13. Heart Failure

OTHER NAMES
congestive heart failure; CHF
DEFINITION
Congestive heart failure (CHF), also called congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood through the body.

CAUSES, INCIDENCE, AND RISK FACTORS
Heart failure may affect either the right side, left side, or both sides of the heart. As pumping action is lost, blood may back up
into other areas of the body, including the liver, gastrointestinal tract, and extremities (right-sided heart failure), or the lungs
(left-sided heart failure).
Structural or functional causes of heart failure include high blood pressure (hypertension), heart valve disease, congenital heart diseases, cardiomyopathy, heart tumor, and other heart diseases. Precipitating factors include infections with high fever or complicated infections, use of negative inotropic drugs (such as beta-blockers and calcium channel blocker), anemia, irregular heartbeats (arrhythmias), hyperthyroidism, and kidney disease.
Other risk factors include smoking, obesity, excess alcohol consumption, and diet high in fat and salt.
Heart failure occurs in approximately 10 out of 100 people, and becomes more prevalent with advancing age.
PREVENTION
Follow the health care provider’s advice for treatment of conditions that may cause congestive heart failure. Follow dietary guidelines. Minimize or eliminate smoking and alcohol consumption.
SYMPTONS
- sensation of feeling the heart beat (palpitations)
- pulse may feel irregular or rapid
- weight gain (unintentional)
- swelling of feel and ankles
- swelling of the abdomen
- pronounced neck veins
- loss of appetite, indigestion
- nausea and vomiting
- shortness of breath, especially with activity
- difficulty sleeping
- shortness of breath which occurs after lying down for a while
- fatigue, weakness, faintness
- decreased alertness or concentration
- cough
- skin discoloration, bluish (cyanosis) or yellow (jaundice)
- decreased urine production (oliguria)
- need to urinate at night (nocturia)
- infants may sweat during feeds (or other exertion)
SIGNS AND TESTS
A physical examination may reveal irregular or rapid heartbeat. There may be distended neck veins, enlarged liver, dependent edema, and signs of pleural effusion (fluid around the lungs).
Listening to the chest with a stethoscope (auscultation) may reveal lung crackles or abnormal heart sounds. Blood pressure may be low or may drop upon rising (orthostatic hypotension).
Enlargement of the heart or decreased heart functioning may be seen on:
- a echocardiogram
- a coronary angiography
- a chest X-ray
- a chest CT scan

 a nuclear heart scans (MUGA, RNV)
- An ECG may show arrhythmias.
- A urinalysis may indicate kidney failure as a cause of the disorder, or as a consequence of left heart failure.
- Multiple blood studies may be performed, including CBC, blood chemistry, and other studies to determine the exact cause of heart failure.
This disease may also alter the following test results:
- urine specific gravity
- urine concentration test
- urinary casts
- thoracentesis
- Swan-Ganz (right heart catheterization)
- sodium, urine
- serum sodium
- protein, urine
- pleural fluid analysis
- pericardiocentesis
- osmolality, urine
- lactic acid
- gamma-glutamyl transpeptidase
- ESR
- creatinine clearance
- creatinine - urine
- creatinine
- chloride; urine
- serum Chloride
- BUN
- ammonium ion
- aldosterone

Treatment Options

Treatment Strategy

 Immediate relief of the precipitating event. Typically, combined drug therapy (e.g., vasodilator, diuretic, digitalis glycoside) is prescribed for CHF. Mechanical or surgical therapies are added with severe CHF. Heart valve surgery, revascularization, or cardiac transplantation as required and as available. Bed rest and reduced activity are recommended until condition is stabilized. Oxygen relieves dyspnea and pulmonary vasoconstriction.

Drug Therapies

 Vasodilators-reduce arterial and venous vasoconstriction (afterload/preload); shifts blood volume from the arterial to the venous side of circulation; cornerstone of treatment; gradually titrate Oral vasodilators: _... Angiotensin-converting enzyme (ACE) inhibitors (e.g., enalapril, 2.5 to 5.0 mg bid to qid); side effects-acute renal failure (avoid potassium-sparing diuretics), cough, angioedema, hypotension _... Angiotensin II receptor antagonists (e.g., Losartan, 12.5 mg qid titrated to 50 mg qid); monitor blood pressure _... Nitrates may relieve venous and pulmonary congestion _... Calcium-channel blockers and alpha- and beta-adrenergic receptor antagonists- variable effects and potential serious adverse effects Parenteral vasodilators: _... Nitroglycerin-10 to 100 mg/min; tolerance problems with long-term use _... Sodium nitroprusside-5 to 150 mg/kg/min; thiocyanate and cyanide toxicity For fluid control and sodium retention _... Restriction of dietary fluid and sodium (<2 g/day) reduces need for diuretics. _... Maximum daily net fluid loss-0.5 to 1.0 liter/day to avoid serious complications (e.g., oliguria, impaired renal function) _... Thiazide diuretics (e.g., chlorothiazide 500 to 1000 mg/day); loop diuretics (e.g., furosemide 20 to 600 mg/day); potassium-sparing diuretics (e.g., spironolactone 25 to 200 mg/day) _... Mechanical removal of fluid-phlebotomy, thoracentesis, dialysis, paracentesis _... Digitalis glycosides-increase myocardial contractile function; prevent rhythm disturbances by increasing cardiac output and lowering filling pressures; digoxin-monitor closely for toxicity (5% to 15% of patients) and drug interactions; 0.25 to 0.5 mg/day then 0.25 mg every six hours to 1.0 to 1.5 mg _... Inotropic agents-for CHF unresponsive to other therapies; poor long-term benefit (e.g., dopamine 1 to 3 mg/kg/min; milrinone 50 mg/kg/min then 0.375 to 0.750 mg/kg/min); closely monitor for tachycardia and arrhythmia

Complementary and Alternative Therapies

 The true goal is to prevent the pathologies leading to congestive heart failure. Nutrition and herbal medicine can play an important role in increasing the strength of the heart without also increasing the workload. In addition, treating the lungs with herbs and physical medicine may increase the comfort of the patient and decrease pulmonary pathology. Mind-body techniques, such as yoga, meditation, relaxation, and biofeedback show promise in increasing cardiovascular health and increasing a sense of well-being.

Nutrition

 _... Antioxidants: vitamin C (1,000 mg tid), vitamin E (400 IU/day), selenium (200 mcg/day) _... Coenzyme Q10: (30 to 50 mg tid) antioxidant, increases oxygenation of tissue, including heart muscle _... Essential fatty acids: (1,500 mg bid) anti-inflammatory _... Garlic, ginger, and onions all have a beneficial effect on platelet aggregation. Increase fiber (especially water-soluble), fruits, vegetables, and vegetarian sources of protein. Increase potassium and decrease sodium in the diet. _... Homocysteine metabolism: Folic acid (800 mcg/day), B6 (50 mg/day), B12 (400 mg/day), betaine (200 to 1,000 mg/day) _... Magnesium: (500 mg) mild vasodilation, decreases vascular resistance _... Taurine: (500 mg bid) enhances cardiac efficiency, mild diuretic _... Carnitine: (750 to 1,500 mg bid) important in fatty acid metabolism, increases efficiency of cardiac function

EXPECTATIONS (PROGNOSIS)
Heart failure is a serious disorder that carries a possibility of reduced life expectancy. Many forms of heart failure are well controlled with medication and correction of underlying disorders. It may become a chronic illness. Heart failure worsens with infection or other physical stressors.
COMPLICATIONS
- pulmonary edema
- total failure of the heart to function (circulatory collapse)
- arrhythmias including lethal arrhythmias
- side effects of medications
- low blood pressure (hypotension)
- light headedness, fainting
- lupus reaction
- headache
- gastrointestinal upset (such as nausea, heartbum, diarrhea)
- digitalis toxicity

Courtesy:

Compiled and Shared By: Habib Anwar 

habib.anwar@hotmail.com