Congestive Heart Failure and Heart Disease

Heart failure affects nearly 6 million Americans. Roughly 670,000 people are diagnosed with heart failure each year. It’s the main reason people older than 65 go into the hospital.

What Is Heart Failure?

Heart failure doesn’t mean the heart has stopped working. Rather, it means that the heart works less efficiently than normal. Due to various possible causes, blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart can’t pump enough oxygen and nutrients to meet the body's needs.

The chambers of the heart may respond by stretching to hold more blood to pump through the body or by becoming stiff and thickened. This helps to keep the blood moving, but the heart muscle walls may eventually weaken and become unable to pump as efficiently. The kidneys may respond by causing the body to retain fluid (water) and salt. If fluid builds up in the arms, legs, ankles, feet, lungs, or other organs, the body becomes congested. Congestive heart failure is the term used to describe the condition.

What Causes Heart Failure?

Heart failure is caused by many conditions that damage the heart muscle, including:

What Are the Symptoms of Heart Failure?

You may not have any symptoms of heart failure, or the symptoms may be mild to severe. Symptoms can be constant or can come and go. The symptoms can include:

• Congested lungs. Fluid backup in the lungs can cause shortness of breath with exercise or difficulty breathing at rest or when lying flat in bed. Lung congestion can also cause a dry, hacking cough or wheezing.
• Fluid and water retention. Less blood to your kidneys causes fluid and water retention, resulting in swollen ankles, legs, abdomen (called edema), and weight gain. Symptoms may cause an increased need to urinate during the night. Bloating in your stomach may cause a loss of appetite or nausea.
• Dizziness, fatigue, and weakness. Less blood to your major organs and muscles makes you feel tired and weak. Less blood to the brain can cause dizziness or confusion.
• Rapid or irregular heartbeats. The heart beats faster to pump enough blood to the body. This can cause a rapid or irregular heartbeat.

If you have heart failure, you may have one or all of these symptoms or you may have none of them. They may or may not indicate a weakened heart.

What Are the Types of Heart Failure?

Systolic dysfunction (or systolic heart failure) happens when the heart muscle doesn't contract with enough force, so there is less oxygen-rich blood pumped throughout the body.

Diastolic dysfunction (or diastolic heart failure) happens when the heart contracts normally, but the ventricles don’t relax properly or are stiff, and less blood enters the heart during normal filling.

A calculation done during an echocardiogram, called the ejection fraction (EF), is used to measure how well your heart pumps with each beat to help determine if systolic or diastolic dysfunction is present. Your doctor can discuss which condition you have.

How Is Heart Failure Diagnosed?

Your doctor will ask you many questions about your symptoms and medical history. You’ll be asked about any conditions you have that may cause heart failure (such as coronary artery disease, angina, diabetes, heart valve disease, and high blood pressure). You’ll be asked if you smoke, take drugs, drink alcohol (and how much you drink), and about what drugs you take.

You’ll also get a complete physical exam. Your doctor will listen to your heart and look for signs of heart failure as well as other illnesses that may have caused your heart muscle to weaken or stiffen.

Your doctor may also order other tests to determine the cause and severity of your heart failure. These include:

• Blood tests. Blood tests are used to evaluate kidney and thyroid function as well as to check cholesterol levels and the presence of anemia. Anemia is a blood condition that happens when there is not enough hemoglobin (the substance in red blood cells that enables the blood to transport oxygen through the body) in your blood.
• B-type natriuretic peptide (BNP) blood test. BNP is a substance secreted from the heart in response to changes in blood pressure that happen when heart failure develops or worsens. BNP blood levels increase when heart failure symptoms worsen, and decrease when the heart failure condition is stable. The BNP level in a person with heart failure -- even someone whose condition is stable -- may be higher than in a person with normal heart function. BNP levels do not necessarily correlate with the severity of heart failure.
• Chest X-ray. A chest X-ray shows the size of your heart and whether there is fluid build-up around the heart and lungs.
• Echocardiogram. This test is an ultrasound which shows the heart's movement, structure, and function.
• Ejection fraction (EF) is used to measure how well your heart pumps with each beat to determine if systolic dysfunction or heart failure with preserved left ventricular function is present. Your doctor can discuss which condition you have.
• Electrocardiogram (EKG or ECG). An EKG records the electrical impulses traveling through the heart.
• Cardiac catheterization. This invasive procedure helps determine whether coronary artery disease is a cause of congestive heart failure.
• Stress Test. Noninvasive stress tests provide information about the likelihood of coronary artery disease.

Other tests may be ordered, depending on your condition.

Is There a Treatment for Heart Failure?

There are more treatment options available for heart failure than ever before. Tight control over your medications and lifestyle, coupled with careful monitoring, are the first steps. As the condition progresses, doctors specializing in the treatment of heart failure can offer more advanced treatment options.

The goals of treating heart failure are to try to keep it from getting worse (lowering the risk of death and the need for hospitalization), to ease symptoms, and to improve quality of life.

Some common types of medicines used to treat it are:

• ACE inhibitors (angiotensin-converting enzyme inhibitors)
• Aldosterone antagonists
• ARBs (angiotensin II receptor blockers)
• ARNIs (angiotensin receptor- neprilysin inhibitors)
• Beta-blockers
• Blood vessel dilators
• Digoxin
• Calcium channel blockers
• Diuretics
• Heart pump medications
• Potassium or magnesium
• Selective sinus node inhibitors
• Soluble guanylate cyclase (sGC) stimulator

Your doctor may also recommend a program called cardiac rehabilitation to help you exercise safely and keep up a heart-healthy lifestyle. It usually includes workouts that are designed just for you, education, and tips to lower your chance of heart trouble, like quitting smoking or changing your diet.

Cardiac rehab also offers emotional support. You can meet people like you who can help you stay on track.

Stages of Heart Failure

The stages classified by the AHA and ACC are different than the New York Heart Association (NYHA) clinical classifications of heart failure that rank patients as class I-II-III-IV, according to the degree of symptoms or functional limits. Ask your doctor what stage of heart failure you are in.

Check the table below to see if your therapy matches what the AHA and ACC recommend. Note that you cannot go backward in stage, only forward.

The table below outlines a basic plan of care that may or may not apply to you, based on the cause of your heart failure and your special needs. Ask your doctor to explain therapies that are listed if you do not understand why you are or are not receiving them.

Stage

Definition of Stage

Usual Treatments

Stage A

• High blood pressure
• Diabetes
• Coronary artery disease
• Metabolic syndrome
• History of cardiotoxic drug therapy
• History of alcohol abuse
• History of rheumatic fever
• Family history of cardiomyopathy

• Quit smoking.
• Treat high blood pressure.
• Treat lipid disorders.
• Discontinue alcohol or illegal drug use.
• An angiotensin converting enzyme inhibitor (ACE inhibitor) or an angiotensin II receptor blocker (ARB) is prescribed if you have coronary artery disease, diabetes, high blood pressure, or other vascular or cardiac conditions.
• Beta blockers may be prescribed if you have high blood pressure or if you've had a previous heart attack.

Stage B

People diagnosed with systolic left ventricular dysfunction but who have never had symptoms of heart failure (pre-heart failure), including people with:

• Prior heart attack
• Valve disease
• Cardiomyopathy

The diagnosis is usually made when an ejection fraction of less than 40% is found during an echocardiogram test.

• Treatment methods above for Stage A apply
• All patients should take an angiotensin converting enzyme inhibitor (ACE inhibitors) or angiotensin II receptor blocker (ARB)
• Beta-blockers should be prescribed for patients after a heart attack
• Surgery options for coronary artery repair and valve repair or replacement (as appropriate) should be discussed

If appropriate, surgery options should be discussed for patients who have had a heart attack.

Stage C

Patients with known systolic heart failure and current or prior symptoms. Most common symptoms include:

• Shortness of breath
• Fatigue
• Reduced ability to exercise

• Treatment methods above for Stage A apply
• All patients should take an angiotensin converting enzyme inhibitor (ACE inhibitors) and beta-blockers
• African-American patients may be prescribed a hydralazine/nitrate combination if symptoms persist
• Diuretics (water pills) and digoxin may be prescribed if symptoms persist
• An aldosterone inhibitor may be prescribed when symptoms remain severe with other therapies
• Restrict dietary sodium (salt)
• Monitor weight
• Restrict fluids (as appropriate)
• Drugs that worsen the condition should be discontinued
• As appropriate, cardiac resynchronization therapy (biventricular pacemaker) may be recommended
• An implantable cardiac defibrillator (ICD) may be recommended

Stage D

Patients with systolic heart failure and presence of advanced symptoms after receiving optimum medical care.

• Treatment methods for Stages A, B & C apply
• Patient should be evaluated to determine if the following treatments are available options: heart transplant, ventricular assist devices, surgery options, research therapies, continuous infusion of intravenous inotropic drugs and end-of-life (palliative or hospice) care

The New York Heart Association (NYHA) clinical classifications of heart failure rank people as class I-II-III-IV, according to the degree of symptoms or functional limits. You can ask your doctor if you want to know what stage of heart failure you’re in.

• Class I: Physical activity is not affected, and you have no unusual fatigue, shortness of breath, palpitations, or pain during normal activities.
• Class II: Slight limitations on normal activities. You may have mild fatigue, shortness of breath, palpitations, or pain during normal activities; no symptoms at rest.
• Class III: Marked limitation on normal activities. You have fatigue, shortness of breath, palpitations, or pain during less than normal activities; no symptoms at rest.
• Class IV: You’re uncomfortable even at rest. Discomfort gets worse with any physical activity.

How Can I Prevent Further Heart Damage?

In an effort to prevent further heart damage:

• Stop smoking or chewing tobacco.
• Reach and maintain your healthy weight.
• Control high blood pressure, cholesterol levels, and diabetes.
• Exercise regularly.
• Don't drink alcohol.
• Have surgery or other procedures to treat your heart failure as recommended.

What Medications Should I Avoid if I Have Heart Failure?

There are several different types of medications that are best avoided in those with heart failure including:

• Nonsteroidal anti-inflammatory medications such as Motrin or Aleve. For relief of aches, pains, or fever take Tylenol instead.
• Some antiarrhythmic agents
• Most calcium channel blockers (if you have systolic heart failure)
• Some nutritional supplements, such as salt substitutes, and growth hormone therapies
• Antacids that contain sodium (salt)
• Decongestants such as Sudafed

If you’re taking any of these drugs, discuss them with your doctor.

It’s important to know the names of your medications, what they’re used for, and how often and at what times you take them. Keep a list of your medications and bring them with you to each of your doctor visits. Never stop taking your medications without discussing it with your doctor. Even if you have no symptoms, your medications decrease the work of your heart so that it can pump more effectively.

How Can I Improve My Quality of Life With Heart Failure?

There are several things you can do to improve your quality of life if you have heart failure. Among them:

• Eat a healthy diet. Limit your consumption of sodium (salt) to less than 1,500 milligrams (1 1/2 grams) each day. Eat foods high in fiber. Limit foods high in trans fat, cholesterol, and sugar. Reduce total daily intake of calories to lose weight if necessary.
• Exercise regularly. A regular cardiovascular exercise program, prescribed by your doctor, will help improve your strength and make you feel better. It may also decrease heart failure progression.
• Don't overdo it. Plan your activities and include rest periods during the day. Certain activities, such as pushing or pulling heavy objects and shoveling may worsen heart failure and its symptoms.
• Prevent respiratory infections. Ask your doctor about flu and pneumonia vaccines.
• Take your medications as prescribed. Do not stop taking them without first contacting your doctor.
• Get emotional or psychological support if needed. Heart failure can be difficult for your whole family. If you have questions, ask your doctor or nurse. If you need emotional support, social workers, psychologists, clergy, and heart failure support groups are a phone call away. Ask your doctor or nurse to point you in the right direction.

Can Surgery Be Used to Treat Heart Failure?

In heart failure, surgery may sometimes prevent further damage to the heart and improve the heart's function. Procedures used include:

Heart Failure Treatment Is a Team Effort

Heart failure management is a team effort, and you are the key player on the team. Your heart doctor will prescribe your medications and manage other medical problems. Other team members -- including nurses, dietitians, pharmacists, exercise specialists, and social workers -- will help you achieve success. But it is up to YOU to take your medications, make dietary changes, live a healthy lifestyle, keep your follow-up appointments, and be an active member of the team.

If you notice anything unusual, don't wait until your next appointment to discuss it with your doctor. Call them right away if you have:

• Unexplained weight gain (more than 2 pounds in a day or 5 pounds in a week)
• Swelling in your ankles, feet, legs, or belly that gets worse
• Shortness of breath that gets worse or happens more often, especially if you wake up feeling that way
• Bloating with a loss of appetite or nausea
• Extreme fatigue or more trouble finishing your daily activities
• A lung infection or a cough that gets worse
• Fast heart rate (above 100 beats per minute, or a rate noted by your doctor)
• New irregular heartbeat
• Chest pain or discomfort during activity that gets better if you rest
• Trouble breathing during regular activities or at rest
• Changes in how you sleep, like having a hard time sleeping or feeling the need to sleep a lot more than usual
• Less of a need to pee
• Restlessness, confusion
• Constant dizziness or light-headedness

Nausea or poor appetite

When Should I Get Emergency Care?

Go to the ER or call 911 if you have:

• New, unexplained, and severe chest pain that comes with shortness of breath, sweating, nausea, or weakness
• Fast heart rate (more than 120-150 beats per minute, or a rate noted by your doctor), especially if you are short of breath
• Shortness of breath that doesn't get better if you rest
• Sudden weakness, or you can't move your arms or legs
• Sudden, severe headache
• Fainting spells

What Is the Outlook for People With Heart Failure?

With the right care, heart failure may not stop you from doing the things you enjoy. Your prognosis or outlook for the future will depend on how well your heart muscle is functioning, your symptoms, and how well you respond to and follow your treatment plan.

Everyone with a long-term illness, such as heart failure, should discuss their desires for extended medical care with their doctor and family. An "advance directive" or "living will" is one way to let everyone know your wishes. A living will expresses your desires about the use of medical treatments to prolong your life. This document is prepared while you are fully competent in case you are unable to make these decisions at a later time.

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