Heart failure is a serious disease that affects nearly 5 million Americans. It is the leading cause of hospitalization in people older than 65.

Heart failure is a condition where the heart does not pump as good as it used to. As a result, your heart is not able to pump blood to the rest of the body as efficiently. When this happens, blood can back up into the heart, stretching out the walls of its chambers. The more they stretch, the harder it is for the heart to pump. More fluid backs up, further weakening the heart. This cycle of stretching of the walls and further weakening of the heart continues. Blood and fluid eventually begins to back up in the the hands, feet, legs, and other organs. This can lead to fluid back up in the lungs and problems breathing. It can also cause dizziness and fatigue. Finally, many people also complain of a rapid and/or irregular heartbeat.

What Causes Heart Failure?

There are many conditions that can cause a weakening of the heart muscle, or 'cardiomyopathy', and potentially heart failure. Coronary artery disease (CAD), a condiiton where the arteries that supply the heart with blood and oxygen become narrowed, can  starve the heart of oxygen and nutrients. This can lead to damage and weakening of the walls of the heart. In other cases, the heart may be weakened by a heart attack. This too can lead to heart failure. Other times, there may be damage to the heart that is caused by things like alcohol, drugs or infection. This can weaken   the heart and bring on heart failure. Finally, other health conditions that put more work on the heart than it can handle can cause heart failure. Examples of these condiitons include thyroid disease, kidney disease, diabetes, and valve disease.

Not All Heart Failure is the Same...

There are two main types of heart failure. It is important for your doctor to know which type you have as there are differences in how they are treated.

Systolic heart failure occurs when the heart can not pump blood out with enough force. As a result, oxygen and nutrient rich blood is not pumped to the tissues efficiently.

Diastolic heart failure occurs when the heart contracts normally, but it does not relax properly. Normally, when the heart is relaxing (inbetween beats), the heart is filling with blood to be pumped out on the next beat. In this type of heart failure, less blood enters the heart to be pumped out to the tissues.

There are also different stages of heart failure that affect how that heart failure is treated. These stages will be discussed shortly.

How Is Heart Failure Diagnosed?

Your doctor will order a variety of tests in order to determine 1) If you have heart failure 2) What type of heart failure you have and 3) How severe the heart failure is.. These tests may include:

• Blood tests. Blood tests are used to help evaluate the cause of heart failure as well as determine if other organs are being affected by it.
• B-type Natriuretic Peptide (BNP) blood test. BNP is a substance secreted from the heart. BNP levels increase when heart failure symptoms worsen, and decrease when symtpoms improve.
• Chest X-ray. A chest X-ray shows the size of your heart and can show if there is fluid build-up around the heart and lungs.
• Echocardiogram. This test uses ultrasound technology to a show real time, moving picture of the heart.
• Ejection fraction (EF). This test is used to measure how well your heart pumps. It can help the doctor determine which type and the severity of heart failure you have.
• Electrocardiogram (EKG or ECG). An EKG show the electrical impulses as they travel through the heart.

Other tests may be ordered, depending on your condition.

 How Is Heart Failure Treated?

The goals of treating heart failure are to decrease the likelihood of disease progression, to lessen symptoms and to improve quality of life.

What treatments your doctor choses for you will depend on the type of heart failure you have and how severe it is. Heart failure is a progressive condition that can worsen as time goes on. For this reason, your medication regimen may change over time. Regardless of which medication(s) you doctor chooses, he/she will probably also recommend a low sodium (low salt) diet. Decreasing the amount of salt in your diet will help decrease the amount of fluid retention and can help lessen the workload on your heart.

ACE inhibitors

These medications work by minimizing blood vessel constriction and reducing sodium and water retention. This helps decrease the workload on your heart. Examples of these medications include the following:

• Capoten (captopril)
• Vasotec (enalapril)
• Prinivil, Zestril (lisinopril)
• Monopril (fosinopril)
• Altace (ramipril)
• Accupril (quinapril)

These medications are especially good choices in patients with diabetes or kidney disease. This is because these medications have been shown to help 'protect' the kidneys in these patients. These drugs are also good choices if the patient has a history of heart attack or stroke. Often these medications are not tolerated well because of an often troublesome side effect; cough. These drugs have the ability to produce dry, persistent cough in many patients. It is unclear why this occurs. Some patients are able to tolerate the drug despite this, but others find it too bothersome and choose to switch medications. As for other side effects, you can feel light headed or dizzy when getting up from a seated position. These drugs can also cause disturbances in your potassium level. One potentially serious side effect of these medications is called 'angioedema'. Symptoms of this condition include swelling of the face, hands and feet. It is serious because it can affect internal organs and can affect your ability to breath. If you notice any facial swelling while taking an ACE inhibitor, talk to a health care professional promptly.

Angiotensin Receptor Blockers

These medications work in a way similar to ACE inhibitors. Examples of these medications include:

• Cozaar (losartan)
• Diovan (valsartan)
• Avapro (irbesartan)
• Atacand (candesartan)

These medications are generally used in patients who can not tolerate ACE Inhibitors because of side effects. These medications do not generally cause the dry, persistent cough that ACE inhibitors often cause. There is less data that shows if this group of medications has the same 'kidney-protecting' properties of the ACE inhibitors in patients with diabetes and kidney disease. There is also little evidence to show that these drugs work as well as ACE inhibitors when it comes to heart failure.

Side effects for these medications are similar to ACE inhibitors in that they too can cause dizziness, potassium disturbances and angioedema.

Diuretics

These are often called 'water pills'. They work by causing the body to loose excess water. Getting rid of this extra fluid in the body can decrease the workload on the heart. Examples of diuretics used in heart failure are:

• Furosemide (Lasix)
• Bumetinide (Bumex)
• Torsemide (Demadex)

Side effects of these medications include changes in sodium, magnesium, calcium and potassium levels. These drugs can also make you feel dizzy when getting up from the seated position. To avoid this, rise slowly when getting up out of a chair or out of bed.

Beta Blockers

These medications decrease the force with which the heart pumps. This decreases the workload on your heart. Examples of beta blockers used to treat heart failure include:

• Zebeta (bisoprolol)
• Coreg (carvedilol)
• Lopressor, Toprol-XL (metoprolol)

These medications are especially helpful if a patient has a history of heart attack. In fact, most patients who have had a heart attack will already be on a beta blocker due to another set of guidelines that tells us that heart attack patients benefit from beta blocker therapy, even if they do not have high blood pressure. This is because research has found that taking a beta blocker after a heart attack can actually decrease your risk of death.

The most common side effect with beta blockers is cold hands and feet. Other common side effects include dizziness, tiredness and sleep disturbances.

Digoxin

Digoxin is a medication that can increase the force at which the heart contracts. This medication is used in situations where the heart needs help pumping enough blood and oxygen to meet the needs of the body.

Other Medications

 The guidelines do suggest a combination of hydralazine and a class of drugs called nitrates for certain patients, particularly those who can not tolerate ACE inhibitors. An example of a nitrate used to treat heart failure is isosorbide dinitrate. Both hydralazine and nitrates help dilate the blood vessels and lessen the workload on the heart. As with many other blood pressure medications, these medications can make you dizzy, especially when getting up from a seated or lying position. To avoid this effect, it is best to always rise slowly when getting up from being seated or lying down. You should not take hydralazine with alcohol, You also should not take nitrates with alcohol or drugs that treat erectile dysfunction like Viagra or Levitra. Alcohol and drugs for erectile dysfunction also dilate the blood vessels. Taking these medications together could cause too much dilation resulting in dizziness, loss of consciousness, heart palpitations and death.

How Can I Expect My Treatment to Progress?

The new guidelines suggest a treatment approach based on the severity of the heart failure. As mentioned before, your treatment regimen may change over time as your condition changes. For this reason, you may start out in one stage listed below but progress into other stages over time.

Stage A: Patients at a High Risk of Developing Heart Failure

For these people, tight blood pressure and blood lipid ('cholesterol, triglycerides...etc') control is a must. It is also recommended that these patients avoid smoking, alcohol and illicit drugs. An ACE inhibitor may be recommended in those patients with a history of diabetes, valve disease, or high blood pressure. It is also recommended that patients with certain arrhythmias bring their heart rate under control. Patients in this group with thyroid conditions should make sure that their thyroid condition is under control. Finally these patients should receive periodic evaluations for symptoms of heart failure.

Stage B: Patients With Left Ventricular Dysfunction Who Have Not Developed Symptoms

These are typically patients whose heart is not pumping as well as it used too, but they do not have symptoms of heart failure. The recommendations suggest that some of these patients begin therapy to reduce the risk of developing full blown heart failure. For example, if the patient has a history of heart attack, they should start an ACE inhibitor and a beta blocker. Patients who do not have a history of heart attack but have a reduced ejection fraction should also be started on an ACE inhibitor and a beta blocker. If the patient has valve disease, the guidelines suggest valve replacement surgery if necessary.

Stage C: Patients With Left Ventricular Dysfunction With Current or Prior Symptoms

These are patients whose heart is not pumping as well as it used to AND who show symptoms. For these patients, the recommendations for Stage A and B above still apply. In fact, all patients in this group should be started on an ACE inhibitor, a beta blocker and digoxin unless contraindicated. In addition, it is recommended that these patients cut back the amount of salt in their diet. Diuretics may also be used. Spironolactone, a diuretic, should be used in patients with more severe heart failure or whose heart failure is not controlled on a combination of diuretic, digoxin, ACE inhibitor and a beta blocker. It is also suggested that patients in Stage C weigh themselves daily. By tracking your weight, you and your doctor can get a better idea of how much water weight you are carrying and adjust your salt and diuretic intake accordingly. Immunization with influenza and pneumococcal vaccines may reduce the risk of a respiratory infection. Although most patients should not participate in heavy labor or exhaustive sports, physical activity is encouraged when tolerated.

General Treatment

Most patients with symptomatic systolic heart failure will be managed with a combination of 4 drugs: a diuretic, an ACE inhibitor, a beta-adrenergic blocker, and digoxin. Patients with fluid retention should be given a diuretic. Even if the diuretic works well, treatment with an ACE inhibitor and a beta-blocker should be initiated and maintained in patients who can tolerate them, because they have been shown to favorably influence the long-term prognosis of heart failure. Therapy with digoxin may be initiated at any time to reduce symptoms and enhance exercise tolerance. 

How Can I Prevent Heart Failure From Worsening?

• Keep Other Conditions Under Control. Keeping other conditions like high blood pressure, high cholesterol and diabetes under control will help keep the stress on your heart to a minimum.
• Monitor your own symptoms. Check for changes in your fluid status by weighing yourself daily and checking for swelling. Call your doctor if you have unexplained weight gain (3 pounds in 1 day or 5 pounds in 1 week) or if you have increased swelling.
• Maintain fluid balance. Your doctor may ask you to keep a record of the amount of fluids you drink and how often you go to the bathroom. Your doctor may ask you to limit your fluid intake to less than 2 liters per day.
• Limit the amount of sodium(salt) in your diet. The more salt we take in, the more fluid your body retains. By limiting your salt intake, you help your body keep off extra fluid. This will help keep the workload on your heart down and can help keep fluid from building up in your legs, feet and lungs.
• Monitor your weight and lose weight if needed. Maintaining a healthy body weight will help keep the workload on your heart down and will help you feel better.
• Take your medications as prescribed. It is also important that you take your medications as prescribed and follow the doctor's recommendations. Noncomplicance with treatment can lead to rapid and profound consequences such as worsening of heart failure and/or hospitalization.
• Schedule regular doctor appointments. It is very important that you and your doctor stay on top of your condiiton to prevent further symptoms and damage to your heart.
• Stop smoking. Heart failure can cause fluid buildup in the lungs making it hard to breathe. Smoking only compounds this effect.
• Do not drink alcohol. Over time, alcohol can weaken the heart. Alcohol can also interact with some of the medications used to treat heart failure.
• Avoid Medications that can worsen heart failure. Certain medications such as Motrin or Aleve can cause fluid retention and worsen heart failure. Other medications such as calcium channel blockers can worsen certain types of heart failure as well. It is important to talk with your doctor or pharmacist to see if you are taking any medications that can worsen your heart failure.

Conclusion

The treatment of heart failure is a team effort. The treatment of your heart failure will be a collaboration between you and many of the other health care professionals on your 'team'. You, your doctors, pharmacists, nurses and nutritionists, will all be working together to make sure you get the most out of your heat failure therapy.