Congestive Heart Failure: An Ongoing Battle

By
Bradley A. Radwaner, M.D., F.A.C.C.

It's easy to take for granted the rhythmic beating of the heart, constantly renewing the body as it pumps 2,000 gallons of blood each day.

With the central pumping system in good working order, like the bunny in the battery ad, we keep going and going and going….When the pump begins to fail, however, it's like working on a run-down battery. Energy levels drop, and even the slightest exertion can cause breathlessness and exhaustion.

Congestive heart failure (CHF) is a chronic condition that affects between two and three million Americans. Most often seen in those over 50, CHF is directly responsible for up to 40,000 deaths and contributes to another 230,000 deaths annually. CHF is a major health problem that has increased by 30 percent since 1970. The increase is due in part to an aging population and in part to higher survival rates from heart attack and stroke.

As more Americans survive these potentially fatal episodes, they add to the number of those with weakened or impaired heart muscles. By age 70, about 10 percent of the population suffers from CHF, a disease that drains seniors of their energy and vitality and seriously detracts from their quality of life.

Congestive heart failure occurs when the heart fails to pump effectively, decreasing blood flow throughout the body and allowing blood to back up into the veins. The heart tries to compensate by beating faster and stretching to increase its capacity. The result is a large, baggy heart with poor pumping action.

The heart is actually two pumps working in tandem. CHF can affect both sides of the heart or just one. Left-sided CHF is the most common, causing fluid to back up into the lungs.

A number of factors can cause CHF. A heart attack or coronary artery disease can damage the heart muscle and lessen its effectiveness as a pump. Defective heart valves also impair pumping ability. Chronic high blood pressure can cause the heart muscle to thicken and become stiff. Alcohol or drug abuse can also cause the heart muscle to deteriorate.

SYMPTOMS OF CHF

Symptoms of congestive heart failure may vary depending on which side of the heart is involved and the severity of the condition.

  • Becoming short of breath or overly tired as a result of slight exertion, or even at rest. This is caused by a buildup of fluid in the lungs, and the extra load placed on the heart.
  • Wheezing. Fluid backs up in the lungs and takes up the space needed for oxygen.
  • Swelling in the ankles and lower legs. The swelling may also be seen in the fingers and hands.
  • A feeling of being unable to breathe. Patients often wake up gasping for breath as fluid that had pooled in the legs and feet during the day settles into the lungs during the night.
  • A need to urinate frequently during the night as the body tries to rid itself of excess fluid.
  • Swollen neck veins, caused by blood backing up in the veins.
  • An enlarged liver.
  • A large weight gain, caused by fluid retention.

If you have any of these symptoms, see a doctor right away. Although there is no outright cure for this condition, treatment will slow the progression of the disease and greatly enhance your quality of life. Delaying treatment may damage the heart muscle and lead to life-threatening consequences.

TREATMENTS, OLD AND NEW

In the recent past, a diagnosis of CHF promised a gloomy outcome. While it's still a chronic disease, advances in medication and surgical techniques offer patients a better chance of a productive life. Early diagnosis holds out the hope of treating CHF before it becomes too severe.

Digitalis, diuretics and vasodilators are the drugs most commonly used to treat CHF. Digitalis, obtained from the foxglove plant, has been used in medicine for over 200 years. Digitalis, usually prescribed under the name digoxin, improves the pumping action of the heart.

Diuretics help the body get rid of excess sodium and water, both of which are excreted in the urine.

Vasodilators have been used in the treatment of CHF for 20 years. They work by dilating or expanding blood vessels, lessening the pressure and allowing blood to flow more easily. The most commonly prescribed of the vasodilators, also known as the ACE inhibitors, are captopril, enalapril and lisinopril.

A study published in the New England Journal of Medicine concluded that the ACE inhibitor, enalapril, when used in conjunction with conventional therapies for CHF, significantly reduces mortality, even among those patients with mild to moderate CHF. In the past the drug had been used to treat only the most serious cases of CHF. As well as saving lives, the drug also reduced the number of hospitalizations in the study group. Mortality was reduced by 16 percent, and hospitalizations were reduced by 37 percent.

According to Deeb N. Salem, M.D., chief of cardiology at New England Medical Center in Boston, "in the United States and other Western countries, use of an ACE inhibitor as standard therapy in symptomatic patients could prevent a few thousand premature deaths and avoid several tens of thousands of hospitalizations annually."

Recently the use of beta blockers have been found to be very beneficial in CHF. Medications block the deleterious effect of adrenaline on the heart and slow the pulse rate, often too fast in patients with CHF. Beta blockers, once thought to be unsafe in patients with weakened hearts, has now been shown to dramatically improve survival when used in combination with ACE inhibitors.

Surgical options exist to treat advanced cases of CHF. An implantable pump, known as left-ventricular assist device, can be inserted into the chest to help the heart's pumping action. ICD's or implantable cardio-defibrillators help prevent sudden death from potentially lethal heart arrhythmias, which patients with weakened hearts are often at risk for.

Heart transplants are becoming more common to give a new chance at life for those with severe CHF. Approximately 2,000 heart transplants were performed last year. Heart transplantation now has a one-year survival rate of 85 percent and five-year survival rates of more than 50 percent.

Cardiomyoplasty is an experimental surgical technique in which a surgeon takes muscle from the patient's back, wraps it forward around the heart and then, with the help of a pacemaker, retrains the muscle to contract with the heart.
New drug therapies and surgical techniques offer hope for continued improvements in the treatment of CHF. Early diagnosis and treatment give patients the best chance of a longer and more productive life.