What are the symptoms of congestive heart failure?
The symptoms of congestive heart failure vary among individuals according to
the particular organ systems involved and depending on the degree to which the
rest of the body has "compensated" for the heart muscle weakness.
- An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible
underlying congestive heart failure, it is obviously a nonspecific symptom that
may be caused by many other conditions. The person's ability to exercise may
also diminish. Patients may not even sense this decrease and they may
subconsciously reduce their activities to accommodate this
limitation.
- As the body becomes overloaded with fluid from congestive
heart failure, swelling (edema) of the ankles and legs or abdomen may be
noticed. This can be referred to as "right sided heart failure" as failure of
the right sided heart chambers to pump venous blood to the lungs to acquire
oxygen results in buildup of this fluid in gravity-dependent areas such as in
the legs. The most common cause of this is longstanding failure of the left
heart, which may lead to secondary failure of the right heart. Right-sided heart
failure can also be caused by severe lung disease (referred to as "cor
pulmonale"), or by intrinsic disease of the right heart muscle (less common)
- In addition, fluid may accumulate in the lungs, thereby
causing shortness of breath,
particularly during exercise and when lying flat. In some instances, patients
are awakened at night, gasping for air.
- Some may be unable to sleep unless sitting
upright.
- The extra fluid in the body may cause increased urination, particularly at night.
- Accumulation of fluid in the liver and intestines may cause nausea, abdominal pain, and
decreased appetite.
How is congestive heart failure diagnosed?
The diagnosis of congestive heart failure is most often a clinical one that
is based on knowledge of the patient's pertinent medical history, a careful
physical examination, and selected laboratory tests.
A thorough patient history may disclose the presence of one or more of the
symptoms of congestive heart failure described above. In addition, a history of
significant coronary artery disease, prior
heart attack,
hypertension,
diabetes, or significant
alcohol use can be clues.
The physical examination is focused on detecting the presence of extra fluid
in the body (breath sounds,
leg swelling, or neck
veins) as well as carefully characterizing the condition of the heart (pulse,
heart size, heart sounds, and
murmurs).
Useful diagnostic tests include the
electrocardiogram (ECG)
and
chest X-ray to detect
previous heart attacks,
arrhythmia, heart
enlargement, and fluid in and around the lungs. Perhaps the single most useful
diagnostic test is the
echocardiogram, in
which
ultrasound is used to
image the heart muscle, valve structures, and blood flow patterns. The
echocardiogram is very helpful in diagnosing heart muscle weakness. In addition,
the test can suggest possible causes for the heart muscle weakness (for example,
prior
heart attack, and severe
valve abnormalities). Virtually all patients in whom the diagnosis of congestive
heart failure is suspected should ideally undergo echocardiography early in
their assessment.
Nuclear medicine studies assess the overall pumping capability of the heart
and examine the possibility of inadequate blood flow to the heart muscle.
Heart catheterization allows the arteries to the heart to be
visualized with
angiography (using dye
inside of the blood vessels that can be seen using X-ray methods). During
catheterization the pressures in and around the heart can be measured and the
heart's performance assessed. In rare cases, a
biopsy of the heart tissue may be recommended to diagnose specific
diseases. This biopsy can often be accomplished through the use of a special
catheter device that is inserted into a vein and maneuvered into the right side
of the heart.
Another helpful diagnostic test is a blood test called a BNP or
B-type natriuretic peptid level. This level can vary with age and
gender but is typically elevated from heart failure and can aid in the
diagnosis, and can be useful in following the response to treatment of
congestive heart failure.
The choice of tests depends on each patient's case and is based on the
suspected diagnoses.
What is the treatment of congestive heart failure?
Lifestyle modifications
After congestive heart failure is diagnosed, treatment should be started
immediately. Perhaps the most important and yet most neglected aspect of
treatment involves lifestyle modifications. Sodium causes an increase in fluid
accumulation in the body's tissues. Because the body is often congested with
excess fluid, patients become very sensitive to the levels of intake of sodium
and water. Restricting salt and fluid intake is often recommended because of the
tendency of fluid to accumulate in the lungs and surrounding tissues. An
American "no added salt" diet can still contain 4 to 6 grams (4000 to 6000
milligrams) of sodium per day. In individuals with congestive heart failure, an
intake of no more than 2 grams (2000 milligrams) of sodium per day is generally
advised. Reading food labels and paying close attention to total sodium intake
is very important. Severe restriction of alcohol consumption also is
advised.
Likewise, the total amount of fluid consumed must be regulated. Although many
people with congestive heart failure take diuretics to aid in the elimination of
excess fluid, the action of these medications can be overwhelmed by an excess
intake of water and other fluids. The maxim that "drinking eight glasses of
water a day is healthy" certainly does not apply to patients with congestive
heart failure. In fact, patients with more advanced cases of congestive heart
failure are often advised to limit their total daily fluid intake from all
sources to 2 quarts. The above guidelines for sodium and fluid intake may vary
depending on the severity of congestive heart failure in any given individual
and should be discussed with their physician.
An important tool for monitoring an appropriate fluid balance is the frequent
measurement of body weight. An early sign of fluid accumulation is an increase
in body weight. This may occur even before shortness of breath or swelling in
the legs and other body tissues (edema) is detected. A
weight gain of two to three pounds over two to three days should
prompt a call to the physician, who may order an increase in the dose of
diuretics or other methods designed to stop the early stages of fluid
accumulation before it becomes more severe.
Aerobic exercise, once
discouraged for congestive heart failure patients, has been shown to be
beneficial in maintaining overall functional capacity, quality of life, and
perhaps even improving survival. Each person's body has its own unique ability
to compensate for the failing heart. Given the same degree of heart muscle
weakness, individuals may display widely varying degrees of limitation of
function. Regular exercise, when tailored to the person's tolerance level,
appears to provide significant benefits and should be used only when the
individual is compensated and stable.
Addressing potentially reversible factorsDepending on the
underlying cause of congestive heart failure, potentially reversible factors
should be explored. For example:
- In certain persons whose congestive heart failure is caused by
inadequate blood flow to the heart muscle, restoration of the blood flow through
coronary artery surgery or catheter procedures (angioplasty, intracoronary
stenting) may be considered.
- Congestive heart failure that is due to severe disease of the
valves may be alleviated by valve surgery in appropriate patients.
- When congestive heart failure is caused by chronic,
uncontrolled high blood pressure (hypertension), aggressive blood pressure
control will often improve the condition.
- Heart muscle weakness that is due to longstanding, severe
alcohol abuse can improve significantly with abstinence from drinking.
- Congestive heart failure that is caused by other disease
states may be similarly partially or completely reversible by appropriate
measures
-
Medications
Until recently, the selection of medications available for the treatment of
congestive heart failure was frustratingly limited and focused mainly on
controlling the symptoms. Medications have now been developed that both improve
symptoms, and, importantly, prolong survival.
Angiotensin Converting Enzyme (ACE) Inhibitors
ACE inhibitors have been used for the treatment of hypertension
for more than 20 years. This class of drugs has also been extensively studied in
the treatment of congestive heart failure. These medications block the formation
of angiotensin II, a hormone with many potentially adverse effects on the heart
and circulation in patients with heart failure. In multiple studies of thousands
of patients, these drugs have demonstrated a remarkable improvement of symptoms
in patients, prevention of clinical deterioration, and prolongation of survival.
In addition, they have been recently been shown to prevent the development of
heart failure and heart attacks. The wealth of the evidence supporting the use
of these agents in heart failure is so strong that ACE inhibitors should be
considered in all patients with heart failure, especially those with heart
muscle weakness.
Possible side effects of these drugs include:
- a nagging, dry cough,
- low blood pressure,
- worsening kidney function and electrolyte imbalances, and
- rarely, true allergic reactions.
When used carefully with proper monitoring, however, the majority of
individuals with congestive heart failure tolerate these medications without
significant problems. Examples of ACE inhibitors include:
For those individuals who are unable to tolerate the ACE inhibitors, an
alternative group of drugs, called the
angiotensin receptor
blockers (ARBs), may be used. These drugs act on the same hormonal pathway
as the ACE inhibitors, but instead block the action of angiotensin II at its
receptor site directly. A small, early study of one of these agents suggested a
greater survival benefit in elderly congestive heart failure patients as
compared to an ACE inhibitor. However, a larger, follow-up study failed to
demonstrate the superiority of the ARBs over the ACE inhibitors. Further studies
are underway to explore the use of these agents in congestive heart failure both
alone and in combination with the ACE inhibitors.
Possible side effects of these drugs are similar to those associated with the
ACE inhibitors, although the dry cough is much less common. Examples of this
class of medications include:
Beta-blockers
Certain hormones, such as epinephrine
(adrenaline), norepinephrine, and other similar hormones, act on the beta
receptor's of various body tissues and produce a stimulative effect. The effect
of these hormones on the beta receptors of the heart is a more forceful
contraction of the heart muscle.
Beta-blockers are
agents that block the action of these stimulating hormones on the beta receptors
of the body's tissues. Since it was assumed that blocking the beta receptors
further depressed the function of the heart, beta-blockers have traditionally
not been used in persons with congestive heart failure. In congestive heart
failure, however, the stimulating effect of these hormones, while initially
useful in maintaining heart function, appears to have detrimental effects on the
heart muscle over time.
However, studies have demonstrated an impressive clinical benefit of
beta-blockers in improving heart function and survival in individuals with
congestive heart failure who are already taking ACE inhibitors. It appears that
the key to success in using beta-blockers in congestive heart failure is to
start with a low dose and increase the dose very slowly. At first, patients may
even feel a little worse and other medications may need to be adjusted.
Possible side effects include:
Beta-blockers should generally not be used in people with certain significant
diseases of the airways (for example,
asthma,
emphysema) or very low resting heart rates. While
carvedilol (Coreg) has been the most thoroughly studied drug in
the setting of congestive heart failure, studies of other beta-blockers have
also been promising. Research comparing carvedilol directly with other
beta-blockers in the treatment of congestive heart failure is ongoing. Long
acting
metoprolol (Toprol XL)
is also very effective in individuals with congestive heart failure.
Digoxin
Digoxin (Lanoxin) has
been used in the treatment of congestive heart failure for hundreds of years. It
is naturally produced by the foxglove flowering plant. Digoxin stimulates the
heart muscle to contract more forcefully. It also has other actions, which are
not completely understood, that improve congestive heart failure symptoms and
can prevent further heart failure. However, a large-scale randomized study
failed to demonstrate any effect of digoxin on mortality.
Digoxin is useful for many patients with significant congestive heart failure
symptoms, even though long-term survival may not be affected. Potential side
effects include:
These side effects, however, are generally a result of toxic levels in the
blood and can be monitored by blood tests. The dose of digoxin may also need to
be adjusted in patients with significant kidney impairment.
Diuretics
Diuretics are often an important component of the
treatment of congestive heart failure to prevent or alleviate the symptoms of
fluid retention. These drugs help keep fluid from building up in the lungs and
other tissues by promoting the flow of fluid through the kidneys. Although they
are effective in relieving symptoms such as shortness of breath and
leg swelling, they have not
been demonstrated to positively impact long-term survival.
Nevertheless, diuretics remain key in preventing deterioration of the
patient's condition thereby requiring hospitalization. When hospitalization is
required, diuretics are often administered intravenously because the ability to
absorb oral diuretics may be impaired, when congestive heart failure is severe.
Potential side effects of diuretics include:
It is important to prevent low potassium levels by taking supplements, when
appropriate. Such electrolyte disturbances may make patients susceptible to
serious heart rhythm disturbances. Examples of various classes of diuretics
include:
One particular diuretic has been demonstrated to have surprisingly favorable
effects on survival in congestive heart failure patients with relatively
advanced symptoms. Spironolactone (Aldactone) has been used for many years as a
relatively weak diuretic in the treatment of various diseases. Among other
things, this drug blocks the action of the hormone aldosterone.
Aldosterone has many theoretical detrimental effects on the heart and
circulation in congestive heart failure. Its release is stimulated in part by
angiotensin II (see ACE inhibitors, above). In patients taking ACE inhibitors,
however, there is an "escape" phenomenon in which aldosterone levels can
increase despite low levels of angiotensin II. Medical researchers have found
that spironolactone (Aldactone) can improve the survival rate of patients with
congestive heart failure. In that the doses used in the study were relatively
small, it has been theorized that the benefit of the drug was in its ability to
block the effects of aldosterone rather than its relatively weak action as a
diuretic (water pill). Possible side effects of this drug include elevated
potassium levels and, in males, breast tissue growth (
gynecomastia).
Another aldosterone inhibitor is
eplerenone
(Inspra).
Heart transplant
In some cases, despite the use of optimal therapies as described above, the
patient's condition continues to deteriorate due to progressive heart failure.
In selected patients,
heart transplantation
is a viable treatment option. Candidates for heart transplantation are generally
under age 70 and do not have severe or irreversible diseases affecting the other
organs. Additionally, a transplant is done only when it is clear that the
patient's prognosis is poor with continued medical treatment of the heart
condition. Transplant patients require close medical follow-up while taking the
necessary drugs that suppress the immune system, and because of the risk of
rejection of the transplanted heart. They also must be monitored for possible
development of coronary artery disease in the transplanted heart.
Although there are thousands of patients on waiting lists for a heart
transplant at any given time, the number of operations performed each year is
limited by the number of available donor organs. For these reasons, heart
transplantation is a realistic option in only a small subset of the large
numbers of patients with congestive heart failure.
Other mechanical therapies
Given the limitations associated with heart transplantation, much attention
has recently been directed towards the development of mechanical assist devices
that are designed to assume part or all of the pumping function of the heart.
There are several devices available for clinical use and many more are actively
being developed. For instance, there are currently left ventricular assist
devices that are approved for use as a temporary mode of circulatory support in
very ill patients until a transplant can be performed. Studies examining the
possible role of these mechanical assist devices on a long term basis as
permanent self-contained implants are ongoing. They may often be used for longer
periods of time in older patients who may not be heart transplant candidates.
The current major limitation of these devices is the risk of infection,
especially at the site where the device exits the body through the skin to
communicate with its external power source.
A less invasive modality, which can be placed without surgery, is the
biventricular pacemaker. This device has proved valuable in
appropriate types of patients with heart failure and impaired ventricles by
improving the synchrony of contraction.
What is the long term prognosis for patients with congestive heart
failure?
Congestive heart failure is generally a progressive disease with periods of
stability punctuated by episodic clinical exacerbations. The course of the
disease in any given individual, however, is extremely variable. Factors
involved in determining the long term outlook (prognosis) for a given patient
include:
- the nature of the underlying heart disease,
- the response to medications,
- the degree to which other organ systems are involved and the
severity of other accompanying conditions,
- the person's symptoms and degree of impairment, and
- other factors that remain poorly understood.
With the availability of newer drugs to potentially favorably affect the
progression of disease, the prognosis in congestive heart failure is generally
more favorable than that observed just 10 years ago. In some cases, especially
when the heart muscle dysfunction has recently developed, a significant
spontaneous improvement is not uncommonly observed, even to the point where
heart function becomes normal.
Heart failure is often graded on a scale of I to IV based on the patient's
ability to function.
- Class I is patients with a weakened heart but without
limitation or symptoms.
- Class II is only limitation at heavier workloads.
- Class III is limitation at everyday activity.
- Class IV is severe symptoms at rest or with any degree of
effort.
The prognosis of heart failure patients is very closely associated with the
functional class.
An important issue in congestive heart failure is the risk of
heart rhythm disturbances (arrhythmias). Of those deaths that occur
in individuals with congestive heart failure, approximately 50% are related to
progressive heart failure. Importantly, the other half are thought to be related
to serious arrhythmias. A major advance has been the finding that nonsurgical
placement of automatic implantable cardioverter/defibrillators (AICD) in
individuals with severe congestive heart failure (defined by an ejection
fraction below 30%-35%) can significantly improve survival, and has become the
standard of care in most such individuals.
In some people with severe heart failure and certain ECG abnormalities, the
left and right side of the heart don't beat in rhythm, and inserting a device
called a biventricular pacer can significantly reduce symptoms
What are the areas of new research in congestive heart failure?
Despite the significant advances in drug therapy for congestive heart failure
over the past 20 years, many exciting developments are under active study. New
classes of medications are being tested in clinical trials, including the
calcium sensitizing agents, vasopeptidase inhibitors, and natriuretic peptides.
As was the case with the ACE inhibitors and beta-blockers, the potential use of
these drugs is based on theoretical considerations that have resulted from an
increased understanding of the processes both underlying and resulting from
heart failure. Additionally, gene therapy that is targeted toward certain genes
thought to contribute to heart failure is being tested.
These developments have justified an unprecedented optimism in the treatment
of congestive heart failure. The majority of individuals, with appropriate
lifestyle measures and medical regimens, can maintain active, fulfilling
lifestyles. The range of treatment options has been significantly strengthened
by drugs such as the ACE inhibitors and beta-blockers. In the future, we will
surely see the addition of many more and equally potent interventions.
source:medicinenet.com
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