Majdi Ashchi, DO, FACC, FSCAI, FABVM, FSVM
Medical Director
Congestive Heart Failure
Congestive Heart failure is a chronic disease needing lifelong management. However, with treatment, signs, and symptoms of heart failure can improve, and the heart muscle sometimes becomes stronger. Treatment may help you live longer and reduce your chance of dying suddenly. Depending on the symptoms of the patient, a combination of medications may be used including:
- Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people with systolic heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart
- Beta blockers. This class of drugs not only slows your heart rate and reduces blood pressure but also limits or reverses some of the damage to your heart if you have systolic heart failure. Examples include carvedilol (Coreg), metoprolol. These medicines reduce the risk of some abnormal heart rhythms and lessen your chance of dying unexpectedly. Beta blockers may reduce signs and symptoms of heart failure, improve heart function, and help you live longer.
- Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Diuretics, such as furosemide (Lasix), also decrease fluid in your lungs so you can breathe more easily. Because diuretics make your body lose potassium and magnesium, your doctor also may prescribe supplements of these minerals.
- Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). These are potassium-sparing diuretics, which also have additional properties that may help people with severe systolic heart failure live longer.
- These are intravenous medications used in people with severe heart failure in the hospital to improve heart pumping function and maintain blood pressure.
- Digoxin (Lanoxin). This drug also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in systolic heart failure
- NEW DRUGS for heart failure
- Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Blocker. A drug called Ivabradine or Corlanor by Amgen Company. It works by affecting the heart’s electrical conduction in order to slow the heart rate or pulse. It should NOT be used if already have severe liver disease, very slow heart rate or blood pressure, or any abnormal electrical conductions system. Do not take with grapefruit.
- Angiotensin-Receptor Neprilysin Inhibitor- Sacubiril/Valsartan-Entresto by Sanofi Company. This drug can be significantly more effective than the ACEI vasotec in reducing the rate of death from cardiovascular causes and or hospitalization for heart failure in heart failure patients. It should be considered instead of ACEI or ARB for first-line therapy in patients with LVEF <35%.
Surgery & Medical Devices
sometimes certain conditions may require surgery or medical devices to correct heart failure.
Coronary bypass surgery or Angioplasty stents
If severely blocked arteries are contributing to your heart failure, coronary artery bypass surgery would be recommended. In this procedure, blood vessels from your leg, arm, or chest bypass a blocked artery in your heart to allow blood to flow through your heart more freely.
Heart valve repair or replacement
If a faulty heart valve causes heart failure, your doctor may recommend repairing or replacing the valve. The surgeon can modify the original valve (valvuloplasty) to eliminate backward blood flow. Surgeons can also repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly. Sometimes repairing the valve includes tightening or replacing the ring around the valve (annuloplasty). Valve replacement is done when valve repair isn’t possible. In valve replacement surgery, the damaged valve is replaced by an artificial (prosthetic) valve. Certain types of heart valve repair or replacement can now be done without open-heart surgery, using either minimally invasive surgery or cardiac catheterization techniques.
Implantable cardioverter-defibrillators (ICDs)
An ICD is a device similar to a pacemaker. It’s implanted under the skin in your chest with wires leading through your veins and into your heart. The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm. An ICD can also function as a pacemaker and speed your heart up if it is going too slow.
Cardiac resynchronization therapy (CRT), or biventricular pacing
A biventricular pacemaker sends timed electrical impulses to both of the heart’s lower chambers (the left and right ventricles) so that they pump in a more efficient, coordinated manner. Many people with heart failure have problems with their heart’s electrical system that cause their already-weak heart muscle to beat in an uncoordinated fashion. This inefficient muscle contraction may cause heart failure to worsen. Often a biventricular pacemaker is combined with an ICD for people with heart failure.
Heart pumps
These mechanical devices, such as ventricular assist devices (VADs), are implanted into the abdomen or chest and attached to a weakened heart to help it pump blood to the rest of your body. VADs are most often used in the heart’s left ventricle, but they can also be used in the right ventricle or in both ventricles. Doctors first used heart pumps to help keep heart transplant candidates alive while they waited for a donor’s heart. VADs are now sometimes used as an alternative to transplantation. Implanted heart pumps can significantly extend and improve the lives of some people with severe heart failure who aren’t eligible for or able to undergo heart transplantation or are waiting for a new heart.
Heart transplant
Some people have such severe heart failure that surgery or medications don’t help. They may need to have their diseased heart replaced with a healthy donor heart. Heart transplants can dramatically improve the survival and quality of life of some people with severe heart failure. However, candidates for transplantation often have to wait a long time before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment or device therapy and can be removed from the transplant waiting list.
Diagnostic Testing
To determine whether you have heart failure, your healthcare team may do some or all of these diagnostic tests and procedures.
Blood tests
a sample of your blood to check your kidney, liver, and thyroid function and to look for indicators of other diseases that affect the heart. A blood test to check for a chemical called N-terminal pro-B-type natriuretic peptide (NT-proBNP) may help in diagnosing heart failure if the diagnosis isn’t certain when used in addition to other tests.
Chest X-ray
X-ray images help your doctor see the condition of your lungs and heart. In heart failure, your heart may appear enlarged and fluid buildup may be visible in your lungs. Your doctor can also use an X-ray to diagnose conditions other than heart failure that may explain your signs and symptoms.
Electrocardiogram (ECG)
This test records the electrical activity of the heart through electrodes attached to your skin. Impulses are recorded as waves and displayed on a monitor or printed on paper. This test helps diagnose heart rhythm problems and damage to your heart from a heart attack that may be underlying heart failure.
Echocardiogram
An important test for diagnosing heart failure is the echocardiogram. An echocardiogram helps distinguish systolic heart failure from diastolic heart failure in which the heart is stiff and can’t fill properly. An echocardiogram uses sound waves to produce a video image of your heart. This test can help the size and shape of your heart and how well your heart is pumping. The echocardiogram also can help doctors look for valve problems or evidence of previous heart attacks, other heart abnormalities, and some unusual causes of heart failure. The ejection fraction is measured during an echocardiogram and can also be measured by nuclear medicine tests, cardiac catheterization, and cardiac MRI. This is an important measurement of how well your heart is pumping and is used to help classify heart failure and guide treatment.
Stress test
Stress tests measure how your heart and blood vessels respond to exertion. It is a test of demand and supply for your arteries. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Or you may receive a drug intravenously that stimulates your heart similar to exercise. Sometimes the stress test can be done while wearing a mask that measures the ability of your heart and lungs to take in oxygen and breathe out carbon dioxide. Stress tests help doctors see if you have coronary artery disease. Stress tests also determine how well your body is responding to your heart’s decreased pumping effectiveness and can help guide long-term treatment decisions.
Cardiac computerized tomography (CT) scan or magnetic resonance imaging (MRI)
These tests can be used to diagnose heart problems, including causes of heart failure. In a cardiac CT scan, you lie on a table inside a doughnut-shaped machine. An X-ray tube inside the machine rotates around your body and collects images of your heart and chest. In a cardiac MRI, you lie on a table inside a long tube-like machine that produces a magnetic field. The magnetic field aligns atomic particles in some of your cells. When radio waves are broadcast toward these aligned particles, they produce signals that vary according to the type of tissue they are. The signals create images of your heart.
Coronary angiogram
In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or in your arm and guided through the aorta into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray. This test helps doctors identify narrowed arteries to your heart (coronary artery disease) that can be a cause of heart failure. The test may include a ventriculogram — a procedure to determine the strength of the heart’s main pumping chamber (left ventricle) and the health of the heart valves (mitral valve or aortic valve).
Myocardial biopsy
In this test, your doctor inserts a small, flexible biopsy cord into a vein in your neck or groin, and small pieces of the heart muscle are taken. This test may be performed to diagnose certain types of heart muscle diseases that cause heart failure.
Causes and Conditions
Congestive heart failure often develops after other conditions have damaged or weakened your heart. However, the heart doesn’t need to be weakened to cause heart failure. It can also occur if the heart becomes too stiff or does not relax at a certain speed.
In heart failure, the main pumping chambers of your heart (the ventricles) may become stiff and not fill properly between heart beats. In some cases of heart failure, your heart muscle may become damaged and weakened, and the ventricles stretch (dilate or enlarge) to the point that the heart can’t pump blood efficiently throughout your body. Over time, the heart can no longer keep up with the normal demands placed on it to pump blood to the rest of your body.
An ejection fraction is an important measurement of how well your heart is pumping and is used to help classify heart failure and guide treatment. In a healthy heart, the ejection fraction is 55 percent or higher — meaning that more than half of the blood that fills the ventricle is pumped out with each heartbeat. But heart failure can occur even with a normal ventricle ejection fraction. This happens if the heart muscle becomes stiff from conditions such as high blood pressure.
The term “congestive heart failure” comes from blood backing up into — or congesting — the liver, abdomen, lower extremities and lungs. However, not all heart failure is congestive. You might have shortness of breath or weakness due to heart failure and not have any fluid building up. This heart failure is classified at diastolic heart failure.
Heart failure can involve the left side (left ventricle), right side (right ventricle) or both sides of your heart. Generally, heart failure begins with the left side, specifically the left ventricle — your heart’s main pumping chamber.
Types of Heart Failure
- Left-sided heart failure: Fluid may back up in your lungs, causing shortness of breath.
- Right-sided heart failure: Fluid may back up into your abdomen, legs and feet, causing swelling.
- Systolic heart failure: The left ventricle can’t contract vigorously, indicating a pumping problem.
- Diastolic heart failure (also called heart failure with preserved ejection fraction): The left ventricle can’t relax or fill fully, indicating a filling problem.
Any of the following conditions can cause heart failure and even if a patient does know they exist:
- Coronary artery disease and heart attack. Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. Over time, arteries that supply blood to your heart muscle narrow from a buildup of fatty deposits — a process called atherosclerosis. The buildup of plaques can cause reduced blood flow to your heart. A heart attack occurs if plaques formed by the fatty deposits in your arteries rupture or break loose. This causes a blood clot (thrombus) to form, which may block blood flow to an area of the heart muscle, weakening the heart’s pumping ability and often leaving permanent damage or scar. If the damage is significant, it can lead to a weakened heart muscle. This will in turn bring down the ejection fraction to below 55%.
- High blood pressure (hypertension). Blood pressure is the force of blood pumping by your heart or LEFT ventricle through your arteries. If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body. Over time, the heart muscle may become thicker (hypertrophy) to compensate for the extra work it must perform. Eventually, your heart muscle may become either too stiff or too weak to effectively pump blood.
- Faulty heart valves. The valves of your heart keep blood flowing in the proper direction (ONE WAY VALVES) through the heart. A damaged valve — due to a heart defect, coronary artery disease or heart infection or wear and tear — forces your heart to work harder to keep blood flowing as it should. Over time, this extra work can weaken your heart. Faulty heart valves, however, can be fixed or replaced with certain criteria applied.
- Damage to the heart muscle (cardiomyopathy). Heart muscle damage (cardiomyopathy) can have many causes, including several diseases, infections, thyroid disease, alcohol abuse and the toxic effect of drugs, such as cocaine or some drugs used for chemotherapy. Genetic factors play an important role in several types of cardiomyopathy, such as dilated cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction and restrictive cardiomyopathy.
- Myocarditis is an inflammation of the heart muscle. It’s most commonly caused by a virus and can lead to left-sided heart failure. Left heart failure can cause right heart failure too.
- Heart defects at birth (congenital heart defects). If your heart and its chambers or valves haven’t formed correctly, the healthy parts of your heart have to work harder to pump blood through your heart, which, in turn, may lead to heart failure.
- Abnormal heart rhythms (heart arrhythmias). Abnormal heart rhythms may cause your heart to beat too fast, which creates extra work for your heart. Over time, your heart may weaken, leading to heart failure. A slow heartbeat may prevent your heart from getting enough blood out of the body and may also lead to heart failure.
- Other diseases. Chronic diseases — such as diabetes, HIV, hyperthyroidism, hypothyroidism, or a buildup of iron (hemochromatosis) or protein (amyloidosis) —also may contribute to heart failure.
Congestive Heart Failure: Signs and Symptoms
Congestive Heart failure, sometimes known as congestive heart failure, occurs when the heart muscle doesn’t pump blood as well as it should. The pump or the ventricle has to be able to pump about 55% of its content with each heartbeat.
Certain disease conditions, such as narrowed arteries in the heart (coronary artery disease or hardening of the arteries) or high blood pressure, gradually leave the heart too weak or stiff to fill and pump efficiently.
Not all conditions that lead to heart failure can be reversed, but treatments can improve the signs and symptoms of heart failure and help you live longer. Lifestyle changes — such as exercising, reducing salt in your diet, managing stress, and losing weight — can improve your quality of life. One way to prevent heart failure is to control conditions that cause heart failure.
Congestive Heart failure signs and symptoms may include:
- Shortness of breath (dyspnea) when a person exerts himself or when he lies down
- Fatigue and weakness
- Swelling (edema) in your legs, ankles, and feet
- Rapid or irregular heartbeat
- Reduced ability to exercise or decrease exercise tolerance
- Persistent cough or wheezing with white or pink blood-tinged phlegm
- Increased need to urinate at night or nocturia
- Swelling of your abdomen (ascites)
- Sudden weight gain from fluid retention
- Lack of appetite and nausea
- Difficulty concentrating or decreased alertness
- Sudden, severe shortness of breath and coughing up pink, foamy mucus
- Chest pain if your heart failure is caused by a heart attack