Congestive Heart Failure

congestive heart failure

High blood pressure can lead to congestive heart failure if your hypertension is not well controlled. Congestive heart failure (or chronic heart failure) is a serious medical condition that disrupts more lives than almost any other condition – including cancer – yet few people are aware the problem even exists.

What is chronic heart failure?

Heart failure is an inability of the heart to pump blood around the body as efficiently as it should – either during exercise or while you are resting. The resulting back pressure, and pooling of blood in the veins, causes fluid to leak out into body tissues which become congested.

Heart failure can come on suddenly (acute) or gradually (chronic). Most cases of acute heart failure are due to a severe heart attack. In contrast, chronic heart failure comes on more slowly so that symptoms come on gradually and you may not notice at first.

Chronic heart failure is the more modern term for congestive heart failure. This is because congestive heart failure implies there is sodium and water retention, which is not always the case. Similarly, congestive heart failure was once divided into right heart failure and left heart failure, depending on whether congestion mainly affected the lungs (left heart failure) or the lower body (right heart failure). More often than not, when one side of the heart is affected the other is placed under extra strain and starts to fail, too, so these terms are also falling out of fashion.

Congestive heart failure symptoms  

Chronic heart failure affects your quality of life more than most common long-term health problems such as back pain, diabetes, high blood pressure, angina or lung disease, yet it is a condition that few people have heard of, and which is often under diagnosed and under treated.

The main symptom of chronic heart failure is shortness of breath, which can be:

  • mild (slight limitation of physical activity)
  • moderate (shortness of breath with exercise)
  • severe (shortness of breath at rest or during minimal physical activity).

The shortness of breath may be associated with coughing, wheezing and sweating. Congestion of the lungs becomes worse on lying down, and people typically sleep propped up on several pillows. Lying down can also cause sudden difficulty in breathing so you may wake at night gasping for breath. You may also experience increased urination at night.

Having heart failure can also lead to loss of energy and fatigue, loss of appetite, nausea, poor circulation and weight gain due to fluid retention. These symptoms of chronic heart failure can make even the simplest of household tasks difficult or impossible.

The New York Heart Association classifies heart failure based on severity of symptoms and limitation of physical activity, so you may be told the severity of your chronic heart failure is:

Class I – ordinary physical activity is not limited and does not cause undue fatigue, breathlessness, or palpitations.

Class II – you are comfortable at rest but have slight limitation of physical activity which results in undue breathlessness, fatigue, or palpitations.

Class III – you are comfortable at rest but have marked limitation of physical activity with significant breathlessness, fatigue, or palpitations.

Class IV – you are unable to carry out any physical activity without discomfort, and may have symptoms at rest, too.

Signs of congestive heart failure  

The signs of chronic heart failure are physical changes that your doctor will look for, but which you may not notice yourself. These include swelling (pitting oedema) of the ankles, legs, abdomen or base of the spine, a rapid or irregular heartbeat, a third heart sound,  crackle sounds in the base of the lungs due to fluid build-up, and a raised jugular venous pressure (which is a fluttering seen in a vein the neck).

Causes of congestive heart failure

Any condition affecting the heart can lead to heart failure including:

  • uncontrolled high blood pressure, which puts extra strain on the heart
  • coronary artery disease, which weakens heart muscle through lack of oxygen
  • heart attack
  • diseases that affect the heart muscle, heart valves, or the membrane surrounding the heart (pericardium)
  • congenital heart disease
  • abnormal heart rhythms, such as atrial fibrillation
  • conditions that increase the work load of the heart (eg anaemia, overactive thyroid)
  • kidney disease
  • obesity
  • drugs (including alcohol, cocaine, and non-steroidal anti-inflammatory drugs).

Your heart ejection fraction

The treatment of heart failure aims to improve symptoms and exercise tolerance, to prevent worsening of symptoms, and to increase your survival. Your treatment will depend on how much blood your heart is able to pump out with each beat.

atrial fibrillation of the heartThe amount of blood that is pumped out of your left ventricle when your heart contracts is your ejection fraction. Some blood always remains inside the chamber of the heart when it beats, even in the fittest person in the best of health, and an ejection fraction of 55% or above is considered normal.

Your ejection fraction is usually measured via an echocardiogram which is essentially an ultrasound of the heart.

For example, if your left ventricle has a total blood volume of 100 ml, and pumps out 60 ml during each heartbeat, then you have an ejection fraction of 60%, which is great.

If your left ventricle is enlarged and has a total blood volume of 140 ml (for example as a result of untreated high blood pressure) and pumps out 60 ml with each heartbeat, you have an ejection fraction of just under 43%, which is reduced.

  • A left ventricular ejection fraction of 55% to 70% is normal.
  • A left ventricular ejection fraction of 40% to 54% is slightly below normal and you may not have symptoms of heart failure.
  • An ejection fraction between 35% and 39% is moderately below normal and you may have mild to moderate heart failure symptoms.
  • An ejection fraction between of less than 35% is severely below normal and you will have moderate to severe heart failure symptoms.

Heart failure with preserved ejection fraction (diastolic heart failure)

Just under half of people with heart failure have a preserved left ventricular ejection fraction (55% or greater). This means that your heart is contracting well but the heart muscle is stiff so the left ventricle does not relax properly between beats. Heart failure with a preserved ejection fraction is particularly common in people with high blood pressure, and those with raised cholesterol, diabetes, obstructive sleep apnea, and in those who smoke.

Heart failure with reduced ejection fraction (systolic heart failure)

Just over half of people with heart failure have a reduced left ventricular ejection fraction (typically 40% or less), in which the heart muscle does not squeeze forcefully enough during each heartbeat. This means the amount of blood pumped out of the heart is less than your body needs. Heart failure with a reduced ejection fraction is particularly common in people who have coronary artery disease, coronary artery disease, weak heart muscle (cardiomyopathy) or heart valve disease. It can also occur with high blood pressure as the heart has to pump blood against increased pressure, which can weaken the heart muscle.

Treatment of congestive heart failure

If your ejection fraction is preserved, your doctor will initially prescribe a loop diuretic (eg furosemide) if necessary to relieve symptoms of fluid overload.

heart failure treatmentIf your ejection fraction is reduced, you will be prescribed a loop diuretic (eg furosemide) plus an angiotensin-converting enzyme (ACE) inhibitor followed by a beta-blocker (or vice versa). These two drugs are not usually started at the same time, as you need to adjust to one before starting the other. Once you are stable on one drug, the other is added in. These drugs are designed to relax your blood vessels, lower your blood pressure and slow the heart, Together, they reduce the work load of your heart so it can pump more efficiently.

In addition to the above treatments, other types of drug may also be offered depending on the severity of symptoms and the underlying causes of heart failure. For example, you may also be offered an antiplatelet drug (to reduce unwanted blood clots) and a statin (to lower cholesterol) if needed.

If you have an ejection fraction of less than 35%, you are at greater risk of abnormal heart rhythms and your doctor may talk to you about having an implantable cardioverter defibrillator (ICD) or cardiac resynchronisation therapy (CRT) in which a small pacemaker is inserted just below the collarbone to detect and correct heart rate irregularities.

Once treatment for heart failure is started, your symptoms should improve quickly, and you should feel a lot better within a few weeks to a few months. It is important to take your heart medicines regularly, as these will help control your symptoms of fatigue and shortness of breath as well as prolonging life.

Sauna bathing and congestive heart disease

A recent review of nine studies researched sauna therapy for congestive heart failure. After 2 weeks of regular sauna bathing, these showed improvements in the distances that could be walked in 6-minutes, reduced heart size on chest X-ray and reduced severity of congestive heart disease (fewer people with Class III or Class IV heart failure) compared to no significant improvements in a control group receiving standard medical care. If you want to try sauna therapy, always check with your doctor first, and always have a companion with you. If your doctor wants to read the research, here’s a link to clinical Effects of Regular Dry Sauna Bathing: A Systematic Review.

Self-help for chronic heart failure

Avoid excessive salt intake by excluding obviously salty foods from your diet. In addition, you should not add salt during cooking or at the table.

Limit your alcohol intake to no more than one or two units per day (or ideally none at all).

Take regular, low-intensity, supervised exercise.

If you smoke, ask your doctor to refer you to a smoking cessation clinic.

Ask your doctor if you need to restrict your fluid intake (restriction should be excessive to avoid dehydration).

Seek medical advice if your feel thirsty, light-headed, or dizzy.

If you have class III or class IV heart failure, avoid swimming or other exercise in water.

If you have stable heart failure, you can undertake normal sexual activity as long as this does not provoke undue symptoms.

Ensure you have an annual influenza vaccination and a once-only pneumococcal vaccination.

Keep a regular check on your weight and contact your doctor if you have a sudden and sustained weight gain  which could indicate a build-up of fluid.

Tell your doctor if you experience:

  • New or increasing shortness of breath, especially when lying flat in bed
  • A new or worsening cough, especially with pink, frothy or bloody sputum
  • New or increasing swelling of your ankles, legs or abdomen
  • A weight gain of 3 lbs (1.3 kg) in one day
  • A weight gain of 5 lbs (2.3 kg) in one week
  • An irregular heart rate, a fast heart rate or palpitations
  • New or increasing dizziness

Not surprisingly, you are more prone to depression if you have heart failure. If you are feeling low, tell your doctor as treatment will greatly improve your overall quality of life.

Chronic heart failure prognosis  

Effective treatment of chronic heart failure is usually successful in relieving symptoms and improving quality of life. Effective treatment can also significantly prolong your life but it is important to keep taking your medicines as prescribed.

The average age at first diagnosis of chronic heart failure is 76 years, although some people are significantly younger and others older, depending on the underlying cause. Treatments are improving all the time, and at least two in three people survive their first year after diagnosis, with around 50% of people surviving for over five years. While this may seem frightening, remember that the average age of diagnosis is 76 years, so a 5 year survival will take you into your 80s, which doesn’t sound quite so bad.

The main reason why some people go downhill with chronic heart failure is because they do not take their medicines regularly as prescribed. Some medicines have to be taken twice a day, and even in clinical trials one in three people do not take their heart failure treatments properly. If you have problems remembering to take your medicines, talk to your doctor or pharmacist. For example, other treatment options that are only needed once a day may be available. Your pharmacist can also suggest different ways of reminding yourself to take your drugs every day.

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