What is Congestive Heart Failure (CHF)?
Congestive heart failure (CHF), as stated by major American health organizations, occurs when the heart’s ventricle cannot fill or pump out blood properly. The main cause globally is heart disease, which can lead to death. CHF is quite common, with around 26 million people suffering from it worldwide. This disease carries a high risk of severe illness and death. It’s also expensive to treat and significantly reduces a person’s ability to function and enjoy life. That’s why it’s vital to diagnose and treat CHF effectively, to prevent repeat hospital stays, lower the risk of illness and death, and improve patient outcomes.
Heart failure can arise from many different causes. Treatments typically focus on reducing symptoms, clearing fluid build-up from the lungs, and stabilizing the patient’s blood flow. Managing heart failure usually involves educating the patient, ensuring they take their medications properly, and preventing flare-ups of the disease.
One method doctors use to categorize heart failure involves measuring the percentage of blood the left ventricle pumps out during each heartbeat, known as the ‘ejection fraction’. There are different types of heart failure based on this measurement:
* Heart failure with a reduced ejection fraction (HFrEF): less than or equal to 40% of blood is pumped out.
* Heart failure with a mildly reduced ejection fraction: between 41% and 49% of blood is pumped out, combined with other signs of heart failure.
* Heart failure with a preserved ejection fraction (HFpEF): more than or equal to 50% of blood is pumped out, combined with other signs of heart failure.
* Heart failure with an improved ejection fraction: more than 40% of blood is pumped out, but there was a time when it was 40% or less.
HFpEF is often overlooked, but it can make up between 44% and 72% of all CHF cases. With this type, over half the blood in the ventricle is pumped out each time, but the ventricle does not fill up properly afterward. The biggest risk factors for HFpEF are high blood pressure, being older, being female, and having diabetes.
Heart failure is also classified into stages by severity of symptoms. The first two stages have no symptoms, while the second two stages are determined by the seriousness of the symptoms. The classification ranges from being at risk for developing heart failure to having constant, severe symptoms despite treatment.
Additionally, doctors use the New York Heart Association Functional Classification to classify patients with heart failure symptoms. This system ranks patients based on the severity of their symptoms, from only having symptoms during heavy activity to having symptoms even at rest. It’s determined by the doctor and widely used to guide treatment.
What Causes Congestive Heart Failure (CHF)?
Congestive Heart Failure (CHF) can be caused by many factors, with the leading cause being coronary artery disease (CAD), which reduces blood flow to the heart. It’s crucial to understand the causes in order to shape the treatment plans effectively. You can group the root causes as coming from within the heart or from other conditions that affect the heart. Four main causes, i.e., ischemic heart disease, chronic pulmonary disease (COPD), high blood pressure heart disease, and rheumatic heart disease, account for about two-thirds of CHF cases. Ischemic heart disease is the top cause globally, and it’s becoming more common in developing countries due to changes in diet and lifestyle.
Another common cause is valvular heart disease, which affects the valves of the heart. Rheumatic heart disease is the most common type in young people, caused by an immune response to a certain type of bacteria and usually affecting the mitral and aortic valves. As people get older, it’s more typical for age-related degeneration to cause valvular disease.
High blood pressure can also lead to CHF, even if there’s no coronary artery disease or ischemic heart disease. High blood pressure puts stress on the heart and can enlarge the heart’s ventricles. Treating high blood pressure effectively can help prevent CHF.
Cardiomyopathy is a term for heart conditions that result in an enlarged, poorly functioning heart that isn’t caused by diseases like ischemic heart disease, valvular heart disease, high blood pressure, or congenital heart disease. Many of these conditions are genetic and can involve sudden cardiac death, so it’s important for doctors to look for signs of these diseases.
Inflammatory cardiomyopathy, caused by inflammation of the heart muscle and inefficient heart function, is often a result of viral infections, but can also be caused by other infections, toxins, or immune diseases. Notably, Chagas disease, a disease common in Latin America, can often lead to myocarditis and heart failure.
Furthermore, diseases that infiltrate the heart tissues can cause heart problems as well. For example, in cardiac amyloidosis, misfolded proteins build up and cause damage. Other diseases like sarcoidosis and hereditary hemochromatosis, a condition that leads to iron overload, also affect the heart.
Takotsubo cardiomyopathy, sometimes called “broken-heart syndrome,” is often not recognized as a cause of CHF. This condition, which can involve temporary heart wall abnormalities, has been diagnosed more frequently during the COVID-19 pandemic.
Heart failure can also occur during or after pregnancy due to an increased level of stress on the heart. It’s more common in older mothers and those with multiple births, and it often involves a genetic component. Moreover, obesity can significantly contribute to heart failure in people under 40, even without the presence of other heart diseases.
Fast heart rate and abnormal heart rhythms can also result in a heart failure state. Lastly, thyrotoxicosis, a high level of thyroid hormones in the body, is a rare cause of heart failure but may affect the heart’s function due to changes in blood volume and heart rate. Rarely, heart failure can be connected with thiamine deficiency, usually seen in the elderly, homeless, or those with alcohol use disorder.
Risk Factors and Frequency for Congestive Heart Failure (CHF)
The global impact of heart failure (HF), also known as congestive heart failure (CHF), is hard to measure due to variations in geographic locations, assessment methods, lack of certain medical equipment, and inconsistent disease staging and diagnosis. However, in 2017, about 1.2 million hospital stays were due to CHF, and there’s been an increase in patients with “heart failure with preserved ejection fraction” (HFpEF) as compared to “heart failure with reduced ejection fraction” (HFrEF).
Some reports suggest the rate of heart failure incidences has stabilized, but the number of cases overall is still rising as more patients receive treatment. Unfortunately, this doesn’t seem to be leading to improved quality of life or reduced hospital visits for heart failure patients. According to the Global Health Data Exchange, there are about 64.34 million cases of CHF worldwide. This results in roughly 9.91 million years lost to disability and costs about 346.17 billion US dollars in healthcare costs.
- Age significantly influences the likelihood of heart failure. The risk increases significantly with age.
- For example, the Framingham Heart Study found that heart failure prevalence was 8 per 1,000 males aged 50 to 59 years, but it rose to 66 per 1,000 males aged 80 to 89.
- After the age of 65, the incidence of heart failure for men doubles every 10 years. For women of the same age group, the rate triples.
- Men typically have higher rates of heart disease and heart failure than women.
- Race is also a factor; Black patients have a 25% higher prevalence of heart failure than white patients.
- Heart failure remains the main reason for hospitalizations in older adults, making up 8.5% of cardiovascular-related deaths in the United States.
Similar patterns are seen in international heart failure statistics. The rate increases significantly with age, metabolic risk factors, and inactive lifestyles. In developing countries, heart disease caused by clogged arteries and high blood pressure are major causes of heart failure. Studies suggest there is a higher prevalence of isolated right-side heart failure in these regions, potentially due to higher rates of tuberculosis, heart membrane disease, and lung disease. However, more robust data is needed to confirm these findings.
Signs and Symptoms of Congestive Heart Failure (CHF)
Heart Failure (HF) is identified and categorized based on symptoms and physical examination findings. To properly treat the patient, it’s crucial to thoroughly understand their symptoms, underlying health conditions, and ability to perform tasks.
Acute CHF mainly shows signs of congestion and may also show signs of impaired blood flow or shock. The most common symptom is shortness of breath, which can be classified as exercise-induced, positional (orthopnea), and whether it’s acute or chronic. Other common symptoms include chest pain, loss of appetite, and fatigue due to exertion. Some patients might experience a lying down cough due to orthopnea, while others may experience stomach discomfort due to liver congestion or fluid in the abdomen. Patients with rhythm irregularities in the heart can experience a rapid heartbeat, fainting, or near-fainting. Edema, especially in the lower limbs, is another symptom that can limit mobility and balance and cause significant weight gain.
While acute HF patients show evident respiratory distress, orthopnea, and sudden night-time shortness of breath, those with chronic HF tend to limit their physical activity, which could hide the symptoms. Recognizing triggers for acute deterioration such as recent infection, not taking heart medication as prescribed, using NSAIDs, or high salt intake is vital.
The findings from a physical examination differ depending on the stage and acuity of the disease. Patients could show symptoms of left-sided HF, right-sided HF, or combined.
- General physical examination: Patients with severe CHF or those with quickly deteriorating HF may show signs of anxiety, sweating, rapid heart rate, and fast breathing. Patients with chronic declining HF may appear wasted. Lung examination findings may reveal a classical symptom, pulmonary rales, which point to moderate-to-severe heart failure. Wheezing might be present in acute decompensated heart failure. As lung congestion severity increases, bubbly and bloody sputum may be seen. Jugular venous distention is another classic finding that all HF patients should be examined for. Patients with high left-side filling pressures may exhibit a hepatojugular reflux.
- Patients with Stage D HF may show signs of poor blood flow such as low blood pressure, delayed capillary refill, cold extremities, poor mental state, and reduced urine output. They may experience pulsus alternans, which is a pulse that alternates between weak and strong and is indicative of severe ventricular dysfunction. The pulse can be irregular if atrial fibrillation or ectopic beats are present. Peripheral edema is usually present with most HF. Weight gain is another way to measure fluid retention, and precise daily weights can be a useful tool for monitoring.
- Precordial examination findings might include an S3 gallop or a displaced apex beat. Patients can have associated murmurs such as the continuous murmur of mitral regurgitation or tricuspid regurgitation, the systolic ejection murmur of aortic valve narrowing, or the early diastolic murmur of aortic regurgitation. Patients with pulmonary hypertension might have a palpable or loud P2 or parasternal heave. Patients with congenital heart disease might also exhibit clubbing, bluish discoloration of the skin, and splitting of the second heart sound.
An S3 gallop is the most significant and early finding associated with HF. Patients with hypertensive heart disease might have an S4 or loud A2. Patients with HF that have preserved EF might have an S4 gallop due to ventricular noncompliance.
The commonly used Framingham Diagnostic Criteria for Heart Failure require:
- Presence of 2 major criteria or,
- 1 major and 2 minor criteria to diagnose HF.
This clinical diagnostic tool is highly sensitive for the diagnosis of HF, but it has relatively low specificity. Here are the major and minor Framingham Diagnostic criteria:
Major Criteria
- Acute lung edema
- Cardiomegaly
- Hepatojugular Reflux
- Neck vein distention
- Sudden night-time shortness of breath or orthopnea
- Pulmonary rales
- Third heart sound (S3 Gallop)
Minor Criteria
- Ankle swelling
- Shortness of breath on exertion
- Hepatomegaly
- Night-time cough
- Pleural effusion
- Rapid heart rate (above 120 beats per minute)
Testing for Congestive Heart Failure (CHF)
When evaluating a patient with heart failure, several exams are key. This includes a complete blood test, a check of iron levels, and tests for kidney and liver function. Depending on the cause and stage of the heart failure, further checks may be needed.
Your doctor will check your blood count (CBC) to see if you have anemia or an infection that’s sparking heart failure. A renal profile, or kidney test, is vital for all heart failure patients; it hints at the amount of kidney damage caused by the heart failure and helps choose the best treatments.
Hyponatremia, or low sodium in the bloodstream, can indicate a higher risk of dying for patients with chronic heart failure. Similarly, liver congestion due to heart failure may raise enzyme levels, as seen on liver tests.
Amyloidosis, a disease where abnormal proteins build up in your organs, is a concern when diagnosing heart failure. Urine tests can be important for this. If your doctor suspects this disease, he or she may order these tests.
B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-ProBNP) levels can help tell if shortness of breath is due to heart issues or not, especially when the cause is unclear. Both these peptides help to indicate heart failure severity and are used to track how well treatments are working.
Troponin-I or T are proteins that, when raised, can indicate ongoing heart damage and can signal an increased risk of serious heart complications and death.
An electrocardiogram (ECG) can show evidence of previous heart attacks, expanded heart chambers, abnormal rhythm or conduction, or particular causes of heart failure.
Chest X-rays can show how congested your lungs are and how enlarged your heart is. An echocardiogram (ultrasound of the heart) may be the first test done if heart failure is suspected. It can show how well the heart is pumping and any abnormalities in the heart’s structure.
Cardiac catheterization can be good for diagnosing ischemic cardiomyopathy, a type of heart muscle disease that can lead to heart failure.
In young patients with heart issues, a CT scan may be used to evaluate the coronary arteries. In older patients, a CT can help identify tumors that might be causing heart failure.
Scan technologies like SPECT-Myocardial Perfusion Imaging and MUGA can help understand the presence of blockages in the arteries in patients not undergoing a heart x-ray. In addition, Cardiac MRI can provide a more in-depth evaluation when doctors are unclear about the stage of disease vs. other findings.
Noninvasive stress imaging tests can help evaluate the benefits of opening up blocked arteries. Genetic tests can be used to identify particular inherited types of heart muscle disease.
Treatment Options for Congestive Heart Failure (CHF)
The goal of treatment for chronic heart failure (CHF) is to improve the patient’s symptoms, quality of life, reduce the need for hospital stays, and improve heart health. Medications are used to control symptoms and reduce the chance of heart problems.
The American College of Cardiology and the American Heart Association have outlined the treatment plans to follow for each stage of heart failure:
In Stage A or “at-risk” stage, various strategies can include managing high blood pressure, treating type 2 diabetes, diet modification, regular exercise, maintaining a healthy weight, and avoiding smoking. Special tools are used to predict the risk of future heart problems in patients with heart failure. Patients at risk of heart failure due to taking potentially heart-damaging medications, like chemotherapy, should be carefully monitored.
In Stage B or “pre-heart failure” stage, treatments focus on preventing the start of clinical heart failure and reducing death and bad heart events. Different types of drugs are used based on specific patient conditions. Some drugs are avoided due to increased risk of bad outcomes and hospital stays.
In Stage C or “heart failure” stage, the patient’s management involves a team of health professionals for better results. This can include patient education, support, vaccinations against respiratory illness, and assessment of physical, mental, and social health during healthcare visits. Diet and exercise are recommended, along with certain medications to reduce symptoms and progression of heart failure.
In the final Stage D or “advanced heart failure” stage, the patient needs to see a heart failure specialist. Short-term and long-term options are considered to support heart function or replace the heart altogether. The decision should be mutual between the patient and healthcare provider, taking into account the patient’s overall physical condition and social and financial support. If necessary, specialists in providing comfort and relieving symptoms, known as palliative care providers, can be involved.
What else can Congestive Heart Failure (CHF) be?
When dealing with symptoms such as fluid overload or difficulty in breathing, doctors often have to consider various other conditions that might show similar signs. These can include:
- Sudden kidney failure
- Respiratory issues leading to severe distress
- Liver damage or ‘cirrhosis’
- Scarring or hardening of the lungs, also known as ‘pulmonary fibrosis’
- A kidney condition causing excessive protein loss in urine, known as ‘nephrotic syndrome’
- Pulmonary embolism meaning a blood clot in the lungs
It’s crucial for healthcare providers to consider and test for these conditions to make an accurate diagnosis.
What to expect with Congestive Heart Failure (CHF)
According to the Centers for Disease Control and Prevention (CDC), the number of deaths related to heart failure (HF) declined from 103.1 deaths per 100,000 population in 2000 to 89.5 in 2009. However, it increased again to 96.9 per 100,000 population in 2014. This trend links to a shift away from coronary heart disease causing HF deaths to metabolic diseases and other non-heart related conditions, including obesity, diabetes, cancer, chronic lung diseases, and kidney disease. The death rate following hospitalization for HF is roughly 10% after 30 days, 22% after 1 year, and 42% after 5 years. This rate can spike to more than 50% in patients with advanced HF.
The Ottawa Heart Failure Risk Score helps predict the future health status in patients showing up at the emergency department with HF. This score measures the risk of death within 14 days, hospital readmission, and the sudden onset of heart disease to aid in safe discharge planning. Patients scoring 0 are seen as low risk. Those scoring 1 to 2 are considered moderate risk, while scoring 3-4 indicates high risk and a score of 5 or higher points to very high risk. This score is based on:
Each of the following items gives one point:
* Having a history of stroke or temporary loss of blood flow to the brain (temporary ischemic attack)
* Oxygen saturation level below 90%
* Heart rate over 110 beats per minute during a 3-minute walk test
* Rapid ischemic ECG changes, alterations indicating insufficient blood supply to the heart
* An NT-ProBNP level (a marker of heart disease) above 5000 ng/L
And each of these items earns two points:
* History of needing mechanical ventilation for difficulty breathing
* Heart rate over 110 beats per minute when admitted
* Blood urea nitrogen (a kidney function marker) more than 33.6 mg/dL (12 mmol/L)
* Serum bicarbonate (an electrolyte in blood) level over 35 mg/d.
Possible Complications When Diagnosed with Congestive Heart Failure (CHF)
Complications of Congestive Heart Failure (CHF) can negatively affect a person’s everyday life. The complications may include:
- Reduced quality of life
- Irregular heartbeat or sudden heart failure
- Significant weight loss and muscle wasting, known as cardiac cachexia
- Diseases affecting both the heart and kidneys, called cardiorenal disease
- Liver not working properly
- Heart valve issues, like functional MR or TR
- Blood clots in heart walls, that raise risk of clot traveling to brain, kidney, lung, or major limb vessels
- Repeated hospital stays and risk of hospital-borne infections
Preventing Congestive Heart Failure (CHF)
Reducing risk factors and managing any other health conditions is key to decreasing the sickness and death related to heart failure. Alongside taking prescribed medications, patients should be advised on how to keep an eye out for heart failure symptoms and evade anything that can trigger the disease. These approaches can help avoid heart failure in patients at high risk and slow its progress in those already diagnosed with it.
Patients need to be educated to look after themselves and stick to their treatment plans. Supervision is crucial, including self-check by the patient and family, visits at home, telephone support, and remote check-ups. Support with social and financial matters plays a vital role in managing the disease properly. Patients need regular medical check-ups to assess fluid levels in the body, response to medication, and to determine if a higher level of care is needed.
