Causes and symptoms

The most common causes of heart failure are:

• coronary artery disease and heart attack (which may be "silent")
• cardiomyopathy
• high blood pressure (hypertension)
• heart valve disease
• congenital heart disease
• alcoholism and drug abuse

The most common cause of heart failure is coronary artery disease. In coronary artery disease, the arteries supplying blood to the heart become narrowed or blocked. When blood flow to an area of the heart is completely blocked, the person has a heart attack. Some heart attacks go unrecognized. The heart muscle suffers damage when its blood supply is reduced or blocked. If the damage affects the heart's ability to pump blood, heart failure develops.

Cardiomyopathy is a general term for disease of the heart muscle. Cardiomyopathy may be caused by coronary artery disease and various other heart problems. Sometimes the cause of cardiomyopathy cannot be found. In these cases the heart muscle disease is called idiopathic cardiomyopathy. Whatever the cause, cardiomyopathy can weaken the heart, leading to heart failure.

High blood pressure is another common cause of heart failure. High blood pressure makes the heart work harder to pump blood. After a while, the heart cannot keep up and the symptoms of heart failure develop.

Defects of the heart valves, congenital heart diseases, alcoholism, and drug abuse cause damage to the heart that can all lead to heart failure.

A person with heart failure may experience the following:

• shortness of breath
• frequent coughing, especially when lying down
• swollen feet, ankles, and legs
• abdominal swelling and pain
• fatigue
• dizziness or fainting
• sudden death

A person with left-sided heart failure may have shortness of breath and coughing caused by the fluid buildup in the lungs. Pulmonary edema may cause the person to cough up bubbly phlegm that contains blood. With right-sided heart failure, fluid build-up in the veins and body tissues causes swelling in the feet, legs, and abdomen. When body tissues, such as organs and muscles, do not receive enough oxygen and nutrients they cannot function as well, leading to tiredness and dizziness.

Diagnosis

Diagnosis of heart failure is based on:

• symptoms
• medical history
• physical examination
• chest x ray
• electrocardiogram (ECG; also called EKG)
• other imaging tests
• cardiac catheterization

A person's symptoms can provide important clues to the presence of heart failure. Shortness of breath while engaging in activities and episodes of shortness of breath that wake a person from sleep are classic symptoms of heart failure. During the physical examination, the physician listens to the heart and lungs with a stethoscope for telltale signs of heart failure. Irregular heart sounds, "gallops," a rapid heart rate, and murmurs of the heart valves may be heard. If there is fluid in the lungs a crackling sound may be heard. Rapid breathing or other changes in breathing may also be present. Patients with heart failure also may have a rapid pulse.

By pressing on the abdomen, the physician can feel if the liver is enlarged. The skin of the fingers and toes may have a bluish tint and feel cool if not enough oxygen is reaching them.

A chest x ray can show if there is fluid in the lungs and if the heart is enlarged. Abnormalities of heart valves and other structures also may be seen on chest x ray.

An electrocardiogram gives information on the heart rhythm and the size of the heart. It can show if the heart chamber is enlarged and if there is damage to the heart muscle from blocked arteries.

Besides chest x ray, other imaging tests may help make a diagnosis. Echocardiography uses sound waves to make images of the heart. These images can show if the heart wall or chambers are enlarged and if there are any abnormalities of the heart valves. An echocardiogram also can be used to find out how much blood the heart is pumping. It determines the amount of blood in the ventricle (ventricular volume) and the amount of blood the ventricle pumps each time it beats (called the ejection fraction). A healthy heart pumps at least one-half the amount of blood in the left ventricle with each heartbeat. Radionuclide ventriculography also measures the ejection fraction by imaging with very low doses of an injected radioactive substance as it travels through the heart.

A new test that measures the level of a particular hormone in the blood was introduced in 2003 and researchers said the test may be useful for testing for heart failure in physicians' offices because it could provide results in 15 minutes.

Cardiac catheterization involves using a small tube (catheter) that is inserted through a blood vessel into the heart. It is used to measure pressure in the heart and the amount of blood pumped by the heart. This test can help find abnormalities of the coronary arteries, heart valves, and heart muscle, and other blood vessels. Combined with echocardiography and other tests, cardiac catheterization can help find the cause of heart failure. It is not always necessary, however.

Treatment

Heart failure usually is treated with lifestyle changes and medicines. Sometimes surgery is needed to correct abnormalities of the heart or heart valves. Heart transplantation is a last resort to be considered in certain cases.

Dietary changes to maintain proper weight and reduce salt intake may be needed. Reducing salt intake helps to lessen swelling in the legs, feet, and abdomen. Appropriate exercise also may be recommended, but it is important that heart failure patients only begin an exercise program with the advice of their doctors. Walking, bicycling, swimming, or low-impact aerobic exercises may be recommended. There are good heart rehabilitation programs at most larger hospitals.

Other lifestyle changes that may reduce the symptoms of heart failure include stopping smoking or other tobacco use, eliminating or reducing alcohol consumption, and not using harmful drugs.

One or more of the following types of medicines may be prescribed for heart failure:

• diuretics
• digitalis
• vasodilators
• beta blockers
• angiotensin converting enzyme inhibitors (ACE inhibitors)
• angiotensin receptor blockers (ARBs)
• calcium channel blockers

Diuretics help eliminate excess salt and water from the kidneys by making patients urinate more often. This helps reduce the swelling caused by fluid buildup in the tissues. Digitalis helps the heart muscle to have stronger pumping action. Vasodilators, ACE inhibitors, ARBs, and calcium channel blockers lower blood pressure and expand the blood vessels so blood can move more easily through them. This action makes it easier for the heart to pump blood through the vessels. Cholesterol-lowering drugs called statins can help prevent death from heart failure. A 2003 study showed a 62% drop in mortality rate among patients with severe heart failure who took statin therapy.

In 2003, a new noninvasive procedure was being tested for patients with congestive heart failure. Called enhanced external counterpulsation (EECP), it consisted of inflating three sets of pneumatic cuffs attached to the patient's legs. The therapy had positive effects on the blood pressure and reduced frequency of episodes of angina (pain) in a clinical trial by as much as 70%.

Surgery is used to correct certain heart conditions that cause heart failure. Congenital heart defects and abnormal heart valves can be repaired with surgery. Blocked coronary arteries usually can be treated with angioplasty or coronary artery bypass surgery.

With severe heart failure, the heart muscle may become so damaged that available treatments do not help. Patients with this stage of heart failure are said to have end-stage heart failure. Heart transplant usually is considered for patients with end-stage heart failure when all other treatments have stopped working.

Prognosis

Most patients with mild or moderate heart failure can be successfully treated with dietary and exercise programs and the right medications. In fact, in 2003, the American Heart Association said that even those awaiting heart transplants could benefit from exercise. Many people are able to participate in normal daily activities and lead relatively active lives.

Patients with severe heart failure may eventually have to consider heart transplantation. Approximately 50% of patients diagnosed with congestive heart failure live for five years with the condition. Women with heart failure usually live longer than men with heart failure.

Prevention

Heart failure usually is caused by the effects of some type of heart disease. The best way to try to prevent heart failure is to eat a healthy diet and get regular exercise, but many causes of heart failure cannot be prevented. People with risk factors for coronary disease (such as high blood pressure and high cholesterol levels) should work closely with their physician to reduce likelihood of heart attack and heart failure.

Heart failure sometimes can be avoided by identifying and treating any conditions that might lead to heart disease. These include high blood pressure, alcoholism, and coronary artery disease. Regular blood pressure checks and obtaining immediate medical care for symptoms of coronary artery disease, such as chest pain, will help to get these conditions found and treated early, before they can damage the heart muscle.

A 2003 initiative called OPTIMIZE H-F was aimed at preventing severe heart failure and deaths among patients discharge from hospitals. The project created a registry or database of patients with heart failure that could be shared among hospitals. Finally, diagnosing and treating heart failure before the heart becomes severely damaged can improve the prognosis. With proper treatment, many patients may continue to lead active lives for a number of years.

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