Congestive Heart Failure: A Patient Guide Overview The diagnosis of congestive heart failure (CHF) can be misleading.

The word failure implies the heart has stopped and is no longer working when, in fact, it really means the heart is not working as efficiently as possible. CHF is an underlying symptom of another disease process. The incidence of CHF is on the rise, affecting five million people in the United States. The condition affects mostly older adults. Approximately eight out of 1,000 people over age 70 are diagnosed with CHF. It is one of the most common reasons for hospitalization in this age group. The rise in CHF is due to people living longer and surviving other medical conditions that put them at risk for the development of CHF. The condition is treatable and its effects are often reversible. How the heart works The heart pumps oxygen and nutrients to the body's tissues and organs. It also helps rid the body of unnecessary waste products. The heart consists of four chambers, the right and left atria and the right and left ventricles. Blood from the body enters the heart through the right atrium to the right ventricle, which brings blood to the lungs. It is here that carbon dioxide is removed from the blood and oxygen is added. Blood then returns to the heart via the left atrium. The heart then pumps the oxygen-rich blood to the rest of the body through the left ventricle. The heart performs this task on an ongoing basis. The diagnosis CHF is not a disease in itself. It is a syndrome in which the heart is unable to pump an adequate supply of blood to meet the oxygen requirements of the body's tissues and organs. The weakening of the heart as a pump in heart failure results in slow blood flow out of the heart to the rest of the body. This causes back up of blood in those chambers in the heart that are weakened and the veins that return blood to the heart from the rest of the body. The pooling of blood in the veins leads to the congestion of surrounding tissues and organs and the development of congestive symptoms such as leg edema (or swelling), nausea and bloating due to bowel edema, and shortness of breath due to lung edema. The development of these CHF symptoms and others depends on the severity of the heart failure, the time it took to develop (suddenly or gradually), and quality of treatment. Risk factors CHF is frequently a symptom of another cardiovascular problem; the underlying disease process is often identified as a result of the symptoms of CHF. The most common causes are: Coronary artery disease and myocardial infarction (heart attack). Cardiomyopathy (diseased heart muscle). Hypertension (high blood pressure). Heart valve abnormalities (particularly the aortic and mitral valves).

Heart arrhythmia (abnormal heart rhythm). Congenital heart defects (those occurring at birth). Toxic substances (excessive alcohol and drug abuse; certain environmental toxins).

Causes for CHF in younger patients include hyperthyroidism, anemia, kidney disease, pregnancy, viral infections, or inflammation of the heart (myocarditis). Sometimes a cause is never identified. Left-sided versus right-sided heart failure CHF may occur in one or both sides of the heart. As one side of the heart begins to fail, the other side can continue to function normally. However, untreated one-sided CHF often leads to excessive strain and subsequent CHF on the other side. CHF usually begins with the left side of the heart and progresses backward until the right side, too, fails. The left side of the heart receives oxygen-rich blood from the lungs and pumps it to the rest of the body. When the left side of the heart begins to fail, blood flow backs up into the lungs. Forward blood flow to the rest of the body may be impeded as well. With right-sided failure, the heart is unable to effectively pump blood to the left side and blood flow backs up to other parts of the body, including the legs and feet, liver, and gastrointestinal tract. Some of the symptoms may overlap. Signs and symptoms Fatigue or weakness (often the earliest symptom of CHF) Shortness of breath with or without activity Orthopnea, or difficulty breathing while lying flat, often graded in severity by how many pillows are required to breath comfortably when sleeping Rapid or irregular pulse Edema or swelling of legs, feet and ankles, abdomen, liver, spleen and lungs A chronic dry or frothy cough that may be blood-tinged or resemble foam Nocturia, or an increase in urination at night Palpitations, or feeling the heart beat Dark colored urine (may not be present if already taking diuretic medications) Oliguria, or decreased urine output Unexplained or unintentional rapid weight gain Distended or swollen neck veins Loss of appetite or indigestion Cold, diaphoretic (sweaty), dusky colored skin.

Changes in behavior such as restlessness, confusion, decreased attention span, and memory

Physical examination and diagnostic tests The clinical symptoms of CHF may be different in each patient. The goal in diagnosing CHF is to determine its underlying cause. The primary diagnostic procedures are as follows: Your doctor will perform an extensive history and physical. The complete physical examination may reveal many signs including: blood pressure changes; a rapid or irregular heart rate; a rapid respiratory rate (e.g., how fast you breathe); cold, sweaty, or dusky skin; unexpected weight gain; distended neck veins; swollen feet, ankles or abdomen; an enlarged liver; or abnormal heart sounds or lung crackles (indicating fluid around the lungs) heard with a stethoscope placed over the chest. Chest x-rays are useful for assessing heart enlargement and fluid accumulation within or around the lungs. Electrocardiograms (ECG or EKG) and echocardiograms may sometimes allude to a diagnosis that caused CHF. These tests are effective for assessing the development of arrhythmias and whether there is evidence of prior heart disease. Echocardiograms, in particular, assess valve and heart wall motion. Frequently, blood and urine tests are also ordered as part of the diagnostic evaluation. Treatment Several treatment goals exist for the CHF patient. First, any underlying event that precipitated the heart failure condition should be treated. If an underlying condition is untreatable, then CHF therapy focuses on the alleviation of symptoms, reduction of further heart failure progression, and improvement in heart pumping efficiency. Treatment of CHF may entail hospitalization, initiation or adjustment of medications, surgery, and lifestyle modification. Appropriate CHF management demands the attention of a qualified health care professional. Multiple medications are often required in the treatment of CHF. When taken consistently and exactly as prescribed, a well-tolerated regimen is highly effective at both alleviating symptoms and prolonging life. The mainstays of medical therapy include: ACE inhibitors (e.g., captopril, lisinopril) and vasodilators, which dilate the blood vessels and reduce the heart's workload Beta blockers (e.g., carvedilol, bisoprolol, metoprolol, atenolol), which reduce arrhythmias and improve the left ventricle's mechanical efficiency Inotropes (e.g., digoxin), which increases the strength of cardiac contractions and reduces symptoms Diuretics (e.g., lasix, aldactone, zaroxolyn), which eliminate water and sodium through the kidneys and reduce edema and shortness of breath.

Some medications are reserved for in-hospital use only or during cases of severe, decompensated heart failure. These medications, which include intravenous vasodilators (e.g., nesiritide, nitrates) and intravenous inotropics (e.g., milrinone, dobutamine), are usually only prescribed by physicians specially trained in heart

failure management. Physicians may also temporarily discontinue some orally prescribed medications during severe cases of symptomatic heart failure. Again, only a physician trained in heart failure management should advise the discontinuation of these medications. Hospitalization Hospitalization might be required if your symptoms are too severe or if you do not respond to initial forms of treatment. Surgery may be indicated for some patients. Surgical options include, but are not limited to: Correcting congenital defects Repairing or replacing defective valves Angioplasty Bypass surgery Placement of an intraaortic balloon pump or ventricular assist device (these two devices are usually reserved as a temporary bridge to a more permanent form of surgical therapy like heart transplantation) Heart transplantation

Lifestyle changes Lifestyle changes are important in the treatment of CHF. They include dietary restriction of sodium (salt), smoking cessation, limiting the consumption of alcohol and fluids, exercise and weight control. All lifestyle modifications must be monitored by appropriate medical personnel. Relief and prevention There are many therapeutic measures you can follow each day to help relieve and prevent the progression of CHF. Some of these are: Regularly follow a doctor-prescribed exercise program. Avoid significant physical labor and emotional stress. Avoid fatigue by planning rest periods and gradually increasing daily activities. Avoid extremes in temperature. Take medication(s) exactly as prescribed and call your physician if one or several do not agree with you. Weigh yourself daily to detect increased fluid retention (do this at the same time each day). Familiarize yourself regularly with your blood pressure and heart rate. Restrict fluids if ordered by your physician.

Know the signs and symptoms of CHF and immediately report any to your physician: edema, increased shortness of breath, distended neck veins, weight gain (as defined by your physician), persistent cough, and increased urination at night. CHF is a disorder that can lead to serious complications and death. For this reason, it is important to know CHF warning signs and to follow your physician's plan of care. Symptoms can be controlled with appropriate treatment and the correction of underlying health problems.