Coronary Artery Disease Overview

The term "heart failure" suggests that the heart has stopped working or has "failed." This is not the case. What it actually means is that the heart is working inefficiently, pumping too weakly. When this happens, fluid builds up in the lungs, among other organs, creating a feeling of breathlessness. Heart failure often is referred to as congestive heart failure, or CHF.

Heart failure occurs equally in men and women and is more prevalent among African-Americans, Hispanics, and American Indians than among whites. In the United States, 75 percent to 80 percent of its roughly 5 million victims are older than 65. Each year, nearly 1 million people are hospitalized with CHF, 30 percent to 60 percent of whom are "readmits." The CHF death rate has increased by 35 percent in the past quarter century; the disease is now the main cause or a contributor in nearly 53,000 U.S. deaths each year, according to the American Heart Association. Unfortunately, diagnosis and treatment are often delayed because many people attribute early symptoms of the condition—feeling tired or short of breath—to aging, and so they do not seek immediate treatment.

The rising incidence of heart failure is related to several factors, including an aging population and a lowered death rate for people who have heart attacks. Although treatments for heart attacks have improved, they often damage the left ventricle, the heart's main pumping chamber. In addition, the high rate of obesity in America has escalated the incidence of diabetes and high blood pressure. Both of these conditions make the heart work harder, increasing the risk of heart failure.

Causes of heart failure

Heart failure is caused by conditions that weaken or damage your heart muscle. Six out of every seven patients hospitalized with CHF have a history of coronary artery disease (i.e., heart attacks); three out of four have hypertension, or high blood pressure, and more than half have defective heart valves or a history of diabetes. A heart attack does its damage by suddenly shutting off blood flow to part of the heart muscle. Hypertension, defective heart valves, and diabetes all make the heart work too hard, causing damage over time. A weakened heart, often referred to as cardiomyopathy, also can be inherited or the result of an infection, thyroid disease, and alcohol or drug abuse. Further, the condition can be idiopathic, meaning the cause is unknown.

"Heart failure" encompasses systolic heart failure (SHF) and diastolic heart failure (DHF). Systolic heart failure (or systolic cardiac dysfunction) occurs when the heart muscle contracts with too little force, causing less oxygen-rich blood to be pumped through the body.

Diastolic heart failure (DHF or diastolic dysfunction) occurs when the heart contracts normally but the ventricle walls don't relax enough to let the chamber fill, as it should, and the heart has less blood to pump out. Unlike systolic heart failure, diastolic heart failure occurs more often in women. The mortality rate of DHF is half that of patients with SHF, yet DHF causes as many hospitalizations as SHF. While guidelines for diagnosing and treating SHF have been widely published, little attention has been paid to constructing similar guidelines for DHF.

A test called ejection fraction, which measures the amount of blood in the left ventricle that is pumped out when the chamber contracts, can help determine if systolic or diastolic heart failure is present. A normal ejection fraction is over 50 percent. An ejection fraction of less than 40 percent usually confirms systolic heart failure. Patients with diastolic heart failure, by contrast, can have a normal ejection fraction.

Risk factors

Risk factors for congestive heart failure include:

• Advancing age
• Coronary artery disease and previous heart attacks
• Valve disease
• High blood pressure
• Diabetes
• Thyroid disease
• Irregular heartbeats or arrhythmias
• Serious drug or alcohol abuse

Overview

As with any chronic illness, heart failure is best controlled by early diagnosis and prevention. Some heart failure is idiopathic (another name for "cause unknown"), but in many cases, lifestyle is a major factor.

One additional note: Claims that women are less vulnerable to heart failure than men are untrue. Heart failure affects women and men equally, so both men and women need to be aware of the condition and how to prevent it from occurring or progressing.

This section discusses heart failure and:

• Coronary artery disease and heart attack
• Damage to the heart valves or a heart murmur
• Heart enlargement
• High blood pressure
• Diabetes
• The family link
• Women

Congestive heart failure and coronary artery disease

Coronary artery disease can cause damage to your heart muscle, which, in turn, may cause heart failure. So think of angina or a prior "coronary event," such as a heart attack, as a timely warning that you need to stop your CAD from progressing and causing further damage.

For starters, remake your lifestyle. High blood pressure, high blood levels of lipids (LDL, total cholesterol, and triglycerides), diabetes, smoking, and obesity are risk factors for coronary artery disease. The prescription:

• If you smoke, stop or at least cut down.
• Exercise on most days.
• Get your cholesterol checked regularly, and treat high blood levels.
• Lose weight if you are overweight.
• Eat a diet low in fat, particularly trans fats.
• Control high blood pressure and diabetes.
• Take the medications your doctor prescribes to improve the function of your heart and stop further damage.
• Consider coronary artery bypass surgery or an interventional procedure to treat narrowed blood vessels.
• See your doctor for regular follow-up visits. Consult a heart specialist (cardiologist) in addition to your primary-care physician for the purpose of adding preventive medications.

Heart failure and valve disease

The heart's valves ensure that blood flows in one direction through the heart. Heart valve disease causes the valves either to not close properly (resulting in a leaky valve) or to not open fully (resulting in a narrowed valve opening). Both types of valve disease cause the heart to work harder, which over time may lead to heart failure.

Heart valve disease is caused by infection, congenital heart disease, and aging. The decision to prescribe medical treatment or proceed with surgical repair or replacement is based on the type of valve disease you have, the severity of the damage, your age, and your medical history.

Heart failure and an enlarged heart

An enlarged heart, also called dilated cardiomyopathy, is an increase in the size of the heart. Your doctor may notice this during a physical exam or chest X-ray. One cause of an enlarged heart is a condition that causes the heart to work harder, such as hypertension or valve disease. An enlarged heart puts you at risk for heart failure. Your doctor will evaluate you to determine why your heart has grown bigger and will treat you to improve heart function as well as to prevent further progression.

Heart failure and high blood pressure

Untreated high blood pressure, or hypertension, can lead to an enlarged heart and heart failure. In addition, hypertension is a risk factor for heart disease, stroke, peripheral vascular disease, kidney disease, and hemorrhages in the blood vessels of the eye.

If you are "prehypertensive" or have high blood pressure you will need to:

• Eat foods low in fat and salt, and rich in fruits, vegetables, and low-fat dairy products
• Lose weight if you are overweight
• Limit your intake of alcohol
• Exercise regularly
• Quit smoking
• Take high blood pressure medicine if your doctor prescribes it. There are several types of medications for treating high blood pressure. Your physician will base your therapy on blood pressure readings and your other medical conditions. Medications must be taken regularly and in the correct dosage; studies show that blood pressure drugs are the most ignored of all prescribed medications. How important is it to get your blood pressure numbers down? The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) noted in its recent report that 55-year-old individuals with blood pressure of 115/75 mm double their risk of developing cardiovascular disease with every rise of 20 mm in systolic pressure and 10 mm in diastolic pressure. You can learn more about the JNC7 guidelines at: http://www.nhlbi.nih.gov/hbp/index.html

Congestive heart failure and diabetes

Diabetes is a risk factor for coronary artery disease, which can lead to heart failure. But diabetes itself also is a risk factor for both systolic and diastolic heart failure, and the risk of heart failure rises with poor control of blood sugar, so individuals with diabetes need to pay close attention to controlling blood sugar.

If you have diabetes, keep the condition under control with diet, exercise, faithful monitoring of blood glucose, and other measures recommended by your doctor. The hemoglobin A1c test, often called the "diabetic report card," provides an average blood sugar level over two to three months. Your result should be less than 7 percent if you have diabetes and less than 6 percent if you do not. Your doctor may ask to check your blood sugar with a glucose monitor several times each day. Give your doctor written records of your monitor's reports.

Take your medicine at the time and in the dosage your doctor recommends. You may need to take oral medication or insulin injections for improved control. Resist the temptations of fast food, bakery windows, and dinner-party indulgences; your diabetic diet may be your best protection against heart failure. A diabetic specialist and a nutritionist can help you control your diabetes and ward off heart failure.

Congestive heart failure and the family link

If any first-degree relatives (parents, siblings, or children) have or had diabetes, kidney disease, high blood pressure, coronary artery disease, cardiomyopathy, or other heart problems, you and your doctor need to be on the lookout for early signs of these conditions so steps can be taken to ward off heart failure. Parents with these conditions, whether or not they have heart failure, need to be aware that many of these are at least partly inherited. In these families especially, creating a healthful home is vital to preventing future illness.

Heart failure and women

About 2.5 million women in the United States have heart failure, and they account for nearly half of all hospital admissions for the disease. Many features of the disease are similar in women and men, but there are important differences:

• Women tend to develop congestive heart failure at an older age than do men.
• Women tend to develop diastolic heart failure with a more normal ejection fraction than do men. (Ejection fraction is the measurement of how much blood is being pumped out of the left ventricle of the heart.) Heart failure can occur as a result of a weakened heart muscle (systolic heart failure) or a stiff, inflexible heart muscle (diastolic heart failure). The causes of heart failure in women are often linked to high blood pressure and diabetes mellitus.
• Although the signs and symptoms of heart failure are the same in men and women, women tend to have more symptoms (such as shortness of breath and difficulty exercising) than do men.
• Women generally survive longer than men with heart failure, but they have more difficulty performing normal daily activities than do men.
• Depression associated with heart failure is more common in women than in men.
• Although rare, peripartum cardiomyopathy is a cause of heart failure unique to women. Peripartum cardiomyopathy is the rare development of heart failure within the last month of pregnancy, or within five months after delivery. Peripartum cardiomyopathy occurs without an identifiable cause.

While there is still much to learn about the diagnosis and treatment of heart failure in women, the goals of treatment are the same for men and women: symptom relief, preventing progression of the condition, and improving quality of life. Treatment options also are the same for women and men, including lifestyle changes, medications, devices, and surgery.

Symptoms

Diagnosing early heart failure can be a challenge because the symptoms often can be similar to symptoms of other conditions. If you have one or more of the symptoms on the list below, make an appointment to see a doctor—and begin keeping a medical diary. The diary should describe your symptoms: how they make you feel, what activities bring them on, what makes them go away, and which ones are the most uncomfortable. This diary could be extremely helpful to you and to your physician.

• Shortness of breath while exercising, climbing stairs, or after eating, caused by fluid buildup in the lungs. Congested lungs not only make breathing difficult even at rest or lying flat at night but can cause a dry, hacking cough or wheezing.
• Swelling (edema) of the ankles, legs, and abdomen or unexplained weight gain can reveal fluid and water retention.
• Frequent nightly urination may indicate that the kidneys are receiving less blood than they need.
• Fatigue and weakness during exercise or mild exertion because the major organs and muscles are starved for blood.
• Dizziness or confusion caused by inadequate blood flow to the brain.
• Nausea, bloating, and loss of appetite.
• Rapid or irregular heartbeat because the heart is working too hard.
• Palpitations (a fluttering or flip-flop feeling in the chest).

Overview

Diagnosing early heart failure can be a challenge, because the symptoms often can be similar to symptoms of other conditions. If you have one or more of the symptoms of heart failure, make an appointment to see a doctor—and begin keeping a medical diary. It could be extremely helpful to you and to your physician.

This section on testing and diagnose includes information on:

• Communicating with your doctor
• The physical exam
• Laboratory tests
• Other tests

Communicating with your doctor

Symptoms that could make a doctor suspect heart failure call for a complete physical exam. Before the exam, start a written record of any symptoms and give a copy to your doctor when you arrive—even better, a day or two before your appointment, to give the physician time to look it over. The diary should describe your symptoms: how they make you feel, what activities bring them on, what makes them go away, and which ones are the most uncomfortable.

Other information you should provide:

• Relevant personal and family history: whether you or any first-degree relatives (parents, siblings, or children) have or had heart or blood vessel disease, cardiomyopathy, diabetes, kidney disease, or high blood pressure.
• Personal habits and information: whether you smoke, what you eat (especially whether you eat a lot of salty or fatty foods), whether you drink any form of alcohol (and if so, how much), and how satisfied you are with your home life, your job, and your sexual activity.
• A list of all medications you are taking—prescription, over-the-counter, herbals, and supplements—along with the dosages.
• Any allergies.
• Records of visits to any other doctors or to an emergency room.
• A record of your weight, recorded every morning after urinating but before eating (if requested).
• A record of your blood sugar or blood pressure (if requested).

A pad and pen are a patient's best friends. Jot down questions for the doctor whenever they occur to you. Bring them in, and write down the doctor's answers. They are easy to forget.

The physical exam

The doctor will be searching for signs of heart failure, as well as other illnesses that might be affecting your heart's pumping ability and producing symptoms.

Skin: The color and warmth show whether your body is getting a good supply of oxygen-rich blood.

Pulse: The pulse shows your heart's rate, rhythm, and regularity.

Swelling in ankles, feet, legs, arms, and abdomen: If swelling is present, your heart may not be pumping efficiently.

Heart sounds: Different sounds through a stethoscope reveal not only the heart's rate and rhythm but also how well it is functioning. A murmur, or whooshing sound, might indicate a leaky valve. A stiff or narrowed valve clicks when it opens and closes. The stethoscope should always be in direct contact with the skin, with no shirt or sweater between.

Blood pressure: A relaxed, resting adult whose blood pressure is higher than a systolic reading of 140 or a diastolic reading of 90 is considered to have hypertension in need of treatment. Age, heart condition, emotions, activity, and medication—even the time of day—can influence the reading. A single elevated reading—especially in a doctor's office, where readings tend to run higher than at home (a well-known phenomenon called "white-coat syndrome")—does not necessarily mean you have high blood pressure. Your blood pressure may need to be checked at different times and in other places to establish what is "normal" for you.

Laboratory tests

Chemical "biomarkers" in the blood help flag a condition or indicate how it is progressing. With heart failure, physicians generally look at several biomarkers, especially if a patient has known heart disease. Patients with higher than normal levels of one or more key biomarkers have been shown to have a far higher risk of developing congestive heart failure or of dying from heart disease than do individuals whose levels are normal.

The following lists typical blood tests and identifies the biomarkers of interest.

• Lipid blood tests: Measures the amount of LDL (the bad cholesterol), HDL (the good cholesterol), and triglycerides, another fatty substance. You can learn more about this test at our lipid blood tests page.
• Enzymes: When heart cells are damaged, several enzymes are released. These include creatine kinase (look for CK on the lab printout), creatine phosphokinase (CPK), lactic dehydrogenase (LD or LDH), troponin, and myoglobin. You can learn more about this test at our enzymes page.
• C-reactive protein (CRP): Indicates the presence of inflammation, which may in turn contribute to heart attacks, stroke, and other cardiovascular problems. You can learn more about this test at our C-reactive protein page.
• Homocysteine: High levels of homocysteine are now considered by many physicians to be an independent predictor of heart disease. (Supplemental folic acid and vitamins B12 and B6 almost always bring high homocysteine down to normal.) You can learn more about this test at our homocysteine page.
• Electrolytes: Primarily sodium and potassium, to be sure that too much or too little sodium or potassium is not causing heart symptoms. You can learn more about this test at our electrolytes page.
• BNP: When heart failure occurs or worsens, the pumping chambers, or ventricles, produce a substance that breaks down to form two proteins: B-type natriuretic peptide (BNP) and N-terminal-pro-BNP (NT-pro-BNP). Both BNP and NT-pro-BNP are secreted into the bloodstream, and their levels rise when heart failure symptoms worsen and fall when symptoms improve. In recent tests, patients who had an elevated level of either protein had a higher risk of death and illness from heart failure. BNP and NT-pro-BNP help determine if you have heart failure rather than another condition that may cause similar symptoms. They also can help the doctor determine if your heart failure has worsened, meaning that more aggressive treatments are needed. Which test your doctor orders (i.e., BNP or NT-pro-BNP) depends on what is available at that medical center. Both tests have been shown to be beneficial.
• Kidney function: Creatinine and blood urea nitrogen (BUN). If the creatinine blood test raises questions, a urinalysis for creatinine will confirm how well the kidneys are working.
• Thyroid function: An overactive thyroid gland—hyperthyroidism—can produce symptoms resembling those of heart failure, so checking the function of the thyroid gland is important.
• Hemoglobin: An oxygen-containing substance carried by the red cells.

Other tests

Chest X-ray: An enlarged heart is a sign of heart failure; the X-ray shows the size of the heart and reveals any buildup of fluid around the heart and lungs, which is another sign. You can learn more about this test at our chest X-ray page.

Echocardiogram: A wand placed on the surface of the chest bounces ultrasound waves off the internal structures of the heart to create pictures of the valves and chambers, permitting the heart's pumping action to be assessed. An echocardiogram is often combined with another ultrasound test to detect changes in the velocity of blood flow through the valves and to gauge the pressure within the pumping chambers. You can learn more about this test at our echocardiogram page.

Ejection fraction (EF): This is a more advanced test, which determines how much of the blood held in the heart's pumping chambers is ejected with each heartbeat. A normal EF is generally greater than 50 percent, meaning more than half of the blood volume is pumped out. Below 40 percent usually confirms a diagnosis of systolic heart failure. Someone with diastolic failure can have a normal EF. EF is measured with various types of nuclear scans, such as a multigated acquisition scan (MUGA), a nuclear ventriculogram, or a radionuclide scan. During a MUGA scan, for example, adhesive electrodes are attached to the chest and connected to an electrocardiograph monitor to chart the heart's electrical activity. An intravenous line is inserted into a vein in the arm. A small amount of blood is withdrawn, mixed with a radioactive tracer that binds to the red blood cells, and reinjected. A large overhead camera focused on the heart analyzes the volume of red blood cells pumped out with each heartbeat. The test takes one to two hours.

Electrocardiogram (EKG): If the doctor has any reason to suspect a heart problem, you will have an electrocardiogram. A large number of adhesive sensors will be placed on your chest and other parts of the body. The electrical impulses traveling through the heart will be monitored and transcribed out on a strip of paper. The test itself is painless, but men with hairy chests will have to endure a few "ouch" moments when the sensors are removed.

Overview

The past 20 years have seen medical and surgical advances in the treatment of congestive heart failure that can extend and improve life. This section describes ways in which CHF is treated, including information on:

• The stages of heart failure
• Medications
• Device therapy
• Surgery

Medications

Most heart failure patients take one or more medications. They can have different effects, such as strengthening the heart's pumping ability, expanding the blood vessels, decreasing the heart's workload, and decreasing water and sodium in the body. Other medications may be used to treat arrhythmias, high blood pressure, and coexisting medical conditions.

Taking heart failure medications as prescribed is one of the most vital aspects of managing heart failure. It is important to know the names of your medications, how they work, how much to take, and when to take them. You should take your medications at the same time every day. Do not stop your prescribed medications or begin taking over-the-counter or herbal medications without first speaking with your physician.

Common heart failure medications include:

• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin II-receptor blockers (ARBs)
• Beta blockers
• Potassium or magnesium
• Digoxin
• Diuretics
• Vasodilators/nitrates
• Aldosterone inhibitors
• Inotropic therapy
• Calcium channel blockers (for diastolic dysfunction only)

This section includes information on:

• ACE inhibitors
• ARBs
• Beta blockers
• Diuretics
• Other drugs
• Prescription medications that can worsen CHF
• Nonprescription medications that can worsen CHF

ACE inhibitors

ACE inhibitors dilate blood vessels and increase blood flow, allowing blood to flow more easily and efficiently. ACE inhibitors are the first line of defense in systolic heart failure. They may also be prescribed for the treatment of diastolic dysfunction.

Every prescription drug has a generic name and a trade, or brand, name. The same drug is often marketed under different trade names. Common ACE inhibitors include:

These drugs should not be taken if you are pregnant or have any of the following medical conditions: a high level of blood potassium, severe kidney problems, severe bilateral renal artery stenosis, or very low blood pressure.

Every medication has benefits and risks. One rare side effect of these drugs that requires immediate medical attention is swelling of the tongue, lips, and throat or difficulty breathing. Other more common side effects include a cough, dizziness, or a salty, metallic taste in the mouth. These side effects may require a change in medication or dosage, or more frequent monitoring by your doctor. Some side effects diminish over time.

Do not take any over-the-counter medications without discussing them with your doctor. Antacids such as Rolaids and Maalox should be avoided; they limit the absorption of ACE inhibitors, especially captopril. Individuals taking a number of different medications, such as older people being treated for several conditions, need to ask about potential drug interactions that might increase the severity of side effects or lessen the effectiveness of the medications.

You may experience side effects other than the ones already mentioned. For more information about this medication and its side effects, ask your doctor, nurse, or pharmacist, or search the National Library of Medicine MedlinePlus database.

Angiotensin-receptor blockers

Angiotensin-receptor blockers, or ARBs, may be given in addition to an angiotensin-converting enzyme (ACE) inhibitor or as a substitute for an ACE inhibitor when patients develop a cough and cannot tolerate the ACE inhibitor. ARBs are used to decrease blood pressure and reduce levels of hormones that cause salt and fluid retention.

These drugs should not be taken if you are pregnant or have any of the following medical conditions: a high level of blood potassium, severe kidney problems, severe bilateral renal artery stenosis, or very low blood pressure.

Every medication has benefits and risks. One rare side effect of these drugs that requires immediate medical attention is swelling of the tongue, lips, and throat or difficulty breathing. Other more common side effects include a muscle pain, back pain, dizziness, or insomnia. These side effects may require a change in medication or dosage, or more frequent monitoring by your doctor. Some side effects diminish over time.

You may experience side effects other than the ones already mentioned. For more information about this medication and its side effects, ask your doctor, nurse, or pharmacist, or search the National Library of Medicine MedlinePlus database.

Beta blockers

Beta blockers can improve the heart's ability to relax and decrease the production of harmful substances produced by the body in response to heart failure. Over time, beta blockers improve the pumping ability of the left ventricle and reduce some symptoms of congestive heart failure. Beta blockers are essential for patients who have mild to moderate congestive heart failure. Certain beta blockers also have been shown to lower CHF deaths, such as carvedilol (Coreg), metoprolol succinate (Toprol), and bisoprolol (Zebeta). Whether patients with severe congestion and symptoms should take beta blockers is still unclear. Some patients may be able to tolerate beta blockers better than others.

Every medication has benefits and risks. Fatigue, dizziness, and lightheadedness are the most common side effects of beta blockers. If you feel dizzy or lightheaded, get up more slowly when you rise from your bed or a chair. Fatigue, bradycardia (a slow heart rate), impotence, and worsening of depression also are common side effects. These may require a change in medication or dosage or more frequent monitoring by your doctor. Fatigue frequently diminishes over time, and so your physician may request that you continue the medication for several months before stopping it. Beta blockers can also cause or aggravate bronchospasm or wheezing, so people with significant lung disease such as severe emphysema or severe asthma may not be able to tolerate these drugs. Also, individuals with diabetes should be aware that beta blockers can mask the symptoms of low blood sugar.

You may experience side effects other than the ones already mentioned. For more information about this medication and its side effects, talk your doctor, nurse, or pharmacist, or search the National Library of Medicine MedlinePlus database.

Diuretics

Diuretics, commonly known as "water pills," cause the kidneys to flush excess fluid from the body. These drugs make it easier for your heart to pump and are used to treat high blood pressure. There are different types of diuretics, but all affect levels of potassium, sodium, magnesium, and other electrolytes in your body. Your doctor will choose a diuretic for you after considering the other medical conditions you may have and the other medications you take. One class is thiazide diuretics (examples: Diuril, Hydrodiuril, Renese, Zaroxolyn). Another class is loop diuretics (including Lasix). Both classes can deplete potassium, causing weakness and fatigue.

Physicians also prescribe potassium-sparing diuretics, called aldosterone blockers (examples: Midamor, Dyrenium, Aldactone, Inspira), to eliminate excess sodium and pooled fluid. Before taking any of these drugs, patients need to tell their doctors whether they are allergic to sulfa or any other drugs, whether they have diabetes, gout, or kidney or liver disease, whether they are pregnant or nursing, and what other prescription drugs and vitamin supplements they are taking.

Because these drugs cause potassium to be retained, salt substitutes, which are rich in potassium, should be avoided. Too high a level of potassium, a condition called hyperkalemia, can be dangerous. Call your doctor immediately if you experience severe nausea and vomiting—including vomiting blood—unusually rapid weight loss, fatigue, drowsiness, or confusion. If your heartbeat becomes irregular or your pulse is slow, weak, or absent (be sure you are taking it correctly), call 911 or go to the emergency room because these symptoms need immediate attention.

You may experience side effects other than the ones already mentioned. For more information about these medications and their side effects, consult your doctor, nurse, or pharmacist, or search the National Library of Medicine MedlinePlus database.

Your doctor will tell you your specific dosage, when to take your medications, and side effects you may have. Patients who take diuretics will need to follow a special diet and check their blood pressure and weight regularly. It's also important to keep appointments for labwork and with your doctor, who will monitor your response to the medication.

Other congestive heart failure drugs

Digoxin (including Lanoxin or Digitoxin) helps to restore a normal, steady heart rhythm and improve circulation by strengthening the force of a heart muscle's contractions.

Every medication has benefits and risks. Many side effects of digoxin are nonspecific—including nausea, vomiting, loss of appetite, and fatigue—making it difficult to determine if they are related to the drug. If you experience changes in vision, such as difficulty distinguishing between yellow and green or seeing a halo effect or flickering lights, notify your physician. These side effects may require a change in medication or dosage, or more frequent monitoring by your doctor. Once your dosage is adjusted, it is unlikely that you will experience side effects if you take digoxin exactly as prescribed.

Vasodilators, like hydralazine and nitrates, are used to treat heart failure and control high blood pressure by relaxing the blood vessels so blood can flow more easily through the body. Vasodilators are prescribed for patients who cannot take ACE inhibitors, among other patients. Most people tolerate hydralazine well. But occasionally, lupuslike symptoms (such as fever, joint or chest pain, sore throat, facial skin rash, and swelling of the joints) crop up. If this happens, you should seek immediate medical attention. Common side effect of nitrates include headache, dizziness, or lightheadedness. If you feel dizzy or lightheaded, stand up more slowly when getting out of bed or a chair. These side effects may require a change in medication or dosage, or more frequent monitoring by your doctor.

You may experience side effects other than the ones already mentioned. For more information about these medications and their side effects, consult your doctor, nurse, or pharmacist, or search the National Library of Medicine MedlinePlus database

Prescription medications that can worsen CHF

Your doctor needs a complete list of your current medications and their dosages. Some heart drugs can worsen congestive heart failure or change the effect of your heart failure medications, among them antiarrhythmics (examples: quinidine, flecainide, propafenone, sotalol, moricizine), calcium channel blockers (examples: verapamil, diltiazem, amlodipine, nifedipine), and certain beta blockers. Women may be asked to avoid estrogens. Viagra, Levitra, and Cialis should not be used if you are taking nitrates (examples: Isordil, Sorbitrate, Imdur, Monoket, nitroglycerin).

It is important to keep a list of your medications with you. If you go to any additional doctors, dentists, or specialists, make sure they are aware of all of your medications, including over-the-counter medications, vitamins, herbal medications, and dietary supplements.

Nonprescription medications that can worsen heart failure

Just because over-the-counter drugs can be obtained without a prescription does not mean they are harmless. Certain ones can aggravate heart failure symptoms or alter the effect of your medications. If you have headaches, muscle pain, or some other problem that calls for relief, consult your doctor before taking any pain reliever or anti-inflammatory drug (examples: ibuprofen, aspirin, Advil, Nuprin, Motrin, Naprosyn, and Feldene, and cox-2 inhibitors such as Celebrex and Bextra).

Some nonprescription drugs are high in sodium, which can cause fluid retention (examples: Alka-Seltzer, Vicks cough syrup, Bisodol, Fleets enema). Read every label before using a product. Most decongestants contain stimulants such as epinephrine or pseudoephedrine. They can stress the heart by elevating the heart rate, and so they should be avoided.

How herbal, vitamin, and dietary supplements affect you may vary according to your age, gender, family history, general nutritional status, other health conditions, and how these conditions are being treated. Be sure to let your doctors know ahead of time if you are thinking about taking any of these sorts of supplements. Even if your physicians do not request this information, bring it up.

Device therapy

Damage to the heart muscle can cause changes in the electrical system of the heart and thus how the heart beats. There are three different types of devices that can be used in the treatment of heart failure to correct an abnormal heartbeat.

Pacemakers:
The traditional pacemaker has two parts: lead wires and a pulse generator, which houses a battery and a tiny computer. The lead wires sense the heart's electrical activity, and when the computer determines that the heart rhythm is off, it responds by sending electrical impulses to the heart muscle to correct its rate. Pacemakers are usually used to treat heart rhythms that are too slow. But they can also be used to treat fast rhythms or to increase the heart rate in response to changes in the patient's activity level.

Biventricular pacemakers:
In the normal heart, the heartbeat originates in an area of specialized cells in the wall of the right atrium and spreads through the atria (top chambers of the heart), causing them to squeeze blood into the ventricles (bottom chambers of the heart), which then contract, pumping blood to the rest of the body. In a patient with heart failure, the right and left ventricles often fail to pump together, a condition known as dysynchrony. When this occurs, the heart has less time to fill with blood and is unable to pump enough blood out into the body, which eventually worsens the degree of heart failure. Biventricular pacemakers are devices that use an additional lead wire to sense atrial contractions and send an electrical impulse to the two ventricles so that they contract at the same time. Called cardiac resynchronization, this therapy can improve symptoms of heart failure, reduce hospitalizations, increase a patient's tolerance for exercise tolerance, and lengthen life.

To be eligible for a biventricular pacemaker, patients must be suffering from severe or moderately severe heart failure symptoms even though they are taking medications to treat it. In addition, they must be experiencing delayed electrical activation of the heart, such as "intraventricular conduction delay" or "bundle-branch block." Patients also need to be aware that the implanting procedure is technically challenging and has a 10 percent failure rate.

Internal cardioverter defibrillator (ICD):
Patients with heart failure are at risk for life-threatening arrhythmias, such as ventricular fibrillation. This is particularly true of patients who have an ejection fraction of less than 35 percent, have survived sudden cardiac arrest, or have a history of ventricular tachycardia (a fast ventricular arrhythmia). The ICD senses electrical activity and sends a shock to the heart if it detects a dangerous heart rhythm. A study called "Sudden Cardiac Death in Heart Failure Trial," published in the New England Journal of Medicine, found that implantable cardiac defibrillators reduce the risk of death from sudden cardiac arrest by 23 percent in patients with heart failure.

Patients may be treated with all three devices or just one or two, depending on the patient's individual medical condition. Ask your doctors about the risks and benefits of these devices and the follow-up care you would need if one or more were used to treat your heart failure.

Surgical options

If medications, strict lifestyle revisions, and a pacemaker or other devices are not enough, surgery may be necessary to prevent further damage to the heart and maintain its ability to function.

Possible procedures include:

• Coronary artery bypass
• Valve repair
• Ventricular surgery
• Implantation of a left ventricular assist device
• Transplantation

Coronary artery bypass

The most common surgery for heart failure is the coronary artery bypass. If the arteries supplying blood to the heart become narrowed, the heart muscle becomes starved for oxygen-rich blood, a condition called ischemia. If those arteries become totally blocked, a heart attack can occur, causing damage to the heart muscle. For many heart failure patients, surgery will relieve symptoms and prevent further damage.

In coronary artery bypass graft surgery a blood vessel graft bypasses one or more blocked coronary arteries to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the chest, leg, or arm. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.

Bypass surgery usually lasts three to five hours. It can be done in different ways. This section includes information on:

• Traditional bypass surgery
• Minimally invasive bypass surgery

Traditional coronary artery bypass

In this procedure, the surgeon makes an incision 6 to 8 inches long down the center of the chest, cuts through the sternum (breastbone), and opens up the rib cage to get direct access to the heart. After the surgery, the surgeon closes the breastbone with special chest wires and the chest with internal or external stitches.

The surgeon may choose to stop the heart so it is motionless before performing the bypass procedure. While the heart is stopped, the heart-lung bypass machine takes over for the heart and lungs, oxygenating blood and circulating it through the body. Alternately, the surgeon may opt to do the procedure on a beating heart—with or without the heart-lung machine. Your surgeon will talk with you about what procedure makes the most sense for you

Minimally invasive direct coronary artery bypass (MIDCAB)

After reviewing your diagnostic tests, your surgeon will decide if you are a candidate for this procedure, which is performed between the ribs through a chest incision just a few inches long. Benefits include a smaller incision (and scar), shorter hospital stay (sometimes as few as three days), faster recovery, less bleeding during surgery, reduced possibility of infection, and less pain postoperatively and during recovery.

MIDCAB surgery usually is reserved for patients whose condition can be addressed by using an artery in the chest to bypass the large coronary artery called the LAD (for left anterior descending). Depending on the technique, the surgeon may choose to perform the surgery on a beating heart—with or without the heart-lung machine—or on a stopped heart—using the heart-lung machine.

Valve surgery

The heart's four valves ensure that blood flows in one direction through the heart. Heart valve disease causes the valves either to not close properly (resulting in a leaky valve) or to not open fully (resulting in a narrowed valve opening). Both types of valve disease cause the heart to work harder, which over time may lead to heart failure.

Heart valve disease is caused by infection, congenital heart disease, and aging. If you require surgery, the surgeon may repair or replace one or more of your heart valves, depending on the type of disease you have. The purpose of surgery is to:

• Preserve the natural anatomy of the heart
• Improve cardiac function
• Diminish symptoms
• Extend your life
• Lessen the possibility of complications and other cardiac risks

Ventricular surgery

Left ventricular reconstruction: A heart attack that occurs in the left ventricle leaves scar tissue in part of the wall, which can thin out and bulge with each heartbeat, adding to the ventricle's workload. Your heart can handle this harder pumping initially, but as time passes, the left ventricle enlarges and pumps less effectively. Combined with other heart damage, this bulging area, or aneurysm, can cause heart failure.

Infarct exclusion surgery allows the surgeon to remove the dead heart tissue and the aneurysm, if possible, and reshape the left ventricle into a more efficiently functioning form. This procedure aims at relieving your heart failure and heart pain. It also may help your heart to pump more normally.

Left ventricular assist device (LVAD)

When all medical therapy has failed and a patient is in end-stage systolic heart failure, a left ventricular assist device may help the heart pump blood more effectively as a "bridge" until a heart becomes available for transplantation, or even as a permanent substitute—so-called "destination therapy." The portable, battery-powered devices are manufactured by various companies, such as Novacor, Thoratec, and Abiomed. Clinical trials are underway to evaluate LVADs as destination therapy.

Implantation of a left ventricular assist device can allow patients to return home to a reasonable semblance of the life they want, sidestepping the challenges of organ shortages. Improvements in the current generation of pulsatile LVADs, or the next generation of small continuous-flow pumps, eventually may provide patients with the opportunity for a full recovery.

Heart transplant

In extremely severe heart failure, a heart transplant may be advised to improve the length and quality of life. Surgeons remove the donor heart, keep it cool in a special solution, and transport it to the hospital where the critically ill recipient is waiting. Surgeons remove the diseased heart, leaving the back walls of the atria (the heart's two upper chambers) intact. They sew the new heart into the chest, atria to atria, and reconnect the blood vessels. Blood can now flow through the new heart into the bodily organs needing it.

A heart transplant is extraordinarily demanding on many levels. Because there are so many more candidates for transplants than there are available hearts, the heart transplant list must be carefully screened. A multidisciplinary team of heart doctors, nurses, social workers, and bioethicists scrutinize the individual's medical history, diagnostic test results, social history, and psychosocial evaluation. The questions are many. Can the patient survive the procedure—and even if the likely answer is yes, will the patient comply with the years of disciplined aftercare necessary? Transplant specialists often say that those who have had a transplant have to think of themselves as chronically ill. They will have to take many medications, visit the doctor for frequent checkups, exercise faithfully, watch their diet, and be on guard for symptoms that could indicated their body is rejecting the donor heart.

If you are approved for the transplant list, you have to wait for an available donor. The wait is often long, and it is always stressful. A sturdy support network of family and friends is essential. A healthcare team must monitor you and closely control your heart failure. Your transplant coordinator explains how you will be notified should a heart become available and learns where you can be reached at a moment's notice.

If a heart does become available, a surgeon from the transplant center flies to the hospital where the donor has died to recover the donor heart, first examining it to make sure it is in good condition. The surgeon removes the donor heart and places it in a cooling solution in an insulated container for transport to the hospital where it will be implanted.

This section also includes frequently asked questions about heart transplantation.

Heart transplants—frequently asked questions

Where does a donor heart come from?

Donor hearts are always anonymous. Grieving families may donate the organs of a young, healthy individual who has been declared brain dead, usually as a result of a head injury, a car or sports accident, or a gunshot wound, to give someone else a chance at life. Once someone has been declared brain dead and the family decides to donate the still-living organs, the information is entered into the United Network for Organ Sharing computerized list. The UNOS list contains blood type, body size, UNOS status (based on clinical status), and the length of time the person with heart failure has been on the waiting list. Neither the donor's race nor gender has any bearing on the match. A computer network matches donors and recipients nationwide.

How long will I be in the hospital after a heart transplant?

How quickly you recover after a heart transplant depends on your age, overall health, and bodily responses to the transplant. Most patients are up and about within a few days of the surgery and home in a week or two.

After the donor heart is transplanted, will it beat the way it did in its donor?

The donor heart comes with its own natural pacemaker and its own coronary arteries. When the heart is removed, the donor's nervous system is disconnected and there is no way to link the heart to the recipient's nervous system. The transplanted heart usually beats adequately but occasionally needs help from a pacemaker.

What is immunosuppression?

Your body's defense system against foreign invaders such as bacteria and viruses is its immune system, which is composed primarily of white blood cells. Your white blood cells consist of different fighter cells, known as B and T cells. B cells fight germs by producing antibodies, which fight against infections and render germs harmless. T cells kill foreign invaders, such as germs and cancer cells, by engulfing them. Each time your body has an immune reaction, it memorizes the particular "fingerprint" of the invading foreign body—the antigen—so that the immune system can respond quickly when the same antigen invades again. Although your immune system helps protect you against "bad" invaders such as infections, it cannot distinguish between a "bad invader" and a "good invader," such as a transplanted heart. As a result, your body's immune system "thinks" the new heart is a foreign invader and attempts to destroy it. To stop this rejection of your heart transplant, you will need to take immunosuppressant medications for the rest of your life. Since immunosuppression makes you more vulnerable to infections, you will need to prevent exposure as much as you can.

What is rejection?

An attack on your transplanted heart by your immune system is a sign of rejection. To prevent damage to the heart, you and your doctors must be alert to signs of rejection and treat it quickly. After a transplant, your transplant team will teach you how to watch carefully for any symptoms of rejection and where to call if you recognize any such symptoms. Your doctor needs to check you regularly for any symptoms of rejection and perform regular myocardial biopsies that can detect any subclinical rejection before symptoms occur. You will be on special medications—called immunosuppressants—to help prevent rejection for the rest of your life.

Can coronary artery disease return after a transplant?

There are two types of coronary artery disease that can occur post transplant. The first type develops naturally over time (like CAD in patients without heart transplants) or as a result of residual disease from the donor heart that was not detected when it was harvested. The second, more common type is called transplant vasculopathy and can occur at any time after a transplant. Transplant vasculopathy is immune mediated and causes a narrowing of the coronary arteries that cannot be fixed by angioplasty or stenting. Treatment for CAD after a heart transplant is difficult, so prevention is the key: Transplant patients need to follow a heart healthy lifestyle and take medications to reduce their risk of CAD.

Overview

Although good management can slow heart failure's progress, it is generally a progressive disease. As the patient's condition advances, the patient's healthcare team will intensity its efforts, adding or changing drugs or raising dosages and stressing the need for the patient to adopt a more healthful lifestyle.

Note: Certain types of heart failure actually can be reversed—not just slowed. For example, if serious valve disease caused the heart failure, surgery to fix the valve might "cure" the patient's heart failure. Similarly, when heart failure is the result of heavy drinking, stopping drinking can reverse the condition.

This section discusses:

• Your management team
• The stages of heart failure
• Medications
• Lifestyle-related goals
• When to call your doctor
• When to call 911 or go to the emergency room
• The years to come

Your management team

More than two thirds of patients with heart failure are under the exclusive care of a primary-care physician. Most clinical guidelines recommend that patients also be monitored routinely by a cardiologist who specializes in heart failure, with help from nurses, dietitians, pharmacists, exercise specialists, and social workers as needed.

Managing congestive heart failure is as much the patient's as the physician's responsibility. Patients must take medications as directed, change their diet as necessary, cut back on fluids, exercise, quit smoking, make and keep follow-up appointments, and accurately report symptoms and any side effects of their medications to all doctors involved in their care. Also, while it may seem obvious, if you're not told when you should come again, ask--and make your next appointment before leaving the office.

The stages of heart failure

The American Heart Association and the American College of Cardiology defined the specific stages of heart failure in 2001 to show patients where they stand and the range of therapies they can expect at that point. For their own purposes, physicians also refer to New York Heart Association clinical categories, which rank patients from Class I to IV according to functional limitations and the severity of symptoms.

Below are the AHA/ACC stages. The following therapies may or may not apply to you, depending on the cause of your heart failure and your specific medical condition. This guide is meant to assist you in discussing treatment options with your physician.

Stage A: No diagnosis or symptoms of heart failure, but the risk is high because of one or more of the following factors: hypertension; diabetes; known coronary artery disease and history of a heart attack; history of cardiotoxic drugs (therapeutic or recreational) or alcohol abuse; history of rheumatic fever; and family history of cardiomyopathy.

Usual therapies: Stop smoking and exercise. Treat hypertension and high blood levels of cholesterol and triglycerides. Stop use of alcohol and illicit drugs. Your doctor may prescribe an angiotensin-converting enzyme (ACE) inhibitor if you have had a previous heart attack, hypertension, or diabetes and a beta blocker if you have had a previous heart attack.

Stage B: Heart failure diagnosed by an ejection fraction (a test measuring the amount of blood pumped out of the main pumping chamber with each heartbeat) below 40 percent (compared with a normal 55 percent or more) but no past or current symptoms.

Usual therapies: All therapies in Stage A plus: Get a surgical consultation for coronary artery revascularization and valve repair or replacement (as appropriate). Your doctor should prescribe an ACE inhibitor and beta blocker (unless contraindicated).

Stage C: Heart failure diagnosed, with past or current symptoms, including shortness of breath, fatigue, and reduced exercise tolerance.

Usual therapies: All therapies in Stage A plus: All patients should take an ACE inhibitor and beta blocker. Your doctor may also prescribe a diuretic and digoxin, if appropriate. All patients should restrict their intake of salt, monitor their weight, and restrict fluid intake (as appropriate). Discontinue drugs that make the condition worse. Your doctor may prescribe spironolactone when symptoms remain severe with other therapies.

Stage D: Advanced symptoms of heart failure after receiving optimal medical care.

Usual therapies: All therapies in Stages A, B, and C plus: evaluation for other treatment options, such as a heart transplant, ventricular-assist device, other surgeries, continuous IV infusion of inotropic drugs, and research therapies.

Medications

Taking medications as prescribed is a vital part of managing heart failure. Many patients will take more than one medication. It is important to know the names of your medications, how they work, how much to take, and when to take them. Take your medications at the same time every day. Never stop your medications without speaking to your physician. Do not take over-the-counter or herbal medications without first asking your doctor.

Heart failure medications are used to strengthen the heart's pumping ability, expand the blood vessels, decrease the workload on the heart, and decrease water and sodium in the body. Other medications may be used to treat arrhythmias, high blood pressure, and coexisting medical conditions.

Common heart failure medications include:

• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin II-receptor blockers (ARBs)
• Beta blockers
• Potassium or magnesium
• Digoxin
• Diuretics
• Vasodilators/nitrates
• Aldosterone inhibitors
• Inotropic therapy
• Calcium channel blockers (for diastolic dysfunction only)

Lifestyle-related goals

Treating heart failure requires a team effort, which includes a commitment to adhering to a healthful lifestyle. Making these changes will help to improve symptoms, slow the progression of heart failure, and improve your daily life. The following are general guidelines; members of your healthcare team will discuss with you specific recommendations.

Diet:

1. Restrict the sodium in your diet to less than 2,000 mg per day. Remove the saltshaker from the table, and learn to read food labels to make the best low-sodium choices. Many frozen, processed, and precooked foods from the supermarket as well as restaurant fast foods are high in sodium and fat.
2. Increase your consumption of fiber by eating more whole grains, vegetables, and fruits.
3. Carefully follow your fluid management guidelines. The general rule is to drink no more than 8 cups of fluid daily, including semiliquid foods such as yogurt and pudding, even if you feel thirsty.
4. Eat a variety of foods to get all the nutrients you need.
5. Consider consulting a dietitian or nutritionist to help with menu planning.

Weight: Maintain a healthy body weight. Drop extra pounds, and keep them off by limiting your total daily caloric intake, following a low-fat diet, and exercising on most days.

Alcohol: Your doctor may recommend limiting or avoiding alcohol. If alcohol is permitted, make it red wine, and have no more than 4 ounces a day (red wine has heart benefits).

Exercise: Regular exercise has many benefits. But always check with your doctor before starting an exercise program. Find out how often you should exercise, and ask for a list of exercises and activities that would be appropriate for you. If you feel more comfortable beginning to exercise in a supervised setting, ask your doctor for a cardiac rehabilitation program near you.

Enjoy life: Stay in touch with friends, and plan daily activities to get out of the house. Still, keep your activities within the limits set by your doctor. Listen to your body so you know when it is time to rest and rebuild your energy.

Tobacco: Do not smoke or chew tobacco. Tobacco increases your risk of heart disease by causing your blood pressure and heart rate to rise.If you need help to quit smoking, ask your healthcare team.

Control additional risk factors: If you have high blood pressure or diabetes, work with your healthcare team to achieve your goals.

Monitor your health: Weigh yourself at the same time every day, using the same scale, preferably in the morning after urinating and before dressing. Record your weight in a diary for your doctor to review at every visit. Call your doctor if you gain more than 3 pounds in one day or 5 pounds in one week.

Get the flu shot and pneumonia vaccine: Talk to your doctors about getting a pneumococcal vaccination every five years and an annual flu shot. Complications of respiratory problems can worsen heart failure.

Stay emotionally healthy: Learning that you have heart failure may provoke feelings of anxiety or depression. These feelings should fade as you begin to take charge of your health and make positive lifestyle changes. But if the negative feelings continue or prevent you from enjoying life, talk to your doctor.

When to call your doctor

If you experience any of the following symptoms, call your doctor. Do not wait until your next appointment to make the call, and do not change or stop taking your medications without first talking to your doctor. If your symptoms are discovered early, your doctor may be able to relieve your symptoms by changing your medications.

• Unexplained weight gain—3 or more pounds in one day or 5 or more pounds in one week
• Increased swelling in the ankles, feet, legs, or abdomen
• More-severe or more-frequent shortness of breath, especially on awakening
• Abdominal fullness or bloating
• Loss of appetite or nausea
• Extreme fatigue or decreased ability to undertake daily activities
• A respiratory infection or bad cough
• A resting heart rate of 120 beats or more per minute
• A new or more noticeably irregular heartbeat
• Chest pain or discomfort that is relieved with rest
• Difficulty breathing during regular activities or at rest
• Difficulty sleeping or needing much more sleep than usual
• Decreased urination
• Restlessness or confusion
• Dizziness or lightheadedness
• Excessive, unexplained perspiration

When to call 911 or go to the emergency room

Take immediate action if you experience any of the following:

• New, severe chest pain or discomfort, especially if you are short of breath, sweating, nauseated, or weak
• A fast heartbeat (more than 120 to 150 beats per minute), especially with shortness of breath
• Shortness of breath that is not relieved by rest
• Sudden weakness or inability to move your arms or legs
• Sudden onset of a severe headache
• A fainting spell with loss of consciousness

The years to come

With the right care and teamwork, heart failure should not keep you from doing most of the things you enjoy. Your future health depends on how well your heart muscle functions, how well and how often you and your doctor work together to control and treat your symptoms, how well you follow your treatment plan, and how well your heart responds to care.

Whatever your medical condition—whether you and your heart are healthy or are beset by long-term, chronic heart failure—you should discuss with your doctor, family, and lawyer the kind and amount of intensive medical care you want when your life is ending. An "advanced directive" or "living will" is a good way to let everyone know your wishes. A living will spells out what medical treatments you do or don't want to prolong your life. Preparing and signing a living will while you are fully competent is in your best interests. There is always a possibility that you could be unable to make such decisions down the road. For help in this area, one good resource is the nonprofit group Aging with Dignity at agingwithdignity.org