Dr. MJ Bazos MD,
What Is Heart Failure?
Heart failure occurs when the heart
loses its ability to pump enough blood through the body. Usually, the loss in
pumping action is a symptom of an underlying heart problem, such as coronary
The term heart failure
suggests a sudden and complete stop of heart activity. But, actually, the heart
does not suddenly stop. Rather, heart failure usually develops slowly, often
over years, as the heart gradually loses its pumping ability and works less
efficiently. Some people may not become aware of their condition until symptoms
appear years after their heart began its decline.
How serious the condition is depends
on how much pumping capacity the heart has lost. Nearly everyone loses some
pumping capacity as he or she ages. But the loss is significantly more in heart
failure and often results from a heart attack or other disease that damages the
The severity of the condition
determines the impact it has on a person's life. At one end of the spectrum, the
mild form of heart failure may have little effect on a person's life; at the
other end, severe heart failure can interfere with even simple activities and
prove fatal. Between those extremes, treatment often helps people lead full
But all forms of heart failure,
even the mildest, are a serious health problem, which must be treated. To
improve their chance of living longer, patients must take care of themselves,
see their physician regularly, and closely follow treatments.
Is There Only One Type of Heart
The term congestive heart
failure is often used to describe all patients with heart failure. In reality,
congestion (the buildup of fluid) is just one feature of the condition and does
not occur in all patients. There are two main categories of heart failure
although within each category, symptoms and effects may differ from patient to
patient. The two categories are:
failure—This occurs when the heart's ability to contract decreases.
The heart cannot pump with enough force to push a sufficient amount of blood
into the circulation. Blood coming into the heart from the lungs may back up and
cause fluid to leak into the lungs, a condition known as pulmonary congestion.
failure—This occurs when the heart has a problem relaxing. The heart
cannot properly fill with blood because the muscle has become stiff, losing its
ability to relax. This form may lead to fluid accumulation, especially in the
feet, ankles, and legs. Some patients may have lung congestion.
How Common Is Heart Failure?
Between 2 to 3 million Americans have
heart failure, and 400,000 new cases are diagnosed each year. The condition is
slightly more common among men than women and is twice as common among African
Americans as whites.
causes 39,000 deaths a year and is a contributing factor in another 225,000
deaths. The death rate attributed to heart failure rose by 64% from 1970 to
1990, while the death rate from coronary heart disease dropped by 49% during the
same period. Heart failure mortality is about twice as high for African
Americans as whites for all age groups.
In a sense, heart failure's growing
presence as a health problem reflects the Nation's changing population: More
people are living longer. People age 65 and older represent the fastest growing
segment of the population, and the risk of heart failure increases with age. The
condition affects 1% of people age 50, but about 5% of people age 75.
What Causes Heart Failure?
As stated, the heart loses some of its
blood-pumping ability as a natural consequence of aging. However, a number of
other factors can lead to a potentially life-threatening loss of pumping
As a symptom of underlying
heart disease, heart failure is closely associated with the major risk factors
for coronary heart disease: smoking, high cholesterol levels, hypertension
(persistent high blood pressure), diabetes and abnormal blood sugar levels, and
obesity. A person can change or eliminate those risk factors and thus lower
their risk of developing or aggravating their heart disease and heart failure.
Among prominent risk factors,
hypertension (high blood pressure) and diabetes are particularly important.
Uncontrolled high blood pressure increases the risk of heart failure by 200%,
compared with those who do not have hypertension. Moreover, the degree of risk
appears directly related to the severity of the high blood pressure.
Persons with diabetes have about a
twofold to eightfold greater risk of heart failure than those without diabetes.
Women with diabetes have a greater risk of heart failure than men with diabetes.
Part of the risk comes from diabetes' association with other heart failure risk
factors, such as high blood pressure, obesity, and high cholesterol levels.
However, the disease process in diabetes also damages the heart muscle.
The presence of coronary disease is
among the greatest risks for heart failure. Muscle damage and scarring caused by
a heart attack greatly increase the risk of heart failure. Cardiac arrhythmias,
or irregular heartbeats, also raise heart failure risk. Any disorder that causes
abnormal swelling or thickening of the heart sets the stage for heart failure.
In some people, heart failure arises
from problems with heart valves, the flap-like structures that help regulate
blood flow through the heart. Infections in the heart are another source of
increased risk for heart failure.
single risk factor may be sufficient to cause heart failure, but a combination
of factors dramatically increases the risk. Advanced age adds to the potential
impact of any heart failure risk.
Finally, genetic abnormalities
contribute to the risk for certain types of heart disease, which in turn may
lead to heart failure. However, in most instances, a specific genetic link to
heart failure has not been identified.
What Are the Symptoms?
A number of symptoms are associated
with heart failure, but none is specific for the condition. Perhaps the best
known symptom is shortness of breath ("dyspnea"). In heart failure, this may
result from excess fluid in the lungs. The breathing difficulties may occur at
rest or during exercise. In some cases, congestion may be severe enough to
prevent or interrupt sleep.
easy tiring is another common symptom. As the heart's pumping capacity
decreases, muscles and other tissues receive less oxygen and nutrition, which
are carried in the blood. Without proper "fuel," the body cannot perform as much
work, which translates into fatigue.
accumulation, or edema, may cause swelling of the feet, ankles, legs, and
occasionally, the abdomen. Excess fluid retained by the body may result in
weight gain, which sometimes occurs fairly quickly.
Persistent coughing is another common
sign, especially coughing that regularly produces mucus or pink, blood-tinged
sputum. Some people develop raspy breathing or wheezing.
Because heart failure usually develops
slowly, the symptoms may not appear until the condition has progressed over
years. The heart hides the underlying problem by making adjustments that
delay—but do not prevent—the eventual loss in pumping capacity. The
heart adjusts, or compensates, in three ways to cope with and hide the effects
of heart failure:
•Enlargement ("dilatation"), which allows
more blood into the heart;
•Thickening of muscle fibers
("hypertrophy") to strengthen the heart muscle, which allows the heart to
contract more forcefully and pump more blood; and
•More frequent contraction, which
By making these
adjustments, or compensating, the heart can temporarily make up for losses in
pumping ability, sometimes for years. However, compensation has its limits.
Eventually, the heart cannot offset the lost ability to pump blood, and the
signs of heart failure appear.
Do Doctors Diagnose Heart Failure?
many cases, physicians diagnose heart failure during a physical examination.
Readily identifiable signs are shortness of breath, fatigue, and swollen ankles
and feet. The physician also will check for the presence of risk factors, such
as hypertension, obesity, and a history of heart problems. Using a stethoscope,
the physician can listen to a patient breathe and identify the sounds of lung
congestion. The stethoscope also picks up the abnormal heart sounds indicative
of heart failure.
If neither the
symptoms nor the patient's history point to a clear-cut diagnosis, the physician
may recommend any of a variety of laboratory tests, including, initially, an
electrocardiogram, which uses recording devices placed on the chest to evaluate
the electrical activity of a patient's heartbeat.
Echocardiography is another means of
evaluating heart function from outside the body. Sound waves bounced off the
heart are recorded and translated into images. The pictures can reveal abnormal
heart size, shape, and movement. Echocardiography also can be used to calculate
a patient's ejection fraction, a measure of the amount of blood pumped out when
the heart contracts.
test is the chest x ray, which also determines the heart's size and shape, as
well as the presence of congestion in the lungs.
Tests help rule out other possible
causes of symptoms. The symptoms of heart failure can result when the heart is
made to work too hard, instead of from damaged muscle. Conditions that overload
the heart occur rarely and include severe anemia and thyrotoxicosis (a disease
resulting from an overactive thyroid gland).
What Treatments Are Available?
Heart failure caused by an excessive
workload is curable by treating the primary disease, such as anemia or
thyrotoxicosis. Also curable are forms caused by anatomical problems, such as a
heart valve defect. These defects can be surgically corrected.
However, for the common forms of heart
failure—those due to damaged heart muscle—no known cure exists. But
treatment for these forms may be quite successful. The treatment seeks to
improve patients' quality of life and length of survival through lifestyle
change and drug therapy.
minimize the effects of heart failure by controlling the risk factors for heart
disease. Obvious steps include quitting smoking, losing weight if necessary,
abstaining from alcohol, and making dietary changes to reduce the amount of salt
and fat consumed. Regular, modest exercise is also helpful for many patients,
though the amount and intensity should be carefully monitored by a physician.
But, even with lifestyle changes, most
heart failure patients must take medication. Many patients receive two or more
Several types of drugs have
proven useful in the treatment of heart failure:
•Diuretics help reduce the amount of fluid
in the body and are useful for patients with fluid retention and hypertension.
•Digitalis increases the force of the
heart's contractions, helping to improve circulation.
•Results of recent studies have placed
more emphasis on the use of drugs known as angiotensin converting enzyme (ACE)
inhibitors. Several large studies have indicated that ACE inhibitors improve
survival among heart failure patients and may slow, or perhaps even prevent, the
loss of heart pumping activity.
Originally developed as a treatment for
hypertension, ACE inhibitors help heart failure patients by, among other things,
decreasing the pressure inside blood vessels. As a result, the heart does not
have to work as hard to pump blood through the vessels.
Patients who cannot take ACE inhibitors
may get a nitrate and/or a drug called hydralazine, each of which helps relax
tension in blood vessels to improve blood flow.
Sometimes, heart failure is
life-threatening. Usually, this happens when drug therapy and lifestyle changes
fail to control its symptoms. In such cases, a heart transplant may be the only
treatment option. However, candidates for transplantation often have to wait
months or even years before a suitable donor heart is found. Recent studies
indicate that some transplant candidates improve during this waiting period
through drug treatment and other therapy, and can be removed from the transplant
Transplant candidates who do not
improve sometimes need mechanical pumps, which are attached to the heart. Called
left ventricular assist devices (LVADs), the machines take over part or
virtually all of the heart's blood-pumping activity. However, current LVADs are
not permanent solutions for heart failure but are considered bridges to
surgical procedure for severe heart failure is available at a few U.S. medical
centers. The procedure, called cardiomyoplasty, involves detaching one end of a
muscle in the back, wrapping it around the heart, and then suturing the muscle
to the heart. An implanted electric stimulator causes the back muscle to
contract, pumping blood from the heart.
Common Heart Failure Medications
Listed below are some of the
medications prescribed for heart failure. Not all medications are suitable for
all patients, and more than one drug may be needed.
Also, the list provides the full range
of possible side effects for these drugs. Not all patients will develop these
side effects. If you suspect that you are having a side effect, alert your
These prevent the production of a chemical that causes blood vessels to narrow.
As a result, blood pressure drops and the heart does not have to work as hard to
pump blood. Side effects may include coughing, skin rashes, fluid retention,
excess potassium in the bloodstream, kidney problems, and an altered or lost
sense of taste.
Increases the force of the heart's contractions. It also slows certain fast
heart rhythms. As a result, the heart beats less frequently but more
effectively, and more blood is pumped into the arteries. Side effects may
include nausea, vomiting, loss of appetite, diarrhea, confusion, and new
•Diuretics. These decrease
the body's retention of salt and so of water. Diuretics are commonly prescribed
to reduce high blood pressure. Diuretics come in many types, with different
periods of effectiveness. Side effects may include loss of too much potassium,
weakness, muscle cramps, joint pains, and impotence.
•Hydralazine. This drug
widens blood vessels, easing blood flow. Side effects may include headaches,
rapid heartbeat, and joint pain.
•Nitrates. These drugs are
used mostly for chest pain, but may also help diminish heart failure symptoms.
They relax smooth muscle and widen blood vessels. They act to lower primarily
systolic blood pressure. Side effects may include headaches.
Can a Person Live With Heart
Heart failure is one of the
most serious symptoms of heart disease. About two-thirds of all patients die
within 5 years of diagnosis. However, some live beyond 5 years, even into old
age. The outlook for an individual patient depends on the patient's age,
severity of heart failure, overall health, and a number of other factors.
As heart failure progresses, the
effects can become quite severe, and patients often lose the ability to perform
even modest physical activity. Eventually, the heart's reduced pumping capacity
may interfere with routine functions, and patients may become unable to care for
themselves. The loss in functional ability can occur quickly if the heart is
further weakened by heart attacks or the worsening of other conditions that
affect heart failure, such as diabetes and coronary heart disease.
Heart failure patients also have an
increased risk of sudden death, or cardiac arrest, caused by an irregular
To improve the chances of
surviving with heart failure, patients must take care of themselves. Patients
•See their physician regularly;
•Closely follow all of their physician's
•Take any medication according to
•Immediately inform their physician of any
significant change in their condition, such as an intensified shortness of
breath or swollen feet.
Patients with heart failure also should:
•Control their weight;
•Watch what they eat;
•Not smoke cigarettes or use other tobacco
•Abstain from or strictly limit alcohol
Even with the best care,
heart failure can worsen, but patients who don't take care of themselves are
almost writing themselves a prescription for poor health.
The best defense against heart failure is
the prevention of heart disease. Almost all of the major coronary risk factors
can be controlled or eliminated: smoking, high cholesterol, high blood pressure,
diabetes, and obesity.
Is the Outlook for Heart Failure?
Within the past decade, knowledge of
heart failure has improved dramatically but, clearly, much more remains to be
learned. The National Heart, Lung, and Blood Institute (NHLBI) supports numerous
research projects aimed at building on what is already known about heart failure
and at uncovering new knowledge about its process, diagnosis, and treatment.
NHLBI research priorities for heart failure include:
•Learning more about basic cellular
changes that lead to heart failure;
•Developing tests to detect the earliest
signs of heart failure;
•Identifying factors that cause heart
failure to worsen;
•Determining how heart failure can be
reversed once it starts;
•Understanding better the heart's ability
to compensate for lost pumping ability; and
•Developing new therapies, especially
those based on early signs of heart failure.
Making the Most of Your Doctor
Here are some points you may
want to discuss with your doctor. Don't hesitate to ask questions to clarify
points. Also, ask your doctor to rephrase a reply you cannot understand. You may
want to take a family member or friend to the appointment with you to help you
better understand and remember what's said.
•Briefly describe your symptoms, even
those you feel may not be important. You may want to keep a list so you will
•Tell the doctor all of the medications
you take—including over-the-counter drugs—and any problems you may
be having with them.
•Be sure you understand all of the
doctor's instructions–especially for medications. Know what drug to take
when, how often, and in what amount.
•Find out what side effects are possible
from any drug the doctor prescribes for you.
•Ask the meaning of any medical term you
•If, after your appointment, you still
have questions or are uncertain about your treatment, call the doctor's office
to get the information you need.
A Question for Your Pharmacist
Your pharmacist is a good resource for
information about medications. Ask if any drug you're taking interacts badly
with certain foods or with other drugs, including nonprescription ones. Your
pharmacist also can help you understand product package inserts and label
•Angiotensin converting enzyme
(ACE) inhibitor—A drug used to decrease pressure inside blood vessels.
surgical procedure that involves detaching one end of a back muscle and
attaching it to the heart. An electric stimulator causes the muscle to contract
to pump blood from the heart.
•Congestive heart failure—A
heart disease condition that involves loss of pumping ability by the heart,
generally accompanied by fluid accumulation in body tissues, especially the
failure—Inability of the heart to relax properly and fill with blood as a
result of stiffening of the heart muscle.
•Dyspnea—Shortness of breath.
sound waves bounced off the heart to produce images of the heart.
accumulation in body tissues.
•Electrocardiogram (EKG or
ECG)—Measurement of electrical activity associated with heartbeats.
•Heart failure—Loss of
blood-pumping ability by the heart.
•Left ventricular assist
device—A mechanical device used to increase the heart's pumping ability.
•Pulmonary congestion (or
edema)—Fluid accumulation in the lungs.
•Sudden cardiac death—Cardiac
arrest caused by an irregular heartbeat.
failure—Inability of the heart to contract with enough force to pump
adequate amounts of blood through the body.
that control the direction of blood flow through the heart.