Overview

Heart Failure, also known as Congestive Heart Failure, is a clinical syndrome that results
from the progressive process of remodeling, in which mechanical and biochemical forces alter
the size, shape, and function of the ventricle’s ability to pump enough oxygenated blood to meet
the body’s metabolic requirements. Compensatory mechanisms of increased heart rate,
vasoconstriction, and hypertrophy eventually fail, leading to the characteristic syndrome of heart
failure: Elevated ventricular or atrial pressures, sodium and water retention, decreased cardiac
output, and circulatory and pulmonary congestion. Systolic dysfunction occurs when the left
ventricle is unable to relax and fill sufficiently to accommodate enough oxygenated blood
returning from the pulmonary circuit. Systolic dysfunction leads to increased vascular resistance
and increased afterload. Diastolic dysfunction leads to pulmonary vascular congestion.

Etiology and Epidemiology

Heart failure is a condition in which the heart no longer functions effectively as a pump.
Depending upon the cause, heart failure may be classified as low output failure or high output
failure(l). Low output failure is said to occur when the pumping efficiency of the heart becomes
reduced by factors that impair cardiac function. High output failure occurs when the cardiac
output of the heart remains significantly elevated for a long period. With high output failure, the
metabolic and oxygen demands of the heart exceeds what can be supplied by the coronary
circulation and the function of the myocardium eventually fails.
Despite the paucity of epidemiologic work on congestive heart failure (CHF), the salient
features of the natural course of cardiac failure are understood. The estimated 1983 incidence of
CHF in the United States was 214,000 men and 184,000 women. The estimate of prevalence was
2.3 million persons, with a remarkable increase with advancing age and higher rates in men than
women at all ages. Overt heart disease plus age are the principal determinants of the incidence of
CHF. Nearly 90% of patients with CHF have systemic hypertension or coronary heart disease, or
both, as the antecedent underlying condition. Diabetes mellitus increases the risk of CHF at all
ages, particularly in women and those treated with insulin. The prognosis after diagnosis of CHF
is grim and is related to the degree of myocardial dysfunction. The challenge is to develop more
effective drugs not only for the management of overt CHF, but also for the prevention of its
progression.

Pathophysiology
* Decreased cardiac contractility (depressed
ventricular function curve): this defect is fundamental
in congestive failure; it appears in a variety of
conditions such as acute myocardial infarction,
chronic uncontrolled hypertension, and valvular
disease. In chronic failure, there is an underlying
biochemical defect that is not understood.
* Decreased cardiac output and decreased ejection
fraction: this consequence of decreased contractility
results in diminished tissue perfusion and increased
pulmonary venous pressure (in "left heart failure")
and/or increased peripheral venous pressure (in "right
heart failure").
 * Autonomic compensatory mechanisms: increased sympathetic discharge results from
inadequate tissue perfusion and hypotension and causes tachycardia, increased renin release, and
increased peripheral arteriolar and venous constriction. These effects increase the cardiac work
load and eventually lead to further decompensation.
* Hormonal compensatory mechanisms: decreased renal blood flow and increased renin release
(which causes a rise in angiotensin II and aldosterone levels) result in salt and water retention
and an increase in vascular pressures. These factors may lead to peripheral or pulmonary edema.
Atrial natriuretic factor (ANF, atriopeptin) is probably released in increased amounts early in
failure and may aid cardiac compensation through its vasodilating and diuretic effects, but its
beneficial action is apparently overcome by detrimental factors as cardiac decompensation
proceeds.
* Cardiac hypertrophy occurs as a further compensatory response to failure.

Therapeutic Rat ionale

* Reduce salt and water retention: Diuretics are the first line drugs
for use in most uncomplicated cases of congestive heart failure.
(Restriction of sodium intake is desirable but sometimes difficult to
achieve.) Reduction of blood volume decreases the size of the heart,
allowing it to function on a more favorable portion of the ventricular
function curve, and reduces the intracapillary pressure that leads to
edema. The diuretics are described in more detail in Chapter 13.

* Increase the force of cardiac contraction: Positive inotropic drugs

such as digitalis glycosides are effective in many cases of chronic
failure and move the heart to a higher ventricular function curve.
They are generally more toxic than the diuretics. Several positive in-
otropic substitutes for digitalis are available for use in special
circumstances.

* Reduce vascular tone: Vasodilators reduce the work of

the heart and improve cardiac ejection and tissue perfusion. They are
especially useful in acute failure, eg, that associated with myocar-
dial infarction and severe hypertension. Vasodilators are described
in greater detail in Chapters 2 and 5.
Treating Congestive Heart Failure

Treating CHF can reduce fatigue, shortness of breath, and swelling of tissue, while enhancing your energy level, ability to
exercise, and feeling of well-being. Everyone's situation is different, so some treatments that fit one person are not
appropriate for another. You and your family should talk with your doctor about the most appropriate medical or surgical
treatment options.

What to expect: Doctors treat patients with CHF by recommending proper diet and modified daily activities. Doctors may
also prescribe one or more of the following medications:

• ACE inhibitors (angiotensin-converting enzyme inhibitors)—help open the arteries and lower blood pressure,
improving blood flow. If you have LVSD, you should be prescribed an ACE inhibitor when you are discharged from
the hospital, unless there is a reason to not prescribe it, such as an allergy. Commonly used ACE inhibitor names
are captopril, enalapril, lisinopril, ramipril, and fosinopril. Not everyone can take ACE inhibitors, but you should ask
your doctor or nurse about this if one is not prescribed for you.
• Diuretics—or “water pills" to help keep fluid from building up in your body and lungs, which helps you breathe
easier.
• Beta blockers—help to improve blood pressure and may help prevent some heart rhythm problems.
• Digoxin─Also called “digitalis,” digoxin helps the heart pump better.
• Lipid-lowering drugs—to help lower cholesterol in patients to decrease the likelihood of new buildup.
• Anti-hypertensive medications─these drugs lower blood pressure and help prevent heart failure or prevent it from
worsening.

People with heart failure often need to limit daily activities and visit their physician frequently. Many treatments can help
prevent or slow down the progress of CHF and enable you to live longer and more comfortably. You must follow the doctor’s
instructions for rest, diet, medication, and modified daily activities. If you do not follow the recommended treatment, you
may need several medications and hospital stays.

In some cases, the doctor finds a cause that is treatable—such as heart valve problems, coronary artery disease, irregular
heartbeats, and alcohol abuse. In these cases, you should follow the doctor’s advice to reverse the cause.

Learning how to care for yourself

When you are leaving the hospital after treatment for CHF, a hospital provides you with written instructions or educational
material to continue your progress. Follow your discharge instructions carefully.

What to expect: Instructions should include the following health and lifestyle recommendations:

• Level of daily activity—You may need to change your daily routine to avoid behavior that will make your
symptoms worse. Typical activities people may have questions about include work, sports, leisure, sex, and
household chores.
• A heart-healthy diet—You may improve your condition by eating more healthful foods. Moderate restrictions on
salt, for example, sometimes apply. Ask your doctor to refer a dietician or other professional to help improve your
diet.
• Instruction about medications—Upon discharge, your doctor should provide you a list of your medications, what
they are used for, their potential side effects, your prescribed doses, and the times you should take them.
• An appointment for a follow-up exam—Schedule a follow-up appointment, where you can confirm that your
medications are working and detect early warning signs of new problems.
• Daily weight monitoring—At home, you should weigh yourself every morning at the same time on the same
scale. Keep a daily record of your weight. Call your doctor if you gain two or more pounds overnight or five pound
in a week.
• Instructions on what to do if symptoms worsen—Discharge instructions should tell you what to do and whom
to contact if your symptoms worsen. Some problems that should be included are:
o You gain two or more pounds overnight or five pounds in a week.
o Your ankles or feet swell more than usual.
o You start coughing at night or have a frequent dry cough.
o Breathing becomes difficult.
o You have a “black-out” spell.