What are the common symptoms of congestive heart failure. How is CHF diagnosed and treated. What are the different types and stages of heart failure. How can patients improve their quality of life with CHF.

Understanding Congestive Heart Failure: An Overview

Congestive heart failure (CHF) is a serious cardiovascular condition affecting millions of Americans. It occurs when the heart’s ability to pump blood cannot keep up with the body’s demands. This results in a buildup of fluid in various parts of the body, including the lungs, ankles, and feet – hence the term “congestive”.

Nearly 6 million Americans are living with CHF, with approximately 670,000 new cases diagnosed each year. It’s the leading cause of hospitalization for individuals over 65 years old. Despite these sobering statistics, with proper treatment and management, many patients can maintain a good quality of life.

The Underlying Causes of Congestive Heart Failure

Congestive heart failure doesn’t develop in isolation. It’s often the result of other health conditions that have damaged or weakened the heart over time. The most common cause is coronary artery disease, but several other factors can contribute to its development:

• High cholesterol and triglyceride levels
• Hypertension (high blood pressure)
• Poor dietary habits
• Sedentary lifestyle
• Diabetes
• Smoking
• Obesity
• Chronic stress

Additionally, certain infections, autoimmune diseases, and medical treatments like chemotherapy can potentially damage heart muscle and lead to CHF.

How does coronary artery disease lead to heart failure?

Coronary artery disease occurs when plaque builds up in the arteries that supply blood to the heart. This narrowing of the arteries restricts blood flow, depriving the heart muscle of oxygen and nutrients. Over time, this can weaken the heart and impair its ability to pump effectively, potentially resulting in heart failure.

Recognizing the Symptoms of Congestive Heart Failure

The symptoms of CHF can vary in severity and may not always be immediately noticeable. However, some common signs include:

• Shortness of breath, especially during physical activity or when lying down
• Fatigue and weakness
• Swelling (edema) in the legs, ankles, and feet
• Rapid or irregular heartbeat
• Persistent cough or wheezing
• Increased need to urinate at night
• Swelling of the abdomen
• Rapid weight gain from fluid retention
• Lack of appetite and nausea
• Difficulty concentrating or decreased alertness

It’s crucial to seek medical attention if you experience any of these symptoms, especially if they worsen or appear suddenly.

Can heart failure symptoms differ between men and women?

While the core symptoms of heart failure are similar for both genders, some differences have been observed. Women are more likely to experience shortness of breath and fatigue, while men may be more prone to experiencing swelling in the extremities. Additionally, women may be more likely to have heart failure with preserved ejection fraction, where the heart muscle becomes stiff but still pumps normally.

Types of Congestive Heart Failure: Understanding the Differences

Congestive heart failure is not a one-size-fits-all condition. It can be categorized into different types based on which part of the heart’s pumping cycle is affected and how the ejection fraction (the percentage of blood pumped out of the heart with each beat) is impacted.

Left-sided vs. Right-sided Heart Failure

Left-sided heart failure occurs when the left ventricle can’t pump blood effectively to the rest of the body. This can lead to fluid buildup in the lungs. Right-sided heart failure happens when the right ventricle has difficulty pumping blood to the lungs, causing fluid to back up in the body, particularly in the legs, ankles, and abdomen.

Systolic vs. Diastolic Heart Failure

Systolic heart failure, also known as heart failure with reduced ejection fraction (HFrEF), occurs when the heart muscle can’t contract with enough force to pump blood effectively. Diastolic heart failure, or heart failure with preserved ejection fraction (HFpEF), happens when the heart muscle becomes stiff and can’t relax properly to fill with blood between beats.

Diagnosing Congestive Heart Failure: A Comprehensive Approach

Diagnosing CHF typically involves a multi-step process that includes:

1. Medical history review and physical examination
2. Blood tests to check for biomarkers of heart failure
3. Chest X-ray to examine heart size and check for fluid in the lungs
4. Electrocardiogram (ECG) to assess heart rhythm and rate
5. Echocardiogram to evaluate heart structure and function
6. Stress tests to determine how the heart responds to exertion
7. Cardiac catheterization in some cases to examine the coronary arteries

The diagnostic process often involves collaboration between the patient’s primary care physician, cardiologist, and other specialists to establish a comprehensive picture of the patient’s condition and develop an appropriate treatment plan.

What role do biomarkers play in diagnosing heart failure?

Biomarkers are substances in the blood that can indicate the presence and severity of heart failure. The most commonly used biomarker for heart failure is B-type natriuretic peptide (BNP) or its precursor, NT-proBNP. These levels increase when the heart is under stress. High levels of BNP or NT-proBNP can help confirm a diagnosis of heart failure and assess its severity, aiding in treatment decisions.

Treatment Strategies for Congestive Heart Failure

The treatment of CHF is tailored to each patient’s specific condition, symptoms, and overall health. The primary goals of treatment are to improve the heart’s function, reduce symptoms, and enhance quality of life. Treatment strategies may include:

• Medications to improve heart function and reduce fluid buildup
• Lifestyle modifications, including diet changes and exercise
• Devices such as implantable cardioverter-defibrillators (ICDs) or cardiac resynchronization therapy (CRT) devices
• Surgical interventions in severe cases

What medications are commonly used to treat heart failure?

Several classes of medications are used in the management of heart failure:

• ACE inhibitors or ARBs to relax blood vessels and reduce blood pressure
• Beta-blockers to slow heart rate and reduce workload on the heart
• Diuretics to help eliminate excess fluid
• Aldosterone antagonists to help the body get rid of salt and water
• Digoxin to strengthen heart contractions
• SGLT2 inhibitors, which have shown promising results in recent studies

The specific combination of medications will depend on the individual patient’s condition and response to treatment.

Living with Congestive Heart Failure: Lifestyle Modifications and Self-Care

While medical treatments are crucial, lifestyle changes play a significant role in managing CHF and improving quality of life. Patients with heart failure are often advised to:

• Maintain a heart-healthy diet low in sodium and saturated fats
• Engage in regular, moderate exercise as recommended by their doctor
• Quit smoking and limit alcohol consumption
• Monitor and control their weight
• Manage stress through relaxation techniques or counseling
• Keep track of symptoms and report any changes to their healthcare provider
• Adhere to their medication regimen

How can patients effectively monitor their condition at home?

Self-monitoring is an important aspect of CHF management. Patients should:

• Weigh themselves daily and track any sudden weight gains
• Monitor their blood pressure and heart rate regularly
• Keep a symptom diary to note any changes in their condition
• Use a pedometer or activity tracker to monitor their exercise levels
• Consider using digital health tools that can help track and manage their condition

Regular communication with healthcare providers about these measurements can help catch any worsening of the condition early.

Advanced Treatments and Surgical Options for Severe Heart Failure

In cases where medication and lifestyle changes are not sufficient to manage CHF, more advanced treatments may be considered:

• Implantable cardioverter-defibrillators (ICDs) to prevent dangerous arrhythmias
• Cardiac resynchronization therapy (CRT) to coordinate the heart’s contractions
• Ventricular assist devices (VADs) to help the heart pump blood
• Heart transplantation for end-stage heart failure

What factors determine eligibility for a heart transplant?

Heart transplantation is considered for patients with end-stage heart failure who have exhausted all other treatment options. Eligibility factors include:

• Severity of heart failure
• Overall health status
• Age (typically under 70, but this can vary)
• Absence of other serious medical conditions
• Ability to comply with post-transplant care regimen
• Psychological stability
• Strong support system

The decision for heart transplantation involves a comprehensive evaluation by a transplant team and careful consideration of the risks and benefits for each individual patient.

Research and Future Directions in Congestive Heart Failure Treatment

The field of CHF treatment is continuously evolving, with ongoing research aimed at improving patient outcomes and quality of life. Some promising areas of research include:

• Gene therapy to repair damaged heart tissue
• Stem cell treatments to regenerate heart muscle
• New drug therapies targeting novel pathways in heart failure
• Improved mechanical assist devices
• Personalized medicine approaches based on genetic profiles

How might artificial intelligence impact heart failure management in the future?

Artificial intelligence (AI) has the potential to revolutionize heart failure management in several ways:

• Predictive analytics to identify patients at high risk of developing heart failure
• AI-powered imaging analysis for more accurate diagnosis and monitoring
• Personalized treatment recommendations based on vast datasets
• Remote monitoring systems that can detect early signs of deterioration
• Virtual health assistants to support patient self-management

While many of these applications are still in development, they hold promise for improving the care and outcomes of heart failure patients in the coming years.

Congestive heart failure is a complex condition that requires a multidisciplinary approach to management. With ongoing advancements in treatment and a focus on personalized care, many patients with CHF can lead fulfilling lives and maintain a good quality of life. The key lies in early diagnosis, adherence to treatment plans, and active participation in self-care strategies. As research continues to uncover new insights and treatment options, the outlook for heart failure patients continues to improve, offering hope for better outcomes and enhanced quality of life.

Congestive Heart Failure (CHF) > Fact Sheets > Yale Medicine

Overview

If you’ve been diagnosed with congestive heart failure, the feeling of your chest constricting can be scary. With congestive heart failure, the heart’s capacity to pump blood cannot keep up with the body’s need. As the heart weakens, blood begins to back up and force liquid through the capillary walls. The term “congestive” refers to the resulting buildup of fluid in the ankles and feet, arms, lungs, and/or other organs.

Almost 6 million Americans have congestive heart failure. However, with the correct treatment, patients can recover to good health. 

What causes congestive heart failure?

The most common cause of congestive heart failure is coronary artery disease. Risk factors for coronary artery disease include:

• high levels of cholesterol and/or triglyceride in the blood
• high blood pressure
• poor diet
• a sedentary lifestyle
• diabetes
• smoking
• being overweight or obese
• stress

In addition to coronary artery disease, several other conditions can damage the heart muscles, including infections, autoimmune diseases, and some treatments such as chemotherapy.

What are the symptoms of congestive heart failure?

Most commonly, a patient may experience shortness of breath, fatigue, problems with the heart’s rhythm called arrhythmias, and edema—or fluid buildup—in the legs. Symptoms may be mild or severe and may not always be noticeable.

How is congestive heart failure diagnosed?

Patients will typically have an intake visit with a heart specialist and nurse or physician’s assistant. During this visit, the doctor will review the patient’s prior records and his or her current health status. This allows the doctor to establish a picture of where the patient is along the spectrum, and make a plan for prognosis and treatment. 

The process often takes more than one meeting and involves both the patient’s local cardiologist and referring physician.

How is congestive heart failure treated?

Doctors will assess the current health status of the patient to establish a baseline, and develop a long-term health plan. This may involve the optimization of medicines and therapies, adding new medication, or possibly enrollment in a clinical trial.

Stabilizing and/or reversing a patient’s condition often involves long-term, collaborative follow-up with a referring cardiologist or physician.

In serious situations, advanced therapies, which include mechanical solutions, a heart transplant, or hospice, may be offered.

What is the outlook for heart failure patients?

There are medicines and treatments that reverse many cases of heart failure, and in most cases, the outlook is generally very good.

What makes Yale Medicine’s approach to treating congestive heart failure unique?

Yale Medicine’s team comprises heart failure cardiologists and cardiac surgeons, dedicated advanced-practice, registered nurses and nurse coordinators, dietitians, exercise physiologists, financial counselors, immunologists specializing in transplants, psychologists, and specialists in palliative care.

With a multidisciplinary approach, Yale Medicine physicians include the patient’s desires as well as input from the family to develop a comprehensive treatment plan that’s right for them.

Symptoms, Causes, Treatment, Types, Stages

Written by WebMD Editorial Contributors

Medically Reviewed by Poonam Sachdev on February 15, 2023

• What Is Heart Failure?
• What Causes Heart Failure?
• Heart Failure Symptoms
• What Are the Types of Heart Failure?
• How Is Heart Failure Diagnosed?
• Heart Failure Treatment
• Stages of Heart Failure
• How Can I Prevent Heart Failure From Getting Worse?
• How Can I Prevent Further Heart Damage?
• What Medications Should I Avoid if I Have Heart Failure?
• How Can I Improve My Quality of Life With Heart Failure?
• Can Surgery Be Used to Treat Heart Failure?
• Heart Failure Treatment Is a Team Effort
• When Should I Get Emergency Care?
• What Is the Outlook for People With Heart Failure?
• More

Heart failure affects nearly 6 million Americans. Roughly 670,000 people are diagnosed with heart failure each year. It’s the main reason people older than 65 go into the hospital.

Heart failure doesn’t mean the heart has stopped working. Rather, it means that the heart works less efficiently than normal. Due to various possible causes, blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart can’t  pump enough oxygen and nutrients to meet the body’s needs.

The chambers of the heart may respond by stretching to hold more blood to pump through the body or by becoming stiff and thickened. This helps to keep the blood moving, but the heart muscle walls may eventually weaken and become unable to pump as efficiently. The kidneys may respond by causing the body to retain fluid (water) and salt. If fluid builds up in the arms, legs, ankles, feet, lungs, or other organs, the body becomes congested. Congestive heart failure is the term used to describe the condition.

Heart failure is caused by many conditions that damage the heart muscle, including:

Coronary artery disease. Coronary artery disease (CAD), a disease of the arteries that supply blood and oxygen to the heart, causes decreased blood flow to the heart muscle. If the arteries become blocked or severely narrowed, the heart becomes starved for oxygen and nutrients.

• Heart attack. A heart attack happens when a coronary artery becomes suddenly blocked, stopping the flow of blood to the heart muscle. A heart attack damages the heart muscle, resulting in a scarred area that doesn’t work the way it should.
• Cardiomyopathy.  This is damage to the heart muscle from artery or blood flow problems,​ or from other causes​ such as from infections or alcohol or drug abuse.
• Conditions that overwork the heart. Conditions including high blood pressure, valve disease, thyroid disease, kidney disease, diabetes, or heart defects present at birth can all cause heart failure. In addition, heart failure can happen when several diseases or conditions are present at once.

You may not have any symptoms of heart failure, or the symptoms may be mild to severe. Symptoms can be constant or can come and go. The symptoms can include:

• Congested lungs. Fluid backup in the lungs can cause shortness of breath with exercise or difficulty breathing at rest or when lying flat in bed. Lung congestion can also cause a dry, hacking cough or wheezing.
• Fluid and water retention. Less blood to your kidneys causes fluid and water retention, resulting in swollen ankles, legs, abdomen (called edema), and weight gain. Symptoms may cause an increased need to urinate during the night. Bloating in your stomach may cause a loss of appetite or nausea.
• Dizziness, fatigue, and weakness. Less blood to your major organs and muscles makes you feel tired and weak. Less blood to the brain can cause dizziness or confusion.
• Rapid or irregular heartbeats. The heart beats faster to pump enough blood to the body. This can cause a rapid or irregular heartbeat.
• Reduced ability to exercise.
• Persistent cough or wheezing with white or pink blood-tinged mucus.
• Very rapid weight gain from fluid buildup.
• Nausea and lack of appetite.
• Difficulty concentrating or decreased alertness.
• Chest pain if heart failure is caused by a heart attack.

If you have heart failure, you may have one or all of these symptoms or you may have none of them. They may or may not indicate a weakened heart.

Systolic dysfunction (or systolic heart failure) happens when the heart muscle doesn’t contract with enough force, so there is less oxygen-rich blood pumped throughout the body.

Diastolic dysfunction (or diastolic heart failure) happens when the heart contracts normally, but the ventricles don’t relax properly or are stiff, and less blood enters the heart during normal filling.

A calculation done during an echocardiogram, called the ejection fraction (EF), is used to measure how well your heart pumps with each beat to help determine if systolic or diastolic dysfunction is present. Your doctor can discuss which condition you have.

Your doctor will ask you many questions about your symptoms and medical history. You’ll be asked about any conditions you have that may cause heart failure (such as coronary artery disease, angina, diabetes, heart valve disease, and high blood pressure). You’ll be asked if you smoke, take drugs, drink alcohol (and how much you drink), and about which medications you take.

You’ll also get a complete physical exam. Your doctor will listen to your heart and look for signs of heart failure as well as other illnesses that may have caused your heart muscle to weaken or stiffen.

Your doctor may also order other tests to determine the cause and severity of your heart failure. These include:

• Blood tests. Blood tests are used to evaluate kidney and thyroid function as well as to check cholesterol levels and the presence of anemia. Anemia is a blood condition that happens when there is not enough hemoglobin (the substance in red blood cells that enables the blood to transport oxygen through the body) in your blood.
• B-type natriuretic peptide (BNP) blood test. BNP is a substance secreted from the heart in response to changes in blood pressure that happen when heart failure develops or worsens. BNP blood levels increase when heart failure symptoms worsen, and decrease when the heart failure condition is stable. The BNP level in a person with heart failure — even someone whose condition is stable — may be higher than in a person with normal heart function. BNP levels do not necessarily correlate with the severity of heart failure.
• Chest X-ray. A chest X-ray shows the size of your heart and whether there is fluid buildup around the heart and lungs.
• Echocardiogram. This test is an ultrasound that shows the heart’s movement, structure, and function.
• Ejection fraction (EF). This is used to measure how well your heart pumps with each beat to determine if systolic dysfunction or heart failure with preserved left ventricular function is present. Your doctor can discuss which condition you have.
• Electrocardiogram (EKG or ECG). An EKG records the electrical impulses traveling through the heart.
• Cardiac catheterization. This invasive procedure helps determine whether coronary artery disease is a cause of congestive heart failure.
• Stress test. Noninvasive stress tests provide information about the likelihood of coronary artery disease.

Other tests may be ordered, depending on your condition.

There are more treatment options available for heart failure than ever before. Tight control over your medications and lifestyle, coupled with careful monitoring, are the first steps. As the condition progresses, doctors specializing in the treatment of heart failure can offer more advanced treatment options.

The goals of treating heart failure are to try to keep it from getting worse (lowering the risk of death and the need for hospitalization), to ease symptoms, and to improve quality of life.

Some common types of medicines used to treat it are:

• ACE inhibitors (angiotensin-converting enzyme inhibitors)
• Aldosterone antagonists
• ARBs (angiotensin II receptor blockers)
• ARNIs (angiotensin receptor-neprilysin inhibitors)
• Beta-blockers
• Blood vessel dilators
• Digoxin
• Calcium channel blockers
• Diuretics
• Heart pump medications
• Potassium or magnesium
• Selective sinus node inhibitors
• SGLT2 (sodium/glucose cotransporter) inhibitors

Your doctor may also recommend a program called cardiac rehabilitation to help you exercise safely and keep up a heart-healthy lifestyle. It usually includes workouts that are designed just for you, education, and tips to lower your chance of heart trouble, like quitting smoking or changing your diet.

Cardiac rehab also offers emotional support. You can meet people like you who can help you stay on track.

In 2001, the American Heart Association (AHA) and American College of Cardiology (ACC) described the stages of heart failure. These stages, which were updated in 2005, will help you understand that heart failure is often a progressive condition and can worsen over time. They will also help you understand why a new medication was added to your treatment plan and may help you understand why lifestyle changes and other treatments are needed.

The stages classified by the AHA and ACC are different than the New York Heart Association (NYHA) clinical classifications of heart failure that rank patients as class I-II-III-IV, according to the degree of symptoms or functional limits. Ask your doctor what stage of heart failure you are in.

Check the table below to see if your therapy matches what the AHA and ACC recommend. Note that you cannot go backward in stage, only forward.

The table below outlines a basic plan of care that may or may not apply to you, based on the cause of your heart failure and your special needs. Ask your doctor to explain therapies that are listed if you do not understand why you are or are not receiving them.

The New York Heart Association (NYHA) clinical classifications of heart failure rank people as class I-II-III-IV, according to the degree of symptoms or functional limits. You can ask your doctor if you want to know what stage of heart failure you’re in.

• Class I: Physical activity is not affected, and you have no unusual fatigue, shortness of breath, palpitations, or pain during normal activities.
• Class II: Slight limitations on normal activities. You may have mild fatigue, shortness of breath, palpitations, or pain during normal activities; no symptoms at rest.
• Class III: Marked limitation on normal activities. You have fatigue, shortness of breath, palpitations, or pain during less than normal activities; no symptoms at rest.
• Class IV: You’re uncomfortable even at rest. Discomfort gets worse with any physical activity.

• Treat you high blood pressure. In heart failure, the release of hormones causes the blood vessels to constrict or tighten. The heart must work hard to pump blood through the constricted vessels. It’s important to keep your blood pressure controlled so that your heart can pump more effectively without extra stress.
• Monitor your own symptoms. Check for changes in your fluid status by weighing yourself daily and checking for swelling. Call your doctor if you have unexplained weight gain (3 pounds in one day or 5 pounds in one week) or if you have increased swelling.
• Maintain fluid balance. Your doctor may ask you to keep a record of the amount of fluids you drink or eat and how often you go to the bathroom. Remember, the more fluid you carry in your blood vessels, the harder your heart must work to pump excess fluid through your body. Limiting your fluid intake to less than 2 liters per day will help decrease the workload of your heart and prevent symptoms from coming back.
• Limit how much salt (sodium) you eat. Sodium is found naturally in many foods we eat. It’s also added for flavoring or to make food last longer. If you follow a low-sodium diet, you should have less fluid retention, less swelling, and breathe easier.
• Monitor your weight and lose weight if needed. Learn what your “dry” or “ideal” weight is. Dry weight is your weight without extra water (fluid). Your goal is to keep your weight within 4 pounds of your dry weight. Weigh yourself at the same time each day, preferably in the morning, in similar clothing, after urinating but before eating, and on the same scale. Record your weight in a diary or calendar. If you gain 3 pounds in one day or 5 pounds in one week, call your doctor. Your doctor may want to adjust your medications.
• Monitor your symptoms. Call your doctor if new symptoms appear or if your symptoms get worse. Do not wait for your symptoms to become so severe that you need emergency treatment.
• Take your medications as prescribed. Medications are used to improve your heart’s ability to pump blood, decrease stress on your heart, decrease the progression of heart failure, and prevent fluid retention. Many heart failure drugs are used to decrease the release of harmful hormones. These drugs will cause your blood vessels to dilate or relax (thereby lowering your blood pressure).
• Schedule regular doctor appointments. During follow-up visits, your doctors will make sure you are staying healthy and that your heart failure is not getting worse. Your doctor will ask to review your weight record and list of medications. If you have questions, write them down and bring them to your appointment. Call your doctor if you have urgent questions. Notify all your doctors about your heart failure, medications, and any restrictions. Also, check with your heart doctor about any new medications prescribed by another doctor. Keep good records and bring them with you to each doctor visit.

In an effort to prevent further heart damage:

• Stop smoking or chewing tobacco.
• Reach and maintain your healthy weight.
• Control high blood pressure, cholesterol levels, and diabetes.
• Exercise regularly.
• Don’t drink alcohol.
• Have surgery or other procedures to treat your heart failure as recommended.

There are several different types of medications that are best avoided in those with heart failure, including:

• Nonsteroidal anti-inflammatory medications such as Motrin or Aleve. For relief of aches, pains, or fever, take Tylenol instead.
• Some antiarrhythmic agents
• Most calcium channel blockers (if you have systolic heart failure)
• Some nutritional supplements, such as salt substitutes, and growth hormone therapies
• Antacids that contain sodium (salt)
• Decongestants such as Sudafed

If you’re taking any of these drugs, discuss them with your doctor.

It’s important to know the names of your medications, what they’re used for, and how often and at what times you take them. Keep a list of your medications and bring them with you to each of your doctor visits. Never stop taking your medications without discussing it with your doctor. Even if you have no symptoms, your medications decrease the work of your heart so that it can pump more effectively.

There are several things you can do to improve your quality of life if you have heart failure. Among them:

• Eat a healthy diet. Limit your consumption of sodium (salt) to less than 1,500 milligrams (1 1/2 grams) each day. Eat foods high in fiber. Limit foods high in trans fat, cholesterol, and sugar. Reduce total daily intake of calories to lose weight if necessary.
• Exercise regularly. A regular cardiovascular exercise program, prescribed by your doctor, will help improve your strength and make you feel better. It may also decrease heart failure progression.
• Don’t overdo it. Plan your activities and include rest periods during the day. Certain activities, such as pushing or pulling heavy objects and shoveling, may worsen heart failure and its symptoms.
• Prevent respiratory infections. Ask your doctor about flu and pneumonia vaccines.
• Take your medications as prescribed. Do not stop taking them without first contacting your doctor.
• Get emotional or psychological support if needed. Heart failure can be difficult for your whole family. If you have questions, ask your doctor or nurse. If you need emotional support, social workers, psychologists, clergy, and heart failure support groups are a phone call away. Ask your doctor or nurse to point you in the right direction.

In heart failure, surgery may sometimes prevent further damage to the heart and improve the heart’s function. Procedures used include:

• Coronary artery bypass grafting surgery. The most common surgery for heart failure caused by coronary artery disease is bypass surgery. Although surgery is more risky for people with heart failure, new strategies before, during, and after surgery have reduced the risks and improved outcomes.
• Heart valve surgery. Diseased heart valves can be treated both surgically (traditional heart valve surgery) and nonsurgically (balloon valvuloplasty).
• Implantable left ventricular assist device (LVAD). The LVAD is known as the “bridge to transplantation” for patients who haven’t responded to other treatments and are hospitalized with severe systolic heart failure. This device helps your heart pump blood throughout your body. It allows you to be mobile, sometimes returning home to await a heart transplant. It may also be used as destination therapy for long-term support in patients who are not eligible for transplant.
• Heart transplant. A heart transplant is considered when heart failure is so severe that it doesn’t respond to all other therapies, but the person’s health is otherwise good.

Heart failure management is a team effort, and you are the key player on the team. Your heart doctor will prescribe your medications and manage other medical problems. Other team members — including nurses, dietitians, pharmacists, exercise specialists, and social workers — will help you achieve success. But it is up to YOU to take your medications, make dietary changes, live a healthy lifestyle, keep your follow-up appointments, and be an active member of the team.

If you notice anything unusual, don’t wait until your next appointment to discuss it with your doctor. Call them right away if you have:

• Unexplained weight gain (more than 2 pounds in a day or 5 pounds in a week)
• Swelling in your ankles, feet, legs, or belly that gets worse
• Shortness of breath that gets worse or happens more often, especially if you wake up feeling that way
• Bloating with a loss of appetite or nausea
• Extreme fatigue or more trouble finishing your daily activities
• A lung infection or a cough that gets worse
• Fast heart rate (above 100 beats per minute, or a rate noted by your doctor)
• New irregular heartbeat
• Chest pain or discomfort during activity that gets better if you rest
• Trouble breathing during regular activities or at rest
• Changes in how you sleep, like having a hard time sleeping or feeling the need to sleep a lot more than usual
• Less of a need to pee
• Restlessness, confusion
• Constant dizziness or light-headedness

Go to the ER or call 911 if you have:

• New, unexplained, and severe chest pain that comes with shortness of breath, sweating, nausea, or weakness
• Fast heart rate (more than 120-150 beats per minute, or a rate noted by your doctor), especially if you are short of breath
• Shortness of breath that doesn’t get better if you rest
• Sudden weakness, or you can’t move your arms or legs
• Sudden, severe headache
• Fainting spells

With the right care, heart failure may not stop you from doing the things you enjoy. Your prognosis or outlook for the future will depend on how well your heart muscle is functioning, your symptoms, and how well you respond to and follow your treatment plan.

Everyone with a long-term illness such as heart failure should discuss their desires for extended medical care with their doctor and family. An advance directive or living will is one way to let everyone know your wishes. A living will expresses your desires about the use of medical treatments to prolong your life. This document is prepared while you are fully competent in case you are unable to make these decisions at a later time.

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Problems of diagnosis and epidemiology of chronic heart failure

Chronic heart failure (CHF) is a condition accompanied by a significant deterioration in quality and a reduction in life expectancy [46]. Its prevalence is quite high. According to epidemiological studies, at least 1.5% (about 3 million) of adult Americans suffer from CHF in the USA, and their number increases by 400 thousand annually. In Europe, according to various sources, the incidence of CHF is 0.4-2%, which corresponds to 2–10 million cases per 500 million population [45]. The prevalence of CHF increases with age: from 1% in persons 50-59years to 10% in persons 80 years and older [14, 22]. With a high prevalence, this disease is associated with high treatment costs, primarily due to frequent hospitalizations: according to the results of the EuroHeart Failure survey program, 40% of hospitalizations of patients with CHF are due to its decompensation [12]. The seriousness of the problem is also evidenced by the fact that, as shown by the Framingham study, 5-year survival after the onset of CHF symptoms is only 25% in men and 38% in women [17].

According to studies conducted in Europe, the USA and Russia, the prevalence of CHF has increased in recent decades [20]. On the one hand, this is due to objective reasons: the aging of the population, improved diagnostics, increased survival rates for myocardial infarction, etc. [19]. On the other hand, the difference in the assessment of morbidity depends on the applied criteria for the diagnosis of CHF (Table 1) .

When using the ejection fraction (EF) of the left ventricle (LV) as the main criterion, patients with preserved EF (CHF-PEF) are not taken into account, and the limits of the normal EF in different studies are defined differently. Conversely, a diagnosis based only on complaints and symptoms is highly inaccurate, since their specificity is low [16, 42]. Thus, according to the first Russian epidemiological population study on the prevalence of CHF using a representative sample of EPOCHA-CHF, which started in 2002 and covered 9regions, the prevalence of CHF in the European part of Russia was 8.9% [8], which is significantly higher than in the MONICA (1992) [28] or Rotterdam (1998) [29] studies. One of the main explanations for this difference is the use of “soft” criteria for diagnosing CHF. Conversely, a relatively low incidence rate, according to the Minnesota study, may be due to the use of rather stringent Framingham criteria and echocardiography (EchoCG) to determine diastolic dysfunction [19, 40].

The Framingham criteria were also used in the EPOCHA-O-CHF follow-up study among inpatients. In making the diagnosis of CHF, laboratory and instrumental data were also taken into account, and CHF was detected in 16.8% (in every sixth) of 17,824 examined patients in cardiology (in 60% of cases) and therapeutic (in 40%) departments [6] .

Slightly higher rates of heart failure (HF) among hospitalized patients are noted in the European EuroHeart Failure survey, which analyzed 46,788 case histories of patients in general medicine, cardiology, cardiac surgery and geriatrics, including those who died. Suspected or confirmed CHF was diagnosed in 24% of cases, and in 83% of patients the diagnosis of heart failure was made at the time of hospitalization or before it, however, it should be noted that echocardiography was performed only in 66% of cases [12].

The most important role in the timely diagnosis of CHF belongs to primary health care [10]. Among the latest European epidemiological studies performed on an outpatient basis, the EURObservational Research Programme: The Heart Failure Pilot Survey (ESC-HF Pilot, 2010) was carried out in 12 European countries, including Russia. Its main goal was to describe the clinical characteristics of CHF, its diagnosis and therapy. This study included 5118 patients with signs of heart failure, of which 63% had a chronic course and were patients in outpatient settings. In the same study, for the first time, special attention was paid to a large number of patients with CHF-PEF [25].

Important information about the epidemiology and diagnosis of CHF was obtained in a retrospective study conducted in the UK using a database of 696,884 patients in general practice [15]. All cases of HF were classified as “definite HF”, “possible HF”, and “prescribing diuretics without a diagnosis of HF”.

The diagnosis of “definite HF” included a history of pulmonary edema, objective evidence of systolic dysfunction in combination with clinical features, and the presence of the phrase “congestive HF” in the documentation. The “possible HF” group included patients with symptoms characteristic of CHF, in combination with a cardiovascular history. It is possible that this group also included patients with non-cardiac causes of symptoms in the absence of CHF. The frequency of “definite HF” was 0.93%, and “possible” – 2.02%. A general practitioner diagnosed CHF in 76% of cases in each group of patients in accordance with his subjective point of view and clinical judgment.

A number of earlier studies have also demonstrated the difficulty of diagnosing CHF in primary care, especially in elderly patients and women, as well as a high percentage of erroneous prescribing of loop diuretics without existing heart failure [41, 48].

Almost all symptoms and clinical signs, even the “classic triad” – shortness of breath, swelling of the legs and moist rales in the lungs, not to mention fatigue and palpitations, often occur in other diseases or are leveled by ongoing treatment, which makes them insensitive and low specific for diagnosing CHF (Table 2) . Thus, the most common cause of lower extremity edema in the elderly is venous insufficiency against the background of physical inactivity, and pulmonary crepitus may reflect poor ventilation of the lungs, an inflammatory process or pneumofibrosis, and not fluid stasis. The sign of swollen jugular veins in patients has a high specificity (97%), however, many patients with documented CHF do not have elevated venous pressure [47].

Symptoms characteristic of CHF should make one suspect this pathology, however, clinical suspicions based on the experience and skill of the physician must be confirmed by objective signs of cardiac dysfunction [5, 21].

The diagnosis of CHF has undoubtedly changed over the past three decades. Modern diagnostic algorithms, based on a number of studies, include echocardiography [13, 23, 37] and brain natriuretic peptide (BNUP) studies as mandatory for confirming the diagnosis [26, 44].

According to the OSCH, RKO and RHMO Guidelines for the diagnosis and treatment of CHF (fourth revision), diagnosis is possible in the presence of symptoms and clinical signs typical of HF, in combination with objective signs of cardiac dysfunction (Table 3) [5].

Symptoms of CHF may be present at rest and/or during exercise, but objective signs of cardiac dysfunction must be detected at rest.

The latest national and European guidelines for the diagnosis and treatment of CHF from 2012 [5, 27] define the symptoms and signs typical of HF (Table 4) .

The greatest difficulties arise, as a rule, in the diagnosis of CHF with preserved LV EF (>50%) [33]. Such patients account for 40-55% of all patients with CHF [24, 30-32], and in our country, according to the EPOCHA-O-CHF study, 73% or more [3]. Usually, the following values ​​of LV EF are used as a “split point”: less than 40% – reduced; 40-50% – “grey zone”; more than 50% – preserved LV EF [5]. The current recommendations of the working group of the European Society of Cardiology (2012) consider more than 45-50% EF as borderline values. This criterion was chosen due to a sharp deterioration in prognosis with EF less than 40%, regardless of etiology [27].

To establish the diagnosis of CHF-SFV (or “diastolic HF”), along with symptoms of CHF and the presence of normal or slightly reduced EF, objective confirmation of diastolic dysfunction is required: abnormal relaxation, filling, distensibility (compliance) or stiffness of the left ventricle. It should be emphasized that “type 1 diastolic dysfunction” detected by “normal” Doppler echocardiography cannot be considered as a criterion for the diagnosis of CHF, and cannot explain the patient’s complaints of shortness of breath, since it corresponds to normal pressure in the left cavities of the heart and is an option norms for the elderly. Thus, “diastolic” HF always includes LV diastolic dysfunction, but the presence of diastolic myocardial dysfunction does not always indicate the presence of CHF [2].

The “gold standard” for diagnosing CHF is catheterization of the heart cavities, which allows measuring the pulmonary capillary wedge pressure, parameters of active relaxation and myocardial stiffness. In everyday practice, invasive methods are not applicable, therefore, echocardiography and BNP are of the greatest importance [39]. In 2007, a working group of the European Society of Cardiology proposed algorithms for both verification and exclusion of diastolic CHF [34], which are currently used (Fig. 1, 2) .Figure 1. Diastolic heart failure exclusion algorithm. Here and in fig. 2: LV EF – left ventricular ejection fraction; ECDO LV – index of the end diastolic volume of the left ventricle; DZLA – average pressure of pulmonary capillary wedges; DZLZh – filling pressure of the left ventricle; b – LV stiffness constant; ? – active relaxation constant; TD – tissue doppler; E/E’ – the ratio of the maximum speed of early transmitral diastolic filling of the left ventricle to the maximum speed of the early diastolic wave of movement of the fibrous ring of the mitral valve; BNP, brain natriuretic peptide; NT-proBNP – N-terminal precursor of brain natriuretic peptide; E/A – the ratio of the speeds of early and late diastolic filling of the left ventricle; DT – deceleration time of early diastolic filling; Ard is the duration of the retrograde wave of blood flow through the pulmonary veins; Ad is the duration of the atrial phase of diastolic filling; LAVI – left atrial volume index; LVMI – index Figure 2. Algorithm for the diagnosis of diastolic heart failure.

These algorithms are quite cumbersome and require tissue Doppler echocardiography and/or BNUP examination, which makes them hardly applicable in everyday outpatient practice, especially in our country.

In addition, due to the low specificity of symptoms, and most often it is shortness of breath and / or fatigue, both European and Russian clinical guidelines indicate the need to exclude non-cardiac pathology as their possible cause, and primarily pathology of the respiratory system. However, in practice, this is often neglected, especially in elderly patients and individuals with indications of any (and not always confirmed) cardiovascular pathology, including arterial hypertension, considering that they have a priori CH available.

Individuals who consult a general practitioner or cardiologist complaining of respiratory discomfort and/or fatigue may be both underdiagnosed and overdiagnosed with CHF-PEF, the objective criteria for diagnosing which continue to be discussed [36].

As shown by a study conducted on the basis of the First Moscow State Medical University. THEM. Sechenov, in men with hypertension and EF more than 50%, the symptoms characteristic of HF (mainly shortness of breath and fatigue) are closely associated with the presence of signs of diastolic dysfunction. In women, this relationship turned out to be much less strong due to the fact that non-cardiac causes of symptoms, and primarily overweight, were of great importance [4]. Other work by this team of authors also confirmed the importance of non-cardiac pathology in the development of chronic dyspnea in patients with a cardiovascular history. According to the results of a detailed examination, it was found that in 75% of hospitalized patients with hypertension and postinfarction cardiosclerosis in the absence of significant systolic dysfunction, restrictive diastolic dysfunction, valvular disorders and atrial fibrillation, decreased exercise tolerance and shortness of breath are due to overweight, respiratory pathology, transient myocardial ischemia, hyperventilation, thyroid pathology and other causes, but not CHF, including in the presence of diastolic dysfunction by the type of violation of LV relaxation [7]. Similar data were obtained earlier by L. Caruana et al. [11], who examined elderly outpatients referred to a cardiologist with suspected CHF due to shortness of breath, edema, and nocturnal asthma attacks. In the majority of patients who did not have echocardiographic signs of cardiac dysfunction other than grade 1 diastolic dysfunction, obvious alternative causes were identified to explain their complaints, primarily lung disease and obesity. A group of Danish scientists also came to a similar opinion, showing that shortness of breath in old age is also more often due to lung diseases and other causes, rather than heart pathology [35].

Thus, diagnostic approaches and, accordingly, information on the prevalence and other epidemiological data on CHF can vary significantly depending on which diagnostic criteria are used and at what stage the diagnosis was made: in an outpatient setting or in a hospital, by a cardiologist or a general practitioner, or general practitioner [18, 38], and whether alternative diagnoses were considered.

The purpose of our own study was to study the causes of dyspnea and other symptoms characteristic of CHF in patients referred to a cardiologist at a Moscow city polyclinic.

Material and methods

In 12 months, 1247 patients over 18 years of age consulted a polyclinic cardiologist. Of these, 409 people were selected with a cardiovascular history and complaints of dyspnea lasting more than 1 month, combined with fatigue of any degree and/or palpitations, swelling of the ankles. Completed the examination of 185 patients (69 men, 116 women). Characteristics of patients is presented in tab. 5 .

The diagnosis of CHF was considered confirmed on the basis of medical documentation or an outpatient examination in the presence of an LV EF of 45%, restrictive LV diastolic dysfunction, persistent atrial fibrillation, hemodynamically significant heart defects, and radiographic signs of congestion in the pulmonary circulation. In the absence of these changes, additional studies were performed to exclude anemia, significant lung pathology, and thyroid dysfunction. Additional examination on the basis of the Cardiology Clinic of the University Clinical Hospital No. 1 of the First Moscow State Medical University. THEM. Sechenov, including the study of BNUP, stress tests with gas analysis, tissue Doppler echocardiography and other methods, were performed in 17 (9%) of patients in whom the cause of symptoms remained unclear.

Results

The results of the survey are presented in fig. 3 (see color label) Figure 3. Distribution of the main causes of symptoms characteristic of chronic heart failure. a – in the general group of patients; b – in men; in – in women. CHF – chronic heart failure; HCM – hypertrophic cardiomyopathy; B. lung – lung disease. It was found that in half of the patients with a history of cardiovascular pathology, the cause of shortness of breath and other symptoms was not CHF, but other causes, most often obesity, lung disease, transient myocardial ischemia and hypothyroidism. First of all, this concerned women, in whom the diagnosis of CHF was confirmed only in 41% of cases, while in men – in 67%. All cardiac causes of dyspnea, which included, in addition to CHF, also transient myocardial ischemia and arrhythmias, were 54% in women and 76% in men.

Conclusion

Data from epidemiological studies on the prevalence of CHF are varied, in particular due to the fact that they used different criteria for the diagnosis of suspected or undoubted CHF. Most of the symptoms (shortness of breath, swelling of the ankles, decreased exercise tolerance) that clinicians rely on to make a diagnosis are nonspecific for HF, especially in women, the elderly, and those with obesity. The modern approach to diagnosis requires objective confirmation that these complaints and symptoms are associated with cardiac dysfunction. In this regard, modern domestic and foreign recommendations include echocardiography (or other instrumental methods for objectifying heart dysfunction) and the study of brain natriuretic peptide in the algorithm for diagnosing CHF. The greatest difficulty can cause the diagnosis of CHF with preserved LV EF, since its criteria are still being developed. At the moment, they are quite cumbersome and in many cases include data from tissue Doppler echocardiography. For obvious reasons, such a diagnostic approach cannot be used in large population-based epidemiological studies. Unfortunately, instrumental confirmation of CHF is often neglected when working with specific patients, especially outpatients, including due to objective reasons. In many countries, including Russia, in wide practice, the study of BNUP or tissue Doppler echocardiography is not available, and conventional echocardiography is often formal, and not always feasible in the clinic.

An important condition for the correct diagnosis of CHF, especially with preserved LV EF, is the exclusion of possible non-cardiac causes of complaints and symptoms. Studies conducted among elderly patients have shown that the most common causes of dyspnea and fatigue, including those with hypertension and signs of mild LV diastolic dysfunction, are most often lung disease, obesity and transient myocardial ischemia.

In our study, 409of outpatients who turned to a cardiologist with suspected CHF based on a “cardiovascular” history and complaints characteristic of CHF, in 50% of cases (in 33% of men and 59% of women) the diagnosis of CHF was not confirmed. Alternative causes of symptoms have been identified, most commonly obesity, obstructive and restrictive lung disease, hypothyroidism, and myocardial ischemia. Underestimation of these causes leads to misdiagnosis and erroneous treatment tactics.

Vericiguat: a prospective new therapy for chronic heart failure

At a Glance

• Merck & Co. is pleased to announce that experimental vericiguat has successfully passed the phase III (randomised, double-blind, placebo-controlled, multicentre, international) VICTORIA (NCT02861534) clinical trial, which tested its safety and efficacy in the treatment of patients (n=5050) with progressive chronic heart failure with reduced ejection fraction (HFrEF).

• In follow-up up to 3. 5 years, vericiguat statistically significantly compared to placebo reduced the risk of hospitalization for heart failure or death due to cardiovascular complications, delaying the time to the onset of these adverse events. Oral vericiguat was initially given daily at a starting dose of 2.5 mg, which was then increased to 5 and 10 mg; therapy was carried out against the background of existing cardiological drugs.

• Heart failure with reduced ejection fraction, also known as systolic heart failure, is characterized by weakened heart contractility, leading to insufficient satisfaction of tissue and organ requirements for oxygenated blood. Approximately one third of patients with symptomatic chronic disease experience a worsening of the disease each year, and of these, about half have to be hospitalized. The progression of chronic HFrEF seriously worsens the prognosis: every fifth patient dies within two years after complications.

Details

Vericiguat, developed by Merck & Co. with Bayer, is a soluble guanylate cyclase (sGC) stimulant. In addition to its vasodilating properties, stimulation with low doses of vericiguat has shown direct antifibrotic effects in preclinical models, improving myocardial remodeling and diastolic relaxation in the absence of any hemodynamic effects.

Restoration of sGC-cGMP signaling deficiency as a new target for heart failure therapy. Image: JACC Heart Fail. 2018 Feb;6(2):96-104.

sGC, being an intracellular enzyme of smooth muscle cells of blood vessels, platelets and cardiomyocytes, is a receptor for its endogenous ligand in the form of nitric oxide (NO). The latter is formed in endothelial cells under the action of physiological stimuli, such as shear forces of laminar blood flow, as well as within the endocardium. NO diffuses into adjacent tissues, including vascular and cardiac muscle cells, and stimulates sGC to produce cyclic guanosine monophosphate (cGMP).

sGC-mediated cGMP synthesis is essential for normal cardiac and vascular function. In patients with heart failure, endothelial dysfunction and reactive oxygen species reduce NO bioavailability, leading to a relative deficiency of sGC with a consequent decrease in cGMP production. Weakened sGC activity, associated with coronary microvascular dysfunction, cardiomyocyte stiffness, interstitial fibrosis, and ultimately myocardial dysfunction, appears to be a major factor in the progression of the latter in heart failure.

Existing drugs that modulate neurohumoral blockade and reduce afterload do not directly affect these pathological mechanisms. Therefore, it is believed that direct stimulation of sGC without binding to NO should be suitable for heart failure due to its vasodilating properties, targeting diastolic myocardial relaxation and endothelial function, which can improve vasotonic regulation, ventricular-arterial coupling, cardiac reserve.

Clinical proof of concept for sGC pacing was found in the LEPHT phase II clinical trial (NCT01065454) in which the sGC stimulator riociguat was shown to be intrinsically tolerable in patients with advanced left ventricular systolic dysfunction and secondary pulmonary hypertension heart failure: noted improvement due to improvement cardiac index, quality of life, hemodynamic resistance of pulmonary and systemic vessels. Remarkably, the beneficial effects of riociguat appeared without any changes in heart rate and blood pressure. As a result, Adempas (riociguat) was born, proposed by Bayer in October 2013 for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension (PAH).

Vericiguat, structurally and pharmacologically different from riociguat, is optimized for chronic use in heart failure, focusing on a daily single dose, due to reduced pharmacokinetic variability.

In the next 2020, Merck & Co. has promised to disclose VICTORIA results. However, it is already clear that for commercial success of vericiguat, it is necessary to provide a reduction in the above risk by at least 10-15% above that provided by Entresto / Yuperio (Entresto / Yuperio, sacubitril + valsartan), a combination of a neprilysin inhibitor with an angiotensin receptor blocker II by Novartis. By the way, 14.5% of the subjects took this drug in the background. In a Phase III PARADIGM-HF (NCT01035255) registration clinical trial, Intresto/Uperio reduced the risk sought by 20%.

At present, Merck & Co. and Bayer, who will share the proceeds from veriguat sales if it wins regulatory approval, see little business value in it at this time. According to EvaluatePharma, veriguat will reach $435 million in sales by 2024.

Things could change dramatically if vericiguat succeeds in the VITALITY (NCT03547583) phase II (randomized, double-blind, placebo-controlled, multicenter, international) clinical trials in patients (n=786) with chronic heart failure with a preserved fraction emission (HFpEF). This cardiopathology does not have any approved drugs, and therefore the fate of any drug here reads an unambiguous bestseller status.

Remarkably, two phase II clinical trials SOCRATES-REDUCED (NCT01951625) and SOCRATES-PRESERVED (NCT01951638) of using vericiguat in the treatment of HFrEF and HFpEF, respectively, did not cope with the candidate drug: it could not statistically significantly affect the change in the level of N-terminal fragment of brain natriuretic peptide (NT-proBNP).

Meanwhile, AstraZeneca’s promoted antidiabetic drug Farxiga/Forxiga (dapagliflozin), added to standard therapy for heart failure with reduced ejection fraction, managed to statistically and clinically significantly delay the time to complications: heart failure. vascular death or worsening heart failure resulting in hospitalization or emergency medical attention. This risk was reduced by 25% and 27%, respectively, in patients with and without type 2 diabetes with this sodium glucose cotransporter type 2 (SGLT2) inhibitor.

In general, vericiguat faces a serious challenge, because it was tested in a population of patients whose disease is characterized by a more severe course than in the case of Intresto/Uperio and Farsiga/Forxiga, since the criterion for inclusion in VICTORIA there was progression of heart failure, which was understood as one of the events of disease decompensation: hospitalization due to cardiovascular complications within 6 months before randomization or the appointment of intravenous diuretics without hospitalization in the period of 3 months before randomization.

At the end of October, Cyclerion Therapeutics withdrew from further development of praliciguat, an experimental sGC stimulant, in the treatment of ejection fraction preserved chronic heart failure after it failed the CAPACITY (NCT03254485) phase clinical trial. II.

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