Congestive Heart Failure - CHF

A Patient's Guide...

• Basic Information
• Causes of Congestive Heart Failure  (CHF)
• Signs and Symptoms of CHF
• Making the Diagnosis of CHF
• Therapies for Congestive Heart Failure
  • Lifestyle Changes
  • Medication
• CHF Outpatient Clinic

The heart is responsible for pumping blood, nutrients, and oxygen to all areas of your body. Congestive heart failure (CHF) occurs when the heart muscle is weakened and doesn’t pump with enough force. CHF can also arise when the valves within the heart do not function properly, or when the heart muscle is thick and stiff.

Congestive heart failure is a chronic condition, which means that it cannot be cured with a short course of treatment. CHF may also be referred to as “CARDIOMYOPATHY”. Do not be intimidated by this medical term. “CARDIO” means “heart”, “MYO” means “muscle”, and “PATH” means pathology or disease. Therefore, cardiomyopathy simply means that there is a problem with heart muscle function.

Proper treatment may require:

• Careful selection and adjustment of medications
• Diet low in sodium
• Daily weighing
• Exercise program.

…Sometimes Cardiac Surgery is required to correct the underlying problem

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Heart attacks due to coronary artery disease are the most common cause of heart failure. Heart attacks can cause scarring and stiffening of the heart muscle, interfering with the heart's pumping function. Viral or bacterial infections also cause heart failure. In many cases, heart failure is brought on by unknown causes.

Here is a more complete list of the causes of CHF:

• CORONARY ARTERY DISEASE / HEART ATTACKS
• HYPERTENSION (high blood pressure)
• VALVULAR HEART DISEASE (leakiness or narrowing of the heart valves)
• CHRONIC ALCOHOL ABUSE
• THYROID GLAND DISORDERS
• VIRAL INFECTIONS
• FOLLOWING CHILDBIRTH
• RADIATION AND CHEMOTHERAPY
• UNIDENTIFIED CAUSES
• HEREDITARY
• CONGENITAL DISORDERS (birth-related defects)

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Signs and Symptoms of CHF:

Heart failure symptoms are often gradual in their development, as the body has great capacity to compensate for early changes in many diseases. Often, patients will wait until their breathing is severely impaired before seeking medical attention.

Shortness of breath (dyspnea)- Breathlessness is often worse during exertion or while lying down.

Waking up breathless at night (orthopnea)- Shortness of breath experienced while lying flat is a telltale sign of a weakened heart. Patients may prop themselves up on pillows or sit upright to breath comfortably.

Coughing. The buildup of fluid in the lungs (Pulmonary Edema) can result in a nagging cough that may worsen when lying down.

Swelling (edema) and weight gain. The feet, ankles, legs, or belly may become distended as fluid backing up from a weakened heart begins to accumulate. Rapid weight gain is common.

Fatigue. A lack of adequate oxygen to provide fuel to working muscles can result in exhaustion from even the simplest activity. 

SYMPTOMS SEEN WITH CHF:

• SHORTNESS OF BREATH
• WAKING AT NIGHT WITH COUGH OR TROUBLE BREATHING
• SLEEPING UPRIGHT (ON PILLOWS OR IN A CHAIR) TO PREVENT WAKING WITH TROUBLE BREATHING
• SWELLING OF THE ANKLES
• WAKING MANY TIMES EACH NIGHT TO URINATE
• EASILY FATIGUED
• INCREASED ABDOMINAL GIRTH
• RAPID UNUSUAL WEIGHT GAIN

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The medical history and physical exam findings are typically confirmed with chest x-rays and echocardiograms. Chest x-rays may show an abnormally large heart or excess fluid in lung tissues, both signs of heart failure.

An echocardiogram provides doctors with information about the heart’s function. This test uses harmless sound waves to image the left ventricle- determining any sign of weakness or prior heart attack. Heart valves are also visualized to diagnose the presence of valve leaking (regurgitation) or narrowing (stenosis) that can often cause or exacerbate heart failure.

A Thallium or Cardiolyte Nuclear Study is a stress test used to search for coronary disease that often lies at the root cause of heart failure. Nuclear stress tests are also very useful to accurately measure the heart’s pumping activity, or ejection fraction.

Cardiac Catheterization/ Coronary Angiogram: If coronary artery disease is suspected from the initial evaluation, an angiogram will often be recommended to diagnose and treat this underlying problem. Catheterization is also used to measure the extent of heart valve problems.

Your doctor may schedule a Six Minute walk to assess your level of physical activity and follow your response to treatment.

TESTS USED TO EVALUATE CHF:

• EKG
• CHEST X-RAY
• ECHOCARDIOGRAM
• NUCLEAR SCAN/STRESS TEST
• CARDIAC CATHETERIZATION
• 6 MINUTE WALK

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Therapies for Congestive Heart Failure

LIFESTYLE CHANGES:

Lifestyle can have a dramatic impact both on the management of heart-failure symptoms and on the pace at which the condition progresses.

Smokers need to quit. Smoking has many adverse effects on the heart and blood vessels. Among other things, it accelerates the progression of coronary heart disease and diminishes the blood’s capacity to carry oxygen to the body.

Exercise is also important to self-care because, done in moderation, it can help the heart pump more efficiently and reduce the demands made on the heart. Light walking, swimming, and bicycling can all help improve cardiac function.

DIET:

Congestive heart failure requires continuous therapy, and a careful, ongoing dialogue with your physician or nurse clinician. Diet is a critical part of this process. The two most harmful ingredients in a patient’s diet are salt and alcohol. Eating salt forces the body to hold on to water. This water collects in the lungs, legs and abdomen, causing swelling (edema), and making it difficult to breathe. By eliminating salt, you will help rid the extra fluid.

Helpful Hints to Avoid Salt Intake:

• Do not eat salty snacks (potato chips, pretzels, popcorn).
• Do not touch the salt shaker. leave it off of the table.
• Avoid soy sauce, canned soups, and canned vegetables.
• Avoid processed meats such as sausage, hot dogs, and salami.
• Eat fresh fruits and vegetables.
• Experiment with other spices (which do not contain salt) in order to make your food more enjoyable.
• Meeting with a dietician may help you identify where salt is hiding in your diet. the dietician may also provide hints to make your food taste better without salt.

ALCOHOL:

You may hear on the news that 1 or 2 drinks a day is good for the heart. This may be true for coronary artery disease with a normal heart muscle. However, alcohol is harmful for patient’s with congestive heart failure. Alcohol makes the heart more sluggish. This includes all forms of alcohol (beer wine, whiskey, vodka, etc.). Some people have heart failure only because they drink alcohol every day (alcoholic cardiomyopathy). In these cases, the heart muscle function may improve if one stops all alcohol intake.

WATER INTAKE:

You may hear suggestions that drinking large amounts of water is beneficial. Please remember, therapy for CHF is directed toward eliminating extra water from your body. Do not force yourself to drink extra water.

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Drug Therapy:

A carefully individualized regimen of medications will treat the symptoms of CHF and help improve the heart's function.

It may be difficult to recall the names and doses of medications.  Please keep an up-to-date list in your wallet or purse, or bring your medications to doctor visits and any hospital admissions.

These drugs lower blood pressure, which allows the heart to work more efficiently. Research has demonstrated that these drugs prolong life, reduce symptoms, and prevent hospitalizations due to heart failure.

This group of drugs may rarely cause a cough. Since CHF also causes a cough, your doctor must decide whether the cough is a signal to increase the ace inhibitor, or discontinue the ace inhibitor. Please be careful to talk with your doctor before changing or stopping any medication. ACE inhibitors may cause you to retain potassium (the opposite effect of many diuretics).

ANGIOTENSIN RECEPTOR BLOCKERS (ARB’s):

Research suggests that these drugs are similar to ACE inhibitors, but do not cause cough. Because there is more extensive research and clinical experience with ACE inhibitors, they are most often utilized before the ARB's. However, the ARB's are a good alternative if the ACE inhibitors are not well tolerated.

BETA BLOCKERS:

Frequently used to control high blood pressure or fast heart rates, they also help the heart pump more effectively. Care must be taken to start these drugs at low doses, then gradually increase the dose under the careful supervision of your physician or nurse clinician. Individuals may actually feel worse during the first few weeks after starting beta blockers. However symptoms generally improve, and therapy can prolong life, improve heart function, and decrease hospitalizations.

DIURETICS:

These drugs help eliminate the extra water and salt that causes swelling of the ankles, and shortness of breath. Some diuretics (furosemide, torsemide, metolazone) may cause excess loss of potassium. Other diuretics (spironolactone, triamterene) may cause your body to retain potassium. Spironolactone (Aldactone) may be helpful in avoiding serious complications of heart failure.

DIGOXIN:

This agent helps improve symptoms of CHF and helps avoid rapid heart rhythms.

POTASSIUM:

This is sometimes required to replace the potassium that is lost from the body during diuretic therapy. Since some drugs (ace inhibitors, angiotensin receptor blockers, and some diuretics) cause the body to retain potassium, not all patients require potassium supplements. Occasional blood tests are required to determine if you will need potassium.

OXYGEN:

Many people with congestive heart failure ask for oxygen at home, to use during periods of increased shortness of breath. If increased shortness of breath occurs with CHF, using oxygen at home may delay you from seeking proper attention in a timely fashion. This delay in making appropriate changes in diet and drug therapy may allow the CHF to become more severe, and more difficult to correct. Oxygen should be reserved for those cases when there is underlying lung disease, such as emphysema.

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Patients with symptoms of advanced heart failure, or those requiring frequent hospital admissions may be enrolled in the CHF outpatient clinic.  Here, patients receive supervised infusions (intravenous medications) with dobutamine, milrinone, or nesiritide (Natrecor). They are carefully monitored by a Nurse Clinician under the direction of your physician. Infusions typically take 3-4 hours and are scheduled once or twice a week.  Patients in the CHF clinic can expect improvement of symptoms and less frequent hospital admission. 

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