Congestive Heart Failure

• Congestive heart failure (CHF) is when the heart’s function as a pump is inadequate to meet the body’s needs.
• Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure.
• The symptoms of congestive heart failure vary, but can include:
     ○ Fatigue
     ○ Diminished exercise capacity
     ○ Shortness of breath
     ○ Swelling (edema)

• The diagnosis of congestive heart failure is based on
     ○ knowledge of the individual’s medical history,
     ○ a careful physical examination, and
     ○ Selected laboratory tests.

• The treatment of congestive heart failure can include lifestyle modifications, addressing potentially reversible factors, medications, heart transplants, and mechanical therapies.
• The course of congestive heart failure in any given patient is exceptionally variable. In severe cases, it can be fatal.

Normal vs Congestive-Heart

Congestive Heart Failure Symptoms

An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible underlying congestive heart failure, it is a nonspecific symptom caused by many other conditions. The person’s ability to exercise may also diminish.

What is congestive heart failure?

Heart failure describes the heart’s inability or failure to meet the needs of organs and tissues for oxygen and nutrients. This decrease in cardiac output, the amount of blood that the heart pumps, is not adequate to circulate the blood returning to the heart from the body and lungs, causing the fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may include shortness of breath, weakness, and swelling.

Understanding blood flow in the heart and body
The right side of the heart pumps blood to the lungs while the left side pumps blood to the rest of the body. Blood from the body enters the right atrium through the vena cava. It then flows into the right ventricle. It is pumped to the lungs through the pulmonary artery, which carries deoxygenated blood to the lungs. In the lungs, oxygen is loaded onto red blood cells and returns to the heart’s left atrium via the pulmonary veins. Blood then flows into the left ventricle where it is pumped to the body’s organs and tissues. Oxygen is downloaded from red blood cells into the various organs. Simultaneously, carbon dioxide, a waste product of metabolism, is added to be removed in the lungs. Blood then returns to the right atrium to start the cycle again. The pulmonary veins are unusual because they carry oxygenated blood, while the pulmonary artery has deoxygenated blood. This is a reversal of duties versus the roles of veins and arteries in the rest of the body.

Left heart failure occurs when the left ventricle cannot pump blood to the body, and fluid backs up and leaks into the lungs causing shortness of breath. Right heart failure occurs when the right ventricle cannot adequately pump blood to the lungs. Blood and fluid may back up in the veins that deliver blood to the heart. This can cause fluid to leak into tissues and organs.

It is essential to know that both sides of the heart may fail to function adequately simultaneously, and this is called biventricular heart failure. This often occurs since the most common cause of right heart failure is left heart failure.

Signs and symptoms of Congestive Heart Failure

Shortness of breath
The hallmark and most common symptom of left heart failure is shortness of breath and may occur.
1. While at rest
2. With activity or exertion
3. While lying flat (orthopnea)
4. While awakening the person from sleep (paroxysmal nocturnal dyspnea); or
5. Due to fluid (water, mainly) accumulation in the lungs or the heart’s inability to be efficient enough to pump blood to the body’s organs when called upon in times of exertion or stress.

Chest Pain
1. Chest pain or angina may be associated, especially if the failure’s underlying cause is coronary heart disease.

Right heart failure, left heart failure, or both
1. People with right heart failure leak fluid into the tissue and organs that deliver blood to the right heart through the vena cava.
2. Backpressure in capillary blood vessels causes them to leak water into space between cells. Commonly, the fluid can be found in the lowest parts of the body.
3. Gravity causes fluid to accumulate in the feet and ankles. Still, as more fluid accumulates, it may creep up to involve all of the lower legs.
4. Fluid can also accumulate within the liver, causing it to swell (hepatomegaly) and within the abdominal cavity (ascites).
5. Ascites and hepatomegaly may make the patient feel bloated, nauseated, and have abdominal pain with distension.
6. Depending upon their underlying illness and the clinical situation, patients may have right heart failure, left heart failure, or both.

Causes of Congestive Heart Failure

Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure. In the United States. The most common causes of congestive heart failure are:
• Coronary artery disease
• High blood pressure (hypertension)
• Longstanding alcohol abuse
• Disorders of the heart valves
• Unknown (idiopathic) reasons, such as after recovery from myocarditis

Less common causes of congestive heart failure include:
• Viral infections of the stiffening of the heart muscle
• Thyroid disorders
• Heart rhythm abnormalities

In people with congestive heart failure with underlying heart disease, taking certain medications could lead to the development or worsening of lung disease. Moreover, drugs that can cause sodium retention or affect the power of the heart muscle.

Stages of congestive heart failure

The New York Heart Association has developed a scale commonly used to determine heart failure’s functional capabilities.

New York Heart Association (NYHA) Functional Classification of Heart Failure
1. Class I: Patients without limitation of physical activity.
2. Class II: Patients with a slight limit of physical capacity. A marked increase in physical activity leads to fatigue, palpitations, dyspnea, or angina pain; they are comfortable at rest.
3. Class III: Patients with marked limitation of physical activity in which minimal ordinary activity results in fatigue, palpitation, dyspnea, or angina pain; they are comfortable at rest.
4. Class IV: Patients who are not only unable to carry on any physical activity without discomfort but who also have symptoms of heart failure or the angina syndrome even at rest; the patient’s pain increases if any physical activity is undertaken.

Risk factors of Congestive Heart Failure

Congestive heart failure is often a consequence of atherosclerotic heart disease, and therefore the risk factors are the same,
• poorly controlled high blood pressure,
• high cholesterol,
• diabetes,
• smoking and
• Family history.

Heart valve disease becomes a risk factor as the patient ages.
Other causes of heart failure have their own set of risk factors and predispositions. It becomes a complication of those diseases. Such causes may include
• obstructive sleep apnea,
• alcohol and drug abuse,
• infections, and
• connective tissue disorders like systemic lupus erythematosus, sarcoidosis, and amyloidosis.

Many patients have stable congestive heart failure but can decompensate when a change occurs to their body. For example, a patient with congestive heart failure may be doing well but then develops pneumonia, an infection of the lungs, or suffers a heart attack.
The patient’s heart may not react to the body’s changing environment and does not have the capability or reserve to meet the body’s energy needs.
Acute decompensation may occur if the patient drinks excess fluid, has a large salt intake that can retain water in the body, or forgets to take their routine medication.

Diagnosing Congestive Heart Failure

Congestive heart failure can be a medical emergency, especially if it acutely decompensates. The patient can present too ill with the inability to breathe adequately. In this situation, the ABCs of resuscitation (Airway, Breathing, and Circulation) need to be addressed. At the same time, the diagnosis of congestive heart failure is made.

Standard tests that are done to help with the diagnosis of congestive heart failure include the following:
• An electrocardiogram (EKG, ECG) helps assess heart rate, rhythm, and indirectly, the ventricles’ size and blood flow to the heart muscle.
• Chest X-ray to look at heart size and the presence or absence of fluid in the lungs.
• Blood tests may include a complete blood count (CBC), electrolytes, glucose, BUN, and creatinine (to assess kidney function).
• B-type natriuretic peptide (BNP) may help decide if a patient has shortness of breath from congestive heart failure or a different cause. It is a chemical located in the heart ventricles and may be released when these muscles are overloaded.
• Echocardiography or ultrasound testing of the heart is often recommended to assess the heart’s anatomy and function. In addition to being able to evaluate the heart valves and muscle, the test can look at blood flow within the heart, watch the chambers of the heart contract, and measure the ejection fraction.
Other tests may be considered to evaluate and monitor a patient with suspected congestive heart failure, depending upon the clinical situation.

Treatment for congestive heart failure

The goal of treatment for congestive heart failure is to have the heartbeat more efficiently to meet the energy needs of the body. Specific treatment depends upon the underlying cause of heart failure, and include:

Medication to decrease body fluids (diuretic)
Treatment may decrease fluid within the body so that the heart does not have to work as hard to circulate blood through the blood vessels in the body. Fluid restriction and a decrease in salt intake may be beneficial.

ACE inhibitors (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin receptor blockers) are medicines that are also shown to increase survival by decreasing systemic resistance and favorable altering the hormonal milieu, which affects the cardiac performance; they are often used with other drugs.
Beta-blockers may control heart rate and increase cardiac output and ejection fraction, and provide a beneficial response to circulating epinephrine (“adrenalin”).
Digoxin (Lanoxin) is an older medicine that may help increase cardiac output and control symptoms.
• A very mild newer diuretic, spironolactone, is of long-term benefit.

Cardiac risk factor modification
Cardiac risk factor modification is the cornerstone of prevention of congestive heart failure. Moreover, it may benefit patients with congestive heart failure.
Management of congestive heart failure include:
• Weight loss
• Exercise
• Stopping smoking
• Controlling high blood pressure, high cholesterol, and diabetes

People with end-stage congestive heart failure (NYHA stage IV) may require aggressive treatments, including left ventricular assist devices (LVAD), an implanted pump that helps increase the heart’s ability to squeeze, or even heart transplantation.
People with congestive heart failure are not transplanted candidates; LVAD may be a permanent treatment.


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