Do you or a loved one suffer from shortness of breath, or do you get swelling in your legs, your feet, your ankles, and how about when you sleep? Do you find that you have to prop yourself up on a bunch of pillows at night in order to breathe well while you sleep, or do you sometimes have to literally sleep sitting up in a chair in order to breathe well? If so, you might have congestive heart failure. In this congestive heart failure overview we'll discuss the definition, the types of congestive heart failure, we'll talk about the causes as well as the warning signs and symptoms, the diagnosis, and the treatment.
What Is Congestive Heart Failure?
Congestive heart failure (CHF) is a condition when the heart does not pump well enough in order to move blood throughout the body the way that it should. You can get CHF in one of two ways, either the heart does not pump strongly enough to empty properly during the squeezing or the contraction part of the heartbeat, the systole. Another indication of CHF is when the heart does not relax well enough in order to fill properly with blood during the relaxation part of the heartbeat, or diastole. Either way, if you have congestive heart failure, you get a backup of blood and fluid, and you get congestion in the lungs and other parts of the body.
How The Heart Works
The heart works in two phases. It works in phase one by contracting and squeezing blood and moving it forward, this is the systolic phase, and then phase two is the relaxation phase, when the heart relaxes and fills with blood. This is the diastolic phase.
Systolic vs Diastolic Heart Failure
Systolic Heart Failure
There are two types of heart failure, systolic heart failure, and diastolic heart failure. So let's first talk about systolic heart failure. Systolic heart failure, also called congestive heart failure with reduced ejection fraction, occurs when there is a failure of the heart to move enough blood forward during the contraction or the squeezing phase of the heart.
So what is the ejection fraction, or reduced ejection fraction? Ejection fraction is the amount or the proportion of blood that is squeezed out with each contraction. What does that mean? Let me give you an example.
If in a heart chamber you have 100 milliliters of blood when the heart is relaxed, and then after it squeezes, after systole, you move out 65 milliliters of blood, then you have moved out 65 of the 100 milliliters of blood. You've moved out 65%, you've ejected 65%, so your ejection fraction is 65%, and this is considered normal in most cases. 50 to 70% ejection fraction is what we consider normal, but be sure to consult your physician and your heart doctor to find out which ejection fraction is a goal for you.
In the case of CHF with a reduced ejection fraction, instead of moving out that adequate amount or percentage of blood with the contraction, you will have a depressed amount of blood. So in the case where you have 100 milliliters of blood in a chamber to start, you may only move out 35 milliliters and your ejection fraction would be 35%. This is a reduced ejection fraction and you may have systolic heart failure or congestive heart failure with a reduced ejection fraction.
So what is the significance of having a reduced ejection fraction? If you are not moving blood forward to the body the way that you're supposed to with the heart, you get a backup of fluid in the lungs and it can back up in the rest of your body. You can get congestion in the lungs, congestion in the liver, congestion in the spleen, and you can activate the renin-angiotensin system in the kidneys and get fluid retention. Swelling of the legs and all kinds of other issues can occur with systolic heart failure.
Causes of Systolic Heart Failure
Ischemic Heart Disease
Ischemic heart disease is the most common cause of systolic heart failure or heart failure with a reduced ejection fraction. So ischemia of the heart occurs if the heart arteries, the coronary arteries, have narrowed, usually due to plaques or atheromas that block the blood flow or limit the blood flow to the heart.
If you have a narrowing or decreased blood flow to the heart, then the heart muscle is not getting the adequate blood supply or adequate oxygen. What happens? You can develop a weak heart muscle and if you have a weak heart muscle, then it is not likely to pump strongly enough, and so this is how ischemic heart disease can lead to systolic heart failure. To learn more about plaques and atheromas, make sure you watch my video on high cholesterol.
Heart Attack Or Myocardial Infarction
Another cause of systolic heart failure is an outright heart attack or myocardial infarction. If these coronary arteries become completely blocked and you get areas of the heart that have no blood flow, then that heart muscle will die and you'll get scar tissue. If you have scar tissue and you no longer have functioning heart muscle, then certainly you will have a decreased ability of the heart muscle to contract, and so heart attacks can definitely be a cause of systolic heart failure as well.
And then there is hypertension or high blood pressure. If you have long-standing high blood pressure, then you could certainly be at risk for CHF with a reduced ejection fraction for that reason, and this is how it works. When a person has very high blood pressure, the heart is forced to push and pump against very high pressure, so what does it do? It tries to bulk up and you get hypertrophy or an increase in the size of the muscle of the heart.
In this case, a big muscle is not good, so when you get ventricular hypertrophy or this big muscle in the heart, that's not a good thing, it can lead to a reduced ejection fraction, and here's how. When you get this big heart muscle, it actually demands more oxygen, and so you have the same heart arteries, and the same coronary arteries feeding the heart muscle but now you have this big muscle that has a greater demand for oxygen but it's not getting enough oxygen, so that can make the heart not pump as well.
On top of that, when you get this hypertrophied heart muscle due to high blood pressure, these big muscles in the heart can actually squeeze against the heart arteries, causing them to narrow and have a poor blood flow. So now you have this big muscle, you have a high oxygen demand, but you have less oxygen and less blood going to the heart, so what happens? You get a decreased ability of the heart to pump well, and you get a reduced ejection fraction caused by longstanding hypertension.
Another cause for systolic heart failure or heart failure with reduced ejection fraction can be a dilated cardiomyopathy, and this is when the walls of the heart or the heart muscle become stretched out and thin. And it can happen for a variety of reasons. You can get dilated cardiomyopathy associated with excessive alcohol use or alcohol abuse. You can also get a dilated cardiomyopathy as a result of certain toxic medications or certain chemotherapies. Even certain viral infections can lead to dilated cardiomyopathy.
Diastolic Heart Failure
Now let's talk about diastolic heart failure or heart failure with a preserved ejection fraction. Diastolic heart failure occurs when the heart does not relax well enough in order to fill properly with blood, and yes, it's still congestive heart failure. Now even though in this diastolic heart failure you have a preserved ejection fraction, that doesn't necessarily mean that you are pumping out an adequate amount of blood. Let me explain.
So in that example I gave earlier of a person with systolic heart failure or heart failure with a reduced ejection fraction, I used these numbers, I said that the heart filled with 100 milliliters, they pumped out only 35 milliliters, and that was a 35% ejection fraction. Well if you are a patient with diastolic heart failure, you may also pump out 35% milliliters of blood, but if your heart only filled with say 53 milliliters of blood to start with, then, in this case, your 35 milliliters compared to the 53 milliliters that you started off with will give you an ejection fraction of about 66%, which is normal, a preserved ejection fraction.
But in both cases, each only still pumped out 35 milliliters of blood with a contraction, so that's just a reminder that even though it is a heart failure with a preserved ejection fraction, it still most definitely is pathological, and it is still congestive heart failure.
Causes Of Diastolic Heart Failure
Coronary Artery Disease
So let's talk about some of the causes of diastolic heart failure or heart failure with a preserved ejection fraction. Coronary artery disease or ischemic heart disease can also cause diastolic heart failure, and long-standing hypertension can cause diastolic heart failure as well. Remember, I gave the example of the left ventricular hypertrophy or that big heart muscle that developed trying to pump against the high blood pressure. Well in that case if you do get concentric hypertrophy or this really big muscle, then some of that muscle will crowd the chamber of the heart, in other words, that big muscle can take up some of the space that's needed to fill the heart properly, so this can lead to diastolic heart failure.
Another cause of diastolic heart failure is restrictive cardiomyopathy. If you have a pericardial disease, that can cause a problem. The pericardium is that sac that surrounds the heart and so if for some reason there is disease in the pericardium or there is a tightening that doesn't allow the heart muscle to relax fully, then pericardial disease can lead to diastolic heart failure.
Aortic Stenosis And Hypertrophic Cardiomyopathy
Also, aortic stenosis and hypertrophic cardiomyopathy can lead to heart failure with preserved ejection fraction as well.
Warning Signs And Symptoms Of Congestive Heart Failure
So now, what are some of the warning signs and symptoms of congestive heart failure? Remember, symptoms are what you feel, signs are what you see.
Shortness Of Breath and Dyspnea On Exertion
Some of the symptoms include shortness of breath, dyspnea on exertion, meaning you have a hard time breathing when you exert yourself, and if you get severe or really chronic CHF, and you can actually develop shortness of breath even with no activity.
Other symptoms include fatigue, just generalized fatigue, being tired all the time.
Nausea And Vomiting
Nausea and vomiting can be symptoms of CHF.
Decreased Appetite Or Early Satiety
You can get a decreased appetite or early satiety, meaning you get full quickly when eating.
Swelling of the Feet And Ankles
Swelling of the feet and ankles, swelling of the legs, and even swelling of the abdomen can all be symptoms of congestive heart failure.
Lightheadedness or Dizziness
Lightheadedness or dizziness can also occur.
Jugular Venous Distention
Some of the signs that may be picked up by your doctor such as jugular venous distention, when you get a bulging out or really enlarged vein that's apparent in the neck, JVD.
Abnormal Heart Rhythms
Your doctor may listen to your heart and notice that you have an arrhythmia.
Pitting edema is another sign your physician may find when he or she examines you, so this goes along with the swelling of the legs we talked about. During the exam, your doctor may take his or her finger and press against your leg where the swelling is, and then once your physician removes that finger, there may be an indentation or a pit left in the leg. This is pitting edema which can be a sign of heart failure.
Your doctor may also hear rails or crackles when they auscultate your lungs when they listen to your lungs with a stethoscope, and this could be a sign of heart failure and a sign of fluid in the lungs or pulmonary edema, pulmonary congestion. And if you have pulmonary edema or pulmonary congestion as a result of congestive heart failure, you may notice that in addition to being short of breath, you have some wheezing or even coughing and you may actually cough up some pink, frothy phlegm, or pink, frothy sputum, which could be a warning sign.
Oh, and remember at the beginning of this article when I asked if you have to be propped up on a bunch of pillows to sleep at night or if you actually have to sit up in a chair in order to breathe at night? Well if this is the case, then you may have orthopnea, which could also be an indication of CHF.
Orthopnea is when you have difficulty lying down at night because the fluid in your body pools into the lungs, causing you to be congested and you cannot breathe well when you're lying flat. So what do you do? You prop yourself up or you sit up. When you do that the fluid can pool to other parts of your body and not be congested in the lungs. Orthopnea can certainly be a warning symptom of congestive heart failure.
Congestive Heart Failure Overview: The Diagnosis
So now I'll give a congestive heart failure overview of the diagnosis and the treatment. In order to be diagnosed, you must consult your physician or your heart doctor, your cardiologist, and your physician will give you a thorough history and physical and they may also run some lab tests and do some imaging studies so they can diagnose you by finding some of the signs on your physical exam that we talked about like the crackles or the jugular venous distention (JVD).
They may also do a chest x-ray and find that you have pulmonary edema, and they can do lab work like a BNP or brain natriuretic peptide or an NT pro-BNP. An N-terminal pro-BNP is another test for congestive heart failure.
Doctors can also do a stress test or a heart catheterization, a cardiac cath, and most certainly an EKG or an ECG to see if you have signs of congestive heart failure. So certainly if you suspect that you may have CHF or that a loved one may have it, please don't hesitate, consult your physician.
Treatment For Congestive Heart Failure
So what are the treatments for congestive heart failure? Well depending on the type of heart failure you have, heart failure with reduced ejection fraction, or heart failure with preserved ejection fraction, then your treatment may vary.
Also, it depends on the severity and the underlying cause of your heart failure, but in general, some treatments include diuretics or water pills, also certain medications such as ACE inhibitors, angiotensin receptor blockers, nitrates, hydralazine, and spironolactone.
You may require procedures such as pacemakers or defibrillators, or you may even need a VAD or a ventricular assist device. And certainly, lifestyle will play a role in your treatment. Your physician may ask that you reduce the amount of fluid you take in each day, and they will very likely suggest that you have a low sodium diet or a low salt intake.
Some patients with severe heart failure may actually require a heart transplant. If you found this congestive heart failure overview to be helpful and informative, please be to share it with the people you care about. And if you have not done so already, please subscribe to my YouTube channel and hit that notification button. That way you'll be among the first to know when I'm releasing new medical content. Also, follow me on Instagram @Dr.Frita, just to see what I'm up to in my everyday life. Please do your best to live your healthiest, happiest life.