What Is Congestive Heart Failure?

A diagnosis of congestive heart failure sounds scary, as if your heart is about to fail at any second. But the underlying heart conditions that commonly cause congestive heart failure, such as coronary artery disease or high blood pressure, typically develop slowly over many years. The development of congestive heart failure usually means that your heart’s ability to pump has weakened, so it can't circulate enough blood to meet your body's needs. Shortness of breath and leg swelling may result.

An estimated 5 million Americans are living with congestive heart failure. Because congestive heart failure is more common as you grow older, it's expected that another 15 million to 20 million people may develop it in the next 5 years. In fact, it's becoming so common that the National Heart, Lung and Blood Institute refers to congestive heart failure as a new epidemic. Congestive heart failure is serious and can be life-threatening. Once severe signs and symptoms develop, the 5-year survival rate if left untreated is 25 percent to 50 percent — worse than the survival rates for many cancers.

Although in most cases there's no way to reverse damage to heart function, treatments can significantly improve signs and symptoms. You also can make lifestyle changes that will help your weakened heart work as efficiently as possible.

Your best defense against congestive heart failure is to prevent or control risk factors that lead to coronary artery disease, such as high blood pressure, high cholesterol levels, diabetes, smoking, alcohol abuse, inactivity and obesity. If you have congestive heart failure, it’s important to manage the condition with your doctor.

Heart Center

Signs and Symptoms

Congestive heart failure typically doesn't occur suddenly. It develops slowly, over time. It's almost always a chronic, long-term condition. The first and often only symptom may be shortness of breath. Signs and symptoms of congestive heart failure can include:

• Fatigue and weakness
  
  
• Shortness of breath (dyspnea) when you exert yourself or when you lie down
  
  
• Persistent wheezing or cough with white or pink blood-tinged phlegm
  
  
• Pronounced neck veins
  
  
• Swelling (edema) in your legs, ankles and feet
  
  
• Swelling of your abdomen
  
  
• Rapid weight gain from fluid retention
  
  
• Lack of appetite and nausea
  
  
• Lightheadedness, dizzy spells or fainting spells
  
  
• Difficulty concentrating or decreased alertness
  
  
• Irregular or rapid heartbeat

Causes

Every minute of your life, your heart a muscular pump in your chest beats approximately once a second. In a single day, your heart pumps about 2,000 gallons of blood through your body's circulatory system.

Your body's circulatory system includes arteries and veins. Arteries deliver oxygen-rich blood to the organs and tissues of your body. Veins bring oxygen-poor blood back to your heart to be cycled through your heart and lungs and back out to the rest of your body, via your arteries.

Your heart, the center of your circulatory system, consists of four chambers. The two upper chambers, the atria, receive blood. The two lower chambers, the ventricles, pump blood.

Blood returning to your heart enters the right upper chamber (right atrium) of the heart. From there, blood empties into the right ventricle underneath. The right ventricle pumps blood into your lungs, where blood is oxygenated. Oxygenated blood from your lungs then returns to your heart, but this time to the left side — to the left upper chamber (left atrium). Blood then flows into the left ventricle underneath — your heart's main pumping chamber. With each heartbeat, your left ventricle pumps blood into your body's largest artery (aorta) and onward to the rest of your body.


Congestive heart failure can involve the left side, right side or both sides of the heart. Typically, heart failure begins with the left side — specifically the left ventricle, your heart's main pumping chamber. Your doctor may refer to your condition as left-sided or left ventricular heart failure. He or she may define it further as systolic failure (when the left ventricle loses its ability to contract vigorously) or diastolic failure (when the left ventricle loses its ability to relax or fill fully) or a combination of both. The distinction is important because the drug treatments for each type may be different. Right-sided heart failure can occur independently or be a consequence of left ventricular heart failure.

Congestive heart failure occurs as a result of other cardiac conditions that have damaged or weakened your heart, forcing it to work harder. A weakened heart results in blood flow slowing throughout your body. This causes blood to pool in your legs, feet and ankles, your kidneys to retain excess water and sodium, and fluid to back up into your lungs, leading to shortness of breath.

Your heart naturally loses some pumping ability as you age. But the loss is significantly more in heart failure and often results from the added stress of a heart attack or other forms of heart disease. In fact, all of the behaviors that you probably associate with heart attack or heart disease — such as smoking, being overweight, eating foods high in cholesterol and fat, and not exercising — also cause or contribute to heart failure.

If you have heart failure, chances are you have had one or more of the following. These conditions damage or weaken the heart. Some of these can be present without you knowing it:

• Coronary artery disease. Coronary artery disease is the most common form of heart disease. Over time, arteries that supply blood to your heart muscle can become narrowed from a buildup of fatty deposits (atherosclerosis). Blood moves more slowly through narrowed arteries. As a result, some areas of your heart muscle may be deprived chronically of oxygen-rich blood. These areas may become weak from the lack of oxygen and pump less vigorously. Sometimes this results in a heart attack with death of heart muscle, but in many cases the blood flow to the muscle is just enough to keep the muscle alive but not functioning well.
  
  
• Heart attack. Congestive heart failure can be a complication of a heart attack. A heart attack occurs when a blood clot forms in a narrowed coronary artery, blocking blood flow to a portion of your heart muscle and damaging it. The damaged portion of the heart can no longer pump as well as it should. The rest of the heart tries to make up for the loss, but may be unable to or may become weakened by the extra workload.
  
  
• High blood pressure (hypertension). Blood pressure is the force of blood pumped by your heart through your body's blood vessels. If arteries throughout your body are too narrowed from a buildup of fatty deposits, your heart has to work harder than it should to circulate blood throughout your body. Over time, the heart muscle may enlarge and become thicker to compensate for the extra work it must perform. Eventually your heart muscle may weaken and fail to effectively pump blood forward.
  
  
• Faulty heart valves. The four valves of the heart keep blood flowing in the proper direction through the heart. A damaged valve forces your heart to work harder to keep blood flowing as it should. Over time this extra work can weaken your heart.
  
  
• Cardiomyopathy. This is damage to the heart muscle. Causes of cardiomyopathy include infections, alcohol abuse and the toxic effect of drugs such as cocaine and some drugs used for chemotherapy. Damage to heart muscle from cardiomyopathy can lead to congestive heart failure.
  
  
• Heart defects present at birth (congenital heart defects). If the heart and its chambers don't form correctly, the healthy parts of the heart have to work harder to compensate. Genetic defects contribute to the risk of certain types of heart disease, which in turn may lead to congestive heart failure.
  
  
• Abnormal heart rhythms (heart arrhythmias). Abnormal heart rhythms may cause your heart to beat too fast. This creates extra work for your heart. Over time, this extra work can weaken your heart, producing congestive heart failure. A heartbeat that's too slow also may prevent the heart from adequately circulating blood and lead to congestive heart failure.

Other diseases — such as diabetes, severe anemia, hyperthyroidism, kidney or liver failure, and emphysema — also may precipitate heart failure.

Coronary artery disease Heart attack High blood pressure Mitral valve stenosis Mitral valve regurgitation Aortic valve stenosis Aortic valve regurgitation Heart arrhythmias Understanding congenital heart defects Diabetes Hyperthyroidism Kidney failure Emphysema

Risk Factors

Having high blood pressure places you at increased risk of congestive heart failure. Uncontrolled high blood pressure increases the risk of heart failure by some 200 percent. Moreover, the degree of risk appears directly related to the severity of the high blood pressure.

Long-standing coronary artery disease also increases your risk of congestive heart failure. Muscle damage and scarring caused by a heart attack further raise your risk of heart failure. Left untreated, some irregular heartbeats (heart arrhythmias) also increase your risk of heart failure.

Diabetes is another a major risk factor for congestive heart failure. People with diabetes have about a two- to eight-fold greater risk of heart failure than those without diabetes. Women with diabetes have a greater risk of heart failure than men with diabetes do. Diabetes raises the risk in part because of its association with other heart failure risk factors. However, the disease process in diabetes also damages the heart muscle.

Kidney conditions also can contribute to heart failure because many can lead to high blood pressure and fluid retention.

A single risk factor may be sufficient to cause heart failure, but a combination of factors dramatically increases the risk. Advanced age adds to the potential impact of any heart failure risk. The majority of Americans with congestive heart failure are older than 65 years.

In some cases, behavior has nothing to do with heart failure. For instance, some people who develop heart failure were born with structural heart defects, and others may have contracted a virus that damaged the heart muscle.

When to Seek Medical Advice

See your doctor if you experience any of the signs and symptoms associated with congestive heart failure. Often signs and symptoms of congestive heart failure send a person to the emergency room, where the condition may first be diagnosed. Other heart and lung problems can cause signs and symptoms that are similar to congestive heart failure.

If you have a diagnosis of congestive heart failure, and if any of the signs or symptoms suddenly become worse or you develop a new sign or symptom, it may indicate that known congestive heart failure is getting worse or not responding to treatment. Contact your doctor promptly.

Screening and Diagnosis

In many cases, physicians diagnose heart failure by taking a careful medical history and performing a physical examination. Your doctor will also check for the presence of risk factors such as high blood pressure. Using a stethoscope, your physician can listen to you breathe and identify the sounds of lung congestion. The stethoscope also picks up the abnormal heart sounds that may indicate heart failure.

In addition to a physical exam, your doctor may recommend any of a variety of tests to diagnose congestive heart failure. Your physician may refer you to a cardiologist — a doctor who specializes in the study of the heart and its function — for tests such as:

• Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. In congestive heart failure, a heart may appear enlarged on an X-ray and fluid accumulation may be visible in the lungs. Your doctor also can use an X-ray to diagnose conditions other than congestive heart failure that may explain your signs and symptoms.
  
  
• Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Impulses are recorded as waves displayed on a monitor or printed on paper. This test helps your doctor diagnose heart rhythm problems and damage to the heart from a heart attack that may be underlying congestive heart failure.
  
  
• Echocardiogram. An echocardiogram uses sound waves to produce a video image of your heart. This image can help doctors determine the capacity at which your heart is pumping. The percentage of blood pumped out of your heart’s main pumping chamber (the left ventricle) with each heartbeat is referred to as the ejection fraction. This percentage can be measured by an echocardiogram or other imaging techniques. In a healthy heart, the ejection fraction is greater than 50 percent. An echocardiogram also helps distinguish systolic heart failure from diastolic heart failure.
  
  
• Coronary catheterization (angiogram). In this test a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or elbow and guided through your main artery, the aorta, into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray. This test helps doctors identify narrowed arteries to your heart (coronary artery disease) that can be a cause of congestive heart failure. The test also helps doctors determine the strength of the left ventricle — the heart's main pumping chamber — and the health of the heart valves.
  
  
• Blood tests. Your doctor may take a sample of your blood to check for indicators of other diseases that affect the heart. In addition, your doctor may order a new blood test for congestive heart failure. The test checks for levels of a hormone called B-type natriuretic peptide (BNP). Your heart secretes BNP in high levels when it's overworked. A large amount of BNP in your blood may indicate congestive heart failure.

Results of these tests help doctors determine the cause of your signs and symptoms and develop a program to treat your heart. To determine the best course of treatment, doctors classify heart failure using a scale of one to four. Class I heart failure is the mildest. You can perform everyday activities and not feel winded or fatigued. Class IV is the most severe, in which you’re short of breath even at rest.

Chest X-rays: Useful images of your heart and lungs Electrocardiogram Echocardiogram Blood tests

Complications

In congestive heart failure, your heart pumps with less force. To compensate, your heart may undergo several changes — including enlargement. An enlarged heart can stretch and contract with more strength, allowing it to pump more blood. The heart muscle may thicken, building muscle to help increase pumping strength. Your heart may also beat faster in an attempt to pump more often. In addition, levels of heart-stimulating hormones go up.

At first these means of compensating help a weakened heart pump harder. But eventually these changes make matters worse by further weakening heart muscle.

The outlook for a person with congestive heart failure depends on the severity of heart failure, overall health and other factors such as age. Mild to moderate congestive heart failure may have little effect on a person's life. However, severe heart failure can be life-threatening. It can lead to sudden death or cardiac arrest. All forms of heart failure are a serious health problem.

Treatment

Doctors sometimes can correct congestive heart failure by treating the underlying cause. For example, controlling a fast heart rhythm may reverse congestive heart failure. But in most cases, once you have congestive heart failure, it's there to stay. However, with treatment, a failing heart can be strengthened and signs and symptoms of congestive heart failure improved.

Medications

Doctors usually treat congestive heart failure with medications. Several types of drugs have proved useful in the treatment of heart failure. They include:

• Angiotensin-converting enzyme (ACE) inhibitors. These drugs — the mainstay treatment for congestive heart failure — help people with congestive heart failure live longer and feel better. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten). ACE inhibitors lower blood pressure and decrease your heart’s workload. They also blunt some of the effects of hormones that promote salt and water retention. Because ACE inhibitors lower blood pressure, you could feel weak or dizzy shortly after taking them. Your doctor may recommend that you take them before bedtime so that you’ll be lying down soon after taking the drug. ACE inhibitors also cause an irritating cough in about 20 percent of people. Sometimes it may be best to put up with the cough, if you can, to gain the medication’s benefits. But be sure to discuss this with your doctor. Switching to another ACE inhibitor may relieve the problem.
  
  
• Angiotensin II (A-II) receptor blockers. This group of drugs has many of the beneficial effects of ACE inhibitors, but they don't cause a persistent cough. They may be an alternative for people who can't tolerate ACE inhibitors. However, A-II receptor blockers — examples include losartan (Cozaar) and valsartan (Diovan) — haven't been as extensively studied in people with congestive heart failure.
  
  
• Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Commonly prescribed diuretics for congestive heart failure include bumetanide (Bumex) and furosemide (Lasix, Fumide). The drugs also decrease fluid in your lungs, so you can breathe more easily. Because diuretics make your body lose potassium and magnesium, your doctor may prescribe supplements of these minerals. If you're taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.
  
  
• Spironolactone (Aldactone). This potassium-sparing diuretic may improve survival for people with severe congestive heart failure. Unlike some other diuretics, spironolactone can raise potassium levels in your blood. Therefore, if you're taking this drug, your doctor will want to check the potassium level in your blood periodically. Occasionally, spironolactone can also cause breast swelling and tenderness.
  
  
• Digoxin (Lanoxin, Digibind). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves your ability to live with the condition.
  
  
• Beta blockers. This class of drug slows your heart rate and reduces blood pressure. These medicines also reduce the risk of some abnormal heart rhythms. Beta blockers may reduce signs and symptoms of congestive heart failure and improve heart function.

You likely will be prescribed two or more medications to treat congestive heart failure. Your physician may prescribe other heart medications — such as nitrates (for chest pain), calcium channel blockers (which lower blood pressure and improve circulation) or blood thinners (which help prevent blood clots) — along with heart failure medications.

In 2001, the Food and Drug Administration approved a new intravenous drug for congestive heart failure called nesiritide (Natrecor). Nesiritide is a synthetic version of a naturally occurring hormone in the body called B-type natriuretic peptide. BNP is secreted in high levels by the heart when it's overloaded with pressure and its volume is expanded. BNP causes the body to excrete excess fluid, helping to combat the effects of congestive heart failure. Nesitiride may benefit people who have very severe congestive heart failure.

Sometimes symptoms of congestive heart failure become severe enough for you to be hospitalized and monitored for a few days. While in the hospital, you may take medications that work quickly to help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen through a mask or small tubes placed in your nose. If you have severe congestive heart failure that doesn't respond to treatment, you may need to use supplemental oxygen in the longer term.

Hypertension drugs: Treating more than just blood pressure Traveling with oxygen: Planning is key

Surgery and medical devices

In some cases doctors recommend surgery to treat the underlying problem that led to congestive heart failure. For example, a damaged heart valve may be repaired or, if necessary, replaced with an artificial one. Sometimes doctors recommend coronary bypass surgery to treat congestive heart failure if the disease is related to severely narrowed coronary arteries.

Some people have such severe congestive heart failure that medications or surgery don't provide adequate help. They may need to have their diseased heart replaced with a healthy donor heart. About 2,000 Americans each year undergo a heart transplant. The procedure has dramatically improved the survival and quality of life of people with severe congestive heart failure. However, candidates for transplantation often have to wait years before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment and other therapy and can be removed from the transplant waiting list.

Researchers continue to search for new and better ways to treat congestive heart failure. Some treatments being studied include:

• Heart pumps. These mechanical devices, called left ventricular assist devices (LVADs), are implanted into the abdomen and attached to a weakened heart to help it pump. Heart pumps help keep heart transplant candidates alive while they're waiting for a donor heart. Studies are ongoing to examine their role as an alternative to transplantation. Despite several serious side effects, implantable heart pumps can significantly extend and improve the lives of some people with end-stage heart failure who aren't eligible for heart transplantation.
  
  
• Biventricular cardiac pacemaker. This type of heart pacemaker sends specifically timed electrical impulses to the heart's lower chambers to treat moderate to severe congestive heart failure. Some 30 percent to 50 percent of people with congestive heart failure have abnormalities in their heart's electrical system that cause their already weak heart muscle to beat in an uncoordinated fashion. This inefficient muscle contraction wastes the heart's precious energy and may cause heart failure to worsen. A biventricular cardiac pacemaker consists of a pulse generator that's implanted in your chest and connected to your heart by three wires (leads) that deliver electrical impulses. One wire is placed in the upper-right chamber (right atrium), one wire is placed in the lower-right ventricle and the third wire is used to stimulate the lower-left ventricle.

Video: Biventricular pacing

• Cardiac wrap surgery. Researchers are studying a technique that wraps a failing heart in a mesh bag, helping to prevent further failure. A surgeon pulls the mesh wrap over the base of the heart and attaches it with stitches. The goal is to prevent a weakened heart from enlarging and failing further.
  
  
• Xenotransplantation. Researchers are exploring the possibility of transplanting genetically manipulated pig hearts into humans with congestive heart failure.
  
  
• Artificial heart. The first all-mechanical artificial heart has been implanted in a human, but careful study continues to lower risks associated with this new device.
  
  
• Implantable sensors. Scientists are experimenting with the implantation of tiny microchip sensors in the hearts of people with congestive heart failure. Each sensor, about the size of a dime, produces signals picked up by an external device that provide doctors with daily reports on pressure within your heart's chambers. In people with congestive heart failure, a change in pressure often precedes a worsening of signs and symptoms that may lead to hospitalization. The sensors help warn when a heart failure crisis is beginning, allowing doctors to treat the condition before it becomes an emergency.

Pacemakers

Prevention

The best defense against heart failure is the prevention of heart disease. Many of the risk factors for heart disease — high blood pressure and coronary artery disease, for example — can be controlled or eliminated by making lifestyle changes and with the help of medications.

Self-Care

Making lifestyle changes can often help relieve symptoms of congestive heart failure and prevent the disease from worsening. These changes may be among the most important and beneficial you can make:

• Restrict sodium. Excess salt contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet. Restrict your sodium intake to less than 2,000 milligrams daily, or the amount recommended by your doctor or dietitian. Also, be careful when using salt substitutes. Some substitutes or "lite" salts contain a mixture of salt and other compounds. To achieve that familiar salty taste, you may use too much of the substitute and actually not reduce your sodium intake. In addition, potassium chloride is found in many salt substitutes. Too much potassium can be harmful if you have kidney problems or if you're taking certain medications for treatment of congestive heart failure. A dietitian can help you outline a healthy, low-salt diet.
  
  
• Limit fats and cholesterol. In addition to avoiding high-sodium foods, limit your intake of saturated fat and cholesterol. A diet high in fat and cholesterol is a risk factor for coronary artery disease, which often underlies or contributes to heart failure.
  
  
• Limit alcohol and fluids. Excessive use of alcohol can directly weaken the heart or predispose the heart to abnormal heart rhythms that may worsen existing heart failure. Alcohol also may interact with some medications used to treat heart conditions. Your physician likely will advise you to abstain from alcohol if you have congestive heart failure. If you have severe heart failure, your doctor may also suggest you greatly limit intake of fluids.
  
  
• Exercise. Exercise was once forbidden for people with congestive heart failure. But studies have shown moderate exercise helps your heart pump more efficiently, reducing the demands on your heart muscle. Before you start exercising, talk to your doctor about an exercise program that's right for you.
  
  
• Stop smoking. Smoking damages your blood vessels, reduces the amount of oxygen in your blood and makes your heart beat faster. Ask your doctor to recommend a program to help you quit. You cannot be considered for a heart transplant if you continue to smoke.
  
  
• Weigh yourself. Do this each morning after you've urinated but before you've had breakfast. Notify your doctor if you experience a rapid weight gain of 3 or more pounds. It may mean that you're retaining fluids and need a change in your treatment plan.
  
  
• Reduce stress. When you're anxious or upset, your heart beats faster and you breathe more heavily. This can make congestive heart failure worse, since your heart is already having trouble meeting the body's demands. Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible.

Coping Skills

Often people with congestive heart failure complain that they wake up tired because lying flat makes it harder to breathe and their sleep is interrupted because of excess fluid or medications that increase the need to urinate.

To improve your sleep at night, prop up your head with pillows and avoid naps and big meals right before bedtime. Also discuss with your doctor changing the time for taking medications, especially diuretics. Taking diuretics earlier in the day may keep you from having to urinate often during the night.

Although many cases of congestive heart failure cannot be reversed, treatment can usually markedly improve symptoms and life expectancy. You and your physician can work together to help make your life more comfortable. Pay attention to your body and how you feel, and tell your doctor when you're feeling better or feeling worse. That way, your doctor will know what treatment works best for you.

Don't be afraid to ask your physician questions about living with congestive heart failure. These steps may improve your interactions with your doctor:

• Before a doctor appointment, prepare a list of any questions or concerns. For example, is it safe for you and your partner to have sex? Most people with congestive heart failure can continue sexual relations once symptoms are under control.
  
  
• Take notes during doctor visits so that you can review key information and instructions later.
  
  
• Make sure that you understand your doctor’s instructions.
  
  
• Keep track of medications you take by making a list of them and sharing that list with any new doctors treating you.

Managing congestive heart failure requires an open dialogue between you and your physician. Be honest about whether you're following recommendations concerning your diet, lifestyle and taking medications. Your doctor often can suggest strategies to help you get on track.

— March 22, 2002 —