What are the main symptoms of congestive heart failure. How is congestive heart failure diagnosed. What are the most effective treatments for congestive heart failure. How can lifestyle changes help manage congestive heart failure. What are the latest research developments in congestive heart failure treatment.

Understanding Congestive Heart Failure: A Comprehensive Overview

Congestive heart failure (CHF) is a serious cardiovascular condition that affects millions of people worldwide. Despite its name, heart failure doesn’t mean the heart has stopped working entirely. Instead, it refers to a situation where the heart muscle has become less efficient at pumping blood throughout the body. This reduced efficiency can lead to a range of symptoms and complications that significantly impact a person’s quality of life.

What exactly happens in congestive heart failure? The heart’s pumping capacity becomes compromised, leading to blood congestion in various parts of the body. As a result, oxygen-rich blood fails to reach organs and tissues effectively, causing a cascade of physiological responses as the body attempts to compensate for this deficiency.

Key Facts About Congestive Heart Failure

• More than 5 million people in the United States have congestive heart failure.
• It’s the most common diagnosis in hospitalized patients over age 65.
• One in nine deaths has heart failure as a contributing cause.
• CHF is often progressive, meaning it can worsen over time with or without treatment.

Recognizing the Symptoms of Congestive Heart Failure

Identifying the symptoms of congestive heart failure is crucial for early diagnosis and treatment. While symptoms can vary from person to person, there are several common signs to watch out for:

• Shortness of breath (dyspnea), especially during physical activity or when lying down
• Persistent coughing or wheezing
• Swelling (edema) in the legs, ankles, and feet
• Rapid or irregular heartbeat
• Fatigue and weakness
• Reduced ability to exercise
• Swelling of the abdomen (ascites)
• Sudden weight gain from fluid retention
• Lack of appetite and nausea
• Difficulty concentrating or decreased alertness

How does congestive heart failure affect breathing? One of the most common and distressing symptoms of CHF is shortness of breath. As the heart struggles to pump blood effectively, fluid can accumulate in the lungs, making it difficult to breathe. This symptom often worsens when lying down, as gravity causes more fluid to shift towards the chest.

Causes and Risk Factors of Congestive Heart Failure

Understanding the causes and risk factors of congestive heart failure is essential for both prevention and management of the condition. While CHF can develop due to various reasons, certain factors significantly increase the likelihood of its occurrence:

Common Causes of Congestive Heart Failure

• Coronary artery disease
• High blood pressure (hypertension)
• Previous heart attack
• Valvular heart disease
• Cardiomyopathy
• Congenital heart defects
• Severe lung disease
• Diabetes
• Sleep apnea

What role does lifestyle play in the development of congestive heart failure? Certain lifestyle factors can significantly contribute to the risk of developing CHF. These include:

• Smoking
• Excessive alcohol consumption
• Lack of physical activity
• Poor diet high in saturated fats, trans fats, and sodium
• Obesity
• Chronic stress

By addressing these modifiable risk factors, individuals can potentially reduce their risk of developing congestive heart failure or slow its progression if already diagnosed.

Diagnostic Approaches for Congestive Heart Failure

Diagnosing congestive heart failure involves a comprehensive approach that combines medical history, physical examination, and various diagnostic tests. This multifaceted strategy helps healthcare providers accurately assess the presence and severity of CHF.

Key Diagnostic Tests for Congestive Heart Failure

1. Electrocardiogram (EKG): This non-invasive test provides information about the heart’s electrical activity, including heart rate and rhythm abnormalities.
2. Chest X-ray: Imaging of the chest can reveal an enlarged heart or signs of fluid accumulation in the lungs.
3. BNP blood test: Measuring levels of B-type natriuretic peptide (BNP) can help determine the severity and prognosis of heart failure.
4. Echocardiogram: This ultrasound-based test provides detailed images of the heart’s structure and function.
5. Holter monitor: A portable device worn for 24-48 hours to record the heart’s electrical activity during daily activities.
6. Exercise stress test: This test evaluates how the heart performs under physical stress, typically involving walking on a treadmill or cycling on a stationary bike.
7. Cardiac catheterization: In some cases, this invasive procedure may be necessary to assess blood flow and pressure within the heart.

How do these diagnostic tests help in managing congestive heart failure? By providing a comprehensive picture of heart function and overall cardiovascular health, these tests enable healthcare providers to develop tailored treatment plans and monitor disease progression over time.

Treatment Strategies for Congestive Heart Failure

While there is no cure for congestive heart failure, various treatment options can help manage symptoms, improve quality of life, and potentially slow disease progression. The treatment approach is typically individualized based on the type and severity of heart failure, underlying causes, and the patient’s overall health status.

Medications for Congestive Heart Failure

Pharmaceutical interventions play a crucial role in managing CHF. Common medications include:

• ACE inhibitors or ARBs: These medications help relax blood vessels and reduce strain on the heart.
• Beta-blockers: These drugs slow heart rate and reduce blood pressure, easing the heart’s workload.
• Diuretics: Often called “water pills,” these medications help reduce fluid retention and relieve congestion.
• Aldosterone antagonists: These drugs help the body eliminate excess sodium and water while retaining potassium.
• Digoxin: This medication can help strengthen heart contractions and slow heart rate.
• SGLT2 inhibitors: Originally developed for diabetes, these drugs have shown benefits in heart failure treatment.

What role do lifestyle modifications play in treating congestive heart failure? Alongside medications, lifestyle changes are crucial for managing CHF effectively. These may include:

• Adopting a heart-healthy diet low in sodium, saturated fats, and trans fats
• Engaging in regular physical activity as recommended by a healthcare provider
• Maintaining a healthy weight
• Quitting smoking and limiting alcohol consumption
• Managing stress through relaxation techniques or counseling
• Monitoring daily fluid intake and weight

Advanced Treatments for Severe Congestive Heart Failure

In cases of severe or progressive heart failure, more advanced treatments may be necessary:

• Implantable cardioverter-defibrillators (ICDs): These devices can detect and correct dangerous heart rhythm abnormalities.
• Cardiac resynchronization therapy (CRT): This treatment uses a specialized pacemaker to coordinate the heart’s contractions.
• Ventricular assist devices (VADs): These mechanical pumps can help support heart function in advanced heart failure.
• Heart transplantation: In select cases, a heart transplant may be considered as a last resort for end-stage heart failure.

Living with Congestive Heart Failure: Self-Care and Management

Successfully managing congestive heart failure requires active participation from patients in their own care. Self-management strategies can significantly impact quality of life and disease progression.

Key Self-Care Strategies for Congestive Heart Failure Patients

1. Medication adherence: Taking prescribed medications as directed is crucial for managing symptoms and preventing complications.
2. Regular monitoring: Tracking daily weight, blood pressure, and symptoms can help detect changes early.
3. Dietary management: Following a low-sodium diet and maintaining proper fluid intake as recommended by healthcare providers.
4. Exercise and physical activity: Engaging in appropriate levels of physical activity as advised by medical professionals.
5. Stress management: Implementing stress-reduction techniques such as meditation, deep breathing, or yoga.
6. Regular medical check-ups: Attending scheduled appointments with healthcare providers for ongoing monitoring and treatment adjustments.
7. Education and support: Participating in heart failure education programs and support groups can provide valuable information and emotional support.

How can patients effectively communicate with their healthcare team? Open and honest communication with healthcare providers is essential for optimal management of congestive heart failure. Patients should report any changes in symptoms, side effects of medications, or concerns about their treatment plan promptly.

Emerging Research and Future Directions in Congestive Heart Failure Treatment

The field of congestive heart failure research is rapidly evolving, with ongoing studies exploring new treatment approaches and management strategies. These advancements offer hope for improved outcomes and quality of life for CHF patients.

Promising Areas of Congestive Heart Failure Research

• Gene therapy: Exploring genetic approaches to repair or replace damaged heart tissue.
• Stem cell therapy: Investigating the potential of stem cells to regenerate heart muscle and improve function.
• Novel drug therapies: Developing new medications targeting specific pathways involved in heart failure progression.
• Artificial intelligence in diagnostics: Utilizing AI algorithms to improve early detection and risk stratification of heart failure.
• Wearable technology: Advancing remote monitoring capabilities for better disease management and early intervention.
• Personalized medicine: Tailoring treatments based on individual genetic profiles and biomarkers.

What impact could these research developments have on congestive heart failure management? As these areas of research progress, they have the potential to revolutionize how congestive heart failure is diagnosed, treated, and managed. This could lead to more effective therapies, improved quality of life for patients, and potentially even methods to prevent or reverse heart failure in some cases.

Prevention Strategies for Congestive Heart Failure

While not all cases of congestive heart failure can be prevented, adopting heart-healthy habits and managing underlying conditions can significantly reduce the risk of developing CHF or slow its progression.

Key Prevention Strategies for Congestive Heart Failure

1. Maintain a healthy blood pressure: High blood pressure is a major risk factor for heart failure. Regular monitoring and management through lifestyle changes or medication can help prevent damage to the heart.
2. Control cholesterol levels: High cholesterol can lead to atherosclerosis, increasing the risk of heart disease and heart failure. A heart-healthy diet, regular exercise, and cholesterol-lowering medications when necessary can help maintain healthy cholesterol levels.
3. Manage diabetes: Uncontrolled diabetes can damage blood vessels and increase the risk of heart failure. Proper diabetes management through diet, exercise, and medication is crucial for heart health.
4. Quit smoking: Smoking damages blood vessels and increases the risk of heart disease. Quitting smoking can significantly reduce the risk of developing heart failure.
5. Maintain a healthy weight: Obesity puts extra strain on the heart and increases the risk of conditions that can lead to heart failure. Achieving and maintaining a healthy weight through diet and exercise is essential for heart health.
6. Regular physical activity: Engaging in regular moderate-intensity exercise can strengthen the heart and improve overall cardiovascular health.
7. Limit alcohol consumption: Excessive alcohol intake can damage the heart muscle. Limiting alcohol consumption to moderate levels can help protect heart health.
8. Manage stress: Chronic stress can contribute to high blood pressure and unhealthy behaviors. Implementing stress-reduction techniques can benefit overall heart health.

How effective are these prevention strategies in reducing the risk of congestive heart failure? While individual results may vary, studies have shown that adopting these heart-healthy habits can significantly reduce the risk of developing heart failure. For example, maintaining a healthy blood pressure alone can lower the risk of heart failure by up to 50% in some populations.

The Role of Regular Health Check-ups in Prevention

Regular medical check-ups play a crucial role in preventing congestive heart failure by allowing for early detection and management of risk factors. These check-ups typically include:

• Blood pressure measurements
• Cholesterol level tests
• Blood glucose tests
• Electrocardiograms (EKGs)
• Discussion of lifestyle habits and family history

By identifying and addressing potential risk factors early, healthcare providers can work with patients to implement preventive strategies and reduce the likelihood of developing congestive heart failure.

The Impact of Congestive Heart Failure on Quality of Life

Congestive heart failure can significantly impact an individual’s quality of life, affecting physical, emotional, and social well-being. Understanding these impacts is crucial for developing comprehensive care plans that address not only the physical symptoms but also the broader aspects of a patient’s life.

Physical Impacts of Congestive Heart Failure

• Reduced ability to perform daily activities due to fatigue and shortness of breath
• Sleep disturbances, including sleep apnea and orthopnea (difficulty breathing when lying flat)
• Decreased exercise tolerance and physical endurance
• Frequent hospitalizations for symptom management and complications

Emotional and Psychological Impacts

• Anxiety and depression related to the chronic nature of the condition
• Fear of worsening symptoms or death
• Frustration with physical limitations and lifestyle changes
• Stress related to financial burdens of ongoing medical care

Social Impacts

• Changes in social roles and relationships due to physical limitations
• Potential loss of employment or reduced work capacity
• Isolation due to reduced ability to participate in social activities
• Strain on family relationships due to caregiving needs

How can healthcare providers address the multifaceted impacts of congestive heart failure on patients’ lives? A holistic approach to care that includes physical symptom management, psychological support, and social services can help improve overall quality of life for CHF patients. This may involve:

• Referrals to mental health professionals for psychological support
• Connecting patients with support groups and community resources
• Providing education on coping strategies and stress management techniques
• Offering vocational rehabilitation services for those experiencing work-related challenges
• Encouraging family involvement in care planning and support

By addressing these various aspects of life impacted by congestive heart failure, healthcare providers can help patients maintain a better quality of life despite the challenges posed by their condition.

Congestive Heart Failure: Prevention, Treatment and Research

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Congestive heart failure (also called heart failure) is a serious condition in which the heart doesn’t pump blood as efficiently as it should. Despite its name, heart failure doesn’t mean that the heart has literally failed or is about to stop working. Rather, it means that the heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood. As a result, it can’t keep up with the body’s demand, and blood returns to the heart faster than it can be pumped out—it becomes congested, or backed up. This pumping problem means that not enough oxygen-rich blood can get to the body’s other organs.

The body tries to compensate in different ways. The heart beats faster to take less time for refilling after it contracts—but over the long run, less blood circulates, and the extra effort can cause heart palpitations. The heart also enlarges a bit to make room for the blood. The lungs fill with fluid, causing shortness of breath. The kidneys, when they don’t receive enough blood, begin to retain water and sodium, which can lead to kidney failure. With or without treatment, heart failure is often and typically progressive, meaning it gradually gets worse.

More than 5 million people in the United States have congestive heart failure. It’s the most common diagnosis in hospitalized patients over age 65. One in nine deaths has heart failure as a contributing cause.

“To avoid heart failure, there’s a need to prevent other heart problems,” says Johns Hopkins cardiologist Steven Jones, M.D.

Prevention

The best way to avoid congestive heart failure is to avoid the conditions that contribute to it, or to carefully manage these conditions if they develop, says Jones.

• Stop smoking—better yet, don’t start. It’s a major factor in the arterial damage that can cause heart failure. Also steer clear of secondhand smoke.

• Eat in heart-healthy ways. The foods that help you are those that contain little saturated fat, trans fat, sugar or sodium. Think fruits and vegetables, low-fat dairy, lean protein such as chicken without the skin, and “good” fats such as those found in olive oil, fish and avocadoes. Get practical ideas to eat for heart health in Eat Smart.

• Lose pounds if you’re overweight. Along with diet, being physically active helps achieve this goal and is also great for your heart.

• If you have another type of heart disease or related condition, closely follow your treatment program. Ongoing care and adherence to prescribed medications, such as statin drugs to treat high cholesterol, can make a big difference. “Recent research shows that a major portion of the long-term benefit of statin therapy is in the prevention of heart failure by way of preventing heart attacks and coronary events that lead to it,” says Jones.  

Diagnosis

There’s no one test to diagnose heart failure. Your doctor will consider your medical history, family history, a physical exam and the results of various tests.  These tests can include:

• Electrocardiogram (EKG): A painless test that gives information about your heart’s electrical activity, including how fast it beats and whether you’ve had previous heart attacks.

• Chest X-ray: A picture of the heart, lungs and other chest structures that reveals whether the heart is enlarged or there are signs of lung damage.

• BNP blood test: B-type natriuretic peptide (BNP) is a hormone that is a marker of severity and prognosis of heart failure.

• Echocardiogram: An ultrasound image of the heart. It’s different from another test, a Doppler ultrasound, which gives a picture of blood flow to the heart and lungs.

• Holter monitor: A measurement of your heart’s electrical activity, taken by a portable device that you wear for a day or two.

• Exercise stress test: You walk on a treadmill or ride a stationary bicycle to see how your heart performs when it has to work hard. If you’re unable to take an exercise test, stress can be induced by administering a drug that causes a similar reaction.

Treatment

There’s no cure for heart failure. Treatment aims to relieve symptoms and slow further damage. TheI exact plan depends on the stage and type of heart failure, underlying conditions and the individual patient. Among the components of a treatment plan: 

Lifestyle changes. These are the same changes as those for preventing heart failure. In addition, you may be advised to avoid salt (because of fluid retention) and caffeine (because of heartbeat irregularities). Your doctor will advise how much fluid and what kinds to drink, as sometimes fluid intake should be limited.  

Medications. According to Jones, the types of medications typically prescribed include these: 

• Vasodilators expand blood vessels, ease blood flow, and reduce blood pressure.
• Diuretics correct fluid retention.
• Aldosterone inhibitors help with fluid retention and improve chances of living longer.
• ACE inhibitors or ARB drugs improve heart function and life expectancy.
• Digitalis glycosides strengthen the heart’s contractions.
• Anticoagulants or antiplatelets such as aspirin help prevent blood clots.
• Beta-blockers improve heart function and chances of living longer.
• Tranquilizers reduce anxiety.

Surgical procedures. In more severe cases, surgery is required to open or bypass blocked arteries, or to replace heart valves. Some congestive heart failure patients are candidates for a type of pacemaker called biventricular pacing therapy, which helps both sides of the heart work in concert, or an implantable cardioverter defibrillator, which shocks the heart into converting a potentially fatal fast rhythm to a normal one. Ventricular assist devices (VAD therapy) may be used as a bridge to heart transplantation or as a treatment in lieu of transplant, says Jones. A heart transplant is considered the last resort, with success rates of about 88 percent after one year and 75 percent after five years.

Other treatments. Because sleep apnea—a condition in which the muscles that allow air into the lungs briefly collapse—is linked to heart failure, you may be evaluated and treated for it. 

Living With…

Here are some of the things you’ll want to do in addition to sticking to the lifestyle changes that can improve the health of a damaged heart:

• Monitor your symptoms.  Heart failure worsens over time, so you need to be familiar with changes in your body. Some of these can be addressed with different medications. Weighing yourself daily is one of the easiest ways to track fluid retention, indicated by a sudden gain. Swelling in the legs and feet can also mean more fluid is accumulating.
• Monitor your health. Keep track of blood pressure, weight and other vital signs as your doctor advises. Get lab work done as recommended, as it gives key clues to your heart health and medication needs. A flu shot and pneumonia vaccine can help you avoid infections that would be especially hard on your compromised lungs.
• Try to keep a positive attitude. Congestive heart failure is a serious condition, says Jones, but with the right help you can still lead a long and productive life. Because anxiety and depression, which can cause you to feel stressed, are common side effects, try to find outlets for your stress. This might be a support group or therapist, relaxing hobbies you love or confiding your concerns to someone you trust.
• Don’t be shy about asking questions. Depending on the stage of disease, your doctor will have different recommendations about how active you should be, including work, exercise and sex.

Research

Johns Hopkins researchers are on the forefront of the study of congestive heart failure. Among their recent findings:

• African-Americans are at increased risk of congestive heart failure. This is due to diabetes and high blood pressure, rather than race alone. In a study involving nearly 7,000 men and women, Johns Hopkins researchers were able to discover the underlying reason that African-Americans are known to develop heart disease more than any other race. When diabetes and high blood pressure are factored out, they face no higher risk.
• A simple blood test can determine which patients will fare better after hospital discharge.  Johns Hopkins researchers realized that congestive heart failure patients with a certain level of a protein linked to heart stress were 57 percent more likely to be readmitted to the hospital.

Shortness of breath: what causes it and how can you manage it?

Are you dealing with shortness of breath? Breathlessness experts Dr Ann Hutchinson and Professor Miriam Johnson explain what causes it, how you can manage it, and where to get support.

Image created by Janice Tonge, who lives with breathlessness, and artist Anna Bean

What’s on this page?

• What is shortness of breath?
• What causes shortness of breath?
• What are the different types of breathlessness?
• How can breathlessness affect your life? 
• How can you manage shortness of breath?
• Information for people caring for you
• Where to get more support

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What is shortness of breath? 

When you are short of breath, it may feel like you can’t get enough air into your lungs, or like you can’t catch your breath. Breathing may feel difficult or uncomfortable. The medical term for shortness of breath is dyspnoea.

What causes shortness of breath? 

Many people who have heart conditions experience shortness of breath every day. Heart conditions such as angina, heart attacks, heart failure and some abnormal heart rhythms like atrial fibrillation can all cause shortness of breath. 

These conditions may cause breathlessness for different reasons. If your heart isn’t pumping enough oxygen-containing blood around the body, your body responds by breathing faster to try to get more oxygen into your body, making you feel short of breath.   

Or if your heart isn’t working as well as it should, this could cause a build-up of fluid in the lungs, making it difficult to breathe.   

Other conditions, including anxiety, asthma, a blood clot in the lungs, cancer, or a chest infection like pneumonia, can also lead to shortness of breath.  We also know that breathlessness  can affect some people after they have had Covid-19.  

When you experience shortness of breath, several things may make the problem worse: 

• Breathlessness can be triggered by physical exertion (such as climbing stairs, gardening, shopping). This may cause you to stop doing those things, so your muscles may get weaker, and you become breathless even more quickly when you try to do them.
• Breathlessness can feel frightening, and you may start having thoughts like “I’m going to die” or “I’m upset people are seeing me like this.” This may trigger feelings of panic, which can lead to rapid breathing, making your breathlessness worse.

If this sounds familiar to you, there are simple things that you can do, which many people with breathlessness find helpful. For example, try to stay active, so your muscles stay strong helping you to do everyday activities more easily, without feeling as breathless. Try to remind yourself that feeling breathless will not harm you.   

What are the different types of breathlessness?

For most people who experience shortness of breath related to their heart condition, there are two main forms:  

An episode of breathlessness that comes on suddenly (acute). If you have heart failure, this can happen if you have too much fluid in your body, which can build up in your lungs, making it difficult to breathe. If you have a heart rhythm problem, this can cause sudden breathlessness.  

Persistent breathlessness, every day (chronic). For example, if you have advanced heart failure you may feel breathless most of the time, even if your condition is being treated and managed as well as it can be.  

How can breathlessness affect your life?  

People with breathlessness tell us that it affects their lives in several ways. It can make it difficult to manage your everyday activities. It can also make you feel frustrated or frightened. But the good news is that there are many things that you can do to cope, so that you can live well with breathlessness.   

We often feel lonely and on the edge of things

Breathlessness can make daily activities difficult and stop you from being able to get out and about. It’s very normal to feel frustrated and isolated if you find you can’t do the things that you used to do. Many people tell us that it makes them feel overwhelmed, depressed and anxious. It can change your relationships with people and can make you fearful for the future.  

People who live with breathlessness have told us things like: “We often feel lonely and on the edge of things.” and “I am all the time worried – worried when this breathing will attack me again.”  

How can you manage shortness of breath?

Although shortness of breath can make things difficult, you can find ways to cope. Living well with breathlessness comes from a combination of accepting that your life has changed, adapting the way you do things, and continuing to take part in activities.  

Some people tell us that breathlessness makes them feel more isolated. That can feel difficult, so do what you can to keep active and involved with others – that will help your life be as good as possible. Remember that breathlessness isn’t anything to be embarrassed about, or that you need to apologise for.  

Top tips for managing breathlessness

• Find a comfortable position to ease your breathlessness, such as sitting on a chair leaning forwards, or lying on your side with your head propped up on cushions. 
• Use a breathing technique – for example, taking slow, relaxed breaths that come from your tummy 
• Cool your face with a wet flannel 
• Use a hand-held battery-operated fan  (If Covid-19 remains a risk, then don’t use the fan if there are people from another household present.)
• Having the window open to get some fresh air 
• Arrange your home to make daily tasks easier 
• Pace your activities so that you are able to complete them 
• Plan your day and allow breaks for rest 
• Stay as active as you can 
• Try to do as much as you can, but accept help when you need it
• Do things to help you deal with worries, such as listening to music, practicing mindfulness and doing gentle exercise
• Remember that breathlessness is not harmful and your breathing will recover with rest
• Eat little and often rather than one big meal 
• Keep in touch with friends and family 
• Be open about how breathlessness affects your life and seek help to manage it 

Information for people caring for you  

Even though breathlessness can have a huge effect on your life, it can be hard for other people to understand.   

Sometimes the effects of breathlessness can be difficult for the people caring for you. They may find it worrying to see you very breathless and will want to know how to help you. Having shortness of breath can also affect your relationships and make you both feel isolated. It’s important that people caring for you take time to look after themselves well and get support from friends, family, and also from professionals when needed.  

• Listen to people describing their difficulties with breathlessness. 
• Carers UK has useful guidance for carers or you can call their advice line on 0808 808. 
• Supporting breathlessness has information on how to support someone to live with breathlessness.

Where to get more support

• Doctors, nurses and physiotherapists can help you manage your breathlessness. Speak to your GP about your symptoms – they may be able to refer you to a local exercise class for people with heart conditions or to a clinic to learn more about managing breathlessness.
• We also know that for some people breathlessness goes on for a long while after having Covid-19. Your Covid Recovery has helpful information about this.
• Hull York Medical School has useful information on breathlessness.
• St Christopher’s Hospice has information and videos to help you manage breathlessness.
• Cambridge University Hospitals have useful information on managing breathlessness
• View the Living with Breathlessness exhibition from Hull York Medical School

About the experts

Dr Hutchinson and Professor Johnson are based at the Wolfson Palliative Care Research Centre where they are carrying out research to help people with breathlessness, as well as work raising awareness of the difficulties breathlessness causes and what can be done to help people live well with breathlessness. 

Published June 2021

Chronic congestive heart failure – Symptoms, diagnosis and treatment

Last viewed: May 27, 2023

Last updated: June 16, 2021 the ability of the ventricles to fill and expel blood.

This is a serious and growing public health problem. It is the only cardiovascular disease whose incidence and prevalence is increasing, partly because the population is aging, but also because of improvements in cardiovascular interventions for disease processes that reduce early mortality but can lead to cardiac changes that lead to is heart failure.

Key findings are dyspnea and fatigue, which can limit exercise tolerance, and fluid retention, which can lead to pulmonary congestion and peripheral edema.

Diagnosis is mainly clinical; Cardiac disorders and non-cardiac conditions or lifestyles that may have caused or exacerbated congestive heart failure should be identified through the history and physical examination findings.

The most useful diagnostic study for evaluating patients is a complete 2-dimensional echocardiography combined with Doppler sonography.

Interventions such as ACE inhibitors, angiotensin receptor blockers, aldosterone antagonists, hydralazine, and nitrates, as well as cardiac resynchronization therapy and implantation, have shown positive effects on patient survival at initial presentation. cardioverter defibrillator.

Definition

Heart failure is a condition in which the heart, without an increase in diastolic pressure, cannot generate enough cardiac output to meet the needs of the body. May occur as a result of any heart disease in which systolic, diastolic, or both ventricular function is impaired. The term “congestive heart failure” (CHF) is used in relation to patients with shortness of breath and atypical sodium and fluid retention in the body, which leads to edema.

Heart failure includes a wide range of clinical presentations, from patients with normal left ventricular ejection fraction (LVEF) > 50% to patients with reduced myocardial contractility (LVEF < 40%).

Based on the LVEF, heart failure is defined as follows: [1] Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur J Heart Fail. 2016 Aug;18(8):891-975.
https://onlinelibrary.wiley.com/doi/full/10.1002/ejhf.592

http://www.ncbi.nlm.nih.gov/pubmed/27207191?tool=bestpractice.com

1. Heart failure with reduced ejection fraction (HFpEF): symptoms, signs and LVEF <40%.

2. Moderately reduced ejection fraction (HF) heart failure: symptoms, signs, and LVEF between 40% and 49% Other signs include elevated natriuretic peptide (natriuretic peptide type B [NEL] >35 ng/l [>35 pk/ ml] or N-terminal brain natriuretic peptide [NT-pro-BNP] >125 ng/L [>125 pq/mL] and at least one additional criterion: (a) relevant organic heart disease (eg, left ventricular hypertrophy [ LVH] or left atrial enlargement), (b) diastolic dysfunction.

3. Heart failure with preserved ejection fraction (HFEF): symptoms, signs and LVEF >50%. Other features include an elevated natriuretic peptide level (NPV >35 ng/L [>35 PQ/mL] or NT-pro-BNP >125 ng/L [>125 PQ/mL] and at least one additional criterion: (a) relevant organic heart disease (eg, LVH or left atrial enlargement), (b) diastolic dysfunction. For more information on this subtype, see our topic on Heart Failure with Preserved Ejection Fraction.

History and examination

Key diagnostic factors

• presence of risk factors
• shortness of breath
• jugular vein swelling
• Gallop rhythm with additional third tone

90 037 cardiomegaly

• hepatojugular reflux
• wheezing
• orthopnea and paroxysmal nocturnal dyspnea
• nocturia

More key diagnostic factors

Other diagnostic factors

• tachycardia (heart rate >120 bpm)
• chest discomfort
• hepatomegaly
• ankle edema
• nocturnal cough
• signs of pleural effusion 900 38
• weakness, muscle weakness or fatigue
• palpitations, faintness or syncope
• lethargy, disorientation

Other diagnostic factors

Risk factors

• Myocardial infarction (MI)
• arterial hypertension
• diabetes mellitus
• dyslipidemia
• advanced age
• male sex
• obesity
• low socioeconomic status

900 37 tobacco smoking

• alcohol abuse
• excessive salt intake
• excessive coffee consumption
• exposure to cardiotoxic drugs
• left ventricular dysfunction
• left ventricular hypertrophy
• renal failure
• valvular heart disease
• tachycardia
• sleep apnea
• depression/stress
• microalbuminuria
• elevated homocysteine ​​9 0038
• cocaine abuse
• family history of heart failure
• atrial fibrillation
• thyroid disease
• anemia
• elevated levels of tumor necrosis factor-alpha (THO-alpha) and interleukin-6 (IL-6)
• elevated C-reactive protein (CRP)
• decreased insulin-like growth factor 1 (IGF-1)
• increased natriuretic peptide
• left ventricular dilatation
• left ventricular mass gain

90 037 impaired diastolic filling of the left ventricle

More factors Risk

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Diagnostic tests

Primary investigations

• transthoracic echocardiography
• ECG
• chest x-ray
• brain natriuretic peptide B type (BNP)/N-terminal pro-brain natriuretic peptide (NT-pro-BNP)
• complete blood count
• plasma electrolytes (including calcium and magnesium)
• creatinine and serum urea nitrogen
• blood glucose
• LFT (liver function tests)
• thyroid function tests (particularly for thyroid-stimulating hormone [TSH])
• blood lipids
• serum ferritin
• transferrin saturation

More studies that shown first

Research

• non-invasive exercise imaging (cardiovascular MRI, stress echo, SPECT, PET)
• standard exercise test (bicycle or treadmill)
• coronary angiogram
• cardiac CT angiography
• cardiopulmonary exercise test to measure maximum oxygen consumption (VO₂max)
• 6-minute walk test
• catheterization of the right departments heart
• myocardial biopsy
• immunosorbent enzyme-binding plasma HIV test
• cardiac MRI
• biomarkers
• multispiral computed tomography (MSCT)

More exams to consider

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Treatment algorithm

Acute 9000 3

resistance to ACE inhibitors

intolerance to ACE inhibitors

CONTINUED

not responding to optimal conservative treatment

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Compilers

Authors

Reviewers 9003 5

Outpatient dyspnoea | Vertkin A.

L., Topolyansky A.V., Knorring G.Yu., Abdullaeva A.U.

It is known that shortness of breath is a fairly common reason for visiting a doctor; it accompanies many diseases of both the respiratory and cardiovascular systems (CVS), disturbing patients in different ways and, unfortunately, far from always having a favorable outcome.
The great Russian clinician D.D. Pletnev wrote: “It is difficult to give an exact definition of the concept of “shortness of breath”. It is difficult because two kinds of phenomena are simultaneously mixed here: objective and subjective. In some cases, the patient complains of shortness of breath, while the doctor does not find any symptoms of it, with the exception of the patient’s complaints, and vice versa. There may be objective symptoms of shortness of breath (increased or slower and deeper breathing, cyanosis), while the patient does not complain of shortness of breath” [1].
“Complaints of patients with cardiovascular disorders are reduced primarily to shortness of breath. Shortness of breath in heart patients usually occurs during physical exertion (walking, climbing stairs, muscle work). In people accustomed to physical exertion, shortness of breath in violation of the cardiovascular system occurs later, while in untrained people, shortness of breath occurs earlier and from less significant exertion. At rest, shortness of breath of cardiac origin appears only in seriously ill patients. Shortness of breath is distinguished from asthma attacks, which most often develop suddenly, at rest or some time after physical (or mental) stress; often these attacks appear at night, during sleep” [2].
In modern clinical medicine, shortness of breath is understood as the subjective perception of respiratory discomfort, which includes sensations of a variety of nature and intensity and may or may not be accompanied by objective respiratory disorders (American Thoracic Society, 1999). It can be accompanied by hyper- and hypopnea, tachy- and bradypnea, hyper- and hypoventilation, it can be subjective, objective or subjective and objective at the same time. Choking is an extreme degree of dyspnea, usually characterized by a painful feeling of lack of air.
A typical reason for a patient to seek medical help is the desire to relieve symptoms and exclude the presence of a serious pathology. Shortness of breath can also occur in a healthy person with significant physical exertion, however, it should be regarded as a sign of a pathological condition only in those cases when it occurs at rest or with a slight exertion that was previously easily tolerated by the patient. The doctor’s task is to exclude life-threatening pathology, including a severe attack of bronchial asthma (BA), pulmonary embolism (PE), myocardial infarction, etc. (Table 1).

In the differential diagnosis of dyspnea, it is necessary to evaluate the factors contributing to it or accompanying this condition (Table 2).

Alarming symptoms when a patient complains are: tachypnea, tachycardia, stridor, cyanosis, hypotension, participation of the auxiliary muscles of the chest in breathing (the so-called “red flags”), which indicates the severity of the condition and requires immediate assistance.
It is necessary to pay attention to the subjective manifestations of shortness of breath: patients may complain of rapid breathing, lack of air, inability to breathe deeply, and sometimes they mean pain that limits respiratory movements by shortness of breath. It is also important that it is harder for the patient – to inhale or exhale? Expiratory dyspnea is more often observed with violations of bronchial patency (additional respiratory muscles work mainly on inhalation), inspiratory – with heart failure (insufficient blood flow causes stimulation of the respiratory center, which makes you breathe more often and deeper).
However, severe bronchial obstruction may be accompanied by a feeling of inability to take a full breath, with cardiac asthma, swelling of the bronchi can cause bronchial obstruction, and patients with anxiety conditions often complain of the inability to take a deep breath. In BA, after coughing with viscous sputum, breathing is facilitated; in heart failure, sputum, usually liquid and foamy, does not bring relief.
One of the key issues is the relationship of dyspnea with exercise. In diseases of the cardiovascular system and respiratory organs, shortness of breath occurs or increases with physical exertion. An episodic, unrelated feeling of lack of air (incomplete inspiration), a periodic need to take a deep breath, are observed in patients with anxiety, autonomic dystonia and hyperventilation. The patient’s exercise tolerance (shortness of breath occurs at rest, when talking, when going uphill or stairs, when walking on a flat surface) allows you to assess the severity of respiratory or heart failure. Choking at night can occur with asthma, and in patients with cardiovascular diseases (CVD) – indicate the development of cardiac asthma. With heart and respiratory failure, breathing always becomes easier in a sitting position, with PE, shortness of breath does not depend on body position, a decrease in shortness of breath when walking can be a sign of autonomic dystonia.
When examining a patient, it is necessary to focus on dry rales audible at a distance, which are described by patients with asthma. However, bubbling breathing occurs with acute left ventricular failure. Shortness of breath in some cases is combined with chest pain (with myocardial infarction, PE, spontaneous pneumothorax), productive or unproductive cough (with COPD, cardiac asthma, pneumonia), hemoptysis (with bronchiectasis, lung cancer, pulmonary tuberculosis, PE), with palpitations (with atrial fibrillation), symmetrical edema (with heart, renal failure), fainting (with pulmonary embolism). Swelling in one leg may indicate deep vein thrombosis (a risk factor for PE).
Pay attention to general symptoms: fever (usually a sign of exacerbation of COPD or pneumonia), lack of appetite and progressive weight loss (suspicious in terms of oncopathology). Patients with panic attacks describe paroxysmal conditions with a host of unpleasant symptoms, including, in addition to anxiety and shortness of breath, pain or discomfort in the left side of the chest, palpitations, muscle tremors, dizziness, paresthesia, etc.
A special place in the questioning of a patient with shortness of breath is the collection of anamnesis (Table 3). The age at which shortness of breath appeared plays a role: CVD often debut in the elderly and senile age, broncho-obstructive – in the young, anxiety disorders – in puberty or menopause.

During the physical examination, it is important to look for the following symptoms.
1. Fever may indicate an infection, and a slight increase in temperature occurs with PE, oncological diseases.
2. Cyanosis indicates the presence of a serious pathology of the heart or lungs. In some cases, it is not expressed in anemia, which is characterized by a pale color of the skin and visible mucous membranes. With carbon monoxide poisoning, the skin turns cherry in color.
3. Hyperhidrosis can be a sign of infection or myocardial infarction.
4. “Hour glasses” and “drumsticks” indicate the presence of a chronic pulmonary disease, more often observed in the formation of bronchiectasis.
5. Patients with COPD are often obese, with a barrel-shaped chest and cyanosis, or, conversely, thin people.
6. Swelling of the legs usually indicate heart failure; unilateral swelling of the leg may be a manifestation of deep vein thrombosis of the legs (a possible source of PE).
7. Exhalation through closed lips is a characteristic sign of emphysema. Harsh breathing and dry scattered rales are detected with bronchial obstruction, unvoiced fine bubbling rales below the shoulder blades – with congestive heart failure. Physical changes in pneumonia include localized shortening of lung sounds, crepitating or ringing fine bubbling rales, and hard or bronchial breathing. Bronchial breathing can also be heard in lung cancer. With pneumothorax, tympanitis is detected on the side of the lesion, breathing is sharply weakened or not carried out. A dull percussion sound is observed with effusion into the pleural cavity.
8. The shift of the apex beat down and to the left indicates cardiomegaly (and, accordingly, speaks in favor of the cardiac nature of shortness of breath). Analysis of heart sounds and the presence of heart murmurs can detect aortic and mitral heart defects. Characteristic signs of heart failure are the appearance of the III tone and the gallop rhythm. The presence of an arrhythmia indicates heart failure, while atrial fibrillation is a risk factor for PE. Blood pressure is most often normal, rises with anxiety, its fall is a possible sign of the development of shock.
Analysis of laboratory data can also guide the doctor – for example, the identification of anemia, which can provoke an increase in heart failure or cause shortness of breath by itself. Erythrocytosis often accompanies the course of COPD, and leukocytosis indicates infections of the lower respiratory tract (purulent bronchitis, pneumonia). Eosinophilia is observed in asthma, allergies. An increase in ESR may indicate an infection or tumor process.
Echocardiography in patients with left ventricular heart failure sometimes reveals signs of LV overload, cicatricial changes in the myocardium, cardiac arrhythmias, in patients with COPD, pulmonary embolism, primary pulmonary hypertension – signs of overload of the right heart. An x-ray examination of the chest organs with left ventricular failure reveals cardiomegaly, signs of stagnation in the pulmonary circulation, effusion in the pleural cavity; with COPD – signs of pneumosclerosis, emphysema.
With spirography, a decrease in FEV1 (PSV) less than 80% of the proper value indicates the presence of bronchial obstruction, an increase in this indicator by 20% or more from the initial value in a sample with short-acting bronchodilators indicates reversible bronchial obstruction (BA), less than 12% indicates irreversible (COPD).
Shortness of breath is one of the most common reasons for seeking medical help and the main manifestation of CHF, which remains one of the world’s leading medical problems [3, 4]. In a significant number of cardiac patients, acute decompensated heart failure (ADHF) becomes the cause of death. According to the 2014 data presented in the latest revision of the European guidelines for the treatment and diagnosis of CHF and ADHF, 10 million patients suffer from CHF. According to experts of the European Society of Cardiology, the percentage of patients with CHF in the coming years will reach 3% of the entire population [3]. It is the decompensation of CHF that is the cause of 5% of all emergency hospitalizations in Europe and occurs in 10% of all patients in hospitals.
The course of decompensation can be different: from the rapid onset and progression of typical symptoms within a few hours to the gradual development of the clinical picture over several weeks (Fig. 1).
At a certain stage, progressive CHF begins to pose a threat to life and requires immediate hospitalization; with such a development of events, the term ADHF has been proposed, which includes: rapid progression of CHF itself; the development of the same acute conditions leading to new acute heart failure (AHF) (acute infarction, PE, acute valvular lesions, etc., see Fig. 1).

Both CHF and OHF lead to ODSN. However, it is necessary to clearly understand the differences in their clinical picture (Table 4).

At the same time, the polyclinic doctor must, using well-known diagnostic techniques (Table 5), correctly assess the patient’s condition, correct therapy, and determine indications for inpatient observation.

The number of patients hospitalized in the cardio intensive care unit (CRO) with decompensated CHF is increasing every year. In 2014, out of 3325 patients hospitalized in the KRO, 2250 (67.7%) were with ADHF: AHF developed against the background of CHF in 80% of cases, and in 20% of patients it occurred for the first time (Fig. 2) [5].

Due to the fact that a large number of patients experience episodes of acute CHF decompensation over and over again, all the efforts of doctors are aimed at reducing the risk of CHF decompensation and sudden death, as well as keeping the patient within the existing FC. However, in modern patients, recurrent episodes of CHF decompensation, comorbid pathology, kidney dysfunction, diuretic resistance, susceptibility to hypertension, predisposition to arrhythmia are increasingly noted [7, 8].
Decompensation of heart failure is primarily an excess of fluid in the body, which naturally requires increased diuretic therapy. However, there are more and more patients with resistance to diuretics. According to the ADHERE registry, the number of such patients exceeds 20% of all those suffering from CHF. It is obvious that decompensated patients require not only increased therapy (by increasing doses or changing routes of administration, for example, infusion of loop diuretics), but also the appointment of new drugs [6].
Torasemide is the first diuretic capable of influencing not only the symptoms of CHF patients, but also the progression of the disease and the course of pathological processes in the heart muscle (Table 6).

According to the diuretic effect, torasemide at a dose of 5 mg corresponds to 25 mg of hydrochlorothiazide, and at a dose of 10 mg – 40 mg of furosemide. However, unlike furosemide, the absorption of torasemide does not depend on the severity of heart failure. The TORIC Study, which included 1377 patients, showed that torasemide had a significantly better effect on major endpoints, including both total and cardiac mortality, than furosemide [9] (Fig. 3).

Another randomized open 6-month study [10] compared the efficacy of torasemide and furosemide in 50 patients with HF II-III FC who did not respond to treatment with low-dose furosemide and ACE inhibitors. Patients of the main group were transferred to torasemide at a dose of 4–8 mg/day, while patients in the comparison group continued to take furosemide at the same dose (20–40 mg/day). Therapy with torasemide for 6 months. contributed to a statistically significant decrease in end-diastolic size, myocardial mass index, LV diastolic dysfunction and natriuretic peptide concentration. There were no similar changes in the furosemide group. According to the authors, they could be explained by the blockade of aldosterone receptors under the action of torasemide.
The accumulated experience of using this drug made it possible to determine its place in the algorithm for the use of diuretics in CHF (Table 7).

In Russia, the generic torasemide drug Trigrim is successfully used. Due to its clinical and pharmacoeconomic efficiency, it deserves wider use in outpatient practice in the management of patients with CHF. Although all loop diuretics increase diuresis at equivalent doses, their effectiveness may be impaired by impaired renal function or absorption in the gastrointestinal tract (as a result of mucosal edema). Therefore, when choosing a drug, it is necessary to take into account the features of its pharmacokinetics and pharmacodynamics. Compared to furosemide, torasemide has a higher and more predictable bioavailability, a longer half-life, and a stable diuretic effect. These properties determine its increased efficacy in patients with heart failure, which has been demonstrated in a number of controlled clinical trials.
An important advantage of torasemide is the reduced risk of hypokalemia. It is believed that it not only has a potassium-sparing effect, but also blocks aldosterone receptors on the membranes of renal tubular epithelial cells, thereby inhibiting the effect of aldosterone on the heart, having a positive effect on the processes of its remodeling in patients with AH and CHF [9, 11].