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    Congestive Heart Failure

    Congestive heart failure is a major health problem facing over
    3 million people and accounting for approximately 1 million hospitalizations
    every year in the United States. Over 400,000 Americans are diagnosed
    with the condition each year. Despite improvements in drugs and surgical
    procedures about 25 percent of those initially diagnosed with the condition
    will die within 1 year, and fewer than half will survive for five.

    When examining heart failure with from a broad point of view it can be
    defined as the inability of the heart to pump blood at a rate that meets
    the body’s metabolic needs. The term congestive heart failure refers to the
    condition those results when the pressures in an ailing heart are elevated,
    subsequently causing the blood to back up into the lungs and veins.

    The onset and progression of heart failure, and the prognosis for patients,
    vary considerably. Although, it occurs most frequently in the elderly, it can
    affect people of any age. It may progress so gradually that it is not noticed
    until it has become a very serious problem, or it may strike with devastating
    rapidity. It is sometimes completely reversible or curable, but in most
    instances it is progressive and fatal. Underlying this variability is the fact
    that inadequate heart function has many different causes, some of which
    are not fully understood. In a significant number of patients, the cause of
    heart failure is never found.

    Causes

    Congestive heart failure usually, but not always, occurs when there is
    impaired contraction of the left ventricle, the main pumping chamber of
    the heart that sends out oxygen-rich blood to all parts of the body. In some
    medical conditions, such as anemia, hypothyroidism, or beriberi (thiamine
    deficiency), heart failure may occur because of the increased metabolic
    demands that cannot be met, despite normal or even above normal cardiac
    contraction. In other conditions, heart function impairment is limited to the
    right ventricle, the cardiac chamber that pumps blood to the lungs for
    oxygenation. However, these last two causes of heart failure, termed high
    output heart failure and primary right heart failure are relatively uncommon.

    Heart Attack

    In the United States and Canada, heart attack is by far the most common
    cause of impaired left ventricle function. A heart attack usually occurs when
    a blood clot blocks a coronary artery that has been previously narrowed by
    atherosclerosis (hardening of the arteries), consequently cutting off part of
    the blood flow to the heart muscle. Heart attacks destroy cardiac muscle cells,
    which may lead to insufficient pumping ability and thus to congestive heart
    failure. Heart failure can occur immediately following a heart attack, as a
    result of massive loss of muscle function, or over days, weeks, or months
    because of progressive stretching of the scar which develops at the site
    of the heart attack.  Alternatively, a series of small heart attacks may result
    in a scarred, ineffective left ventricle.

    Valve Disease

    Disease of the heart valves can also cause heart failure. The heart valves
    regulate the flow of blood between the chambers of the heart, and damage
    to either of the valves (the mitral and aortic) on the left side of the heart can
    lead to heart failure. As an example, the mitral valve, which prevents blood
    from flowing back into the lungs, may suddenly rupture, causing acute
    congestive heart failure and usually requiring surgery to repair or replace
    the valve. Slowly developing leaks (back flow of blood) of the mitral or aortic
    valve or restricted blood flow through an aortic valve that has become
    thickened and immobile can also lead to heart failure by overwhelming
    the heart’s ability to pump blood efficiently.

    Hypertension and Alcohol

    High Blood Pressure (hypertension) and alcohol abuse are two other
    important causes of congestive heart failure. Hypertension damages
    the heart by forcing it to work harder over time against increased resistance.
    It responds by becoming enlarged and weakened. Hypertension was once a
    leading cause of heart failure, especially in African Americans, but it is
    becoming a less common cause in the United States, probably because
    of better detection and treatment of high blood pressure.

    Alcohol in large quantities, depresses heart function by a process that is
    not well understood. Cardiac dysfunction due to alcohol, especially in its
    early stages, is reversible, but only with abstinence from drinking.

    Infections

    Viral, parasitic, and bacterial infections are important causes of congestive
    heart failure. Viruses that cause heart dysfunction sometimes damage it
    permanently. Viral infections of the heart appear to be particularly virulent
    in infants and pregnant women. Many types of viruses have been linked
    with heart failure.

    Parasitic and bacterial infections of the heart occur more often in less
    developed regions of the world. In South America, for example, a leading
    cause of heart failure is Chagas’ disease, a parasitic disease transmitted
    to humans by an insect bite. Rheumatic fever, once common in the United
    States, is caused by streptococcal bacteria and can lead to valve disease
    and heart failure. This condition has become far less common in areas of
    the world with access to modern medicine, largely because of the widespread
    use of antibiotics for strep throat, a common cause of sore throat in children.

    Rare Causes

    The list is actually very long when it comes to rare causes of heart failure.
    Some unusual causes discovered over the years include exposure to or
    ingestion of cobalt, a metallic element once used as a foam stabilizer in a
    particular brand of beer, and the venom of some insect bites. Certain medications
    can also lead to heart failure as a side effect, such as the
    anticancer drug doxorubicing (brand name Adriamycin).

    Stiff Ventricles

    Sometime in the mid 90’s doctors started to realize that not only impaired
    contraction but also impaired relaxation of the heart can lead to symptoms
    of congestive heart failure. Normally the ventricles fill with blood during a
    relaxation phase of the cardiac cycle called diastolic. In some patients with
    high blood pressure, diabetes, and other conditions, the ventricles are stiffer  
    than they should be during diastole, preventing adequate filling of the pumping
    chamber. The result can be congestion in the lungs caused by the backup of
    blood. It is important for doctors to determine whether congestive heart failure
    is due to impaired contraction or impaired relaxation since the treatments  
    required are very different – enhanced contraction of the heart in one case,
    enhanced relaxation in the other.

    Symptoms

    The first symptom of congestive heart failure is usually increased
    breathlessness during physical activity. As the condition progresses,
    individuals may experience chronic coughing, accumulation of fluid in
    the feet and ankles, fatigue, and shortness of breath when lying down.
    In severe cases continual breathlessness and confusion can occur.
    Particularly in the early stages, the symptoms may be difficult for a physician
    to distinguish from those of other illnesses, such as asthma, pneumonia, or
    blood clots in the lungs. However, a dramatic symptom highly characteristic
    of congestive heart failure is sudden episodes of breathlessness at night, a
    condition that specialists call paroxysmal nocturnal dyspnea. This episode
    usually awakens sufferers and may cause them to sit bolt upright or rush to
    an open window seeking relief. Symptoms of heart failure progress at very
    different rates in different people. Life threatening complications may develop
    over hours or over years.

    Diagnosis

    Doctors usually diagnose congestive heart failure by taking the patients
    medical history, conducting a physical examination, and confirming the
    findings with a chest X ray, echocardiogram, or nuclear scan of the heart.
    Upon physical examination the physician will frequently hear a crackling
    noise in the lungs (caused by excessive fluid) and an extra heart sound.
    Swelling of the lower extremities and engorged veins in the neck are also
    characteristic findings. The chest X ray typically shows an enlarged heart
    and signs of abnormal accumulation of fluid in the lungs.
    Echocardiography, or sound wave imaging of the heart, and scans of the
    heart using a radioactive isotope (harmless to the patient) are important
    adjuncts to the diagnosis of congestive heart failure. These procedures
    help in determining the severity fo the problem an in establishing the cause
    of heart failure. Echocardiography is the best way to assess the heart valves,  
    and nuclear scans are usually used to find out whether blockages in the
    coronary arteries are the source of trouble. Either procedure is capable
    of establishing a quantitative value for the strength of the left ventricle’s
    contraction; something called the ejection fraction, which is a measure of the
    proportion of blood volume in the left ventricle being propelled into the body.
    Numerous studies have shown that the lower the ejection fraction, the worse
    the prognosis.

    On occasion, cardiologists may perform a biopsy of the heart in order to
    obtain a small tissue sample for microscopic analysis. This procedure may
    help in the diagnosis of some unusual causes of heart failure.


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