart failure, your heart may appear enlarged and fluid buildup may be visible in your lungs. Your doctor can also use an X-ray to diagnose conditions other than heart failure that may explain your signs and symptoms.

• Electrocardiogram (EKG)

This test records the electrical activity of your heart through electrodes attached to your skin. Impulses are recorded as waves and displayed on a monitor or printed on paper.

This test helps your doctor diagnose heart rhythm problems and damage to your heart from a heart attack that may be underlying heart failure.

• Echocardiogram

An important test for diagnosing heart failure is the echocardiogram. An echocardiogram helps distinguish systolic heart failure from diastolic heart failure in which the heart is stiff and can’t fill properly.

An echocardiogram uses sound waves to produce a video image of your heart. This test can help doctors see the size and shape of your heart and how well your heart is pumping.

The echocardiogram also can help doctors look for valve problems or evidence of previous heart attacks, other heart abnormalities, and some unusual causes of heart failure.

Your ejection fraction is measured during an echocardiogram and can also be measured by nuclear medicine tests, cardiac catheterization and cardiac MRI. This is an important measurement of how well your heart is pumping and is used to help classify heart failure and guide treatment.

• Doppler Ultrasound

A Doppler ultrasound uses sound waves to measure the speed and direction of blood flow. This test often is done with echo to give a more complete picture of blood flow to the heart and lungs.

Doctors often use Doppler ultrasound to help diagnose right-side heart failure.

• Holter Monitor

A Holter monitor records your heart’s electrical activity for a full 24- or 48-hour period, while you go about your normal daily routine.

You wear small patches called electrodes on your chest. Wires connect the patches to a small, portable recorder. The recorder can be clipped to a belt, kept in a pocket, or hung around your neck.

• Nuclear Heart Scan

A nuclear heart scan shows how well blood is flowing through your heart and how much blood is reaching your heart muscle.

During a nuclear heart scan, a safe, radioactive substance called a tracer is injected into your bloodstream through a vein. The tracer travels to your heart and releases energy. Special cameras outside of your body detect the energy and use it to create pictures of your heart.

A nuclear heart scan can show where the heart muscle is healthy and where it’s damaged.

A positron emission tomography (PET) scan is a type of nuclear heart scan. It shows the level of chemical activity in areas of your heart. This test can help your doctor see whether enough blood is flowing to these areas. A PET scan can show blood flow problems that other tests might not detect.

• Stress test

Stress tests measure how your heart and blood vessels respond to exertion. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Or you may receive a drug intravenously that stimulates your heart similar to exercise. Sometimes the stress test can be done while wearing a mask that measures the ability of your heart and lungs to take in oxygen and breathe out carbon dioxide.

Stress tests help doctors see if you have coronary artery disease. Stress tests also determine how well your body is responding to your heart’s decreased pumping effectiveness and can help guide long-term treatment decisions.

If your doctor also wants to see images of your heart while you’re exercising, he or she may order a nuclear stress test or a stress echocardiogram. It’s similar to an exercise stress test, but it also uses imaging techniques to visualize your heart during the test.

• Cardiac computerized tomography (CT) scan or magnetic resonance imaging (MRI)

These tests can be used to diagnose heart problems, including causes of heart failure.

In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest.

In a cardiac MRI, you lie on a table inside a long tube-like machine that produces a magnetic field. The magnetic field aligns atomic particles in some of your cells. When radio waves are broadcast toward these aligned particles, they produce signals that vary according to the type of tissue they are. The signals create images of your heart.

• Cardiac Catheterization

During cardiac catheterization, a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. This allows your doctor to look inside your coronary (heart) arteries.

During this procedure, your doctor can check the pressure and blood flow in your heart chambers, collect blood samples, and use x rays to look at your coronary 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. This test helps doctors identify narrowed arteries to your heart (coronary artery disease) that can be a cause of heart failure. The test may include a ventriculogram — a procedure to determine the strength of the heart’s main pumping chamber (left ventricle) and the health of the heart valves.

• 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.

Results of these tests help doctors determine the cause of your signs and symptoms and develop a program to treat your heart.

Congestive heart failure treatment

Early diagnosis and treatment can help people who have heart failure live longer, more active lives. Treatment for heart failure depends on the type and severity of the heart failure.

Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and symptoms of heart failure can improve, and the heart sometimes becomes stronger. Treatment may help you live longer and reduce your chance of dying suddenly.

Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, the treatment of heart failure involves a balance of the right medications and, in some cases, use of devices that help the heart beat and contract properly.

The goals of treatment for all stages of heart failure include:

• Treating the condition’s underlying cause, such as coronary heart disease, high blood pressure, or diabetes
• Reducing symptoms
• Stopping the heart failure from getting worse
• Increasing your lifespan and improving your quality of life

Treatments usually include heart-healthy lifestyle changes, medicines, and ongoing care. If you have severe heart failure, you also may need medical procedures or surgery.

Lifestyle and home remedies

Making lifestyle changes can often help relieve signs and symptoms of heart failure and prevent the disease from worsening. These changes may be among the most important and beneficial you can make. Lifestyle changes your doctor may recommend include:

• Stop smoking. Smoking damages your blood vessels, raises blood pressure, reduces the amount of oxygen in your blood and makes your heart beat faster.

If you smoke, ask your doctor to recommend a program to help you quit. You can’t be considered for a heart transplant if you continue to smoke. Avoid secondhand smoke, too.

• Discuss weight monitoring with your doctor. Discuss with your doctor how often you should weigh yourself. Ask your doctor how much weight gain you should notify him or her about. Weight gain may mean that you’re retaining fluids and need a change in your treatment plan.

• Check your legs, ankles and feet for swelling daily. Check for any changes in swelling in your legs, ankles or feet daily. Check with your doctor if the swelling worsens.
• Eat a healthy diet. Aim to eat a diet that includes fruits and vegetables, whole grains, fat-free or low-fat dairy products, and lean proteins.
• Restrict salt in your diet. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet.

Check with your doctor for the sodium restriction recommended for you. Keep in mind that salt is already added to prepared foods, and be careful when using salt substitutes.

• Maintain a healthy weight. If you’re overweight, your dietitian will help you work toward your ideal weight. Even losing a small amount of weight can help.
• Consider getting vaccinations. If you have heart failure, you may want to get influenza and pneumonia vaccinations. Ask your doctor about these vaccinations.
• Limit fats and cholesterol. In addition to avoiding high-sodium foods, limit the amount of saturated fat, trans fat and cholesterol in your diet. A diet high in fat and cholesterol is a risk factor for coronary artery disease, which often underlies or contributes to heart failure.
• Limit alcohol and fluids. Your doctor likely will recommend that you don’t drink alcohol if you have heart failure, since it can interact with your medication, weaken your heart muscle and increase your risk of abnormal heart rhythms.
• Getting medical care for other related conditions is important. If you have diabetes or high blood pressure, work with your health care team to control these conditions. Have your blood sugar level and blood pressure checked. Talk with your doctor about when you should have tests and how often to take measurements at home.

If you have severe heart failure, your doctor may also suggest you limit the amount of fluids you drink.

• Be active. Moderate aerobic activity helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. Before you start exercising though, talk to your doctor about an exercise program that’s right for you. Your doctor may suggest a walking program.

Check with your local hospital to see if it offers a cardiac rehabilitation program; if it does, talk to your doctor about enrolling in the program.

• Reduce stress. When you’re anxious or upset, your heart beats faster, you breathe more heavily and your blood pressure often goes up. This can make heart failure worse, since your heart is already having trouble meeting the body’s demands.

Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible. Spend time with friends and family to be social and help keep stress at bay.

• Sleep easy. If you’re having shortness of breath, especially at night, sleep with your head propped up using a pillow or a wedge. If you snore or have had other sleep problems, make sure you get tested for sleep apnea.

To improve your sleep at night, prop up your head with pillows. Also, discuss with your doctor changing the time for taking medications, especially diuretics. Taking diuretics earlier in the day may decrease the need to urinate as often during the night.

Medications

Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one or more medications, including:

• Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people with systolic heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Zestril) and captopril (Capoten).
• Angiotensin II receptor blockers. These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the same benefits as ACE inhibitors. They may be an alternative for people who can’t tolerate ACE inhibitors.
• Beta blockers. This class of drugs not only slows your heart rate and reduces blood pressure but also limits or reverses some of the damage to your heart if you have systolic heart failure. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta).

These medicines reduce the risk of some abnormal heart rhythms and lessen your chance of dying unexpectedly. Beta blockers may reduce signs and symptoms of heart failure, improve heart function, and help you live longer.

• Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Diuretics, such as furosemide (Lasix), also decrease fluid in your lungs so you can breathe more easily.

Because diuretics make your body lose potassium and magnesium, your doctor also may prescribe supplements of these minerals. If you’re taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.

• Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). 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.

• Inotropes. These are intravenous medications used in people with severe heart failure in the hospital to improve heart pumping function and maintain blood pressure.
• Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in systolic heart failure. It may be more likely to be given to someone with a heart rhythm problem, such as atrial fibrillation.

You may need to take two or more medications to treat heart failure. Your doctor may prescribe other heart medications as well — such as nitrates for chest pain, a statin to lower cholesterol or blood-thinning medications to help prevent blood clots — along with heart failure medications.

You may be hospitalized if you have a flare-up of heart failure symptoms. While in the hospital, you may receive additional medications to help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen through a mask or small tubes placed in your nose. If you have severe heart failure, you may need to use supplemental oxygen long term.

Surgery and medical devices

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 (valvuloplasty) 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. In valve replacement surgery, the damaged valve is replaced by an artificial (prosthetic) valve.

Certain types of heart valve repair or replacement can now be done without open heart surgery, using either minimally invasive surgery or cardiac catheterization techniques.

• Implantable cardioverter-defibrillators. An implantable cardioverter-defibrillator 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 implantable cardioverter-defibrillator monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the implantable cardioverter-defibrillator tries to pace your heart or shock it back into normal rhythm. An implantable cardioverter-defibrillator can also function as a pacemaker and speed your heart up if it is going too slow.

• Cardiac resynchronization therapy 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 implantable cardioverter-defibrillator for people with heart failure.

• Heart pumps. These mechanical devices, such as ventricular assist devices, are implanted into the abdomen or chest and attached to a weakened heart to help it pump blood to the rest of your body. Ventricular assist devices are most often used in the heart’s left ventricle, but they can also be used in the right ventricle or in both ventricles.

Doctors first used heart pumps to help keep heart transplant candidates alive while they waited for a donor heart. Ventricular assist devices are now sometimes used as an alternative to transplantation. Implanted heart pumps can significantly extend and improve the lives 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. Major complications associated with left ventricular assist devices include bleeding, infection, and device malfunction. Temporary right ventricular failure immediately following an left ventricular assist device placement can occur in 30% of patients requiring inotropes or right ventricular assist device ¹⁰.

Figure 3. An intracorporeal left ventricular assist device and its components

[Source ¹⁰]

• 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. Usually, patients <50 years of age who are brain dead are potential cardiac donors. Contraindications for heart donation include significant heart dysfunction, congenital heart disease, malignancies (except basal cell and squamous cell carcinomas of skin, primary tumors of the central nervous system with low metastatic potential), or transmissible diseases ¹⁰.

Heart transplants can dramatically improve the survival and quality of life of some people with severe heart failure. However, candidates for transplantation often have to wait a long time before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment or device therapy and can be removed from the transplant waiting list.

Heart transplantation is the treatment of choice for patients with heart failure refractory to medical therapy. Data from the 2008 report from the registry of the International Society for Heart and Lung Transplant showed that patient survival at 1 and 3 years for patients who received cardiac transplantation was approximately 85% and 79%, respectively ¹¹. Recent advances in medical and device therapies have also improved the survival of heart failure patients comparable to that for post-heart transplant ¹². More patients need heart transplantation than there are donor hearts available. Heart transplantation is limited to patients who are most likely to benefit with a significant improvement in symptoms and life expectancy.

• Stem Cells – Experimental Approaches

Early clinical studies in patients with heart failure have shown the feasibility of transfer of distinct stem and progenitor cell populations to the heart, and have demonstrated beneficial effects on cardiac function and/or tissue viability ¹³. However, due to small study sizes, lack of randomised control groups, poor understanding of the mechanisms of action of transplanted cells, lack of information on procedural issues (that is, optimal cell type, cell dosage, timing of cell transfer, optimal route of application), and safety concerns with some progenitors (such as the arrhythmogenicity associated with skeletal myoblast grafts), further basic research and the initiation of large, double‐blind, placebo‐controlled, randomised clinical trials with hard end‐points (including mortality) are warranted before the role of cell‐based therapy of heart failure can be judged.

End-of-life care and heart failure

Even with the number of treatments available for heart failure, it’s possible that your heart failure may worsen to the point where medications are no longer working and a heart transplant or device isn’t an option. If this occurs, you may need to enter hospice care. Hospice care provides a special course of treatment to terminally ill people.

Hospice care allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one at home or in hospice residences. Hospice care provides emotional, psychological, social and spiritual support for people who are ill and those closest to them.

Although most people under hospice care remain in their own homes, the program is available anywhere — including nursing homes and assisted living centers. For people who stay in a hospital, specialists in end-of-life care can provide comfort, compassionate care and dignity.

Although it can be difficult, discuss end-of-life issues with your family and medical team. Part of this discussion will likely involve advance directives — a general term for oral and written instructions you give concerning your medical care should you become unable to speak for yourself.

If you have an implantable cardioverter-defibrillator, one important consideration to discuss with your family and doctors is turning off the defibrillator so that it can’t deliver shocks to make your heart continue beating.

Congestive heart failure stages

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 ¹⁴. Basically, the heart can’t keep up with its workload.

At first the heart tries to make up for this by ¹⁴:

• 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 ¹⁴:

• 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), 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 ¹⁴.

Eventually the heart and body just can’t keep up, and the person experiences the fatigue, breathing problems or other symptoms that usually prompt a trip to the doctor.

The body’s compensation mechanisms help explain why some people may not become aware of their condition until years after their heart begins its decline. It’s also a good reason to have a regular checkup with your doctor ¹⁴.

Doctors usually classify or “stage” patients’ heart failure according to the severity of their symptoms ¹⁵. The table below describes the most commonly used classification system, the New York Heart Association Functional Classification ¹⁶. It places patients in one of four categories based on how much they are limited during physical activity.

Table 1. New York Heart Association Classification of Heart Failure

Class	Patient Symptoms
I	No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).
II	Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).
III	Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.
IV	Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

[Source ¹⁵]

Table 2. American College of Cardiology/American Heart Association Guidelines of Heart Failure

Class	Objective Assessment
A	No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity.
B	Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest.
C	Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest.
D	Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.

[Source ¹⁵]

Note: American College of Cardiology/American Heart Association Guidelines of Heart Failure – the system includes a category for people who are at risk of developing heart failure. For example, a person who has several risk factors for heart failure but no signs or symptoms of heart failure is Stage A. A person who has heart disease but no signs or symptoms of heart failure is Stage B. Someone who has heart disease and is experiencing or has experienced signs or symptoms of heart failure is Stage C. A person with advanced heart failure requiring specialized treatments is Stage D.

Doctors use this classification system to identify your risk factors and begin early, more aggressive treatment to help prevent or delay heart failure.

These scoring systems are not independent of each other. Your doctor often will use them together to help decide your most appropriate treatment options. Ask your doctor about your score if you’re interested in determining the severity of your heart failure. Your doctor can help you interpret your score and plan your treatment based on your condition.

Congestive heart failure life expectancy

Currently, heart failure is a serious condition and has no cure. But many people with heart failure lead a full, enjoyable life when the condition is managed with heart failure medications and healthy lifestyle changes. It’s also helpful to have the support of family and friends who understand your condition.

Eighty percent of men and 70% of women <65 years of age diagnosed with heart failure will die within 8 years ¹⁰. Following an initial hospitalization for heart failure, there is a 50% readmission rate at 6 months and nearly 20% incidence of death within 12 months ¹⁷.

Patients with end stage heart failure fall into stage D of the ABCD classification of the American College of Cardiology/American Heart Association and class III–IV of the New York Heart Association functional classification; they are characterised by advanced structural heart disease and pronounced symptoms of heart failure at rest or upon minimal physical exertion, despite maximal medical treatment according to current guidelines ³, ¹⁸. This patient population has a 1‐year mortality rate of approximately 50% and requires special therapeutic interventions ¹⁹.

Treatments—such as medicines and lifestyle changes—can help people who have the condition live longer and more active lives. Researchers continue to study new ways to treat heart failure and its complications.

Managing heart failure requires an open dialogue between you and your doctor. Be honest about whether you’re following recommendations concerning your diet, lifestyle and taking medications. Your doctor often can suggest strategies to help you get and stay on track.

You and your doctor can work together to help make your life more comfortable. Pay attention to your body and how you feel, and tell your doctor when you’re feeling better or worse. This way, your doctor will know what treatment works best for you. Don’t be afraid to ask your doctor questions about living with heart failure.

Steps that may help you manage your condition include:

• Keep track of the medications you take. Make a list and share it with any new doctors treating you. Carry the list with you all the time. Don’t stop taking any medications without talking to your doctor. If you experience side effects to medications, discuss them with your doctor.
• Avoid certain over-the-counter medications. Some over-the-counter medications, such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) and diet pills, may worsen heart failure and lead to fluid buildup.
• Be careful about supplements. Some dietary supplements may interfere with heart failure medications or could worsen your condition. Talk to your doctor about any supplements you are taking.
• Keep track of your weight and bring the record to visits with your doctor. An increase in weight can be a sign you’re building up fluids. Your doctor may tell you to take extra diuretics if your weight has increased by a certain amount in a day.
• Keep track of your blood pressure. Consider purchasing a home blood pressure monitor. Keep track of your blood pressure between doctor appointments and bring the record with you to visits.
• Write down your questions for your doctor. Before a doctor appointment, prepare a list of any questions or concerns. For example, is it safe for you and your partner to have sex? Most people with heart failure can continue sexual activity once symptoms are under control. Ask for clarification, if necessary. Be sure you understand everything your doctor wants you to do.
• Know your doctor’s contact information. Keep your doctor’s phone number, the hospital’s phone number, and directions to the hospital or clinic on hand. You’ll want to have these available in case you have questions for your doctor or you need to go to the hospital.

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