Congestive Heart Failure (CHF)

It should be noted that the right side of the heart (right atrium to the right ventricle to the right pulmonary artery) pumps deoxygenated blood received from the body back to the lungs to get oxygenated. Alternatively, the left side of the heart (left atrium to the left ventricle to the aorta) pumps out the oxygenated blood received from the lungs to the rest of the body. At the end of each heartbeat, both ventricles contract to produce the sound and send blood back to the lungs (right ventricle by the right pulmonary artery) and to the rest of the body (left ventricle by the aorta). When the heart is unable to maintain the pressure necessary to pump out blood (due to structural or functional problems) effectively with each heartbeat, congestive heart failure occurs.

Ejection fraction is the ratio of blood leaving the ventricle after being pumped out to the volume of blood remaining in the ventricle after contraction. Therefore, ejection fraction (EF) measures the ability of the heart's ventricles to contract and pump blood. Usually, ejection fraction refers to the ejection fraction of the left ventricle, unless specified, as it is more significantly implicated in congestive heart failure (CHF). All the blood present in the ventricle is not pumped out even under normal conditions, but at least 50 to 70% is with each heartbeat.

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Based on the ejection fraction, or the ability of the left ventricle to pump out blood into the aorta and on to the rest of the body, congestive heart failure is classified into the following two types: 

• Heart failure with reduced ejection fraction: If the ejection fraction of the left ventricle is less than 40% (normal is between 50 to 70%)
• Heart failure with preserved ejection fraction: If the ejection fraction of the right ventricle is more than at least 40% (normal is between 50 to 70%)

(Read More - Coronary Artery Disease)

Not all congestive heart failures are equally disabling, some cases are more severe than others. Typically, chronic congestive heart failure is more stable and managed on a daily basis with regular medications. Whereas, when there is an acute worsening of symptoms, it is referred to as acute heart failure and generally needs hospital admission and treatment. Some signs and symptoms of congestive heart failure include:

• Breathlessness or shortness of breath is the most common feature of congestive heart failure. Depending on when it occurs, the severity of the condition can be graded. Breathlessness can occur on exertion while lying flat or even at rest in severe cases. The severity of congestive heart failure on the basis of breathlessness can be described as:
  • Very mild or class 1: The patient is asymptomatic and only gets breathless on very heavy exercise.
  • Mild or class 2: The patient gets breathless on doing ordinary physical activities considered normal for their age group.
  • Moderate or class 3: Although comfortable at rest, the patient gets breathless on very slight physical activity like dressing oneself.
  • Severe or class 4: The patient may be breathless at rest and very uncomfortable with any physical activity.
• Fluid retention: As the overall blood circulation of the body is hampered, fluid tends to collect as edema in the ankles, legs, buttocks or abdomen. 
• Fatigue or feeling tired all the time 
• Chest pain can be present if the patient has experienced an attack of angina or a heart attack 
• Palpitations, or the feeling of being able to hear one's heartbeat, can occur with a heart rhythm disorder
• A fluttering sensation in the chest can be felt with some rhythm disorders as well
• Dizziness
• Feeling lightheaded
• Fainting spells
• Persistent cough
• Loss of appetite
• Constipation

(Read More - Congenital Heart Disease)

Conditions that impact and change the structure or function of the heart permanently can induce chronic or congestive heart failure (CHF). Examples of common conditions that can cause CHF include:

• Myocardial infarction or heart attack: Atherosclerotic plaque build up inside coronary arteries can sometimes cause the blood circulation of the heart to stop in a certain area. This can lead to the death of the heart muscle tissue and lead to heart-pumping failure later.
• Angina: Similar to a heart attack, angina also results from a blockage in the coronary arteries of the heart but usually resolves in under twenty minutes. Repeated impedance to the blood circulation of the heart can cause the heart muscle to dysfunction and heart failure to occur.
• Cardiomyopathy: This group of disorders cause abnormalities in the heart muscle responsible for pumping blood that can result in congestive heart failure.
• High blood pressure: Long-term poorly controlled high blood pressure can also damage the heart and its pumping mechanism.
• Heart valve disease: Valves that open and close at the right time are present between the atria and ventricles and the ventricles and the outlets through which they pump blood out (aorta and pulmonary artery). Some conditions can cause abnormalities in the structure or function of the heart valves that can cause obstruction to the flow of blood from the heart to the body.
• Abnormal heart rhythm disorders or arrhythmias: The normal rate and rhythm of the heartbeat (called sinus rhythm) may be replaced by irregular heartbeats in some individuals. These rhythm disorders or arrhythmias, like atrial fibrillation, cause the heart to contract at an irregular rate, thereby affecting the effective blood volume pumped out per minute.
• Severe anemia: Anemia is the deficiency of the oxygen-carrying red blood pigment called hemoglobin. When hemoglobin deficiency is severe, oxygen demands of the heart are not met and it can dysfunction.
• Thyroid disease: Both hypothyroidism and hyperthyroidism can cause the heart to dysfunction and heart failure to set in.
• Paget’s disease of bone: Paget’s is a type of bone disease in which the old bone is first broken down and then replaced by abnormal bone. The newly formed abnormal bone is richly supplied by new blood vessels, which divert the blood supply of the body and cause an increased demand for blood flow leading to heart failure.
• Chemotherapy: Doxorubicin, a drug used in chemotherapy for many types of cancers, can lead to congestive heart failure at high doses.
• Drug abuse: Drugs like cocaine can cause inflammation of the heart (myocarditis), leading to heart tissue damage and pumping failure.

(Read More - Endocarditis treatment)

Certain conditions can elevate the risk of developing heart diseases and congestive heart failure. Some such risk factors are:

• Smoking
• High blood cholesterol levels
• Excessive alcohol consumption
• Unhealthy diet
• Sedentary lifestyle
• Being overweight or obese
• Excessive psychological or emotional stress

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Upon suspicion of congestive heart failure, the doctor will begin by taking a thorough medical history from the patient. Special emphasis will be laid on any pre-existing heart conditions, lifestyle diseases and other medical history. After taking a complete history, the doctor will conduct a physical examination of the patient. All systems of the body will be examined and close attention will be paid to the cardiovascular system. The doctor will usually use a stethoscope to auscultate all the heart sounds very thoroughly. Afterwards, some medical investigations will be ordered to confirm the diagnosis and guide the treatment plan for the patient.

(Read More - Valvular Heart Disease treatment)

Some investigations that are ordered to diagnose and confirm congestive heart failure include:

• B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP): This hormone helps keep the blood ejected from the heart at a steady level. An elevation could signify heart failure, but it may be raised in other conditions as well. The higher the blood levels, the more severe the congestive heart failure is likely to be. 
• Electrocardiograph (ECG): An ECG traces the rate and rhythm of the heart on a special chart. This can help assess any heart rhythm disorders if present.
• Echocardiogram: A specialised imaging tool used to visualise the heart and all its components can help uncover the cause of heart failure as well as report the ejection fraction of the left ventricle.
• Other tests including blood, urine and radiological imaging studies will also be conducted to rule out other causes for the presenting symptoms.

(Read More - Hypertrophic cardiomyopathy treatment)

After congestive heart failure has been diagnosed, confirmed and graded, treatment begins. 

Conservative treatment may include:

• Lifestyle modification is key to reducing morbidity from congestive heart failure. Weight reduction to maintain a healthy body mass index (BMI) between 18.5 to 25, quitting smoking, cutting back on alcohol and unhealthy foods, exercising and following a healthy diet are very important.
• Regularly weighing oneself: Patients with moderate to severe congestive heart failure are advised to weigh themselves regularly to detect any sudden and significant increase in weight due to water retention.
• Vaccinations: Congestive heart failure can make patients more susceptible to infections and they should get the pneumococcal vaccine and annual influenza vaccines.

Medical treatment may include:

• Management of chronic congestive heart failure: These medicines are taken everyday and help reduce the mortality from congestive heart failure. 
  • ACE inhibitors (examples are captopril) or Beta Blockers (examples include Carvedilol, Nebivolol and Bisprolol) are the first line groups of drugs used. ACE inhibitors are preferred if the patient has water retention or is diabetic, whereas beta-blockers are preferred if the patient has suffered from angina or heart attack. One medicine is started at a time but both may be added if needed.
  • Spironolactone: If the above drugs are unable to control the condition, this medicine may be initiated.
  • Digoxin: This drug is usually only started if the patient suffers from a heart rhythm disorder known as atrial fibrillation.
• Management of acute heart failure: Pulmonary edema, or pooling of fluid in the lung tissues, can occur with acute heart failure. It is managed by giving the patient oxygen and water pill medicines like Furosemide to remove the extra fluid from the body through urine.

Special devices: Heart rhythm disorders may need special devices to be placed next to the patient's heart to keep the heart beating at a steady regular rate. Such devices can be: 

• Implantable cardioverter defibrillator (ICD)
• Pacemaker (Read more: Pacemaker Surgery)

(Read More - Broken Heart Syndrome)