Heart Failure

(Congestive Heart Failure; Chronic Heart Failure; Left Ventricular Dysfunction; Left Ventricular Failure)

Definition

In heart failure, the heart is unable to pump the right amount of blood throughout the body. This causes blood to back up in the veins. Depending on which part of the heart is affected most, this can lead to a build up of excess fluid in the lungs, feet, and elsewhere. Heart failure can worsen with time, which may lead to the use of many treatments. Because of this, doctors are aggressive in treating heart failure to try to prevent it from worsening.

Blood Flow Through the Heart

Causes

The leading causes of heart failure are:

Other common causes include:

Problems with the heart's valves due to:
- Rheumatic heart disease
- Bacterial endocarditis
- Congenital defects
- Calcium deposits from atherosclerosis
High blood pressure
Diabetes

Other less common causes include:

Cardiomyopathy (weakened, damaged heart muscle from various causes)
Certain medications
Abnormal heartbeats ( arrhythmias)
Hyperthyroidism (overactive thyroid)
Amyloidosis
Kidney failure and/or liver failure
Thiamine ( vitamin B1) deficiency

Symptoms

Symptoms include:

Shortness of breath—at first only with activity, then progressing to shortness of breath at rest
Unexplained weight gain
Swelling of feet, ankles, or legs
Need to sleep propped up
Fatigue, weakness
Wheezing
Cough —may be dry and hacking or wet sounding, may have a pink, frothy sputum
Frequent urination, especially at night
Abdominal pain

Risk Factors

Risk factors include:

Advancing age
Obesity
Excess intake of salt and fat
Excess alcohol intake
Sex: male
Race: Black
Smoking
Pregnancy
High fever
Severe infection
Chronic lung disease ( emphysema)
Chemotherapy

Diagnosis

The doctor will ask about your symptoms and medical history. She will also do a physical exam, which will include:

Listening to your lungs and heart with a stethoscope
Feeling the abdomen for tenderness and liver swelling
Checking your feet, ankles, and legs for swelling

Tests may include:

Blood tests—to look for certain markers in the blood that help the doctor determine what is happening with your heart
Urine tests—to look for certain markers in the urine that help the doctor determine what is happening with your heart
Electrocardiogram (ECG, EKG)—records the heart's activity by measuring electrical currents through the heart muscle
Echocardiogram —uses high-frequency sound waves (ultrasound) to examine the size, shape, function, and motion of the heart
Exercise stress test —records the heart's electrical activity during increased physical activity (may be coupled with echocardiogram or neclear scan)
- If you cannot exercise, you may be given medicine. This medicine simulates physical exertion.
Nuclear scanning—uses radioactive material (such as thallium) to highlight areas with diminished flow
Coronary angiography —uses a catheter, dye, and x-rays to look for abnormalities (eg, narrowing, blockage) in the arteries and evaluate the function of the heart

Treatment

Treatment of Underlying Conditions

Heart failure may be caused by another condition. Treating this condition should improve your heart failure or prevent if from getting worse.

Lifestyle Changes

The following lifestyle changes can help treat the symptoms of heart failure and slow down its progression:

Avoid alcohol.
If you smoke, quit.
Lose weight if needed.
Eat a healthy diet. Your diet should be low in fat and salt and high in fiber.
Ask your doctor if you need to restrict fluids. Find out how much salt and fluid is right for you.
Begin an exercise program with guidance from your doctor. Aerobic training may help improve your level of physical activity and quality of life.
Weigh yourself every morning. This will allow you to quickly detect if you are retaining fluid.

Medications

Your doctor will most likely prescribe a combination of medications, such as:

ACE inhibitors or their alternatives to widen blood vessels
Digoxin (also called digitalis) to help your heart pump
Beta-blockers to slow your heart rate and lower blood pressure
Diuretics to remove excess fluid in your body

You may also be given medications to:

Thin the blood (eg, aspirin, warfarin [eg, Coumadin])
Help manage chest pain (eg, nitroglycerin)
Help manage cholesterol levels
Help control high blood pressure

If heart failure worsens, you may need medical devices to help your heart pump blood properly. If you have heart failure, follow your doctor's instructions.

Prevention

The best way to prevent heart failure is to reduce your risk of:

Coronary artery disease
High blood pressure
Diabetes

Take these steps to reduce your risk:

Begin a safe exercise program with the advice of your doctor.
If you smoke, quit.
Limit alcohol.
Lose weight if needed. Once you have lost weight, maintain a healthy weight.
Eat a healthy diet. The DASH diet, in particular, may reduce the risk of high blood pressure and heart failure, particularly in women. The DASH diet is:
- Rich in fruits, vegetables, and low-fat dairy foods
- Low in saturated fat, total fat, and cholesterol
Eat whole grain breakfast cereal. In addition to the other healthy habits, this may reduce your risk.

RESOURCES:

American College of Cardiology
http://www.acc.org/

American Heart Association
http://www.americanheart.org/

Family Doctor.org
http://familydoctor.org/

CANADIAN RESOURCES:

Health Canada
http://www.hc-sc.gc.ca/index_e.html/

Heart and Stroke Foundation of Canada
http://ww2.heartandstroke.ca/

REFERENCES:

ACC/AHA Practice Guidelines. American College of Cardiology website. Available at: http://www.acc.org... . Accessed July 16, 2008.

Congestive heart failure. American Heart Association website. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4585 . Updated March 2002. Accessed July 16, 2008.

Dambro MR. Griffith's 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.

Heart pumps. Mayo Clinic website. Available at: http://www.mayoclinic.com/health/heart-failure/HB00076 . Accessed on Accessed July 16, 2008.

Hunt, SA, Abraham, WT, Chin, MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation . 2005;112:e154.

Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult. American College of Cardiology Foundation (ACCF) . 2005;46(6):e1-82.

Paterna S, Parrinello G, Cannizzaro S, et al. Medium term effects of different dosage of diuretic, sodium, and fluid administration on neurohormonal and clinical outcome in patients with recently compensated heart failure. Am J Cardiol. 2009;103:93-102. Epub 2008 Oct 17.

What is heart failure? National Heart, Lung, and Blood Institute website. Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_WhatIs.html . Updated December 2007. Accessed July 16, 2008.

4/16/2009 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Nilsson BB, Westheim A, Risberg MA. Effects of group-based high-intensity aerobic interval training in patients with chronic heart failure. Am J Cardiol. 2008 Nov 15;102:1361-1365. Epub 2008 Sep 11.

7/6/2009 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php : Levitan EB, Wolk A, Mittleman MA. Consistency with the DASH diet and incidence of heart failure. Arch Intern Med. 2009;169:851-857.

8/31/2009 DynaMed Systematic Literature Surveillance http://www.dynamicmedical.com/what.php : Djoussé L, Driver JA, Gaziano JM. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA. 2009;302:394-400.

Last reviewed November 2009 by David N. Smith, MD
Last Updated: 2/8/2010

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