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Congestive Heart Failure

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Physicians who treat this condition

The term “heart failure” can be very alarming. While it does not mean the heart has “failed” or stopped working, it is a serious condition. Congestive heart failure (CHF) means the heart does not pump as well as it should to meet the body’s oxygen demands, often due to heart diseases such as cardiomyopathy or cardiovascular disease. CHF can result from either a reduced ability of the heart muscle to contract or from a mechanical problem that limits the ability of the heart’s chambers to fill with blood. When weakened, the heart is unable to keep up with the demands placed upon it; blood returns to the heart faster than it can be pumped out so that it gets backed up or congested—hence the name of the disorder.

CHF occurs most frequently in those over age 60 and is the leading cause of hospitalization and death in that age group. In over 50 percent of cases, sudden death occurs due to a cardiac arrhythmia, or irregular heartbeat. Unfortunately, antiarrhythmic medications may not be effective in controlling arrhythmias caused by CHF.

Patients with CHF can enjoy better health if they treat the underlying cause, if possible. For many patients the outlook is uncertain and depends on the extent of the disease and the patient’s response to therapy. However, in other cases, restricted salt intake and medication are used to ease the strain on the heart and to relieve symptoms. While CHF is a serious health risk, it is possible for patients to live with CHF and manage many symptoms effectively with proper treatment if they adhere to prescribed regimens. Noncompliance with a doctor’s recommendations regarding diet or medication increases the risk that the disease will worsen.

When to Call an Ambulance
When to Call Your Doctor
Symptoms
Causes
Prevention
Diagnosis
Treatment

When to Call an Ambulance
Call an ambulance immediately if you experience severe breathlessness or crushing chest pain with or without nausea, vomiting, profuse sweating, weakness or intense feelings of dread. Such symptoms may indicate a heart attack.

When to Call Your Doctor

  • Make an appointment with a doctor if you regularly experience fatigue and shortness of breath after mild physical activity.
  • Call your doctor if you experience any of the following during treatment for congestive heart failure: fever, rapid or irregular heartbeat, wheezing, severe shortness of breath or any worsening of the other symptoms of congestive heart failure.

Symptoms
Congestive heart failure is a progressive process and should not be confused with a heart attack, which involves sudden tissue death of the heart muscle. Although heart failure may occur suddenly in some cases, gradual loss of function is more common. Fatigue, shortness of breath on exertion and increased frequency of nighttime urination develop and worsen over time. Shortness of breath is often worse when lying down, (a condition known as orthopnea), as fluid from the legs pools in the lungs. Elevating the head with pillows eases chest congestion, but in advanced stages the patient may be unable to recline at all without severe breathlessness, and may need to sleep upright in a chair.

Failure of the left side of the heart (left-sided failure) is most common. It leads to increased pressure in the pulmonary veins in the lungs, which forces fluid into the surrounding microscopic air sacs, or alveoli, that transfer oxygen to the bloodstream. As the alveoli fill with fluid, they no longer function properly, which limits the amount of oxygen available to the body (see pulmonary edema for more information) and produces the most characteristic symptoms of congestive heart failure: fatigue and shortness of breath. In right-sided failure, the increased pressure in the veins returning blood from the rest of the body combined with the compensatory retention of sodium and water leads to fluid accumulation and swelling in the abdomen, liver and legs. Often, both left- and right-sided heart failure occur together.

CHF symptoms include:

  • Shortness of breath and wheezing after limited physical exertion. In advanced cases shortness of breath occurs even at rest, and attacks of severe breathlessness disturb sleep (left-sided failure).
  • Severe fatigue and weakness.
  • Dry cough or cough that produces frothy or bloody sputum (left-sided failure).
  • Frequent urination during the night (right-sided failure).
  • Swelling of the ankles and feet, or swelling in the lower back if the patient is bedridden (right-sided failure).
  • Rapid weight gain due to fluid retention (right-sided failure).
  • Abdominal pain and a feeling of fullness (right-sided failure).
  • Swollen neck veins (right-sided failure).
  • Loss of appetite (anorexia); nausea and/or vomiting.
  • Irregular or rapid heartbeat.
  • Anxiety; in severe cases irritability, restlessness, and mental confusion may occur. 

Causes
CHF occurs when the heart attempts to compensate for the “congestion” (or backup) of blood in a number of ways. It beats faster and expands somewhat more than usual as it fills with blood, so that when it contracts, more blood is forced out to the body. In addition, the decreased volume of blood reaching the kidneys causes them to start a hormonal cascade (renin-angiotensin system), which results in the retention of sodium and water. These efforts help meet the body’s demands in the short term, but they ultimately have very harmful long-term effects. Faster beating allows less time for the heart to refill after contraction, so that less blood ends up being circulated. Also, the extra effort increases the heart muscle’s demand for oxygen; if this need is not met adequately, heart rhythm can become dangerously erratic (see cardiac arrhythmias for more information) and ultimately fatal.

The following provides an overview of some of the underlying diseases or conditions that can cause CHF:

  • Coronary artery disease (obstruction of the coronary arteries by atherosclerotic plaque so that heart tissue is starved of oxygen) often leads to a heart attack, which damages the heart muscle and causes CHF.
  • Valvular heart disease, such as aortic stenosis can cause CHF.
  • Heart muscle injury due to viral infections (see myocarditis) or long-term drug or alcohol use (see cardiomyopathy) may result in CHF.
  • Conditions that overwork the heart, such as heart valve defects, high blood pressure, increased levels of thyroid hormones (thyrotoxicosis) and anemia may lead to CHF.
  • Infiltration of the heart muscle by other tissue, as occurs with amyloidosis (accumulation of a waxy substance), may cause CHF.
  • Pulmonary embolism, severe bacterial or viral infections, pregnancy or childbirth, and physical overexertion are all triggers for CHF to develop in a weakened heart.
  • Right-sided heart failure commonly results from left-sided heart failure.
  • CHF may result from restricted entry of blood into the heart due to thickening of the tissue surrounding the heart (pericardium), or to accumulation of excessive fibrous tissue in the heart muscle.
  • Familial cardiomyopathy can lead to heart failure

Prevention
You can reduce your risk of developing CHF with lifestyle changes that promote better health.

  • Don’t smoke.
  • Consume no more than two alcoholic beverages a day.
  • Eat a healthy, balanced diet low in salt and fat, exercise regularly and lose weight if you are overweight.
  • Adhere to a prescribed treatment program for other forms of heart disease.
  • If you are diabetic, maintain careful control of your blood sugar.

Diagnosis
The Johns Hopkins Cardiomyopathy and Heart Failure Practice, directed by Dr. Stuart Russell, uses a multidisciplinary approach to the evaluation and management of patients with heart failure due to any cause. Important components of this team approach include social work, dietary counseling, physical rehabilitation, educational programs and support groups. Our goal is to empower patients to better care for themselves. We believe that transplantation is the “court of last resort” and will do everything possible to avoid transplantation, if possible. 

At Johns Hopkins, evaluation for heart failure begins with an examination by one of our physicians at our Outpatient Center (satellite facility) at Green Spring Station. If necessary, you may be asked to undergo one or more of the following tests. Exercise treadmill tests and electrocardiograms are performed at the outpatient locations. The others are done in the hospital’s Cardiovascular Diagnostic Laboratory.  We can also now offer all these tests in a single day at the same place in our Heart Success One-Day Clinic.

  • Chest X-rays may be taken to determine the heart’s size and shape, as well as the presence of congestion in the lungs.
  • An electrocardiogram, also called an ECG or EKG, records your heart’s electrical activity during rest to determine abnormal heart rhythms. ECG abnormalities can indicate rhythm disturbances, heart muscle damage, inadequate blood flow to segments of the heart, and enlargement of the heart muscle. You may be given a portable ECG device, known as a Holter monitor, to measure the heart’s electrical activity over a 24-hour period.
  • Exercise stress tests, also known as treadmill tests, help determine irregular heart rhythms during exercise. During this test, the heart’s electrical activity is monitored through small metal sensors applied to your skin while you exercise on a stationary bicycle or treadmill.
  • Your doctor may order an echocardiogram to evaluate heart function. During this test, 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 the ejection fraction, or volume of blood pumped out to the body when the heart contracts.
  • Coronary angiography, or X-ray of the heart’s blood vessels, may be performed to evaluate pressures in the heart chambers and the pumping function. In this procedure, a tiny catheter is inserted into an artery of a leg or arm and threaded up into the coronary arteries. A contrast material is then injected from the end of the catheter into the coronary arteries, which provides a clear image of the blood vessels on X-ray.

For more information about terms used in this section, please visit our Heart and Circulatory System Glossary.

Treatment

The Johns Hopkins Cardiomyopathy and Heart Failure Practice, as described in the previous section, evaluates and manages patients with heart failure due to any cause.

Core components of treatment:

  • Clinical care of patients with heart failure and following cardiac transplantation.
  • Basic science, hemodynamic, genetic and clinical research pertaining to cardiomyopathy, heart failure and cardiac transplantation.
  • Education directed at both patients and professionals regarding cardiomyopathy, heart failure and cardiac transplantation.

Services provided:

  • All facets of clinical care of patients with cardiomyopathy, heart failure or cardiac transplantation.
  • Left ventricular assist devices.
  • Novel research programs for patients with cardiomyopathy or heart failure.
  • Endomyocardial biopsy.

Possible courses of treatment:

  • Lifestyle changes such as reducing salt intake (salt contributes to fluid retention and swelling), eating smaller, more frequent meals (less effort is required to digest smaller portions) and avoiding caffeine (which can exacerbate heartbeat irregularities) may be helpful.
  •  Wearing support stockings can help reduce swelling in the legs.
  • Most often, some type of medication is prescribed for heart failure patients.
  • Vasodilators, often the foundation of treatment for CHF, may be prescribed to dilate blood vessels, reducing blood pressure and easing blood flow.
  • Diuretics (such as hydrochloro thiazide, metolazone, furosemide or bumetanide) reduce the amount of fluid in the body and are useful for patients with fluid retention and hypertension.
  • Weigh yourself daily, because a sudden gain in weight is usually due to fluid retention and may require an increase in your water pill (diuretic).
  • Digitalis glycosides strengthen the heart’s contractions, helping to improve circulation. In the United States digoxin is the most commonly prescribed type of digitalis.
  • Anticoagulants (such as warfarin) help prevent blood clots.
  • Beta blockers (such as carvedilol and metoprolol), calcium channel blockers (such as amlodipine) and tranquilizers (such as diazepam) help improve blood flow, ease breathing and relieve anxiety.
  • Beta blockers added to ACE inhibitors have been shown to improve survival. If ACE inhibitors are not tolerated, angiotension receptor blockers, such as losartan and valsartan, may be substituted.
  • It may be necessary, in advanced cases, to administer oxygen through a nasal tube. Mechanical devices for administration of oxygen are available for home use after the condition has stabilized in the hospital.
  • More severe cases of heart failure may require surgery to bypass blocked blood vessels or replace heart valves.
  • If the blood vessels are clogged with plaque, the doctor may perform an outpatient procedure called percutaneous transluminal angioplasty.
  • During this procedure the doctor will use local anesthesia and insert a catheter (a long, narrow tube) with a deflated balloon at its tip into the narrowed part of the artery. The balloon is then inflated, compressing the plaque and enlarging the inner diameter of the blood vessel so blood can flow more easily.

If other treatments fail and the heart muscle has been too badly damaged, you may require a heart transplant. The survival rate for this surgery is 80 percent after one year and over 60 percent after four years.

Cardiovascular Diagnostic and Interventional Laboratory
The Johns Hopkins Hospital Cardiovascular Diagnostic Laboratory (CVDL) is a state-of-the-art imaging facility performing over 24,000 diagnostic and interventional procedures annually. The CVDL operates 11 procedure rooms.

There are three general areas within the CVDL: Cardiology, Radiology and Electrophysiology. The Cardiology section is involved in treating patients with disorders of the heart and vascular tree including coronary artery disease, congestive heart failure, valve disease, congenital heart defects, cardiomyopathy and peripheral vascular disease.

Services specific to cardiomyopathy, a leading cause of heart failure, in the CDVL include:

  • Diagnosis and evaluation of cardiomyopathic conditions using endomyocardial biopsy.
  • Hemodynamic and metabolic assessment of hypertrophic cardiomyopathy using transvenous pacing protocols, percutaneous septal myocardial ablation. 

Physicians Who Treat This Condition:


 

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