Congestive Heart Failure

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.
• 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.

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.

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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
• Soluble guanylate cyclase (sGC) stimulator

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.

• Keep your blood pressure low. 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 three pounds in one day or five 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.

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.

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
• Nausea or poor appetite

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