Congestive Heart Failure
Disease Details
Family Health Simplified
- Description
- Congestive heart failure is a chronic condition where the heart is unable to pump blood effectively, leading to a buildup of fluid in the lungs and other tissues.
- Type
-
Congestive heart failure (CHF) is a complex condition typically associated with the heart's inability to pump blood effectively. It is generally not categorized as a single type of condition because it can result from various types of heart disease.
The genetic transmission of CHF can vary. While most cases are related to environmental factors and lifestyle choices, there are genetic forms. When CHF has a genetic basis, it is often inherited in an autosomal dominant pattern. This means an affected person has a 50% chance of passing the gene to their offspring. Other inheritance patterns, such as autosomal recessive or X-linked, are less common but can also occur depending on the specific underlying genetic mutation. - Signs And Symptoms
- Congestive heart failure is a pathophysiological condition in which the heart's output is insufficient to meet the needs of the body and lungs. The term "congestive heart failure" is often used because one of the most common symptoms is congestion or fluid accumulation in the tissues and veins of the lungs or other parts of a person's body. Congestion manifests itself particularly in the form of fluid accumulation and swelling (edema), in the form of peripheral edema (causing swollen limbs and feet) and pulmonary edema (causing difficulty breathing) and ascites (swollen abdomen). Pulse pressure, which is the difference between the systolic ("top number") and diastolic ("bottom number") blood pressures, is often low/narrow (i.e. 25% or less of the level of the systolic) in people with heart failure, and this can be an early warning sign.Symptoms of heart failure are traditionally divided into left-sided and right-sided because the left and right ventricles supply different parts of the circulation. In biventricular heart failure, both sides of the heart are affected. Left-sided heart failure is the more common.
- Prognosis
-
Prognosis in heart failure can be assessed in multiple ways, including clinical prediction rules and cardiopulmonary exercise testing. Clinical prediction rules use a composite of clinical factors such as laboratory tests and blood pressure to estimate prognosis. Among several clinical prediction rules for prognosticating acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying people and identifying those at low risk of death during hospitalization or within 30 days. Easy methods for identifying people that are low-risk are:
ADHERE Tree rule indicates that people with blood urea nitrogen < 43 mg/dL and systolic blood pressure at least 115 mm Hg have less than 10% chance of inpatient death or complications.
BWH rule indicates that people with systolic blood pressure over 90 mm Hg, respiratory rate of 30 or fewer breaths per minute, serum sodium over 135 mmol/L, and no new ST–T wave changes have less than 10% chance of inpatient death or complications.A very important method for assessing prognosis in people with advanced heart failure is cardiopulmonary exercise testing (CPX testing). CPX testing is usually required prior to heart transplantation as an indicator of prognosis. CPX testing involves measurement of exhaled oxygen and carbon dioxide during exercise. The peak oxygen consumption (VO2 max) is used as an indicator of prognosis. As a general rule, a VO2 max less than 12–14 cc/kg/min indicates poor survival and suggests that the person may be a candidate for a heart transplant. People with a VO2 max <10 cc/kg/min have a clearly poorer prognosis. The most recent International Society for Heart and Lung Transplantation guidelines also suggest two other parameters that can be used for evaluation of prognosis in advanced heart failure, the heart failure survival score and the use of a criterion of VE/VCO2 slope > 35 from the CPX test. The heart failure survival score is calculated using a combination of clinical predictors and the VO2 max from the CPX test.
Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life. With the exception of heart failure caused by reversible conditions, the condition usually worsens with time. Although some people survive many years, progressive disease is associated with an overall annual mortality rate of 10%.Around 18 of every 1000 persons will experience an ischemic stroke during the first year after diagnosis of HF. As the duration of follow-up increases, the stroke rate rises to nearly 50 strokes per 1000 cases of HF by 5 years. - Onset
- Congestive heart failure (CHF) typically has a gradual onset, often developing over time as the heart becomes progressively less efficient at pumping blood. The onset may be marked by symptoms such as shortness of breath, fatigue, and swelling (edema), particularly in the legs, ankles, and feet. It's often a result of underlying conditions such as coronary artery disease, high blood pressure, or previous heart attacks.
- Prevalence
- The prevalence of congestive heart failure (CHF) varies globally, but in the United States, it affects approximately 6.5 million adults. The condition is more common in older adults, with the prevalence increasing significantly with age.
- Epidemiology
- In 2022, heart failure affected about 64 million people globally. Overall, around 2% of adults have heart failure. In those over the age of 75, rates are greater than 10%.Rates are predicted to increase. Increasing rates are mostly because of increasing lifespan, but also because of increased risk factors (hypertension, diabetes, dyslipidemia, and obesity) and improved survival rates from other types of cardiovascular disease (myocardial infarction, valvular disease, and arrhythmias). Heart failure is the leading cause of hospitalization in people older than 65.
- Intractability
- Congestive heart failure (CHF) is not necessarily intractable, but it is a chronic condition that typically requires ongoing management. While it is usually not curable, various treatments can significantly improve symptoms and quality of life. These treatments include lifestyle modifications, medications, and in some cases, surgical interventions. The effectiveness of management depends on the underlying cause and the patient's adherence to treatment regimens.
- Disease Severity
-
Congestive heart failure (CHF) is a serious and chronic condition where the heart is unable to pump blood effectively to meet the body's needs. Its severity can vary widely:
1. **Mild (Stage I)**: Symptoms are minimal and often occur only during exertion.
2. **Moderate (Stage II-III)**: Symptoms become more noticeable with less activity and may affect daily living.
3. **Severe (Stage IV)**: Symptoms are present even at rest, significantly impacting the quality of life.
Management typically includes lifestyle changes, medications, and sometimes surgical interventions. Regular monitoring and adherence to treatment plans are crucial. - Healthcare Professionals
- Disease Ontology ID - DOID:6000
- Pathophysiology
- Heart failure is caused by any condition that reduces the efficiency of the heart muscle, through damage or overloading. Over time, these increases in workload, which are mediated by long-term activation of neurohormonal systems such as the renin–angiotensin system and the sympathoadrenal system, lead to fibrosis, dilation, and structural changes in the shape of the left ventricle from elliptical to spherical.The heart of a person with heart failure may have a reduced force of contraction due to overloading of the ventricle. In a normal heart, increased filling of the ventricle results in increased contraction force by the Frank–Starling law of the heart, and thus a rise in cardiac output. In heart failure, this mechanism fails, as the ventricle is loaded with blood to the point where heart muscle contraction becomes less efficient. This is due to reduced ability to cross-link actin and myosin myofilaments in over-stretched heart muscle.
- Carrier Status
- Congestive heart failure (CHF) is a chronic progressive condition where the heart is unable to pump sufficient blood to meet the body's needs. Since it is not an infectious disease or a classic genetic disorder, the concept of "carrier status" does not apply to congestive heart failure. It is primarily influenced by factors such as hypertension, coronary artery disease, heart valve disorders, and lifestyle factors.
- Mechanism
-
Congestive heart failure (CHF) is a condition where the heart is unable to pump blood effectively to meet the body's needs.
**Mechanism:**
The heart's reduced pumping capability, usually due to damage to the heart muscle from conditions such as coronary artery disease, hypertension, or myocardial infarction, leads to inadequate blood flow and accumulation of fluid in tissues (congestion). This results in symptoms like shortness of breath, fatigue, and edema.
**Molecular Mechanisms:**
1. **Neurohormonal Activation:** The failing heart triggers the activation of neurohormonal systems like the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system. Chronic activation contributes to fluid retention, vasoconstriction, and further stress on the heart.
2. **Oxidative Stress:** Increased production of reactive oxygen species (ROS) leads to cellular damage in heart tissues, exacerbating heart muscle dysfunction.
3. **Inflammatory Cytokines:** Heart failure triggers the release of inflammatory cytokines (e.g., TNF-α, IL-6), promoting further cardiac remodeling and dysfunction.
4. **Altered Calcium Handling:** Defective calcium cycling in cardiomyocytes impairs myocardial contraction and relaxation, reducing the heart's efficiency.
5. **Fibrosis:** Activation of fibroblasts and deposition of extracellular matrix proteins in the heart lead to stiffening of the myocardium, impeding normal cardiac function and exacerbating heart failure. - Treatment
-
For congestive heart failure (CHF), treatment options typically include:
1. **Lifestyle Changes**:
- Sodium restriction
- Fluid restriction
- Weight management
- Regular physical activity with moderation
- Quitting smoking and reducing alcohol intake
2. **Medications**:
- ACE inhibitors or ARBs to relax blood vessels and reduce the workload on the heart
- Beta-blockers to decrease the heart rate and reduce blood pressure
- Diuretics to reduce fluid buildup
- Aldosterone antagonists to help the body get rid of excess sodium
- Vasodilators to lower blood pressure and decrease heart workload
- Digoxin to improve heart muscle contractions and slow down the heart rate
3. **Devices**:
- Implantable cardioverter-defibrillators (ICDs) to prevent sudden cardiac arrest
- Cardiac resynchronization therapy (CRT) to improve the timing of the heart's contractions
4. **Surgical Interventions**:
- Coronary artery bypass grafting (CABG) for severe coronary artery disease
- Heart valve repair or replacement for valve diseases
- Left ventricular assist devices (LVADs) for advanced heart failure as a bridge to transplant or as destination therapy
- Heart transplantation in severe cases where other treatments have failed
Close monitoring and regular follow-up with healthcare providers are crucial to managing CHF effectively. - Compassionate Use Treatment
-
Compassionate use treatments and off-label or experimental treatments for congestive heart failure (CHF) can include several approaches:
1. **Compassionate Use Treatments:**
- These involve access to investigational drugs or devices outside of clinical trials for patients with serious conditions who have no other treatment options. For CHF, this might include advanced therapies like new heart pumps or experimental drugs.
2. **Off-Label Treatments:**
- Medications like Ivabradine, primarily used for heart rate control, may be used off-label for symptomatic heart failure.
- Drugs such as certain pulmonary vasodilators, ordinarily used for pulmonary hypertension, can be repurposed to manage heart failure symptoms.
3. **Experimental Treatments:**
- Gene Therapy: Research is ongoing to develop gene therapies that target the molecular causes of heart failure.
- Stem Cell Therapy: Experimental studies are investigating the use of stem cells to repair damaged heart tissue.
- Novel Pharmacological Agents: New classes of medication like sodium-glucose cotransporter-2 (SGLT2) inhibitors, initially for diabetes, show promise in treating heart failure.
These treatments are typically considered when standard therapies don't provide sufficient benefit or when the patient's condition is particularly severe. Always involve a healthcare professional for detailed evaluation and guidance. - Lifestyle Recommendations
-
Lifestyle recommendations for congestive heart failure (CHF) include:
1. **Dietary Changes:**
- **Low-Sodium Diet:** Aim for less than 2,000 milligrams of sodium per day to prevent fluid retention.
- **Fluid Restriction:** Limit fluid intake to prevent exacerbation of symptoms, as advised by your healthcare provider.
- **Balanced Nutrition:** Focus on a heart-healthy diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats.
2. **Physical Activity:**
- **Regular Exercise:** Engage in moderate exercise like walking, swimming, or cycling, as recommended by a healthcare provider.
- **Cardiac Rehabilitation:** Participate in supervised exercise programs if recommended.
3. **Weight Management:**
- **Monitor Weight:** Weigh yourself daily to monitor fluid retention and notify your doctor of significant changes.
- **Healthy Weight:** Maintain a healthy weight to reduce the strain on your heart.
4. **Medication Adherence:**
- **Follow Prescription Regimens:** Take medications exactly as prescribed to manage symptoms and prevent complications.
5. **Limit Alcohol and Caffeine:**
- **Alcohol:** Limit or avoid alcohol consumption based on your healthcare provider’s advice.
- **Caffeine:** Moderate your caffeine intake.
6. **Smoking Cessation:**
- **Quit Smoking:** Engage in programs or use resources to stop smoking, as it exacerbates heart failure.
7. **Regular Check-ups:**
- **Follow-up Appointments:** Regularly visit your healthcare provider to manage and monitor your condition.
8. **Stress Management:**
- **Relaxation Techniques:** Practice stress-relief activities like yoga, meditation, or deep-breathing exercises.
Implementing these lifestyle changes can significantly help manage congestive heart failure and improve overall quality of life. Always consult with your healthcare provider for personalized recommendations. - Medication
- A number of medications may cause or worsen the disease. This includes NSAIDs, COX-2 inhibitors, a number of anesthetic agents such as ketamine, thiazolidinediones, some cancer medications, several antiarrhythmic medications, pregabalin, alpha-2 adrenergic receptor agonists, minoxidil, itraconazole, cilostazol, anagrelide, stimulants (e.g., methylphenidate), tricyclic antidepressants, lithium, antipsychotics, dopamine agonists, TNF inhibitors, calcium channel blockers (especially verapamil and diltiazem), salbutamol, and tamsulosin.By inhibiting the formation of prostaglandins, NSAIDs may exacerbate heart failure through several mechanisms, including promotion of fluid retention, increasing blood pressure, and decreasing a person's response to diuretic medications. Similarly, the ACC/AHA recommends against the use of COX-2 inhibitor medications in people with heart failure. Thiazolidinediones have been strongly linked to new cases of heart failure and worsening of pre-existing congestive heart failure due to their association with weight gain and fluid retention. Certain calcium channel blockers, such as diltiazem and verapamil, are known to decrease the force with which the heart ejects blood, thus are not recommended in people with heart failure with a reduced ejection fraction.Breast cancer patients are at high risk of heart failure due to several factors. After analysing data from 26 studies (836,301 patients), the recent meta-analysis found that breast cancer survivors demonstrated a higher risk heart failure within first ten years after diagnosis (hazard ratio = 1.21; 95% CI: 1.1, 1.33). The pooled incidence of heart failure in breast cancer survivors was 4.44 (95% CI 3.33-5.92) per 1000 person-years of follow-up.Quadruple medical therapy using a combination of angiotensin receptor-neprilysin inhibitors (ARNI), beta blockers, mineralocorticoid receptor antagonists (MRA), and sodium/glucose cotransporter 2 inhibitors (SGLT2 inhibitors) is the standard of care as of 2021 for heart failure with reduced ejection fraction (HFrEF).There is no convincing evidence for pharmacological treatment of heart failure with preserved ejection fraction (HFpEF). Medication for HFpEF is symptomatic treatment with diuretics to treat congestion. Managing risk factors and comorbidities such as hypertension is recommended in HFpEF.Inhibitors of the renin–angiotensin system (RAS) are recommended in heart failure. The angiotensin receptor-neprilysin inhibitors (ARNI) sacubitril/valsartan is recommended as first choice of RAS inhibitors in American guidelines published by AHA/ACC in 2022. Use of angiotensin-converting enzyme (ACE) inhibitors (ACE-I), or angiotensin receptor blockers (ARB) if the person develops a long-term cough as a side effect of the ACE-I, is associated with improved survival, fewer hospitalizations for heart failure exacerbations, and improved quality of life in people with heart failure. European guidelines published by ESC in 2021 recommends that ARNI should be used in those who still have symptoms while on an ACE-I or ARB, beta blocker, and a mineralocorticoid receptor antagonist. Use of the combination agent ARNI requires the cessation of ACE-I or ARB therapy at least 36 hours before its initiation.Beta-adrenergic blocking agents (beta blockers) add to the improvement in symptoms and mortality provided by ACE-I/ARB. The mortality benefits of beta blockers in people with systolic dysfunction who also have atrial fibrillation is more limited than in those who do not have it. If the ejection fraction is not diminished (HFpEF), the benefits of beta blockers are more modest; a decrease in mortality has been observed, but reduction in hospital admission for uncontrolled symptoms has not been observed.In people who are intolerant of ACE-I and ARB or who have significant kidney dysfunction, the use of combined hydralazine and a long-acting nitrate, such as isosorbide dinitrate, is an effective alternate strategy. This regimen has been shown to reduce mortality in people with moderate heart failure. It is especially beneficial in the black population.Use of a mineralocorticoid antagonist, such as spironolactone or eplerenone, in addition to beta blockers and ACE-I, can improve symptoms and reduce mortality in people with symptomatic heart failure with reduced ejection fraction (HFrEF).SGLT2 inhibitors are used for heart failure.
- Repurposable Drugs
-
There are various drugs that have been repurposed or considered for repurposing in the treatment of congestive heart failure (CHF). These include:
1. **Metformin** - Primarily used for type 2 diabetes, it has shown potential in improving cardiovascular outcomes in CHF patients.
2. **SGLT2 inhibitors** - Originally for diabetes, drugs like dapagliflozin and empagliflozin have shown benefits in heart failure patients.
3. **Vericiguat** - Initially studied for other cardiovascular conditions, it has shown promise in reducing heart failure-related hospitalizations.
4. **Ivabradine** - Used for angina, it helps by reducing heart rate and improving symptoms in CHF.
5. **Allopurinol** - Typically used for gout, it may improve endothelial function and reduce oxidative stress in CHF patients.
These medications have shown varying degrees of efficacy and are at different stages of clinical validation for CHF treatment. - Metabolites
-
Congestive heart failure (CHF) is associated with several metabolic changes. Key metabolites altered in CHF include:
1. **B-type natriuretic peptide (BNP):** Elevated levels are a hallmark of heart failure and are used in diagnosis and monitoring.
2. **N-terminal pro-B-type natriuretic peptide (NT-proBNP):** Another marker that is elevated in CHF, used similarly to BNP.
3. **Lactic acid:** Often increased due to hypoperfusion and subsequent anaerobic metabolism.
4. **Acylcarnitines:** Elevated levels indicate impaired fatty acid oxidation.
5. **Ketone bodies (β-hydroxybutyrate, acetoacetate):** Increased in severe heart failure as a result of altered energy substrate utilization.
6. **Amino acids (glutamine, branched-chain amino acids):** Altered levels can reflect changes in protein metabolism.
7. **Ceramides:** Elevated levels in CHF are associated with adverse outcomes.
These metabolic changes reflect the complex biochemical environment present in congestive heart failure, affecting diagnosis, monitoring, and potentially guiding therapeutic strategies. - Nutraceuticals
-
For congestive heart failure (CHF), nutraceuticals that have been studied include:
1. **Coenzyme Q10 (CoQ10):** May improve symptoms and quality of life by supporting energy production in heart cells.
2. **Omega-3 fatty acids:** Found in fish oil, they can help reduce inflammation, lower triglycerides, and improve heart function.
3. **Hawthorn:** Some studies suggest it may improve heart function and reduce symptoms of CHF.
4. **L-carnitine:** An amino acid derivative that might enhance energy production in heart cells.
5. **Magnesium and potassium:** These electrolytes are crucial for proper heart function and may be beneficial, particularly if levels are low.
Consultation with a healthcare provider is essential before starting any nutraceuticals for CHF management. - Peptides
-
Congestive heart failure (CHF) is often monitored and assessed using biomarkers, notably Natriuretic Peptides (NPs) such as B-type Natriuretic Peptide (BNP) and N-terminal pro-BNP (NT-proBNP). These peptides are released by the heart in response to changes in pressure that occur with heart failure and serve as important indicators for diagnosis and management of CHF.
Nanotechnology (nan) is also emerging as a promising field in the detection and management of CHF. Nanomaterials can be used to develop highly sensitive and specific diagnostic tools, enhance drug delivery systems, and even aid in tissue engineering for heart repair. Research is ongoing to maximize the potential benefits of nanotechnology in improving outcomes for CHF patients.