Congestive heart failure (patient information)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Jinhui Wu, M.D., Edzel Lorraine Co, D.M.D., M.D. [2]

Heart failure is a clinical syndrome in which the heart cannot pump enough blood throughout the body. It can be caused by many types of cardiovascular diseases, such as coronary artery disease, hypertension, diabetes, valve heart diseases and endocrine diseases. Usual signs and symptoms include blood and fluid to back up into the lungs, edema in the feet, ankles and legs, tiredness and shortness of breath. Patient's symptoms, echocardiogram and cardiac MRI can be evidence to assess the heart function. Treatments include treating the underlying cause of your heart failure, medicines, percutaneous coronary intervention, left ventricular assist device (LVAD) and heart transplantation. The prognosis of heart failure varies widely. It depends on the cause of heart failure, left ventricular ejection fraction and the duration of the disease.

• Early cases of heart failure do not have any symptoms.

• As the disease develops, people may notice one or more of the following symptoms:
• Ankle edema or swelling of the feet and legs
• Claudication or pain with walking
• Confusion and altered mentation
• Cool extremities or cold and clammy hands
• Cyanosis or bluish color to the skin
• Dizziness
• Dyspnea on ordinary exertion or greater shortness of breath with usual activities
• Fainting
• Fatigue
• Hemoptysis or frothy sputum
• Nocturia or urination during the night
• Nocturnal cough
• Orthopnea or sleeping on pillows
• Palpitations or extra heart beats
• Paroxysmal nocturnal dyspnea or awakening at night with shortness of breath
• Shortness of breath
• Syncope or passing out
• Weakness
• Wheezing or cardiac asthma

• Other health problems may also cause these symptoms. Only a doctor can tell for sure. A person with any of these symptoms should tell the doctor so that the problems can be diagnosed and treated as early as possible.

• Heart failure is a long-term (chronic) condition, but it can sometimes develop suddenly.

• The condition may affect only the right side or only the left side of the heart. These are called right-sided heart failure or left-sided heart failure. More often, both sides of the heart are involved.

• Heart failure is present when:

• Your heart muscle cannot pump (eject) the blood out of the heart very well. This is called systolic heart failure.

• Your heart muscles are stiff and do not fill up with blood easily. This is called diastolic heart failure.

• Both of these problems mean the heart is no longer able to pump enough oxygen-rich blood out to the rest of your body, especially when you exercise or are active.

• As the heart's pumping action is lost, blood may back up in other areas of the body. Fluid builds up in the lungs, liver, gastrointestinal tract, and the arms and legs. This is called congestive heart failure.

• The most common cause of heart failure is coronary artery disease (CAD), a narrowing of the small blood vessels that supply blood and oxygen to the heart.

• Heart failure can also occur when an infection weakens the heart muscle. This condition is called cardiomyopathy.

• Other heart problems that may cause heart failure are:

• Congenital heart disease
• Heart attack
• Heart valve disease
• Some types of abnormal heart rhythms (arrhythmias)

• Other diseases that can cause or contribute to heart failure:

• Emphysema
• Overactive thyroid
• Severe anemia
• Underactive thyroid

Certain factors increase your risk of getting heart disease, then increase your risk of getting heart failure. You are at a higher risk if you are:

• A woman aged 55 or older
• A man aged 45 or older
• Obesity or overweight
• Smoking
• High cholesterol
• High blood pressure
• Heavy drinking
• Diabetes
• Lack of exercise

There are a variety of diseases that cause shortness of breath, most of them lung diseases like asthma or chronic obstructive pulmonary disease.

• BNP(Brain natriuretic peptide)/ NT-proBNP (N-terminal pro b-type natriuretic peptide) test: Either BNP or NT-proBNP may be used to help diagnose heart failure and to grade the severity of that heart failure. Furthermore, the levels can help doctors differentiate between heart failure and lung diseases.

• Cardiac biomarkers: This is a blood test. It needs to be done to identify your basic cardiac diseases such as acute coronary syndrome.

• Electrocardiogram: This is a simple and painless test that records the heart's electrical activity. It is needed to detect your primary cardiac diseases.

• Chest X-ray: The test can show an x-ray silhouette of the heart and lungs. When heart failure appears, the picture may show an enlarged heart and pulmonary venous congestion.

• Echocardiogram: This is a painless and minimally invasive test for patients. Cardiac echo can demonstrate both structure and function of the heart. It can tell the doctor the left ventricular ejection fraction and help doctor detect the heart function.

• Cardiac MRI (magnetic resonance imaging): Cardiac MRI can create both still and moving pictures of the heart and major blood vessels. It can help doctors analyze the structure and function of the heart and decide the treatment protocols for the patient.

• Thoracentesis: In heart failure, the pleural space is filled with more fluid than normal and can cause patient feels shortness of breath. During the procedure, the doctor inserts a thin needle or plastic tube into the pleural space and draws out the excess fluid to detect the cause of the pleural effusion.

Patients with early heart failure can compensate. With the disease developing, the heart function decompensate and patients demonstrate a series of signs and symptoms. Call your health care provider if symptoms of heart failure develops. If you experience either of the following symptoms, seeking urgent medical care as soon as possible:

• Serious shortness of breath
• Patients can not lie in flat at night, even orthopnea.
• Hemoptysis or congh pink frothy sputum

Because heart failure is a clinical syndrome that is the end result of multiple heart diseases, the following measures are important:

• Treat basic cardiac disease such hypertension, improve myocardial perfusion and perform surgery for stenotic or leaking heart valves.
• Treat exacerbating conditions such as pneumonia, arrhythmia, hypokalemia.
• Restrict sodium intake.

• Diuretics: Diuretics can reduce volume overload and reduce shortness of breath and edema. There are three kinds of diuretics, loop diuretics, thiazides and potassium-sparing diuretics. Given the risk of hypo or hyperkalemia, the blood level of electrolyes should be checked regularly.

• Angiotensin converting enzyme inhibitors (ACEI): Angiotensin converting enzyme inhibitors (ACEI) are widely used in cardiovascular diseases. This includes a large group of drugs, such as Enalapril (Vasotec/Renitec), Ramipril (Altace/Tritace/Ramace/Ramiwin), Quinapril (Accupril), Perindopril (Coversyl/Aceon), Lisinopril (Lisodur/Lopril/Novatec/Prinivil/Zestril) and Benazepril (Lotensin). They can improve symptoms and prognosis of heart failure in several ways including afterload reduction and favorable ventricular remodeling. Usual side effects include dry cough and angioedema. Patients who can not tolerate cough are often switched to an angiotensin II receptor antagonist. Patients with bilateral renal artery stenosis or severe renal impairment are not appropriate for angiotensin converting enzyme inhibitor (ACEI).

• Angiotensin II receptor antagonist: These type of drugs can block the activation of angiotensin II AT1 receptors. Blockade of AT1 receptors directly causes vasodilation, reduces secretion of vasopressin, reduces production and secretion of aldosterone. Because angiotensin II receptor antagonists do not inhibit the breakdown of bradykinin or other kinins, and are thus only rarely associated with the persistent dry cough and/or angioedema that limit ACE inhibitor therapy. Usual used drugs in heart failure are Candesartan, Valsartan, Telmisartan, Losartan, Irbesartan, and Olmesartan.

• Beta blockers: Beta blockers can reduce heart rate which will lower the myocardial energy expenditure and then prolong the diastolic filling and lengthen coronary perfusion. It can also improve the ejection fraction of the heart and decrease the toxicity of catecholamines on the myocardium. Clinical trials show Bisoprolol, Carvedilol and sustained-release Metoprolol are specifically indicated as adjuncts to standard ACE inhibitor and diuretic therapy in congestive heart failure. Patients with asthma, severe conduction block or severe heart failure may not be appropriate candidates for beta blocker therapy.
• Digitalis: Digitalis can strengthen the contractility of the heart. But because the pharmacokinetics of digoxin are complex, and the toxic levels are only slightly higher than therapeutic levels, digoxin should be used judiciously under the close supervision of a cardiologist.

Coronary artery disease (CAD) and impaired blood flow to the heart is one of the main causes of heart failure. Removing the blockages in the coronary arteries can improve overall heart function, which may improve or resolve heart failure symptoms. The procedure is usually performed in the cardiac catherization lab. A catheter, a very small tube with a tiny deflated balloon on the end, is inserted through an incision in the groin area and pushed through to the diseased artery. Then the balloon is inflated to push open the artery. The balloon is removed once the artery has been fully opened. A stent may be placed during the procedure to keep the blood vessel open. Clinical trials have demonstrated that percutaneous coronary intervention (PCI) is a very effective and safe procedure to reopen blocked vessels and can improve a patient's symptoms.

The left ventricular assist device (LVAD) is a mechanical pump-type device that can help maintain the pumping ability of a heart unable to effectively work on its own. One typical type of LVAD will have a tube going into the left ventricle that pulls blood from the ventricle into a pump. The pump then ejects blood into the aorta. LVADs are typically used for weeks to months as a "bridge" to more definitive therapy rather than a final or "destination" therapy.

Heart transplant may be the only effective treatment option for patients with severe, progressive heart failure that can not be helped by medications, dietary and lifestyle changes. During a heart transplant procedure, the surgeons connect the patient to a heart-lung machine, which takes over the functions of the heart and lungs. Then the surgeons remove the diseased heart and replace it with the donor heart. Finally, the major blood vessels are reconnected and the new heart is ready to work. The outlook for people with heart transplants is good during the first few years after the transplant. Over 85 percent of patients live for more than a year after their operations.

Patients diagnosed with congestive heart failure should avoid using the following medications:

• Acebutolol
• Sotalol
• Timolol
• Verapamil
• Propafenone
  If you have been diagnosed with congestive heart failure, consult your physician before starting or stopping any of these medications.

Patients diagnosed with NYHA Class III or IV heart failure should avoid using the following medications:

• Pioglitazone
• Rosiglitazone
• Finogolimod
  If you have been diagnosed with NYHA Class III or IV heart failure, consult your physician before starting or stopping any of these medications.

Patients diagnosed with Overt cardiac failure should avoid using the following medications:

• Atenolol
• Labetalol
  If you have been diagnosed with Overt cardiac failure, consult your physician before starting or stopping any of these medications.

Patients diagnosed with Decompensated cardiac failure should avoid using the following medications:

• Esmolol
• Fingolimod
  If you have been diagnosed with Decompensated cardiac failure, consult your physician before starting or stopping any of these medications.

Patients diagnosed with Progressive cardiac failure should avoid using the following medications:

• Mannitol
  If you have been diagnosed with Progressive cardiac failure, consult your physician before starting or stopping any of these medications.

Directions to Hospitals Treating Congestive heart failure

Heart failure is a terminal syndrome of heart diseases. And heart disease is the leading cause of the death and a major cause of disability in the U.S. Cardiologists have verified there are many things you can do reduce your chances of getting heart disease. Keeping track of symptoms and reporting any changes that concern you to your healthcare professonal and working more closely with your healthcare team.

• Monitoring your blood pressure
• Exercise regularly
• Quitting smoking
• Checked for diabetes and if you have it, keep it under control
• Know your cholesterol and triglyceride levels and keep them under control
• Eat a lot of fruits and vegetables
• Maintain a healthy weight
• Managing stress

The prognosis of people with heart failure can vary dramatically. The following factors may help the doctor estimate the prognosis.

• The severity of the symptoms: It is well established that patients who have more severe symptoms of heart failure do not survive as long as those who have mild symptoms. For example, patients with class IV heart failure have the poorest prognosis, while patients with class I have the best.

• Heart function: The ejection fraction of left ventricle (LVEF) is an important indicator of the prognosis. The more severely damaged your heart muscle is, the worse your ejection fraction and worse prognosis will be, regardless of your symptoms.

• The causes of heart failure: Heart failure associated with alcohol use or pregnancy may spontaneously recover itself over time. Heart failure can be caused by treatable conditions such as hyperthyroidism or hypothyroidism, anemia, or vitamin deficiency. The prognosis of these conditions are generally excellent. Heart failure as a result of a valve condition may also be reversible if the valve problem is recognized early and fixed before permanent damage happens. People with heart failure caused by severe hypertension may see considerable improvement of their symptoms when they control their hypertension. But the majority of patients have heart failure as a result of coronary artery disease (CAD) have a worse prognosis and a higher death rate than people who have heart failure that is not a result of CAD.

• How long you've had heart failure: There is no specific length of time after which your heart function is unlikely to improve. General speaking, the longer you have had heart failure, the poorer prognosis may be even with appropriate treatment.

• Compensatory factors: "compensatory factors" are various adjustments to correct the effects of heart failure on other organs. When heart failure occurs, various hormone levels including renin, aldosterone, norepinephrine, atrial natriuretic peptide, and prostaglandin, may increase. Increases in these hormonal factors and other compensatory factors often make heart failure worse over time.

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