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Encyclopedia > Congestive heart failure
Congestive heart failure
ICD-10 I50.0
ICD-9 428.0

Congestive heart failure (CHF), also called congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body. It is not to be confused with "cessation of heartbeat", which is known as asystole, or with cardiac arrest, which is the cessation of normal cardiac function in the face of heart disease. Because not all patients have volume overload at the time of initial or subsequent evaluation, the term "heart failure" is preferred over the older term "congestive heart failure". Congestive heart failure is often undiagnosed due to a lack of a universally agreed definition and difficulties in diagnosis, particularly when the condition is considered "mild". The following codes are used with International Statistical Classification of Diseases and Related Health Problems. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The heart and lungs, from an older edition of Grays Anatomy. ... Human blood smear: a - erythrocytes; b - neutrophil; c - eosinophil; d - lymphocyte. ... In medicine, asystole is a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow. ...

Contents


Causes

Causes and contributing factors to congestive heart failure include (with specific reference to left (L) or right (R) sides):

  • Genetic family history of CHF
  • Ischaemic heart disease/Myocardial infarction (coronary artery disease)
  • Infection
  • Alcohol ingestion
  • Anemia
  • Thyrotoxicosis (hyperthyroidism)
  • Arrhythmia
  • Hypertension (L)
  • Coarctation of the aorta (L)
  • Aortic stenosis/regurgitation (L)
  • Mitral regurgitation (L)
  • Pulmonary stenosis/Pulmonary hypertension/Pulmonary embolism all leading to cor pulmonale (R)
  • Mitral valve disease (R)

The usual heart irritants can make CHF deadly: arterial plaque, stress, smoking, old age, lack of exercise, overworked heart, and obesity. In genetic family history of CHF, the cause is a weak heart having thinner muscle walls than usual, and often weakened further by one or more of the above heart irritants. Arterial plaque (caused by eating fatty or greasy foods) lines the inside of the arteries and heart, increasing blood pressure and tiring the heart. In obesity cases, the heart is squashed by fat surrounding it, giving it too little room to beat. The result is irregular heart beats causing inefficient blood pumping and a tired heart. Hyperthyroidism (or overactive thyroid gland) is the clinical syndrome caused by an excess of circulating free thyroxine (T4) or free triiodothyronine (T3), or both. ... Cor pulmonale is a medical term used to describe a change in structure and function of the right ventricle of the heart as a result of a respiratory disorder. ... The word plaque or placque may mean: Wiktionary has related dictionary definitions, such as: plaque, placque Dental plaque, a yellowish film that builds up on the teeth Atheromatous plaque, a buildup of fatty deposits within the wall of a blood vessel Mucoid plaque, a supposed thick coating of plaque in...


Classification

There are many different ways to categorize heart failure, including:

  • the side of the heart involved, (left heart failure versus right heart failure)
  • whether the abnormality is due to contraction or relaxation of the heart (systolic heart failure vs. diastolic heart failure)
  • whether the abnormality is due to low cardiac output or low systemic vascular resistance (low-output heart failure vs. high-output heart failure)

The NYHA functional class is a commonly used way to gauge the progression of CHF in a particular patient. This classification is used to determine how much CHF limits their lifestyle, and does not apply to a particular decompensated episode. Depending on symptoms, patients may move in either direction on the NYHA scale. Systolic is the adjective form of systole, typically referring to the contraction activity of the heart. ... Diastolic is the adjective form of diastole referring to relaxation of the heart, between muscle contractions. ... The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying the extent of heart failure. ...

  • Class I: No symptoms at any level of exertion
  • Class II: Symptoms with heavy exertion
  • Class III: Symptoms with light exertion
  • Class IV: Symptoms with no exertion

Heart failure stages from the ACC/AHA guidelines represent a newer classification that complements the NYHA classification.

  • Stage A: At risk for developing heart failure without evidence of cardiac dysfunction
  • Stage B: Evidence of cardiac dysfunction without symptoms
  • Stage C: Evidence of cardiac dysfunction with symptoms
  • Stage D: Symptoms of heart failure despite maximal therapy

An important feature of the staging classification is that patients can only progress in one direction: from Stage A to D. This is meant to reflect the progressive nature of heart failure.


Signs and Symptoms

Left Heart Failure: Symptoms of decompensated heart failure include dyspnea (shortness of breath) on exertion, orthopnea (dyspnea that increases upon lying down), fatigue and paroxysmal nocturnal dyspnea ("cardiac asthma", shortness of breath that occurs hours or minutes after lying down). Nocturnal cough, Confusion and memory impairment (in advanced stages), and diaphoresis and cool extremities at rest. The term symptom (from the Greek syn = con/plus and pipto = fall, together meaning co-exist) has two similar meanings in the context of physical and mental health: Strictly, a symptom is a sensation or change in health function experienced by a patient. ... Dyspnea (Latin dyspnoea, Greek dyspnoia from dyspnoos, short of breath) or shortness of breath (SOB) is perceived difficulty breathing or pain on breathing. ... orthopnea ... kjkjk ...


Signs of decompensated left heart failure include: Displaced PMI (usually to left due to cardiomegaly), Pathologic S3 Gallop, S4, Crackles at the lung bases due to pulmonary edema (fluid accumulation in the lungs), Dullness to percussion and tactile fremitus of lower lung fields. Increased intensity of pulmonic component of 2nd heart sound. In medicine, a sign is a feature of disease as detected by the doctor. ... Pulmonary edema is swelling and/or fluid accumulation in the lungs. ...


Right Heart Failure: Symptoms and Signs include: Peripheral edema (fluid build-up in dependent portions of the body), ascites (fluid in the abdominal cavity), nocturia (due to increased venous return with leg elevation), Jugular venous distention, Hepatomegaly, hepatojugular reflux, and right ventricular heave. The term symptom (from the Greek syn = con/plus and pipto = fall, together meaning co-exist) has two similar meanings in the context of physical and mental health: A symptom can be a physical condition which shows that one has a particular illness or disorder (see e. ... This article is about the Signs Signs, see Signs (disambiguation). ... Peripheral edema ... Nocturia is the need to get up during the night in order to urinate, thus interrupting sleep. ... Hepatomegaly is the condition of having an enlarged liver. ...



Individuals with heart failure are sensitive to small shifts in their intravascular volume status (the amount of fluid in their circulatory system). Increasing the volume in their circulatory system can cause symptoms and signs of decompensated heart failure, while decreasing the volume in the circulatory system can cause hypotension. Human circulatory system. ... In physiology and medicine, hypotension refers to an abnormally low blood pressure. ...


Chest X-rays (CXRs) are frequently used to aid in the diagnosis of CHF. Signs of CHF on CXR are[1]: Frontal chest X-ray. ... In medicine, a sign is a feature of disease as detected by the doctor. ...

Edema (BE: oedema, formerly known as dropsy) is swelling of any organ or tissue due to accumulation of excess fluid. ... In chest radiology, Kerley B lines are a sign seen with interstitial pulmonary edema. ... Consolidation is the act of merging many things into one. ... Cardiomegaly is a medical condition wherein the heart is enlarged. ...

Treatment

The treatment of CHF focuses on treating the symptoms and signs of CHF and preventing the progression of disease. If there is a reversible cause of the heart failure (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, or hypertension), that should be addressed as well. Reversible cause treatments can include exercise, eating healthy foods, reduction in salty foods, and reduction or abstinence of smoking and drinking alcohol. An infection is the detrimental colonization of a host organism by a foreign species. ... In chemistry, an alcohol is any organic compound in which a hydroxyl group (-OH) is bound to a carbon atom of an alkyl or substituted alkyl group. ... This article discusses the medical condition. ... Hyperthyroidism (thyrotoxicosis or fast thyroid gland) is the clinical syndrome caused by an excess of circulating free thyroxine (T4) and free triiodothyronine (T3), or both. ... A cardiac arrhythmia, also called cardiac dysrhythmia, is a disturbance in the regular rhythm of the heartbeat. ... For other forms of hypertension see hypertension (disambiguation). ...


Non-pharmacological measures

Patients with CHF are educated to undertake various non-pharmacological measures to improve symptoms and prognosis. Such measures include (Smith et al., 2003):

  • Moderate physical activity, when symptoms are mild or moderate; or bed rest when symptoms are severe.
  • Weight reduction – through physical activity and dietary modification, as obesity is a risk factor for heart failure and ventricular hypertrophy.
  • Sodium restriction – excessive sodium intake may precipitate or exacerbate heart failure, thus a "no added salt" diet (60–100 mmol total daily intake) is recommended for patients with CHF. More severe restrictions may be required in severe CHF.
  • Fluid restriction – patients with CHF have a diminished ability to excrete free water load. They are also at an increased risk of hyponatremia due to the combination of decreased sodium intake and diuretic therapy. Generally water intake should be limited to 1.5 L daily or less in patients with hyponatremia, though fluid restriction may be beneficial regardless in symptomatic reduction.

Although ventricular hypertrophy may occur in either the left or right or both ventricles of the heart , left ventricular hypertrophy (LVH) is more commonly encountered. ... General Name, Symbol, Number sodium, Na, 11 Chemical series alkali metals Group, Period, Block 1, 3, s Appearance silvery white Atomic mass 22. ... The electrolyte disturbance hyponatremia or hyponatraemia exists in humans when the sodium level in the plasma falls below 135 mmol/l. ... The electrolyte disturbance hyponatremia or hyponatraemia exists in humans when the sodium level in the plasma falls below 135 mmol/l. ...

Pharmacological management

It has been noted that there is a significant evidence–practice gap in the treatment of CHF, particularly the underuse of ACE inhibitors and β-blockers. (Jackson et al., 2005) Treatment of CHF aims to relieve symptoms, maintain a euvolemic state (normal fluid level in the circulatory system), and to improve prognosis by delaying progression of heart failure and reducing cardiovascular risk. Drugs used include: diuretic agents, vasodilator agents, positive inotropes, ACE inhibitors, beta blockers, and aldosterone antagonists (e.g. spironolactone). A diuretic is any drug that elevates the rate of bodily urine excretion. ... A vasodilator is a substance that causes blood vessels in the body to become wider by relaxing the smooth muscle in the vessel wall, or vasodilation. ... An inotrope is an agent which increases or decreases the force or energy of muscular contractions. ... Captopril, the first ACE inhibitor ACE inhibitors, or inhibitors of Angiotensin-Converting Enzyme, are a group of pharmaceuticals that are used primarily in treatment of hypertension and congestive heart failure, in most cases as the drugs of first choice. ... Beta blockers or beta-adrenergic blocking agents are a class of drugs used to treat a variety of cardiovascular conditions and some other diseases. ... Aldosterone antagonist refers to drugs which antagonise the action of aldosterone at mineralocorticoid receptors. ... Spironolactone (marketed as Aldactone or Spiritone) is a synthetic 17-lactone steroid which is a renal competitive aldosterone antagonist in a class of pharmaceuticals called potassium-sparing diuretics, used primarily to treat low-renin hypertension, hypokalemia, and Conns syndrome. ...


Angiotensin-modulating agents

ACE inhibitor (ACEI) therapy is recommended for all patients with systolic heart failure, irrespective of symptomatic severity or blood pressure. (Krum et al., 2001; NICE, 2003; Hunt et al., 2005) ACE inhibitors improve symptoms, decrease mortality and reduce ventricular hypertrophy. Angiotensin II receptor antagonist therapy (also referred to as AT1-antagonists or angiotensin receptor blockers), particularly using candesartan, is an acceptable alternative if the patient is unable to tolerate ACEI therapy. (Granger et al., 2003; Pfeffer et al., 2003) Captopril, the first ACE inhibitor ACE inhibitors, or inhibitors of Angiotensin-Converting Enzyme, are a group of pharmaceuticals that are used primarily in treatment of hypertension and congestive heart failure, in most cases as the drugs of first choice. ... Although ventricular hypertrophy may occur in either the left or right or both ventricles of the heart , left ventricular hypertrophy (LVH) is more commonly encountered. ... Angiotensin II receptor antagonists, also known as angiotensin receptor blockers (ARBs) or AT1-receptor antagonists, are a group of pharmaceuticals which modulate the renin-angiotensin-aldosterone system. ... Candesartan (kan-de-SAR-tan) belongs to the class of medicines called angiotensin II inhibitors. ...


Diuretics

Diuretic therapy is indicated for the relief of congestive symptoms. Several classes are used, with combinations reserved for severe heart failure (Smith et al., 2003): A diuretic is any drug that elevates the rate of bodily urine excretion. ...

Loop diuretics are diuretics that act on the ascending loop of Henle in the kidney. ... Furosemide (INN) or frusemide (former BAN) is a loop diuretic used in the treatment of congestive heart failure and edema. ... Thiazides are diuretics, a class of drug that promote water loss from the body. ... Hydrochlorothiazide (Apo-Hydro®, Aquazide H®, Microzide®, Oretic®), sometimes abbreviated HCT, HCTZ, or HZT is a popular diuretic drug that acts by inhibiting the kidneys ability to retain water. ... Potassium-sparing diuretic refers to diuretic drugs that do not promote the secretion of potassium into the urine. ... Amiloride is an antihypertensive, a potassium-sparing diuretic that was first approved for use in 1967 and helps to treat hypertension and congestive heart failure. ... Hypokalemia is a condition in which the body fails to retain sufficient potassium to maintain health. ... Spironolactone (marketed as Aldactone or Spiritone) is a synthetic 17-lactone steroid which is a renal competitive aldosterone antagonist in a class of pharmaceuticals called potassium-sparing diuretics, used primarily to treat low-renin hypertension, hypokalemia, and Conns syndrome. ... Eplerenone (INN) (IPA: ) is an aldosterone antagonist used as an adjunct in the management of chronic heart failure. ...

Beta blockers

Until recently, β-blockers were contraindicated in CHF, owing to their negative inotropic effect and ability to produce bradycardia – effects which worsen heart failure. However, current guidelines recommend β-blocker therapy for patients with systolic heart failure due to left ventricular systolic dysfunction after stabilization with diuretic and ACEI therapy, irrespective of symptomatic severity or blood pressure. (NICE, 2003) As with ACEI therapy, the addition of a β-blocker can decrease mortality and improve left ventricular function. Several β-blockers are specifically indicated for CHF including: bisoprolol, carvedilol, and extended-release metoprolol. Beta blockers or beta-adrenergic blocking agents are a class of drugs used to treat a variety of cardiovascular conditions and some other diseases. ... Bisoprolol is a drug belonging to the group of beta blockers, a class of drugs used primarily in cardiovascular diseases. ... Carvedilol (Coreg®) is a non-selective beta blocker indicated in the treatment of mild to moderate congestive heart failure (CHF). ... Metoprolol is a beta blocker drug used in treatment of several diseases of the cardiovascular system. ...


Positive inotropes

Digoxin, once used as first-line therapy, is now reserved for control of ventricular rhythm in patients with atrial fibrillation; or where adequate control is not achieved with ACEI plus loop diuretic. There is no evidence that positive inotropes reduce mortality in CHF. Digoxin is a cardiac glycoside extracted from the foxglove plant, digitalis. ... Atrial fibrillation (AF or afib) is an abnormal heart rhythm (cardiac arrhythmia) which involves the two small, upper heart chambers (the atria). ...


Alternative vasodilators

The combination of isosorbide dinitrate/hydralazine is the only vasodilator regimen, other than ACE inhibitors or angiotensin II receptor antagonists, with proven survival benefits. This combination appears to be particularly beneficial in CHF patients with an African American background, who respond less effectively to ACEI therapy. (Exner et al., 2001; Taylor et al., 2004) Isosorbide dinitrate/hydralazine is a drug combination specifically indicated for African Americans with congestive heart failure. ...


Devices and surgery

Patients with NYHA class III or IV, left ventricular ejection fraction (LVEF) of 35% or less and a QRS interval of 120 ms or more may benefit from cardiac resynchronization therapy (CRT; pacing both the left and right ventricles), through implantation of an bi-ventricular pacemaker, or surgical remodelling of the heart. These treatment modalities may make the patient symptomatically better, improving quality of life and in some trials have been proven to reduce mortality. Mil-li-sec-ond One hundreth of a second ... In the heart, a ventricle is a chamber which collects blood from an atrium (another heart chamber) and pumps it out of the heart. ... The right ventricle is one of four chambers (two atria and two ventricles) in the human heart. ... This article is about a medical device which electrically stimulates the heart. ...


The COMPANION trial demonstrated that CRT improved survival in individuals with NYHA class III or IV heart failure with a widened QRS complex on EKG. (Bristow et al., 2004) The CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all cause mortality, and a reduction in cardiovascular-related hospitalization. (Cleland et al., 2005) ECG may also refer to the East Coast Greenway Lead II An Electrocardiogram (ECG or EKG, abbreviated from the German Elektrokardiogramm) is a graphic produced by an electrocardiograph, which records the electrical voltage in the heart in the form of a continuous strip graph. ...


Patients with NYHA class II, III or IV, and LVEF of 35% (without a QRS requirement) may also benefit from an implantable cardioverter-defibrillator (ICD), a device that is proven to reduce all cause mortality by 23% compared to placebo. This mortality benefit was observed in patients who were already optimally-managed on drug therapy. (Bardy et al., 2005) An implantable cardioverter-defibrillator (ICD) is a device that is implanted under the skin of patients that are at risk of sudden death due to ventricular fibrillation. ...


Another current treatment involves the use of left ventricular assist devices (LVADs). LVADs are battery-operated mechanical pump-type devices that are surgically implanted on the upper part of the abdomen. They take blood from the left ventricle and pump it through the aorta. LVADs are becoming more common and are often used by patients who have to wait for heart transplants.


The final option, if other measures have failed, is cardiac transplant surgery (heart transplant) or implantation of an artificial heart. An artificial heart is a device that is implanted into the body to replace the original biological heart. ...


See also

Cardiogenic shock results from the inability of the heart to pump blood through the body. ...

External links

  • Congestive Heart Failure information from Seattle Children's Hospital Heart Center

References

  • Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005;352(3):225-37. PMID 15659722
  • Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004;350:2140-50. PMID 15152059
  • Cleland JGF, Daubert J-C, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005;352(15):1539-49. PMID 15753115
  • Donatelle RJ. Health: The basics, 6th edition. San Francisco: Pearson Education; 2005.
  • Exner DV, Dries DL, Domanski MJ, Cohn JN. Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction. N Engl J Med 2001;344(18):1351-7. PMID 11333991
  • Granger CB, McMurray JJ, Yusuf S, Held P, Michelson EL, Olofsson B, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function intolerant to angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet 2003;362(9386):772-6. PMID 13678870
  • Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005;112(12):e154-235. PMID 16160202.
  • Jackson S, Bereznicki L, Peterson G. Under-use of ACE-inhibitor and β-blocker therapies in congestive cardiac failure. Australian Pharmacist 2005;24(12):936.
  • Krum H, National Heart Foundation of Australia and Cardiac Society of Australia & New Zealand Chronic Heart Failure Clinical Practice Guidelines Writing Panel. Guidelines for management of patients with chronic heart failure in Australia. Med J Aust 2001;174(9):459-66. PMID 11386592
  • National Institute for Clinical Excellence. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 5. London: National Institute for Clinical Excellence; 2003 Jul. Available from: www.nice.org.uk/pdf/CG5NICEguideline.pdf
  • Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, et al. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme. Lancet 2003;362(9386):759-66. PMID 13678868
  • Smith A, Aylward P, Campbell T, et al. Therapeutic Guidelines: Cardiovascular, 4th edition. North Melbourne: Therapeutic Guidelines; 2003. ISSN 1327-9513
  • Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R Jr, Ferdinand K, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004;351(20):2049-57. PMID 15533851

The New England Journal of Medicine (NEJM) is a peer-reviewed medical journal published by the Massachusetts Medical Society. ...

See also


  Results from FactBites:
 
Congestive Heart Failure (CHF) - CardiologyChannel (527 words)
Congestive heart failure, or heart failure, is a condition in which the heart is unable to adequately pump blood throughout the body and/or unable to prevent blood from "backing up" into the lungs.
Heart failure is characterized by shortness of breath (dyspnea) and abnormal fluid retention, which usually results in swelling (edema) in the feet and legs.
Heart failure becomes more prevalent with age and the number of cases is expected to grow as the overall age of the population increases.
Congestive Heart Failure (1454 words)
Congestive heart failure occurs when the heart is unable to pump blood effectively throughout the body.
Congestive heart failure can be caused by a number of conditions that damage the heart muscle, including a heart attack or heart infection; coronary artery disease; excessive alcohol consumption; an over- or under-active thyroid gland; and untreated high blood pressure.
Congestive heart failure can also be caused by damage to or abnormalities in the valves inside the heart, which regulate blood flow out of the heart, and genetic conditions, such as hypertrophic cardiomyopathy, in which the heart muscle becomes thickened due to enlarged heart muscle cells.
  More results at FactBites »

 
 

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