Heart failure

Answer 1

Definition

Heart failure, also called congestive heart failure, is a condition in which the heart can no longer pump enough blood to the rest of the body.

Alternative Names

CHF; Congestive heart failure; Left-sided heart failure; Right-sided heart failure

Causes, incidence, and risk factors

Heart failure is almost always a chronic, long-term condition, although it can sometimes develop suddenly.

The condition may affect the right side, the left side, or both sides of the heart.

• Right-sided heart failure means the right ventricle of the heart loses its pumping function.
• Left-sided heart failure means the heart's ability to pump blood forward from the left side of the heart is decreased. The left side of the heart normally receives blood rich in oxygen from the lungs and pumps it to the remainder of the body.

Heart failure is often classified as either systolic or diastolic.

• Systolic heart failure means that your heart muscle cannot pump, or eject, the blood out of the heart very well.
• Diastolic heart failure means that your heart's pumping chamber does not fill up with blood.

Both of these problems mean the heart is no longer able to pump enough blood out to the rest of your body, especially when you exercise or are active.

As the heart's pumping action is lost, blood may back up in other areas of the body, producing congestion in the lungs, the liver, the gastrointestinal tract, and the arms and legs. As a result, there is a lack of oxygen and nutrition to organs, which damages them and reduces their ability to work properly.

Perhaps the most common cause of heart failure is coronary artery disease, a narrowing of the small blood vessels that supply blood and oxygen to the heart. For information on this condition and its risk factors, see: Coronary artery disease.

Heart failure can also occur when an illness or toxin weakens the heart muscle or changes the heart muscle structure. Such events are called cardiomyopathies. There are many different types of cardiomyopathy. For information, see: Cardiomyopathy

Other heart problems that may cause heart failure are:

• Congenital Heart disease
• Heart valve disease
• Some types of abnormal heart rhythms (arrhythmias)

Diseases such as emphysema, severe anemia, hyperthyroidism, or hypothyroidism, may cause or contribute to heart failure

Symptoms

Common symptoms are:

• Shortness of breath with activity, or after lying down for a while
• Cough
• Swelling of feet and ankles
• Swelling of the abdomen
• Weight gain
• Irregular or rapid pulse
• Sensation of feeling the heart beat (palpitations)
• Difficulty sleeping
• Fatigue, weakness, faintness
• Loss of appetite, indigestion

Other symptoms may include:

• Decreased alertness or concentration
• Decreased urine production
• Nausea and vomiting
• Need to urinate at night

Infants may sweat during feeding (or other activity).

Some patients with heart failure have no symptoms. In these people, the symptoms may develop only with these conditions:

• Abnormal heart rhythm (arrhythmias)
• Anemia
• Hyperthyroidism
• Infections with high fever
• Kidney disease

Signs and tests

A physical examination may reveal the following:

• Fluid around the lungs (pleural effusion)
• Irregular heartbeat
• Leg swelling (edema)
• Neck veins that stick out (are distended)
• Swelling of the liver

Listening to the chest with a stethoscope may reveal lung crackles or abnormal heart sounds.

The following tests may reveal heart swelling,decreased heart function, or lung congestion:

• Chest x-ray
• ECG
• Echocardiogram
• Cardiac stress tests
• Heart CT scan
• Heart catheterization
• MRI of the heart
• Nuclear heart scans

This disease may also alter the following test results:

• Blood chemistry
• BUN
• Complete blood count
• Creatinine
• Creatinine clearance
• Liver function tests
• Uric acid-blood test
• Sodium - blood test
• Urinalysis
• Sodium - urine test

Treatment

If you have heart failure, your doctor will monitor you closely. You will have follow up appointments at least every 3 to 6 months and tests to check your heart function. For example, an ultrasound of your heart (echocardiogram) will be done once in awhile to see how well your heart pumps blood with each beat.

You will need to carefully monitor yourself and help manage your condition. One important way to do this is to track your weight on a daily basis. Weight gain can be a sign that you are retaining fluid and that your heart failure is worsening. Make sure you weigh yourself at the same time each day and on the same scale, with little to no clothes on.

Other important measures include:

• Take your medications as directed. Carry a list of medications with you wherever you go.
• Limit salt intake.
• Don't smoke.
• Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan based on your degree of heart failure and how well you do on tests that check the strength and function of your heart. DO NOT exercise on days that your weight has gone up from fluid retention or you are not feeling well.
• Lose weight if you are overweight.
• Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest as well. Keep your feet elevated to decrease swelling.

Here are some tips to lower your salt and sodium intake:

• Look for foods that are labeled "low-sodium," "sodium-free," "no salt added," or "unsalted." Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels.
• Don't cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG).
• Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, Hot Dogs, sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese.
• Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese.
• Use oil and vinegar, rather than bottled dressings, on salads.
• Eat fresh fruit or sorbet when having dessert.

Your doctor may consider prescribing the following medications:

• ACE inhibitors such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart
• Diuretics including hydrochlorothiazide, chlorthalidone, chlorothiazide, furosemide, torsemide, bumetanide, and spironolactone to help rid your body of fluid and salt (sodium)
• Digitalis glycosides to increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances
• Angiotensin receptor blockers (ARBs) such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors
• Beta-blockers such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease

Certain medications may make heart failure worse and should be avoided. These include nonsteroidal anti-inflammatory drugs, thiazolidinediones, metformin, cilostazol, PDE-5 inhibitors (sildenafil, vardenafil), and many drugs that treat abnormal heart rhythms.

Valve replacements or repair coronary bypass surgery (CABG), and angioplasty may help some people with heart failure.

The following devices may be recommended for certain patients:

• A single or dual chamber pacemaker to help with slow heart rates or certain other heart signaling problems
• A biventricular pacemaker to help the left and right side of your heart contract at the same time.
• An implantable cardioverter-defibrillator to correct or prevent severe arrhythmias (abnormal heart rhythms)

Severe heart failure may require the following treatments:

• Intra-aortic balloon pump (IABP), a temporary device placed into the aorta
• Left ventricular assist device (LVAD), which takes over the role of the heart by pumping blood from the heart into the aorta; it's most often used by those who are waiting for a heart transplant.

Note: These devices can be life saving, but they are not permanent solutions. Patients who become dependent on circulatory support will need a heart transplant.

Heart failure symptoms may be improved with biventricular pacemaker or cardiac resynchronization therapy. Ask your provider if you are a candidate for this type of treatment.

Expectations (prognosis)

Heart failure is a serious disorder. It is usually a chronic illness, which may get worse with infection or other physical stress.

Many forms of heart failure can be controlled with medication, lifestyle changes, and treatment of any underlying disorder.

Complications

• Irregular heart rhythms (can be deadly)
• Pulmonary edema
• Total heart failure (circulatory collapse)

Possible side effects of medications include:

• Cough
• Digitalis toxicity
• Gastrointestinal upset (such as nausea, heartburn, diarrhea)
• Headache
• Light-headedness and fainting
• Low blood pressure
• Lupusreaction
• Muscle cramps

Calling your health care provider

Call your health care provider if weakness, increased cough or sputum production, sudden weight gain or swelling, or other new or unexplained symptoms develop.

Go to the emergency room or call the local emergency number (such as 911) if you experience severe crushing chest pain, fainting, or rapid and irregular heartbeat(particularly if other symptoms accompany a rapid and irregular heartbeat).

Prevention

Follow your health care provider's treatment recommendations and take all medications as directed.

Keep your blood pressure , heart rate, and cholesterol under control as recommended by your doctor. This may involve exercise, a special diet, and medications.

Other important treatment measures:

• Do not smoke.
• Do not drink alcohol.
• Reduce salt intake.
• Exercise as recommended by your health care provider.

References

Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. J Am Coll Cardiol. 2005;46:1-82.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 25.

Hess OM and Carroll JD. Clinical assessment of heart failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 23.

Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. Epub 2009 Mar 26.

Answer 2

Definition

Heart failure is a condition in which the heart can no longer pump enough blood to the rest of the body.

Alternative Names

CHF; Congestive heart failure; Left-sided heart failure; Right-sided heart failure - Cor pulmonale; Cardiomyopathy - heart failure

Causes, incidence, and risk factors

Heart failure is a long-term (chronic) condition, but it can sometimes develop suddenly.

The condition may affect only the right side or only the left side of the heart. These are called right-sided heart failure or left-sided heart failure. More often, both sides of the heart are involved.

Heart failure is present when:

• Your heart muscle cannot pump (eject) the blood out of the heart very well. This is called systolic heart failure.
• Your heart muscles are stiff and do not fill up with blood easily. This is called diastolic heart failure.

Both of these problems mean the heart is no longer able to pump enough oxygen-rich blood out to the rest of your body, especially when you exercise or are active.

As the heart's pumping action is lost, blood may back up in other areas of the body. Fluid builds up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called congestive heart failure.

The most common cause of heart failure is coronary artery disease(CAD), a narrowing of the small blood vessels that supply blood and oxygen to the heart. For information on this condition and its risk factors, see: Heart disease - risk factors

Heart failure can also occur when an infection weakens the heart muscle. This condition is called cardiomyopathy. For more information, see: Cardiomyopathy

Other heart problems that may cause heart failure are:

• Congenital heart disease
• Heart attack
• Heart valve disease
• Some types of abnormal heart rhythms (arrhythmias)

Other diseases that can cause or contribute to heart failure:

• Emphysema
• Overactive thyroid
• Severe anemia
• Underactive thyroid

Symptoms

Symptoms of heart failure often begin slowly. At first, they may only occur when you are very active. Over time, you may notice breathing problems and other symptoms even when you are resting.

Heart failure symptoms may also begin suddenly; for example, after a heart attack or other heart problem.

Common symptoms are:

• Cough
• Fatigue, weakness, faintness
• Loss of appetite
• Need to urinate at night
• Pulse that feels fast or irregular, or a sensation of feeling the heart beat (palpitations)
• Shortness of breath when you are active or after you lie down
• Swollen (enlarged) liver or abdomen
• Swollen feetand ankles
• Waking up from sleep after a couple of hours due to shortness of breath
• Weight gain

Signs and tests

Your health care provider will examine you for signs of heart failure:

• Fast or difficult breathing
• Irregular or fast heartbeat and abnormal heart sounds
• Leg swelling (edema)
• Neck veins that stick out (are distended)
• Sounds ("crackles") from fluid buildup in your lungs, heard through a stethoscope
• Swelling of the liver or abdomen

An echocardiogram (echo) is often the best test to diagnose, learn the cause of, and monitor your heart failure. Your doctor will use it to guide your treatment.

Other imaging tests are:

• Cardiac stress tests
• Heart catheterization
• MRI of the heart
• Nuclear heart scans

Lab tests are done to help your doctor:

• Check how well your kidneys are working (BUN, creatinine, creatinine clearance, urinalysis)
• Look for a low blood count or anemia -- complete blood count(CBC)
• Test for brain natriuretic peptide (BNP)
• Watch sodiumand potassium levels in your blood

Treatment

MONITORING AND SELF CARE

If you have heart failure, your doctor will monitor you closely. You will have follow-up appointments at least every 3 to 6 months and tests to check your heart function.

Knowing your body and the symptoms that your heart failure is getting worse will help you stay healthier and out of the hospital. At home, watch for changes in your heart rate, pulse, blood pressure, and weight. See: Home monitoring

Weight gain, especially over a day or two, can be a sign that your body is holding onto extra fluid and your heart failure is getting worse. Talk to your doctor about what you should do if your weight goes up or if you develop more symptoms.

Limit how much salt you eat. Your doctor may also ask you to limit how much fluid you drink during the day.

Other important changes to make in your lifestyle:

• Ask your doctor how much alcohol you may drink.
• Do not smoke.
• Stay active. Walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan for you. DO NOT exercise on days when your weight has gone up from fluid or you are not feeling well.
• Lose weight if you are overweight.
• Lower your cholesterol by changing your lifestyle.
• Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest too.

MEDICATIONS, SURGERY, AND DEVICES

Your doctor will ask you to take medicines to treat your heart failure. Medicines treat the symptoms, prevent your heart failure from getting worse, and help you live longer.

These medicines:

• Help the heart muscle pump better
• Keep your blood from clotting
• Lower your cholesterol levels
• Open up blood vessels or slow your heart rate so your heart doesn't have to work as hard
• Replace potassium
• Rid your body of excess fluid and salt (sodium)

It is very important that you take your medicine as your doctor and nurse directed. Do not take any other drugs or herbs without first asking your doctor or nurse about them. These include:

• ibuprofen (Advil, Motrin)
• Naproxen (Aleve, Naprosyn)
• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)

The following surgeries and devices may be recommended for certain patients with heart failure:

• Coronary bypass surgery (CABG) and angioplasty may help improve blood flow to the damaged or weakened heart muscle.
• Heart valve surgery may be done if changes in a heart valve are causing your heart failure.
• A pacemaker can help treat slow heart rates or help both sides of your heart contract at the same time.
• A defibrillatorsends an electrical pulse to stop life-threatening abnormal heart rhythms.

END-STAGE HEART FAILURE

Severe heart failure occurs when treatments no longer work. Certain treatments may be used when a person is waiting for a heart transplant:

• Intra-aortic balloon pump (IABP)
• Left ventricular assist device (LVAD)

At a certain point, the health care provider will decide whether it is best to keep treating heart failure. The patient, along with his or her family and doctors, may want to discuss the option of palliative or comfort care at this time.

Expectations (prognosis)

Often, you can control heart failure by taking medicine, changing your lifestyle, and treating the condition that caused it.

Heart failure can suddenly get worse due to:

• Angina
• Eating high-salt foods
• Heart attack
• Infections or other illnesses
• Not taking medicines correctly

Heart failure is usually a chronic illness, which may get worse over time. Some people develop severe heart failure, in which medicines, other treatments, and surgery no longer help. Many people are at risk for deadly heart rhythms.

Calling your health care provider

Call your health care provider if you develop:

• Increased cough or phlegm
• Sudden weight gain or swelling
• Weakness
• Other new or unexplained symptoms

Go to the emergency room or call the local emergency number (such as 911) if you experience:

• Fainting
• Fast and irregular heartbeat (especially if you also have other symptoms)
• Severe crushing chest pain

Prevention

Follow your health care provider's treatment recommendations and take all medications as directed.

For information on risk factors and prevention, see: Heart disease - risk factors

Keep your blood pressure , heart rate, and cholesterol under control as your doctor recommends. This may involve exercise, a special diet, and medications.

Other important treatment measures:

• Do not smoke.
• Do not drink alcohol.
• Reduce how much salt you eat.
• Exercise as your health care provider recommends.

References

Emanuel LL, Bonow RO. Care of patients with end-stage heart disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 34.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 28.

Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. Epub 2009 Mar 26.

Reviewed By

Review Date: 07/22/2011

Michael M. Chen, MD, PhD, Assistant Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.