Congestive Heart Failure
What is congestive heart failure?
Congestive heart failure, also called CHF or heart failure, is a serious and complex disease in which the heart muscle has been damaged or has to work too hard because of heart disease and other conditions, such as obesity. Although the heart continues to beat, the damaged heart muscle is too weak to efficiently pump enough oxygen-rich blood to and from the body, resulting in potentially life-threatening congestion in the lungs and other tissues of the body.
Congestive heart failure is a common complication of heart attack and other types of heart disease that damage the heart muscle. These diseases include hypertension, heart valve disorders, arrhythmias, and cardiomyopathy. Congestive heart failure can also be caused by anemia.
In general, congestive heart failure affects both the left and right sides of the heart, but it can affect one side more than the other, depending on the location and severity of damage.
In left-sided CHF, the left side of the heart is damaged and unable to effectively pump blood from the heart to the body. This results in blood backing up into the lungs and increasing blood pressure in the lungs. The increase in pressure causes a buildup of fluid in the lungs, which can lead to a life-threatening condition called acute pulmonary edema.
In right-sided CHF, the right side of the heart is damaged and unable to effectively relax to permit blood flowing from the body back into the heart. This results in a backup of blood and an increase in pressure in the veins that carry blood from the body to the heart. In turn, this leads to swelling (edema) of the lower extremities and sometimes of other areas of the body.
Acute CHF, in which fluid builds up rapidly in the lungs and causes pulmonary edema, is an immediately life-threatening condition that can quickly lead to respiratory failure, cardiac arrest and death. Immediate emergency treatment best minimizes the risk of these and other serious complications of heart failure. Seek immediate medical care (call 911) if you, or someone you are with, have symptoms of acute congestive heart failure, such as shortness of breath, difficulty breathing, congested cough, and chest pain. If you do not have the above symptoms, but have swelling in the extremities, abdomen or face, seek prompt medical care.
What are the symptoms of congestive heart failure?
Congestive heart failure symptoms are due to a lack of oxygen in the tissues of the body caused by a damaged heart that cannot pump blood efficiently. Symptoms can vary between individuals and can differ depending on the severity of the disease and the side of the heart affected (left side, right side, or both sides).
It is common to have some symptoms of both left-sided and right-sided congestive heart failure. Early symptoms may develop slowly, and in some cases, you may not have noticeable symptoms until congestive heart failure has progressed and become severe.
Symptoms of right-sided congestive heart failure
The primary symptom of congestive heart failure caused by damage to the right side of the heart is swelling (edema) of the feet and ankles. In more severe cases, edema can extend to the legs, abdomen, upper extremities, and face.
Symptoms of right-sided congestive heart failure include:
- Malaise (feeling sick)
- Swelling (edema), which may include swelling of the feet, ankles, legs, abdomen, arms and face
Symptoms of left-sided congestive heart failure
The primary symptom of congestive heart failure caused by damage to the left side of the heart is shortness of breath and difficulty breathing (dyspnea) due to a buildup of fluid in the lungs. A buildup of fluid in the lungs is called pulmonary edema.
Shortness of breath and difficulty breathing can occur at rest or with exertion and often occurs when lying down, which can interrupt sleep. In mild cases, shortness of breath can be relieved to various degrees by sleeping in a semi-upright position.
Congestion and fluid in the lungs also lead to wheezing, chest pain, and an ongoing cough that brings up frothy phlegm that may be tinged with blood.
Serious symptoms that might indicate a life-threatening condition
Left-sided congestive heart failure can result in an immediately life-threatening condition called acute pulmonary edema, a sudden buildup of fluid in the lungs. Seek immediate medical care (call 911) if you, or someone you are with, have symptoms of left-sided congestive heart failure including:
- Anxiety and restlessness
- Change in level of consciousness or alertness, such as passing out or unresponsiveness
- Change in mental status or sudden behavior change, such as confusion, delirium, lethargy, hallucinations and delusions
- Chest pain, chest tightness, chest pressure, palpitations
- Cold, clammy skin
- Fatigue and weakness
- Loose, wet cough that may produce frothy and possibly blood-tinged phlegm
- Pallor (an extremely pale or grayish coloring) or cyanosis (a bluish coloring of the nails, lips and possibly the skin)
- Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, or choking
What causes congestive heart failure?
Congestive heart failure is a common complication of heart diseases and conditions that damage the heart muscle or make it work too hard. This makes the heart weak and unable to pump blood effectively through the body. Diseases, disorders and conditions that can cause congestive heart failure include:
- Advanced age (65 years and older)
- Atherosclerosis and coronary artery disease (buildup of plaque on the walls of the coronary arteries; atherosclerosis is a type of arteriosclerosis)
- Cardiac arrhythmias (abnormal heart rhythms)
- Cardiomyopathy (diseased heart muscle)
- Congenital heart diseases (heart diseases or abnormalities present at birth)
- Diabetes (chronic disease that affects your body’s ability to use sugar for energy)
- Heart attack, also called myocardial infarction (death of heart tissue due to a lack of oxygen)
- Heart valve disorders
- Hypertension (high blood pressure)
- Hyperthyroidism (overactive thyroid)
- Myocarditis (type of inflammation of the heart)
- Severe anemia (low number of red blood cells)
Who gets congestive heart failure and what are the risk factors?
An estimated 6.2 million people in the United States have heart failure. Diseases and conditions that increase the risk of developing heart disease or cardiovascular disease also increase the risk of eventually developing congestive heart failure as a complication.
Risk factors include:
- African American ancestry
- Atherosclerosis and coronary artery disease (buildup of plaque on the arteries that supply the heart)
- Diabetes (chronic disease that affects your body’s ability to use sugar for energy)
- Excessive alcohol consumption
- Family history of heart disease or cardiovascular disease
- Hypertension (high blood pressure)
- Sedentary lifestyle
Having high levels of certain substances in the body, which can be determined by blood tests, can also increase the risk for heart disease and congestive heart failure. These include:
- High cholesterol, which can lead to atherosclerosis
- High C-reactive protein level, which reflects inflammation
- High homocysteine level, which may damage artery walls and increase the risk of developing blood clots. Blood clots can cause a heart attack and lead to congestive heart failure.
Reducing your risk of congestive heart failure
You can reduce your risk of developing heart disease and congestive heart failure by:
- Eating a heart-healthy diet that is low in saturated fat and trans fats and high in fiber, whole grains, fruits, and vegetables
- Limiting alcohol intake to one drink per day for women and two drinks per day for men
- Maintaining a healthy weight
- Not smoking
- Participating in a regular exercise program
- Reducing excessive stress
- Seeking regular medical care and prenatal care and following your treatment plan for such conditions as high cholesterol, obesity, hypertension, and diabetes
How is congestive heart failure diagnosed?
In addition to a complete medical history and physical examination, diagnostic procedures for heart failure may include any, or a combination of, the following:
- Chest X-ray: a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
- Echocardiogram: a noninvasive test that uses sound waves to produce a study of the motion of the heart's chambers and valves. The echo sound waves create an image on the monitor as an ultrasound transducer is passed over the heart.
- Electrocardiogram (ECG or EKG): a test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.
- BNP testing: B-type natriuretic peptide (BNP) is a hormone released from the ventricles in response to increased wall tension (stress) that occurs with heart failure. The higher the BNP levels, the worse the heart failure.
How is congestive heart failure treated?
The cause of the heart failure will determine what kinds of treatment options are viable. If heart failure is caused by a valve disorder, performing heart valve surgery may improve your heart function. Most cases of heart failure, however, are caused by a damaged heart muscle; although there's no cure for this, the right balance of medications, lifestyle changes, and sometimes special devices has proven to be successful.
General prevention and treatment measures for congestive heart failure
Treatment for congestive heart failure includes preventive care aimed at minimizing the risk factors for having a heart attack and other forms of heart disease. General preventive and treatment measures include:
- Lifestyle and dietary changes to achieve and maintain an ideal weight and fitness level. Doctors recommend a heart-healthy diet that is low in saturated fat, trans fats, and sodium. Excessive salt leads to fluid retention and increases blood pressure.
- Periods of prescribed rest
- Regular medical care and treatment of risk factors, such as high cholesterol, hypertension, obesity, smoking, diabetes, and excessive alcohol consumption
Medications used to treat congestive heart failure
Treatment of congestive heart failure also includes medications.
Doctors prescribe medicine to manage symptoms and to make it easier for the heart to function, which will improve symptoms and reduce the risk of complications.
- Angiotensin-converting enzyme (ACE) inhibitors (benazepril, fosinopril, lisinopril, enalapril, captopril), which lower blood pressure and reduce strain on the heart
- Angiotensin-II receptor blockers (ARBs), which are an alternative to lower blood pressure for those who can't tolerate ACE inhibitors. Examples include losartan (Cozaar) and valsartan (Diovan).
- Combination valsartan-sacubitril (Entresto), which is used in place of an ARB or ACE inhibitor
- Aldosterone blockers (Aldactone), which may be used for severe congestive heart failure
- Anticoagulants (aspirin, Coumadin, Plavix), which prevent the formation of blood clots that can lead to heart attack and stroke
- Beta-blockers (metoprolol, atenolol and propranolol), which lower blood pressure, control heart rate, and reduce strain on the heart
- Cholesterol-lowering medications (statins), which can reduce the risk of heart attack and stroke. Cholesterol-lowering medications also reduce the risk of recurrent heart attack and stroke.
- Digitalis drugs (digoxin), which slow and strengthen the beating of the heart to make the heart muscle more effective in pumping blood
- Diuretics (Lasix, Bumex, HCTZ), which pull excess fluid out of the lungs and tissues of the body by increasing urine production
Treatment of severe congestive heart failure
Severe congestive heart failure with acute pulmonary edema (a rapid buildup of fluid in the lungs) is often diagnosed and initially treated in an emergency room setting. Treatment includes:
- Intensive monitoring and stabilization of heart rhythm and vital signs. In some cases, this may require cardiopulmonary resuscitation (CPR), and advanced life-support measures, such as intubation and mechanical ventilation to support breathing.
- Intravenous medications to rapidly draw fluid out of the lungs and reduce strain on the heart
- Monitoring your heart rate and rhythm with an electrocardiogram (known as an EKG or ECG) and blood tests to determine the extent of heart damage
- Supplemental oxygen to ease breathing and increase the amount of oxygen that is delivered to the heart tissue and the rest of the body
- Treatment of abnormal heart rhythms (cardiac arrhythmias) with medications and possibly electrical cardioversion or defibrillation
Surgical treatments for congestive heart failure
A variety of surgical procedures may be used in the treatment of some cases of congestive heart failure including:
- Angioplasty and stent placement or coronary artery bypass may be an option for people with congestive heart failure who have severely blocked coronary arteries.
- Heart transplant may be the only treatment option in severe cases of congestive heart failure in which medications and lifestyle and dietary changes do not improve heart function.
- Left ventricular assist device (LVAD) is a device surgeons connect to the heart to improve heart function. It may be used as a "bridge treatment" while waiting for a heart transplant or as a treatment in itself.
- Pacemaker may be used in some cases to control abnormal heart rhythms.
- Valve surgery repair or replacement of damaged heart valves
Other treatments for congestive heart failure
Other treatments and therapies include:
- Cardiac rehabilitation and physical therapy can help strengthen the body, reduce complications, increase alertness, reduce fatigue, improve your overall health, and enhance your ability to function in everyday activities.
- Palliative care to improve the overall quality of life for families and patients with serious diseases
- Regular follow-up care to help monitor your treatment and progress and to address any problems or complications promptly
- Complementary or alternative treatments, such as acupuncture, massage therapy, and yoga to reduce stress and improve well-being. Complementary treatments are not meant to substitute for full medical care.
What are the possible complications of congestive heart failure?
Complications of congestive heart failure are life threatening. Complications include a rapid or severe buildup of fluid in the lungs (pulmonary edema), which can lead to respiratory failure, respiratory arrest, and death. Pulmonary edema also increases the risk of developing serious infections of the lungs, such as pneumonia.
Congestive heart failure also impacts the quality of life and can lead to serious and permanent disability. The prognosis depends on the severity of congestive heart failure, the underlying cause, your age and general health, and the presence of coexisting diseases, such as diabetes.
You can help minimize the risk of serious complications of congestive heart failure by following the treatment plan you and your doctor design specifically for you. Serious and life-threatening complications of congestive heart failure include:
- Cardiogenic shock
- Pulmonary edema
- Serious or lethal cardiac arrhythmias (abnormalities in heart rhythm, such as atrial fibrillation, ventricular tachycardia, and ventricular fibrillation)