Introduction

In order to understand what occurs in congestive heart failure, it is useful to be familiar with the how the heart works and its anatomy. The heart is composed of two independent pumping systems, one on the right side, and the other on the left. Each has two chambers, an atrium and a ventricle. The ventricles are the major pumps in the heart.

The external structures of the heart include the ventricles, atria, arteries and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.

The Right Side of the Heart. The right system receives blood from the veins of the whole body. This is “used” blood, which is poor in oxygen and rich in carbon dioxide.

The right atrium is the first chamber that receives blood.
The chamber expands as its muscles relax to fill with blood that has returned from the body.
The blood enters a second muscular chamber called the right ventricle.
The right ventricle is one of the heart's two major pumps. Its function is to pump the blood into the lungs.
The lungs restore oxygen to the blood and exchange it with carbon dioxide, which is exhaled.

The Left Side of the Heart. The left system receives blood from the lungs. This blood is now oxygen rich.

The oxygen-rich blood returns through veins coming from lungs (pulmonary veins) to the heart.
It is received from the lungs in the left atrium, the first chamber on the left side.
Here, it moves to the left ventricle, a powerful muscular chamber that pumps the blood back out to the body.
The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to perform contractions powerful enough to force the blood to all parts of the body.
This strong contraction produces systolic blood pressure (the first and higher number in blood pressure measurement). The lower or diastolic blood pressure is measured when the left ventricle relaxes to refill with blood between beats.
Blood leaves the heart through the ascending aorta, the major artery that feeds blood to the entire body.

The Valves. Valves are muscular flaps that open and close so blood will flow in the right direction. There are four valves in the heart:

The tricuspid regulates blood flow between the right atrium and the right ventricle.
The pulmonary valve opens to allow blood to flow from the right ventricle to the lungs.
The mitral valve regulates blood flow between the left atrium and the left ventricle.
The aortic valve allows blood to flow from the left ventricle to the ascending aorta.

Click the icon to see an image of the internal structures of the heart.

The Heart's Electrical System. The heartbeats are triggered and regulated by the conducting system, a network of specialized muscle cells that form an independent electrical system in the heart muscles. These cells are connected by channels that pass chemically caused electrical impulses.

Click the icon to see an image of the conduction system of the heart.

Description of Heart Failure

Congestive heart failure, often called simply “heart failure,” is not a disease but is a condition or process, in which the heart is unable to pump enough blood to meet the needs of the body’s tissues. The heart doesn’t “fail” in the sense of ceasing to beat (as occurs during a heart attack). Rather, it weakens, usually over the course of months or years, so that it is unable to pump out all the blood that enters its chambers. As a result, fluids tend to build up in the lungs and tissues, causing congestion (hence the name “congestive” heart failure).

Ways the Heart Can Fail. Heart failure can occur in several ways:

The muscles of the heart pumps (ventricles) become thin and weakened. They stretch (dilate) to the extent that they cannot pump the blood with enough force to reach all the body’s tissues.
The heart muscles stiffen or thicken. In this case they lose elasticity and cannot relax. Insufficient blood enters the chamber and so not enough blood is pumped out into the body to serve its needs.
Sometimes the valves of the heart are abnormal. (Valves open or close to control the flow of blood entering or leaving the heart). They may narrow, such as in aortic stenosis, causing a back up of blood, or they may close improperly so that blood leaks back into the heart. The mitral valve (which regulates blood flow between the two chambers on the left side of the heart) often becomes leaky in severe heart failure--a condition called mitral regurgitation.

Click the icon to see an image of the valves of the heart.

The very mechanisms that the body uses to compensate for inefficient heart pumping can, over time, change the architecture of the heart (called remodeling) and finally lead to irreversible problems.

The specific effects of heart failure on the body depend on whether it occurs on the left or right side. Over time, however, in either form of heart failure, the organs in the body do not receive enough oxygen and nutrients, and the body's wastes are removed slowly. Eventually, vital systems break down.

Failure on the Left Side (Systolic Failure). Failure on the left side of the heart is the more common event. The failure can be a result of abnormal systolic (contraction) or diastolic (relaxation) action.

In most of these cases, the failure is caused by a systolic abnormality (called systolic failure). In such cases, the heart muscles weaken and cannot keep up with the demands of the body. The left ventricle is usually dilated. Fluid backs up and accumulates in the lungs. Systolic heart failure typically occurs in men between the ages of 50 and 70 years who have had a heart attack.
Between 20% and 50% of heart failure cases have abnormal diastolic actions, in which there is an abnormality in the way the heart relaxes. Most often in failure on the right side, the heart muscles thicken so that the muscles relax abnormally. In this case, fluid entering the heart backs up. This causes the veins in the body and tissues surrounding the heart to swell. It is often a precursor to systolic failure. Patients with diastolic failure are typically women, overweight, and elderly, and have high blood pressure and diabetes.

In both cases, with the weakened pump, fluid builds up in the lungs, and from there it builds up in tissues throughout the body, causing congestion.

Failure on the Right Side. Failure on the right side of the heart is most often a result of failure on the left. Because the right heart receives blood from the veins, failure here causes the blood to back up. As a result, the veins in the body and tissues surrounding the heart to swell. This causes swelling in the legs.

Ejection Fraction. To help determine severity, physicians use a calculation called an ejection fraction. This is the percentage of the blood pumped out during each heartbeat. An ejection fraction of 50% to 75% is considered normal, and, in general, a low percentage is considered an indication of failure. The ejection fraction in left-side heart failure typically falls below 40%. In severe failure it may drop as low as 5%.

Of note, between 20% and 50% of heart failure patients have a normal ejection fraction, an indication of diastolic heart failure.

Causes

Heart failure has many causes and can evolve in different ways:

It can be a direct, last-stage result of heart damage from one or more of several heart or circulation diseases.
It can occur over time as the heart tries to compensate for abnormalities caused by these conditions, a condition called remodeling.

In all cases, the weaker pumping action of the heart means that less blood is sent to the kidneys. The kidneys respond by retaining water and salt. This in turn increases edema (fluid buildup) in the body, which causes widespread damage.

High Blood Pressure

Uncontrolled high blood pressure, or hypertension, can cause a heart attack, but it is also a major cause of heart failure even in the absence of an attack. In fact, about 75% of cases of heart failure start with hypertension. It generally develops in the following way:

To compensate for increased blood pressure, the heart muscles thicken.
Over time the force of the heart muscle contractions weakens and the muscles have difficulty relaxing, thereby preventing the normal filling of the heart with blood.

[For more information, see the Well-Connected report #14, High Blood Pressure.]

Hypertension is a disorder characterized by consistently high blood pressure. Generally, high blood pressure consists of systolic blood pressure (the "top" number, which represents the pressure generated when the heart beats) higher than 140, or diastolic blood pressure (the "bottom" number, which represents the pressure in the vessels when the heart is at rest) over 90.

Coronary Artery Disease

Coronary artery disease is the end result of a complex process called atherosclerosis (commonly called "hardening of the arteries"). It is the most common cause of heart attack and involves the build-up of unhealthy cholesterol on the arteries, with inflammation and injury in the cells of the blood vessels. The arteries narrow and become brittle and subject to damage. Heart failure in such cases most often results from a localized pumping defect in the left side of the heart. [For detailed information, see other Well-Connected reports, including #3, Coronary Artery Disease and Angina and #23, Cholesterol, Lipoproteins, and Other Lipids.]

Click the icon to see an image of atherosclerosis.

Damage after a Heart Attack

People now often survive heart attacks, but eventually many develop heart failure from the physical damage done to the heart muscles by the attack. So ironically, heart attack recovery is probably one of the major factors in the dramatic increase in heart failure cases over the past decade. On an encouraging note, however, new therapies that are reducing the severity of heart attacks may help stabilize the heart failure rates. [For more information, see the Well-Connected report #12, Heart Attack.]

Valvular Heart Disease

The valves of the heart control the flow of blood leaving and entering the heart. Abnormalities can lead to failure:

They can narrow, causing a backup of blood.
They can close improperly, causing blood to leak back into the heart.

Click the icon to see an image of the heart valves.

In the past, rheumatic fever, which scars the heart valves and prevents them from closing, was a major cause of death from heart failure. Fortunately, antibiotics have relegated this disease to a minor cause of heart failure. Birth defects may also cause abnormal valvular development. Although more children born with heart defects are now living to adulthood, they still face a higher than average risk for heart failure as they age.

Cardiomyopathies

Cardiomyopathies are diseases that damage the heart muscles and lead to heart failure. Injury to the heart muscles may cause them to thin out (dilate) or become too thick (become hypertrophic). In either case, the pumping action is disrupted.

Dilated Cardiomyopathy. Dilated cardiomyopathy involves an enlarged heart ventricle. The muscles thin out, reducing the pumping action usually on the left side. Although this condition is associated with genetic factors, the direct cause often is not known (in which case it is called idiopathic dilated cardiomyopathy). Research strongly indicates that viruses, such as Coxsackie virus, or other infections may be at the base of this condition. Experts posit that an autoimmune response occurs in which infection-fighting antibodies attack a person's own proteins in the heart, mistaking them for foreign agents.

Click the icon to see an image of dilated cardiomyopathy.

Hypertrophic Cardiomyopathy. In hypertrophic cardiomyopathy, the heart muscles become thick and contract with difficulty. Some research indicates that this occurs because of a genetic defect that causes a loss of power in heart muscle cells and, subsequently, diminished pumping strength. To compensate for this power loss, the heart muscle cells grow. This condition, rare in the general population, is often the cause of sudden death in young athletes.

Click the icon to see an image of hypertrophic cardiomyopathy.

Corrective Mechanisms, Remodeling, and the Failing Heart

High blood pressure, heart attacks, or other initial processes that impair the pumping actions of the heart trigger a number of hormonal and neurochemical mechanisms to correct imbalances in pressure and blood flow. Unfortunately, while these corrective responses help in the short term, they increase the work of the heart. The mechanisms, then, are now viewed as major contributors to the end stages of heart failure. Some are described briefly in the following sections.

Remodeling. The heart responds to high blood pressure and overload by enlarging in order to increase blood input. This leads to structural damage called remodeling:

In order to accommodate the increased blood input, the heart muscle cells elongate. The muscular walls of the heart that they form become thinner and inefficient.
The muscle cells undergo other changes that result in calcium loss. Calcium is a mineral that is crucial for healthy heart contractions.
The thinner heart muscles and the impaired heart contractions further weaken the heart's pump.
Mitral valve regurgitation is a possible outcome of remodeling. The mitral valve regulates blood flow between the two chambers on the left side of the heart. In response to remodeling, the structural changes in the heart may distort the mitral valve so that the blood leaks backward into the left atrium of the heart instead of flowing out into the body's circulation.
These changes are generally irreversible, although heart pacemakers and certain drugs, including beta-blockers and ACE inhibitors, may reverse some of the remodeling in some patients.

Activation of the Sympathetic Nervous System. The sympathetic nervous system consists of the nerve cells that automatically govern and regulate the beating heart.

This nervous system responds to the failing heart pump by signaling the release of stress hormones, in particular a powerful one called norepinephrine.
These hormones flood the heart, causing it to beat even faster.
These rapid heart beats, although intended to accommodate the weakened pumping actions, only accelerate the damage.

The Renin-Angiotensin-Aldosterone System (RAAS). The renin-angiotensin-aldosterone system (RAAS) is a group of hormones that are responsible for the opening and narrowing of blood vessels and retention of fluids. They also affect cell development in the heart.

The RAAS hormones are called into action by the failing heart.
They respond to the lower blood volume of the weakened heart by constricting the blood vessels and retaining fluids and sodium.
The heart then works harder to pump blood through these narrowed vessels. Blood pressure, then, is forced to increase, which creates a vicious cycle.

Immune System Response. The immune system may also compound the damage:

In response to injury in the heart muscle cells or in other parts of the body that occurs as the heart fails, the immune system releases factors intended to protect these areas.

In excess, however, they can cause inflammation and damage.

The most important of these factors are called cytokines. Active cytokines include tumor necrosis factor (TNF) and possibly interleukins 1 and 6.
High levels of these cytokines have been observed in patients with the most severe classes of heart failure.
They may play an important role in the process leading to remodeling. High levels of these cytokines might actually trigger muscle cell growth and enlargement of the heart.

Other Players. Other molecules or compounds have been identified that might play a positive or negative role in the process of the failing heart:

Natriuretic peptides are a family of compounds released to counterbalance the effects of RAAS. Atrial natriuretic peptide (ANP) is a specific member of this family that opens blood vessels and counteracts the sodium-retaining properties of aldosterone (one of the RAAS hormones). It is of particular interest to researchers looking for new treatments.
Endothelin is a powerful protein involved in blood vessel constriction, cell proliferation and build-up, and other negative effects on the heart.
Nitric oxide is important for blood vessel dilation and elasticity.

Risk Factors

Nearly five million Americans currently suffer from heart failure, and about 550,000 new cases of heart failure are now diagnosed each year. In 1970 there were only 250,000 new cases, so the annual numbers have risen dramatically. Nevertheless, such numbers represent an increasingly older population. According to a 2002 study, the actual risks for men are stable and for women they may even be declining. In addition, the risk for death after heart failure is diagnosed has declined by 12% every decade. The study was limited, however. Subjects were nearly all Caucasian and they had access to good preventive health care. In general, because diabetes and obesity are at epidemic levels, experts have expected heart failure rates to increase.

Advancing Age

Heart failure is the most common reason for hospitalization in the elderly, and as the population ages, the incidence of congestive heart failure is rising dramatically. According to one report, it occurs at a rate of about 10 per 1,000 people after age 65. The positive implication of that report, however, is that people are living longer with heart failure.

Male Gender

Men are at higher risk for heart failure than women, although the difference narrows with age. Women also have a better survival rate than men do when heart failure is caused by valvular heart disease, high blood pressure, or alcohol abuse. (Some studies indicate that this is because men may be more susceptible to the process of heart muscle-cell remodeling, a damaging effect of hypertension.)

The survival rates of women and men are more similar, however, when heart failure evolves from coronary artery disease or heart attack. In fact, women are much more likely to develop heart failure after a heart attack than men. In such cases, some evidence suggests that the reasons for this may include less aggressive approach to treatment for the initial heart conditions.

African-American Ethnicity

African-Americans are at higher risk for heart failure than are Caucasians, and studies have reported that they tend to do much worse. In a 2003 study, however, in which Caucasians and African-Americans had comparable treatment, African-Americans actually had lower one-year mortality rates (with slightly higher rates of rehospitalizations). Still, more studies are needed to determine if there are actual biologic differences in specific patients. Some evidence, for example, suggests that African-Americans are more often likely than Caucasians to develop diastolic heart failure (a failure of the heart muscle to relax normally), which is often a precursor to systolic heart failure (impaired ability to pump blood). Caucasians tend to develop systolic heart failure first. In one study comparing Caucasian and African-Americans who only had diastolic heart failure, African-Americans had a 30% higher mortality rate.

Family History and Genetics

A family history of early congestive heart failure caused by cardiomyopathies (diseases that damage the heart muscle) may predispose people to the disease. Researchers are also looking for changes in specific genes that might regulate systems involved in heart failure and so increase susceptibility in certain populations.

Chronic Alcohol Abuse

Chronic alcohol abuse can damage the heart muscles, can cause hypertension, and may prove to be one cause of idiopathic dilated cardiomyopathy. Moderate alcohol consumption, on the other hand (generally defined as two drinks a day for men and one for women), may protect against heart failure. Teetotalers, though, are not advised to begin drinking.

Medical Conditions that Increase the Risk for Heart Failure

Coronary artery disease. More than 60% of the cases of congestive heart failure in the United States may be due to coronary artery disease and any of its risk factors (smoking, sedentary living, obesity).
Heart attack. The injured heart after at an attack is at high risk for failure. Therefore, the improved survival rates from heart attack over the past decades have actually been responsible for the dramatic increase in heart failure rates.
High blood pressure. Hypertension is a significant risk factor and is present in 75% of heart failure patients. (One study suggested that people with hypertension who suffer from depression are at particular risk for heart failure, possibly because depression affects the nervous system involved in regulating the heart.)
Diabetes. People with diabetes are at high risk for heart failure, particularly if they also have coronary artery disease. Indeed, even blood sugar abnormalities that presage diabetes increase the risk.
Obesity. Obesity is associated with both hypertension and type 2 diabetes--conditions that place people at risk for heart failure. New evidence strongly suggests that obesity itself is a major risk factor for heart failure, particularly in women. In a major 2002 study, about 14% of heart failure cases in women and 11% in men could be attributed to obesity. Both overweight and obese women had a significantly higher than normal risk for heart failure. Only obesity conferred a significant risk in men.
Valvular heart disease. Specific valvular conditions that are common in heart failure patients include aortic stenosis and mitral regurgitation.
Severe emphysema. This chronic lung disease is a major risk factor for right-side heart failure.

Emphysema is a lung disease involving damage to the air sacs (alveoli).There is progressive destruction of alveoli and the surrounding tissue that supports the alveoli. With more advanced disease, large air cysts develop where normal lung tissue used to be. Air is trapped in the lungs due to lack of supportive tissue which decreases oxygenation.

Cardiomyopathies due to various causes, including birth defects, HIV infection, and other infections.
In rare cases, heart failure can occur in women around the time of childbirth, a condition called peripartum cardiomyopathy.

Click the icon to see an image of peripartum cardiomyopathy.

An overactive thyroid (hyperthyroidism) can have severe effects on the heart and increase the risk for heart failure.
Amyloidosis. With this disease, a starchy protein (amyloid) builds up in tissues and organs, can lead to congestive heart failure.
Surviving childhood cancers. Survivors now face a risk for developing congestive heart failure in later years, particularly those treated with certain chemotherapies, such as doxorubicin. Newer cancer advances may reduce this risk.
Acute myocarditis. This rare viral infection involves the heart muscle and can produce temporary but potentially life-threatening heart failure.

Medications and Other Factors Associated with Heart Failure

Thiamin (a vitamin B) deficiency can lead to reversible cardiomyopathy. Long-term use of anabolic steroids (male hormones used to build muscle mass) increases the risk for heart failure. The drug itraconazole (Sporanox), taken orally for skin, nail, or other fungal infections, has been linked to heart failure in a small number of cases.

Diagnosis

Physicians can often make a preliminary diagnosis of heart failure with only a medical history and careful physical examination. An English study suggests, in fact, that the condition may be under-diagnosed. The following signs along with a history of heart disease strongly suggest heart failure:

Enlarged heart.
Irregular heart sounds.
Abnormal sounds in the lungs.
Swelling or tenderness of the liver.
Fluid retention.
Elevation of pressure in the veins of the neck.

Confirming these findings definitely or determining the severity of the condition, however, is difficult. Further tests are usually needed.

Laboratory Tests for Associated Medical Conditions

Both blood and urine tests are used to check for malfunctions of the liver and kidneys and to detect signs of diabetes.

Blood tests can also be used to evaluate the following:

Cholesterol and lipid levels.
Anemia.
Thyroid disease.

Urine tests can also be used to assess:

Albumin. The presence of this protein in the urine is usually a sign of kidney disease, but even tiny amounts (microalbumin) signal an increased risk for heart failure in people with and without diabetes.

Exercise Stress Test

The exercise stress test measures heart rate, blood pressure, and oxygen consumption while a patient is performing physically, usually walking on a treadmill. It is an important diagnostic component in determining heart failure symptoms. Doctors also use exercise tests to gauge long-term outlook and the effects of particular treatments.

Electrocardiogram

An electrocardiogram (ECG) cannot diagnose heart failure, but it is simple and painless to perform and can indicate underlying heart problems by detecting the following:

Enlargement of the heart muscle, which may help to determine long-term outlook.
The presence of coronary artery disease.
Abnormal cardiac rhythms. A rhythm pattern called a prolonged QT interval, for example, might predict people with heart failure who are at risk for severe complications and would need more aggressive therapies.

The major benefit of an ECG is help in determining patients who most likely do not need an echocardiogram, a more accurate (but more expensive) diagnostic test.

The electrocardiogram (ECG, EKG) is used extensively in the diagnosis of heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. Several different types of electrocardiogram exist.

Echocardiography

The best diagnostic test for congestive heart failure is echocardiography coupled with studies known as Doppler flow. Echocardiography is a noninvasive, entirely safe test that uses ultrasound to image the heart as it is beating. Cardiac ultrasounds provide the following information:

Accurate indications of valve function.
The amount of blood flow through the heart’s chambers.
The location of the failure, whether has occurred on the left side, the right side, or both.

Physicians use information from the echocardiogram for calculating the ejection fraction (the percent of the blood pumped out during each heartbeat), which is important for determining the severity of heart failure.

Imaging Tests

Radionuclide Ventriculography. Radionuclide ventriculography is an imaging technique that employs the injection of a tiny amount of radioactive material (called a trace element). As this substance passes through the bloodstream it is picked up on x-rays. This is a very important imaging technique for heart failure patients. It is very sensitive in revealing heart enlargement or evidence of fluid accumulation around the heart and lungs. It is typically used in concert with angiography.

Contrast Enhanced Magnetic Resonance Imaging. Magnetic resonance imaging (MRI) scans that use contrast dies to improve resolution are proving helpful for identifying patients with irreversible heart damage. Damage appears as very bright areas on the scan.

Angiography

Physicians may recommend angiography if they suspect that blockage of the arteries is contributing to heart failure. This procedure is invasive and involves the following:

A thin tube, or catheter, is inserted into one of the large arteries in the arm or leg.
It is gently guided through the artery until it reaches the heart.
The catheter measures internal blood pressure at various locations, giving the physician a comprehensive picture of the extent and nature of the heart failure.
Dye is then injected through the tube into the heart.
X-rays known as angiograms are taken by following the dye’s movement through the heart and arteries.
These images help locate problems in the heart’s pumping action or blockage in the arteries.

Major complications of angiography are rare (about 0.1%) but can occur. They include stroke, heart attacks, and kidney damage. The more experienced the medical center in this procedure, the lower the risk.

Click the icon to see an image of cardiac catheterization.

Tests for Markers

Researchers are looking for biologic factors (called markers) that will confirm a diagnosis or suggest a better or worse prognosis. Many are under investigation. Examples are the following.

Tumor Necrosis Factor. Elevated levels of tumor necrosis factor (TNF) may be a very strong and accurate predictor of a poor outlook. This immune factor is known to be a potent agent in the inflammatory process.

Natriuretic Peptides. These compounds may be elevated in response to the heart failure disease process and may help doctors determine whether a particular treatment is working. Of special interest is one called B-type natriuretic peptide (BNP), which may be associated with greater heart rate variability and severity in heart failure patients.

Brain Metabolites. High levels of a compound called N-acetylaspartate, generated as a byproduct of chemical processes in the brain, may indicate a poor outlook.

Treatment

Recent expert guidelines for evaluating the severity of heart failure and determining treatments uses a staging system that is similar to that used for major cancers:

Stage A: Patients are at high risk for heart failure but there is no evidence of structural damage to the heart. Risk factors include high blood pressure, heart diseases, diabetes, previous use of medications toxic to the heart (such in some chemotherapies), history of rheumatic fever, family history of cardiomyopathy.
Stage B: Patients have a structural heart abnormality but no symptoms of heart failure. Such abnormalities include left ventricular hypertrophy or dilatation, asymptomatic valvular heart disease, a previous heart attack.
Stage C: Patients have a structural abnormality and have present or previous symptoms of heart failure, including shortness of breath or fatigue related to the heart problem.
Stage D: Patients have end-stage symptoms that do not respond to standard treatments.

Treatments for Conditions that Cause Heart Failure (Stage A)

The first step in managing congestive heart failure is to treat the primary conditions causing or complicating heart failure. They typically include one or more of the following:

Coronary artery disease. Treatment includes lifestyle management (including diet, exercise, and smoking cessation), medications, and possibly bypass or angioplasty. Quitting smoking, for example, appears to reduce illness and prolong survival within two years, with benefits comparable to those of drug treatments. [For more information see Well-Connected Report #3, Angina and Coronary Artery Disease.]
Valvular abnormalities, such as aortic stenosis and mitral regurgitation. Surgery may be required.
High blood pressure. The goal is to aim for a systolic pressure below 140 (130 for diabetics) and a diastolic blood pressure below 80 mg. This is especially important for people with diabetes. Effective reduction of blood pressure reduces the risk of heart failure by 30% to 50%. Diuretics continue to be the best choice for most older adults. In important studies in 2002 and 2003, diuretics achieved a lower risk for heart failure-and also stroke and angina--than an ACE inhibitor. (ACE inhibitors, however, were more than effective than diuretics in one major trial and are important for patients with diabetes or kidney problems.) Of note, a major study reported that calcium channel blockers were not as effective as a diuretic in preventing heart failure. In fact, the drugs may slightly increase the risk. [For more information, see Well-Connected Report #14, High Blood Pressure.]
Diabetes. Treating diabetes is extremely important for reducing the risk for heart disease. ACE inhibitors are especially beneficial, particularly for people with diabetes. [For information on treatments, see Well-Connected Report #60, Type 2 Diabetes or Report #9 Type 1 Diabetes.]
Abnormal health rhythms (arrhythmias). Ventricular assisted devices, notably biventricular pacers (BVPs), are proving to be important in preventing hospitalizations for patients with these conditions.
Anemia. Giving erythropoietin (EPO) and iron injections to heart failure patients with underlying anemia not only reverses the anemia, but may markedly improve heart symptoms as well. [For more information, see Well-Connected Report #57, Anemia.]
Thyroid disorders.

Drug Treatment of Heart Failure in Stages B, C, and D

Treating heart failure itself at as early a stage as possible offers the best chance for a longer and better-quality life. A number of classes of medications are used to treat heart failure:

ACE inhibitors (which open blood vessels) are used for virtually all patients in stages B through D. The combination of the diuretic spironolactone along with an ACE inhibitor may have specific advantages. This combination may more effective in non-African-American patients than in African-Americans.
Beta blockers are increasingly recommended once fluid volume has been stabilized with other agents.
Digoxin (Lanoxin) is an older drug that is still useful to reduce the need for hospitalization. Unlike the other treatments for CHF, it increases the heart’s ability to contract. Digoxin may be added in patients with persistent symptoms or for those with atrial fibrillation.
Vasodilators are agents that open blood vessels. A combination of them, hydralazine and nitrates, are conferring survival advantages, particularly for African-American patients.

The specific medication or, more commonly, a combination of medications, is determined by the type and severity of the heart failure.

General Guidelines for Heart Failure Surgery

Heart transplantation is the most important surgical procedure for very severe heart failure that does not respond to any other treatments. Studies indicate that most patients in stable condition can be managed safely with medications for many months while waiting for a transplant. A number of procedures or devices are also now available for patients waiting for transplants. Some may even offer permanent alternatives. They include the following:

Portable pumps that continuously infuse medications such as dopamine and prostaglandin E-1 can allow the patient to remain mobile and active.
Implanted devices for controlling arrhythmias and improving pumping actions.
Surgical innovations, including ventricular remodeling, dynamic cardiomyoplasty, and the artificial heart.

Patients may also need procedures to treat conditions, such as coronary artery disease or mitral valve prolapse, that contribute to heart failure.

Medications

Among the most important drug classes in the treatment of Stage B through D heart failure are angiotensin-converting enzyme (ACE) inhibitors. An analysis of the major studies suggested that ACE inhibitors may reduce the risk of death, heart attack, and hospital admissions by 28% in patients with existing congestive heart failure.

These agents block the effects of the renin-angiotensin-aldosterone system, which is thought to play a powerful role in the development of heart failure. By preventing the formation of an artery-constricting substance called angiotensin II, blood vessels widen and blood pressure drops, decreasing the workload of the heart. ACE inhibitors also improve heart and lung muscle function, which should be very helpful for patients with existing heart failure.

For most people with existing high blood pressure and no evidence for heart failure (Stage A), diuretics would be a better option. In an important 2003 study, diuretics achieved a lower risk for heart failure--and also stroke and angina--than an ACE inhibitor. However, another 2003 comparison study reported fewer heart attacks and lower risk for death with ACE inhibitors than with diuretics, particularly in elderly Caucasian men. More research is needed to confirm the specific benefits of each agent.

In any case, ACE inhibitors are particularly important for patients with diabetes. A large study, for example, reported that diabetic patients who took these drugs had fewer heart attacks and lower all-cause mortality rates compared to those who took other anti-hypertensive agents. ACE inhibitors also may help slow progression of kidney disease, independently of their effect on blood pressure. (Some experts believe, in fact, that angiotensin may be the common factor linking diabetes and high blood pressure. This natural chemical not only influences all aspects of blood pressure control but it also interferes with insulin's normal metabolic signaling.)

Brands. ACE inhibitors include captopril (Capoten), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), ramipril (Altace), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Candidates. Experts believe that at least 50% to 75% of patients with congestive heart failure should be treated with ACE inhibitors.

Studies have reported benefits in a wide range of heart failure patients, including those with less severe symptoms, patients with diabetes, the elderly, women, and individuals with or without coronary artery disease. (They may not be African Americans, however.)
The drugs may improve outcomes in patients with risk factors for or evidence of impending heart failure but who have not yet developed symptoms.

Studies have indicated, however, that physicians (especially those who are not cardiologists) actually prescribe them for far fewer patients than is recommended. Women, for example, are less likely to get ACE inhibitors than Caucasian males. And when they are being prescribed, some studies indicate they are not prescribed in high enough doses to be most effective. Even worse, about 15% of patients were being prescribed expensive calcium-channel blockers, which may even be harmful for some patients with heart failure.

Side Effects of ACE Inhibitors. The primary adverse effect of ACE inhibitors is low blood pressure, which can be severe in some patients, particularly when therapy is first initiated.

The most distressing side effect is an irritating cough, which some people find intolerable. Interestingly, although all ACE inhibitors may have this side effect, sometimes switching to another brand will reduce this symptom. Iron supplements or the drug picotamide may prove to help reduce the frequency of coughs.

Severe side effects are rare and include the following:

Although ACE inhibitors can protect against kidney disease, they also increase potassium retention in the kidneys. This increases the risk for cardiac arrest if potassium levels become too high. Because of this action, they are not generally given with potassium-sparing diuretics or potassium supplements.
A rare but severe side effect that has been observed is called granulocytopenia, which is an extreme reduction in infection-fighting white blood cells.
In rare cases (0.3%), patients suffer a sudden and severe allergic reaction called angioedema that causes swelling in the eyes and mouth and may close off the throat.

Note: Of great concern is research suggesting that aspirin (and other so-called NSAIDs) increases the risk for heart failure in patients taking ACE inhibitors. NSAIDs are commonly used by patients with heart disease to prevent heart attacks.

Beta Blockers

At one time, beta blockers were not used for most people with heart failure because these drugs reduce the pumping action of the heart in the short run. However, studies are now finding certain beta blockers may have significant benefits for heart failure patients, and in fact may be responsible for a dramatic drop in mortality rates in patients with severe heart failure. Specific beneficial actions for heart failure patients include the following:

They have a proven track record for treating high blood pressure, angina, arrhythmias, and for prevention of heart attack in high-risk patients.
Early use of beta blockers may even help prevent left ventricular remodeling, one of the damaging processes that leads to heart failure, in patients with idiopathic dilated cardiomyopathy and in those who suffered a first heart attack.
These agents may also block important inflammatory immune factors called cytokines, including the one called tumor necrosis factor (TNF). TNF has been heavily implicated in the damage done during the process leading to heart failure.
Beta blockers may prevent norepinephrine (adrenaline) from binding to heart cells. Elevated levels of norepinephrine, a stress hormone, can overstimulate the failing heart and are associated with severe heart failure.

It should be noted that for any significant benefits, beta blockers need to be used in combination with other agents, such as ACE inhibitors, diuretics, or both. The effects of beta blockers on certain populations, such as the elderly or African Americans, requires further study.

Beta Blocker Brands. Beta blockers are categorized as nonselective and selective (which are older agents).

Carvedilol and Other Nonselective Beta Blockers. Carvedilol (Coreg) is known as a nonselective beta blocker and was the first approved beta blocker for heart failure patients.
Long-acting Metoprolol and Selective Beta Blockers. Studies are finding that some older and less expensive beta blockers called selective beta blockers may also reduce mortality rates. Long-acting metoprolol (Lopressor) has not been specifically approved for patients with heart failure. Bisoprolol (Zebeta) is another selective beta blocker that might be beneficial in these patients. Atenolol (Tenormin) is the most commonly prescribed beta blocker in general, but its effect on heart failure is unknown.

Small studies comparing metoprolol with carvedilol report significant and similar improvement in both groups with lower survival rates from both drugs. Both drugs increase the distance that patients can walk to the same degree, although over time, heart efficiency may be greater in patients who take carvedilol. A major comparison study is underway.

Candidates. Experts now recommend beta blockers for all patients with stable heart failure and who do not have substantial fluid retention or recent worsening of heart failure that have required digoxin or digitalis.

Problems with Beta-Blockers and Patients who Should Avoid Beta Blockers. Because they can narrow bronchial airways and constrict blood vessels, patients with asthma, emphysema, and chronic bronchitis should use them with care and should use a selective drug. Other patients who may not be good candidates include people with brady-arrhythmias (very slow heart rate) or heart block who are not on a pacemaker and patients with diabetes who have frequent episodes of hypoglycemia.

Some beta-blockers tend to lower HDL cholesterol (the beneficial cholesterol) by about 10%; the effect is most marked in smokers.

Beta blockers must be carefully monitored and the dosages regulated very carefully, because heart failure may actually worsen in the early stages of treatment. Angina, heart attack, and even sudden death have occurred in patients who discontinued treatment without gradual withdrawal.

Common Side Effects. Fatigue and lethargy are the most common psychologic side effects. Some people experience vivid dreams and nightmares, depression, and memory loss. Dizziness and lightheadedness may occur upon standing. Exercise capacity may be reduced. Other side effects may include coldness in the extremities (legs and toes; arms and hands), asthma, decreased heart function, and gastrointestinal problems. Sexual dysfunction was a problem with older beta-blockers, but does not appear to be significant with newer agents.

If side effects become very distressing, the patient should call a physician, but it is extremely important not to stop the drug abruptly.

Caution During Administration and Withdrawal of Beta Blockers

The following precautions should be taken when administering the drug to avoid worsening of heart failure in the beginning of treatment:

Treatment should be initiated only after symptoms have been optimized with other drugs, usually diuretics and ACE inhibitors.
Drugs should be administered only by specialists experienced in treating heart failure.

Most serious adverse events occur within six weeks of starting the drug. And more than half occur within two weeks when patients are on the lowest dose.

Some patients at higher risk for worsening heart failure with beta blockers or those who should avoid these drugs include the following:

People with asthma.
Those with very slow heart beats (bradycardia).
Individuals with very low blood pressure.
Patients on intravenous inotropics (digitalis, digoxin).
Patients with certain heart conduction disorders.

It is extremely important not to stop the drug abruptly. Angina, heart attack, and even sudden death have occurred in patients who discontinued treatment without gradual withdrawal.

Diuretics

Diuretics act on the kidneys to rid the body of excess salt and water. These agents have been the mainstays of high blood pressure treatment. A landmark 2002 study reported that patients who take them have a lower incidence of heart failure, heart disease, and stroke after five to six years compared to those who took a calcium-channel blocker or an ACE inhibitor.

They have also long been used to relieve fluid retention, a hallmark of congestive heart failure, and aggressive use of diuretics, even in people taking ACE inhibitors, can reduce hospitalizations and improve exercise capacity. In addition, certain diuretics, notably spironolactone (Aldactone) block aldosterone, a hormone involved in the remodeling process of the heart, a primary mechanism in heart failure. This agent is proving to be beneficial for patients in late stages of heart failure.

Diuretic Types. Diuretics come in many brands and are generally inexpensive. Some need to be taken once a day, some twice a day. Diuretics are virtually always used in combination with other drugs. Three primary types of diuretics exist:

Potassium-sparing agents. Potassium-sparing diuretics, especially spironolactone (Aldactone), are proving to be important for Stage C and D congestive heart failure. Spironolactone has shown dramatically lower mortality rates from heart events, particularly in combination with an ACE inhibitor. Its benefits for patients with heart failure derive from its ability to block aldosterone, a hormone involved with salt retention and heart muscle growth. Spironolactone has shown evidence of reducing production of collagen--a protein that in excess can cause organ scarring. Other potassium-sparing agents include amiloride (Midamor), and triamterene (Dyrenium).
Thiazides. Thiazides often serve as the basis for high blood pressure treatment, either taken alone for mild to moderate hypertension or used in combination with other types of drugs. There are many thiazides and thiazide-related drugs. There are many thiazides and thiazide-related drugs; some common ones are chlorothiazide (Diuril), chlorthalidone (Hygroton), indapamide (Lozol), and hydrochlorothiazide (Esidrix, HydroDiuril). These agents are usually prescribed for patients with mild heart failure and good kidney functioning.
Loop diuretics. Loop diuretics block sodium transport in parts of the kidney; they act faster than thiazides and have a great diuretic effect. It is important therefore to control the medication and avoid dehydration and potassium loss. Loop diuretics include bumetanide (Bumex), furosemide (Lasix), and ethacrynic acid (Edecrin). They are generally used for severe heart failure, especially when kidney function is impaired. One 2000 study reported that twice-daily infusions of furosemide over six to 12 days improved symptoms in patients with severe heart failure who had not responded to other treatments. One-year survival rates after the treatment were 80%.

Administration. Treatment is usually started at a low dose and increased until urine output rises and the patient loses weight because of fluid loss. If the patient does not respond quickly enough, more than one diuretic may be required, or it may need to be given intravenously. Diuretics are usually taken long term, with the patient monitored periodically for fluid retention.

Problems with Diuretics. The loop and thiazide diuretics deplete the body's supply of potassium, which, if left untreated, increases the risk for arrhythmias. Arrhythmias are heart rhythm disturbances that can, in rare instances, lead to cardiac arrest. In such cases, physicians will either prescribe lower doses of the current diuretic, recommend potassium supplements, or use potassium-sparing diuretics either alone or in combination with a thiazide. Potassium-sparing drugs have their own risks, which include dangerously high levels of potassium in people with existing elevated levels of potassium or in those with damaged kidneys. It should be noted, however, that, in general, all diuretics are more beneficial than harmful.

Common Side Effects. Common side effects of diuretics are fatigue, depression, irritability, urinary incontinence, loss of sexual drive, breast swelling in men, and allergic reactions. Diuretics can trigger attacks of gout. They may also increase the risk of gastrointestinal (GI) bleeding. Diuretics may raise cholesterol level and, used alone, they have no effect on enlarged heart size (hypertrophy). Arrhythmias can also occur as an interaction between diuretics and certain drugs, including some antidepressants, anti-arrhythmic drugs themselves, and digitalis.

Digitalis

Digitalis is derived from the foxglove plant. It has been used to treat heart disease since the 1700s. Digoxin (Lanoxin) is the most commonly prescribed digitalis preparation. It is referred to as an inotropic drug and has the following benefits:

It increases the strength of the heart’s contraction.
It decreases heart size.
It reduces certain heart rhythm disturbances (arrhythmias).
It allays symptoms and reduces the need for hospitalizations slightly.

Unfortunately, digitalis does not reduce mortality rates, although it does reduce hospitalizations and worsening of heart failure. Controversy has been ongoing for more than 100 years over whether the benefits of digitalis outweigh its risks and adverse effects.

Candidates. Digitalis may be useful for the following patients:

Patients with left-side (systolic) dysfunction who do not respond to other agents (diuretics, ACE inhibitors).
Heart failure patients with atrial fibrillation.

Digitalis may be harmful in the following patients:

Patients with right-side heart failure.
Patients who stop taking digoxin after using it in combination with ACE inhibitors are at risk for worsening heart failure.

Side Effects and Problems. While digitalis is generally a safe drug, it can have toxic side effects caused by overdose or other accompanying conditions. The most serious side effects are arrhythmias (abnormal heart rhythms that can be life-threatening). Early signs of toxicity may be irregular heartbeat, nausea and vomiting, stomach pain, fatigue, visual disturbances (e.g., yellow vision, seeing halos around lights, flickering or flashing of lights), and emotional and mental disturbances.

Factors that increase the risk of toxicity include the following:

Advanced age.
Low blood potassium levels (which can be caused by diuretics).
Hypothyroidism.
Anemia.
Valvular heart disease.
Impaired kidney function.
Digitalis interacts with many other drugs, including quinidine, amiodarone, verapamil, flecainide, amiloride, and propafenone.

Using a blood test to monitor drug levels limits toxicity to about 2% of patients taking the drug. For most patients with mild to moderate heart failure, low-dose digoxin may be as effective as higher doses. If side effects are mild, patients should still consider continuing with digitalis if they experience other benefits.

Vasodilators: Hydralazine and Nitrates

Vasodilators improve both the quality and duration of life for heart failure patients. They open the arteries and veins, thereby reducing the heart’s workload and allowing more blood to reach the tissues. A combination of two vasodilators, hydralazine (e.g., Apresoline, Alazine) and isosorbide dinitrate (e.g., Iso-Bid, Isorbid, Dilatrate), improves symptoms and may prolong life. Combinations are more effective than either drug used alone and are recommended when patients cannot tolerate ACE inhibitors. They may have particular benefits for African-American patients.

Intravenous nitroglycerin (Nitro-Bid Iv, Nitrostat IV, Tridil) and intravenous nitroprusside (Nitropress) are useful in short-term therapy of acute heart failure and acute pulmonary edema. Intravenous nitroglycerin tends to lose effectiveness quickly, but one study showed that patients who were also given oral hydralazine continued to tolerate this drug.

Other Agents Sometimes Used

Angiotensin-Receptor Blockers. Drugs known as angiotensin-receptor blockers (ARBs), also known as angiotensin II receptor antagonists, are similar to ACE inhibitors in their ability to lower blood pressure. They may have fewer or less-severe side effects than ACE inhibitors, especially coughing. The ARBs include valsartan (Diovan), losartan (Cozaar), candesartan (Atacand), telmisartan (Micardis), and irbesartan (Audpro). Studies are reporting benefits, including improvements in both symptoms and survival. Although it is not clear whether they are any better than the less expensive ACE inhibitors, evidence is accumulating to indicate that they may reasonable alternatives to ACE inhibitors. At this time, valsartan is the only ARB approved as an alternative to ACE inhibitors for heart failure patients.

Calcium-Channel Blockers. Calcium works on heart muscle and on blood vessels to affect blood pressure and the heart muscle’s ability to contract. Calcium-channel blockers are commonly used to control high blood pressure and angina. Unfortunately, they are currently over-prescribed for patients with heart failure. A major study reported that they were not as effective as a diuretic in preventing heart failure. Certain calcium-channel blockers may in fact, worsen heart failure; these include nifedipine, diltiazem, and verapamil. Newer generation calcium-channel blockers may have some benefits. Lercanidipine, for example, is a unique CCP that may be effective and safe for a wider range of patients than with other CCBs and may have properties that protect against heart failure.

Drugs Used to Treat Arial Fibrillation. Drugs used to treat irregular heart beats (arrhythmias), which are a particular danger for congestive heart patients, have not been very successful in prolonging survival when used as part of the treatment regimen for congestive heart failure. Exceptions are two drugs, amiodarone (Cordarone) and dofetilide (Tikosyn) used for atrial fibrillation, an important cause of arrhythmias in heart failure patients. Studies on amiodarone have reported improved mortality rates in patients with severe heart failure and atrial fibrillation. A combination of amiodarone with a pacemaker-type device (called cardioversion) may even restore normal heartbeats in such patients, even in heart failure patients with atrial fibrillation who are in poor health.

Drugs Used to Improve Lung Function

Ipratropium. Ipratropium (Atrovent), a drug normally used by asthma patients, was tested in a small study of smokers and nonsmokers with congestive heart failure for improving lung function. Breathing improved in all patients who were administered four puffs of the drug using an inhaler. The drug has no known adverse effects on the heart, and there were no other side effects in this group. More studies are needed.

Theophylline. Theophylline, also an asthma drug, was found to improve oxygen levels and lung function in heart failure patients who also experienced central sleep apnea, the disordered breathing syndrome associated with left-side heart failure.

Drugs Used for Decompensated Heart Failure and Pulmonary Edema

Treating Decompensated Heart Failure. Decompensated heart failure is a life-threatening condition in which the heart fails over the course of minutes or a few days, often as the result of a heart attack or sudden and severe heart valve problems. Agents used for this emergency situation include intravenous diuretics, dobutamine, milrinone, nitroglycerin, and sodium nitroprusside. A genetically engineered natriuretic peptide called nesiritide (Natrecor) is proving to be particularly effective. Agents under investigation, such as levosimendan, a unique drug called a calcium sensitizer, may prove to be beneficial additions.

Treating Pulmonary Edema. Treatment of pulmonary edema (fluid in the lungs), another life-threatening emergency, sometimes requires intravenous injections of vessel-widening nitrates (nitroglycerin and nitroprusside). Newer classes of drugs currently being investigated for decompensated heart failure, such as natriuretic peptides and calcium sensitizers, are also under study for pulmonary edema.

Experimental Agents

A number of new agents are being tested for heart failure patients. A 2001 study suggested that 70% of patients who participate in such trials may feel better, whether or not their drug is objectively effective. To date, studies have been modest or disappointing on certain agents that appear to have specific actions that block the disease process leading to heart disease. They include omapatrilat, etanercept (a cytokine blocker), endothelin receptor blockers, and arginine-vasopressin antagonists.

Aldosterone Blockers. Aldosterone is a hormone that is critical in regulating the body's balance of salt and water. Excessive levels may play important roles in hypertension and heart failure. Additional agents that block this hormone are being developed. Eplerenone (Inspra) is the first to be approved. Its actions are similar to potassium-sparing diuretics, and like these agents, it poses some risk for high potassium levels, which in some cases can be dangerous.

Neutral Endopeptidase Inhibitors (NEPs). Neutral endopeptidase inhibitors (NEPs) combine the activity of ACE inhibitors with actions that produce higher levels of an enzyme called atrial natriuretic peptide. The effects of atrial natriuretic peptide are the following:

It opens blood vessels.
Induces fluid elimination.
Opposes the actions of the compensating systems responsible for ongoing damage of the failing heart.

NEPs under investigation include omapatrilat (Vanlev), candoxatril, and ecadotril. Preliminary studies of omapatrilat, however, are reporting little advantages compared to ACE inhibitors in patients with heart failure. Side effects are very similar to those of ACE inhibitors, including coughing.

Statins. Statins are important drugs used to lower cholesterol and to prevent heart disease leading to heart failure, even in people with normal cholesterol levels. Specific statins include lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), luvastatin (Lescol)and atorvastatin (Lipitor). They are proving to have many other health benefits as well. Some evidence suggests the have properties that may benefit patients with congestive heart failure.

Testosterone Injections. Small studies suggest that testosterone injections (anabolic therapy) in elderly men with existing heart failure may be helpful in increasing heart output and relieving depression.

Allopurinal. Allopurinal, a standard agent for gout, may prove to have properties that help patients with congestive heart failure. The drug blocks the xanthine oxidase (XO), which may improve blood flow and heart muscle efficiency in patients with hyperuricemia (high blood levels of uric acid). Hyperuricemia is common in heart failure.

NSAIDs: A Special Warning

Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, ibuprofen (Advil), and naproxen (Aleve), among many other common pain relievers.

Recent use of NSAIDs has been associated with a higher risk of hospitalization in heart failure patients. The strongest association was in patients taking diuretics or ACE inhibitors. (They also may interfere with the effects of angiotensin II receptor antagonists.)

Of concern was one study suggesting that anyone with a history of heart disease who is taking NSAIDs might be at higher risk for heart failure. A 2002 study, however, found no higher risk for the first occurrence of heart failure in NSAID users, although it did report a higher risk for relapse in patients with existing heart failure who were taking these agents. Most cardiologists strongly recommend both low dose aspirin and ACE inhibitors for many patients with hearts disease and heart failure. Still, the connection between NSAIDs and heart failure needs to be clarified.

Surgery

Coronary Bypass or Angioplasty. Patients with heart failure and severe coronary artery disease often benefit from angioplasty or bypass surgery. The surgery may enhance the heart’s pumping action and help to relieve symptoms.

Coronary artery balloon angioplasty - series

Click the icon to see an illustrated series detailing coronary artery balloon angioplasty.

Click the icon to see an illustrated series detailing heart bypass surgery.

Mitral Valve Surgery. In appropriate patients, mitral valve surgery may significantly reduce the severity of heart failure. In a study of 92 patients with late-stage heart failure and faulty valves, reconstruction of the heart’s mitral valve drastically improved heart function.

CPAP for Treating Sleep Apnea. Heart failure is associated with sleep apnea, in which tissues at the back of the throat periodically collapse and become blocked, causing the sleeper to gasp for air. Sleep apnea has been associated with poorer survival in patients with congestive heart failure. A mask-like device worn over the nose at night that provides continuous positive airway pressure (CPAP) is an effective treatment for sleep apnea. Patients with heart failure who respond to it may experience improvements in ejection fraction and disturbed heart rhythms. There is some question, however, whether it provides long-term benefits for heart failure. Some experts suggest oxygen therapy or the asthma drug theophylline for this condition.

Click the icon to see an image of CPAP treatment.

Devices to Control Heart Arrhythmias and Pumping Actions

A growing array of heart devices and machines are changing the face of heart failure treatment. They have gained widespread acceptance for use as a bridge to transplant in patients who are on medications but still have severe symptoms and are awaiting a donor heart. Increasingly, though, doctors are exploring the possibility that such devices may be satisfactory treatments themselves, forestalling the need for a transplant altogether in some patients.

Ventricular Assist Devices (VADs). Ventricular assist devices are machines that help improve pumping actions. Several models with slightly different features are in use or under investigation. Some include the following:

Biventricular pacers (BVPs) affect both left and right chambers. They may be beneficial for a large minority of heart failure patients who have left bundle branch block, a condition in which the electrical impulses in the heart do not follow their normal pattern. The InSync pacing system is the first of these devices to be approved specifically to relieve the symptoms of moderate to severe heart failure. It consists of a small pulse generator implanted under the skin near the shoulder and three wires that are threaded to both heart pumps (ventricles). Studies are reporting that the biventricular pacer is improving symptoms and reducing hospitalizations. Additional studies are under way to determine if there is any survival advantage with this procedure. Not all patients benefit, even those who meet the criteria.
Left ventricular assist device (LVAD) are used for patients whose heartbeat has slowed dangerously (a condition called bradycardia) to help take over the pumping action of the failing heart. Studies now suggest that in some people the use of an LVAD may allow some of the damaged heart muscle to heal, perhaps even helping some patients avoid heart transplants. Until recently, these machines required remaining in the hospital. Smaller battery-powered LVAD units, however, are allowing many patients to leave the hospital and are proving to be effective bridges to heart transplants in adults. The HeartMate, for example, a portable LVADs about the size of a portable CD player (2 in. by 4 in.), is implanted in the upper abdomen. The implanted device plugs into an external power base, which is employed when the patient is at rest to recharge the battery and provide continuous power.
Fully implanted miniature artificial pumps that assist the heart (not replace it) are also being tested. The DeBakey ventricular assist device (VAD) for example, is a tiny heart pump that weighs less than four ounces. It has been approved in Europe. The Jarvik 2000 heart pump is also showing promise.

There are risks involved with many of these devices, including bleeding, blood clots, and right-side heart failure. Infections are a particular hazard.

Intra-aortic Balloon Pump.The intra-aortic balloon pump (IABP) is helpful for maintaining heart function in people with left-side failure waiting for transplants and in those who develop a sudden and severe deterioration of heart function.

The IABP is an implanted thin balloon usually inserted into the artery in the leg and threaded up to the aorta leading from the heart.
Its pumping action is generated by inflating and deflating the balloon at certain rates.

Usually, it is used only for short periods, but some studies indicate that patients may be able to use it safely for somewhat longer periods (an average duration of 23 days in one study).

Implantable Cardioverter-Defibrillators. Devices called Implantable cardioverter-defibrillators (ICDs), which are sometimes combined with pacemakers, may be effective for preventing arrhythmias in heart failure patients. Studies have found them effective in preventing sudden death from severe rhythm disturbances in patients with weakened hearts from previous arrhythmias and in patients with genetic hypertrophic cardiomyopathy. They have also shown limited benefits in improving exercise capacity and quality of life and slowing the progression of heart failure.

Ventricular Remodeling and Restoration

Ventricular Remodeling. Ventricular remodeling (also called partial left ventriculectomy or the Batista procedure, after its inventor) may allow some patients with dilated cardiomyopathy to avoid a heart transplant.

The procedure involves the following:

The surgeon first performs ventriculectomy, which is the removal of a section of healthy heart muscle weighing about three ounces.
The surgeon then reshapes the heart to a more normal size and form.
Any faulty heart valves are repaired.

Ventricular remodeling is still relatively new and mortality rates are very high. More research is needed to target the patients who would most benefit. Studies on long-term improvement are mixed to date.

Surgical Anterior Ventricular Endocardial Restoration (SAVER). A related operation called surgical anterior ventricular endocardial restoration (SAVER), or the Dor procedure (after its inventor), combines elements of ventricular remodeling and coronary bypass surgery. It may be beneficial for those whose heart muscle has been scarred by a heart attack. An early study found that 85% of patients who had the surgery did not need to return to the hospital during an 18-month follow-up period. Additional trials are under way.

Dynamic Cardiomyoplasty

Dynamic cardiomyoplasty is an investigative treatment that has been useful in carefully selected patients with congestive heart failure, though long-term and larger studies are still needed:

The procedure detaches one end of a muscle from the back and wraps it around the ventricles of the heart.
After a few weeks, these relocated muscles are conditioned with a pacemaker to behave and beat as if they were heart muscles.

Initial tests indicated that the procedure benefited the failing heart in many ways, including improving systolic pressure, limiting dilation of the heart, reducing heart muscle stress, and possibly reversing unwanted cardiac remodeling. But there have been subsequent problems with heart rhythm disturbances and in conditioning the relocated muscles, and one study was stopped because of no difference in survival rates in patients with or without this procedure. Additional experience indicated that it was the restraining effect of the muscle wrap on the weakened heart that may have provided key benefits. Surgeons, then, are now investigating cardiac support devices that cradle the heart in a mesh-like support as a possible new surgical avenue.

Implantable Artificial Heart

Surgeons implanted the first self-contained, artificial heart, known as the AbioCor, in five Americans in 2001. The heart, powered by an external battery that transmits electrical pulses through the skin, is a yo-yo shaped device about the size of a grapefruit. Although it did extend survival somewhat during these initial tests, it is highly experimental and intended only for those with very severe heart damage who are not expected to live longer than 30 days.

Heart Transplantation

Patients who suffer from severe heart failure and whose symptoms do not improve with drug therapy or mechanical assistance may be candidates for heart transplantation. Some 3,700 people are awaiting a transplant, although only about 2000 operations are performed each year. Not all transplant units accept Medicare patients.

Traditionally transplants are performed only on more robust patients and patients under 60. About 76% of transplant patients are male and 85.4% are white. Studies now suggest that older and sicker patients may achieve the best benefits. In fact, a study of almost 900 patients found that transplantation increased survival only for the sickest of patients.

While the risks of this procedure are high, the two-year survival rate is about 78% and after five years it ranges from 50% to over 70%. In general, the highest risk factors for death three or more years after a transplant operation are coronary artery disease and the adverse effects (infection and certain cancers) of immunosuppressive drugs used in the procedure. The rejection rates in older people appear to be similar to those of younger patients.

Lifestyle Changes

Between 30% to 47% of patients who require hospitalization for heart failure are back in the hospital again within six months. Many people return because of lifestyle factors, such as poor diet, failure to comply with medications, and social isolation.

Home Support and Rehabilitation Programs

In one study, elderly people who had no emotional support at home had triple the risk of a heart attack after hospitalization for heart failure than those who did have such support. (In women, this risk was eightfold.) In another study, the greatest risk factor for death and readmission to the hospital after a first hospitalization for heart failure was being single, regardless of the health of the patient at discharge. A third study confirmed that a strong marriage predicted long-term survival. Evidence continues to mount that programs that offer intensive follow-up to ensure that the patient complies with lifestyle changes and medication regimens at home are reducing rehospitalization and costs and improving survival. Patients without available rehabilitation programs should seek support from local and national heart associations and groups.

Monitoring Weight Changes

Heart failure patients should weigh themselves each morning and keep a record. Any changes are important:

A sudden increase in weight of more than two or three pounds may indicate fluid accumulation and should prompt an immediate call to the physician.
Rapid wasting weight loss over a few months is a very serious sign and may indicate the need for surgical intervention.

Dietary Factors

Mediterranean Diet. There is some evidence suggesting that the Mediterranean diet helps protect the heart and may even reduce the risk for heart failure after a first heart attack. Its emphasis on whole grains, fish, olive oil, garlic, and moderate, daily intake of wine may have many benefits for the heart. The diet recommends the following:

A relatively high fat intake (about 35% to 45% of daily calories, mostly in monounsaturated and polyunsaturated fats.) The Mediterranean diet is known for its use of olive oil, but the greatest benefits found in a major study of this diet appeared to be derived from the use of canola oil, which is rich in omega-3 fatty acids. Olive oil, in fact, does not contain omega-3 fatty acids. On the other hand, olive oil may have beneficial effects independent from those on lipids, such as improving insulin and blood glucose levels and reducing blood pressure.
Daily glass or two of wine.
The same protein intake as the AHA, although fish is the primary source. (It avoids high-fat dairy and meat products.) In fact, one 2001 study suggested that fish-consumption, not wine, that is the heart-protective ingredient in this diet.
Lower carbohydrate intake than AHA. Emphasizes not only fresh fruits and vegetables, but also higher amounts of nuts, legumes, beans, and whole grains.
Foods seasoned with garlic, onions, and herbs.

DASH Diet. A diet known as Dietary Approaches to Stop Hypertension (DASH) is now recommended as an important step in managing blood pressure so it may be useful for many patients with heart failure. This diet is not only rich in important nutrients and fiber, but also includes foods that contain two and half times the amounts of electrolytes, potassium, calcium, and magnesium as are found in the average American diet.

Potassium-rich foods, which are important for patients with heart failure, include bananas, oranges, prunes, cantaloupes, carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados and broccoli. It is important to note, however, that patients taking Aldactone, those with kidney dysfunction, and some of those taking ACF inhibitors may have to restrict their potassium intake.

The diet also stresses avoiding saturated fats, as any healthy diet does, although it includes calcium-rich dairy products that are no- or low-fat. When choosing fats, it also advises monounsaturated oils, and it stresses whole grains, fresh fruits and vegetables every day.

Salt Restriction. People with high blood pressure are generally urged to restrict salt, although certain people may be more susceptible to its effects. For example, a high intake of salt may be an independent risk factor for the development of heart failure in people who are overweight. All heart failure patients should limit their salt intake, and in severe cases, very stringent salt restriction may be necessary. Patients should not add salt to their cooking and their meals. They should also avoid foods high in sodium; these include ham, bacon, hot dogs, lunch meats, prepared snack foods, dry cereal, cheese, canned soups, soy sauce, and condiments. Some patients may need to reduce their water intake as well. People with high cholesterol levels or diabetes require additional dietary precautions. [For more information, seeWell-Connected Report #43, Heart-Healthy Diet.]

Exercise

Traditionally, people with heart failure were discouraged from exercising. Now, exercise, when performed under medical supervision, is proving to be extremely important for many patients with stable conditions. Studies have reported that patients with stable conditions who engage in regular moderate exercise (twice a week) experience a better quality of life and lower mortality rates than those who don't.

The following guidelines are critical:

Experts warn that exercise is not appropriate for all heart failure patients. Physicians should always be consulted before any patient with heart failure starts an exercise program.
People who are approved for exercise and not used to exercising should start with five to 15 minutes of easy exercise with frequent breaks. Although the goal would be to build to 30 to 45 minutes of walking, swimming, or low-impact aerobic exercises three to five times every week, even shorter times spent exercising is useful.

The following are some examples of studies reporting benefits from specific exercises.

Progressive strength training may be particularly useful for heart failure patients since it strengthens muscles, which commonly deteriorate in this disorder. Strength training typically employs light weights, weight machines, or even the body’s weight (leg raises or sit-ups, for example). Even simply performing daily handgrip exercises can improve blood flow through the arteries.
Patients who exercise regularly using supervised treadmill and stationary-bicycle exercises have increased exercise capacity by 14% to 36%. In one study, heart failure patients as old as 91 years old increased their oxygen consumption significantly after six months of supervised treadmill and stationary bicycle exercises. Exercising the legs may actually help correct problems in heart muscles in these patients. In one study, patients who did leg extension exercises for eight weeks had higher levels of an enzyme involved in forming new blood vessels. Exercise has also been associated with evidence of reduced inflammation in blood vessels.

Bed Rest

Bed rest may be required in cases of severe congestive heart failure. To reduce congestion in the lungs, the patient’s upper body should be elevated; for most patients, resting in an armchair is better than lying in bed. Relaxing and contracting leg muscles is important to prevent clots. As the patient improves, progressively more activity will be recommended.

Warm Baths and Saunas

Experts have traditionally recommended that people with heart failure avoid warm baths, which can increase the heart rate. Now, studies are reporting that carefully controlled bathing for short periods may not be harmful and, in fact, may be beneficial, reducing irregular heart beats and increasing cardiac output and ejection fraction. Warm water may behave like a vasodilating drug, opening up the vessels gently and improving circulation. The people in the study sat in water up to their chests at 106° F or in a dry sauna at 140° F. In both situations they sat for 10 minutes with their torsos tilted at 45 degrees. None of them experienced pain in the heart, shortness of breath, or irregular heart beats.

Warning Note: Prolonged periods in hot or even warm conditions can be dangerous, however. Any patient with heart failure should consult the physician first, not bathe unaccompanied, and be sure that the temperature does not go above those described in this report for either water bathing or dry saunas.

Stress Reduction

Stress reduction techniques may have direct physical benefits lowering stress hormones, including cortisol (which suppresses the immune system) and norepinephrine (also known as adrenaline), the chemical messenger associated with heart dysfunction. Many effective stress reduction techniques, including meditation and relaxation methods, are available.

Alternative Remedies

Patients with heart failure may resort to alternative remedies. It should strongly be noted that such remedies are not regulated. They are often ineffective or, worse, in some cases may have sever or toxic effects. Of particular note for patients with congestive heart failure is an interaction between St. John's wort, an herbal medicine used for depression, and digoxin. Taking St. John's wort can significantly interfere with the heart agent.

Arginine. Some evidence suggests that arginine (also called L-arginine) may have some benefit. This amino acid appears to reduce endothelin, a protein that causes blood vessel constriction and is found in high amounts in heart failure patients. It can have adverse effects, however, including gastrointestinal problems. It can also lower blood pressure and change levels of certain chemicals and electrolytes in the body. It may increase the risk for bleeding. Some people have an allergic reaction to it, which in same cases may be severe. It may worsen asthma.

Coenzyme Q10. Some small studies suggest that coenzyme Q10 (CoQ10) may have some value for patients with heart failure, particularly in combination with vitamin E. CoQ10 is a vitamin-like substance found in organ meats and soybean oil. More recent studies, however, have found no effect on the heart or the quality of life with CoQ10 or vitamin E.

Other Vitamins and Supplements. A wide array of additional vitamins (thiamin, B6, and C), minerals (calcium, magnesium, zinc, manganese, copper, selenium), nutritional supplements (carnitine, creatine phosphate), and herbal remedies (e.g., hawthorn) have been proposed as treatments for heart failure. None have been adequately tested. While it is probably wise to eat a nutrient-rich diet, it is important to stress that no supplement or diet can cure the condition.

Warnings on Alternative and So-Called Natural Remedies

Alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.

There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Most reported problems occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals.

The following website is building a database of natural remedy brands that it tests and rates. Not all are yet available (www.consumerlab.com).

The Food and Drug Administration has a program called MEDWATCH for people to report adverse reactions to untested substances, such as herbal remedies and vitamins (800-332-1088).

Congestive Heart Failure

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