Congestive Heart Failure

Content provided by the Faculty of the Harvard Medical School

Congestive Heart Failure

What Is It?

Contrary to its name, congestive heart failure does not mean the heart has failed completely. It means the heart no longer is able to meet the body's need for blood because it is pumping inefficiently. This inefficient pumping causes blood to back up in the veins leading to the heart, and causes the kidneys to retain fluid. This causes the body's tissues to swell. The swelling, called edema, most commonly affects the legs, but it also can occur in the lungs, causing breathing difficulty, and in other tissues and organs.

Congestive heart failure often is the end stage of another form of heart disease. Its many causes include:

• Coronary artery disease,

• High blood pressure (hypertension)

• Heart valve disorders (including rheumatic heart disease)

• Congenital heart disorders

• Cardiomyopathy (disease of the heart muscle)

• Heart attack

• Cardiac arrhythmias (problems with the heart rate and/or rhythm)

• Exposure to toxins, including excessive alcohol

Hyperthyroidism, diabetes and chronic (long-lasting) lung disease also increase the risk of congestive heart failure.

In some people with congestive heart failure, the heart muscles become weaker and cannot pump as well. In other people, the heart muscles become stiff, and the heart cannot fill with enough blood between heartbeats.

The number of cases of congestive heart failure continues to increase in the United States. This probably is the result of an aging population, together with medical advances that have prolonged the lives of people with other forms of heart disease, allowing congestive heart failure to develop.

Symptoms

The first symptom of congestive heart failure can be fatigue. As the condition gets worse, there can be breathing difficulties during exertion, and eventually, shortness of breath and wheezing when you are resting. As fluid accumulates in the lungs, people with heart failure may begin to sleep propped up with pillows to make breathing easier. Fluid also can collect in the legs and ankles, causing swelling. In people who are less active, collected fluid can accumulate in the middle of the body. Some people need to urinate several times during the night as the kidneys drain off some of the excess fluid that accumulates in the lower body during the day. As the body accumulates more and more fluid, the patient may notice significant weight gain. There also can be a chronic cough caused by fluid accumulation in the lungs.

Although congestive heart failure usually affects both sides of the heart, in some people it affects only the left or right side. In these cases, symptoms vary depending on which side is affected. When heart failure affects mainly the left side of the heart, the symptoms are more likely to involve breathing difficulties. When mainly the right side is affected, the main symptoms may be leg and abdominal swelling.

Diagnosis

Your doctor will review your medical history and will ask for details about your symptoms, including how many blocks you can walk without becoming short of breath, the number of pillows you sleep on, and how often you wake up at night to urinate.

During your physical examination, your doctor will check your vital signs (such as blood pressure and temperature), check your heart rate and rhythm, and listen for abnormal heart sounds with a stethoscope. He or she also will listen to your lungs for abnormal breathing sounds that indicate fluid is building up in your lungs. Your doctor will press on the skin of your legs and ankles to check for edema (swelling), and also may feel your abdomen to check the size of your liver because fluid backup from the heart may cause liver swelling.

You also will have diagnostic tests, including an electrocardiogram and a chest X-ray to check for enlargement of the heart and fluid in the lungs. Other diagnostic tests may be needed to find the cause of your congestive heart failure. For example, a test called an echocardiogram may be done to look for heart valve abnormalities, abnormal movement of the heart wall (a sign of heart attack), or other heart problems. The echocardiogram is a particularly important test because it can determine whether the heart muscles have weakened or become stiff. The treatment can differ depending on the type of heart failure.

Expected Duration

Congestive heart failure often is a lifelong condition. However, if the cause is treatable, congestive heart failure can go away.

Prevention

To avoid congestive heart failure, you must prevent the various forms of heart disease that lead to it. To prevent coronary heart disease, eat a healthy, balanced diet, control your blood pressure and cholesterol level, maintain a normal body weight, exercise regularly, and don't smoke. Limit alcohol use to one to two drinks per day. Some congestive heart failure cannot be prevented.

Treatment

The treatment of congestive heart failure focuses on lessening symptoms, decreasing hospitalizations and improving life expectancy. To accomplish these goals, your doctor will advise a low salt diet and medications, which may include:

• A diuretic ("water pill") to remove excess body fluid by increasing urine output

• An angiotensin-converting enzyme inhibitor or angiotensin receptor blocker to expand blood vessels and improve forward blood flow

• A beta-blocker to help prolong the life of heart muscle cells

• Digoxin (Lanoxin) to strengthen the heart's contractions

• A potassium sparing diuretic such as spironolactone which in low doses has been shown to improve longevity

Sometimes, anticoagulants (blood thinners) also are prescribed to prevent blood clots, particularly if the patient requires a long period of bed rest.

In addition to treating the symptoms of heart failure, your doctor will address any factors the underlying cause. Heart failure related to coronary artery disease may require additional medications, angioplasty or surgery. When heart failure is caused by a poorly functioning heart valve, your doctor may advise surgical repair or valve replacement. For some people with heart failure, losing weight or stopping all consumption of alcohol can dramatically improve symptoms. Your doctor will inform you of how much exercise is appropriate. Balancing physical activity with rest is important in more advanced stages of heart failure.

When medications and self-treatment are no longer helpful, a heart transplant may be considered. This treatment option is limited by a shortage of donor hearts and usually is reserved for patients younger than 65.

When To Call A Professional

Call your doctor if you have any of the following symptoms, particularly if you already have been diagnosed with some form of heart disease:

• Marked fatigue

• Difficulty breathing

• Swelling of the ankles and legs

• Increase in abdominal girth

• Episodes of breathlessness

Prognosis

The outlook depends on the patient's age, the severity of the heart failure, the severity of the underlying heart disease, and other factors. When congestive heart failure develops suddenly and has a treatable cause, people sometimes can regain normal heart function after treatment. With appropriate treatment, even people who develop congestive heart failure as a result of long-standing heart disease often can enjoy many years of productive life.

Additional Info

American Heart Association (AHA) 7272 Greenville Ave. Dallas, TX 75231 Toll-Free: (800) 242-8721 Fax: (214) 706-2139 http://www.americanheart.org/

National Heart, Lung and Blood Institute (NHLBI) 6701 Rockledge Dr. P.O. Box 30105 Bethesda, MD 20824-0105 Phone: (301) 592-8573 http://www.nhlbi.nih.gov/

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Last updated:	August 21, 2006