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Patient Instructions

Heart failure, also called congestive heart failure, is a condition in which the heart can no longer pump enough blood to the rest of the body.

Heart failure is almost always a chronic, long-term condition, although it can sometimes develop suddenly.

The condition may affect the right side, the left side, or both sides of the heart.

• Right-sided heart failure means the right ventricle of the heart loses its pumping function.
• Left-sided heart failure means the heart's ability to pump blood forward from the left side of the heart is decreased. The left side of the heart normally receives blood rich in oxygen from the lungs and pumps it to the remainder of the body.

Heart failure is often classified as either systolic or diastolic.

• Systolic heart failure means that your heart muscle cannot pump, or eject, the blood out of the heart very well.
• Diastolic heart failure means that your heart's pumping chamber does not fill up with blood.

Both of these problems mean the heart is no longer able to pump enough blood out to the rest of your body, especially when you exercise or are active.

As the heart's pumping action is lost, blood may back up in other areas of the body, producing congestion in the lungs, the liver, the gastrointestinal tract, and the arms and legs. As a result, there is a lack of oxygen and nutrition to organs, which damages them and reduces their ability to work properly.

Perhaps the most common cause of heart failure is coronary artery disease, a narrowing of the small blood vessels that supply blood and oxygen to the heart. For information on this condition and its risk factors, see: Coronary artery disease.

Heart failure can also occur when an illness or toxin weakens the heart muscle or changes the heart muscle structure. Such events are called cardiomyopathies. There are many different types of cardiomyopathy. For information, see: Cardiomyopathy

Other heart problems that may cause heart failure are:

• Congenital heart disease
• Heart valve disease
• Some types of abnormal heart rhythms (arrhythmias)

Diseases such as emphysema, severe anemia, hyperthyroidism, or hypothyroidism, may cause or contribute to heart failure

Common symptoms are:

• Shortness of breath with activity, or after lying down for a while
• Cough
• Swelling of feet and ankles
• Swelling of the abdomen
• Weight gain
• Irregular or rapid pulse
• Sensation of feeling the heart beat (palpitations)
• Difficulty sleeping
• Fatigue, weakness, faintness
• Loss of appetite, indigestion

Other symptoms may include:

• Decreased alertness or concentration
• Decreased urine production
• Nausea and vomiting
• Need to urinate at night

Infants may sweat during feeding (or other activity).

Some patients with heart failure have no symptoms. In these people, the symptoms may develop only with these conditions:

• Abnormal heart rhythm (arrhythmias)
• Anemia
• Hyperthyroidism
• Infections with high fever
• Kidney disease

A physical examination may reveal the following:

• Fluid around the lungs (pleural effusion)
• Irregular heartbeat
• Leg swelling (edema)
• Neck veins that stick out (are distended)
• Swelling of the liver

Listening to the chest with a stethoscope may reveal lung crackles or abnormal heart sounds.

The following tests may reveal heart swelling,decreased heart function, or lung congestion:

• Chest x-ray
• ECG
• Echocardiogram
• Cardiac stress tests
• Heart CT scan
• Heart catheterization
• MRI of the heart
• Nuclear heart scans

This disease may also alter the following test results:

• Blood chemistry
• BUN
• Complete blood count
• Creatinine
• Creatinine clearance
• Liver function tests
• Uric acid -blood test
• Sodium - blood test
• Urinalysis
• Sodium - urine test

If you have heart failure, your doctor will monitor you closely. You will have follow up appointments at least every 3 to 6 months and tests to check your heart function. For example, an ultrasound of your heart (echocardiogram) will be done once in awhile to see how well your heart pumps blood with each beat.

You will need to carefully monitor yourself and help manage your condition. One important way to do this is to track your weight on a daily basis. Weight gain can be a sign that you are retaining fluid and that your heart failure is worsening. Make sure you weigh yourself at the same time each day and on the same scale, with little to no clothes on.

Other important measures include:

• Take your medications as directed. Carry a list of medications with you wherever you go.
• Limit salt intake.
• Don’t smoke.
• Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise plan based on your degree of heart failure and how well you do on tests that check the strength and function of your heart. DO NOT exercise on days that your weight has gone up from fluid retention or you are not feeling well.
• Lose weight if you are overweight.
• Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest as well. Keep your feet elevated to decrease swelling.

Here are some tips to lower your salt and sodium intake:

• Look for foods that are labeled “low-sodium,” “sodium-free,” “no salt added,” or “unsalted.” Check the total sodium content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you how to understand these labels.
• Don’t cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate, MSG).
• Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato and other vegetable juices, and cheese.
• Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce, or cheese.
• Use oil and vinegar, rather than bottled dressings, on salads.
• Eat fresh fruit or sorbet when having dessert.

Your doctor may consider prescribing the following medications:

• ACE inhibitors such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart
• Diuretics including hydrochlorothiazide, chlorthalidone, chlorothiazide, furosemide, torsemide, bumetanide, and spironolactone to help rid your body of fluid and salt (sodium)
• Digitalis glycosides to increase the ability of the heart muscle to contract properly and help treat some heart rhythm disturbances
• Angiotensin receptor blockers (ARBs) such as losartan and candesartan to reduce the workload of the heart; this class of drug is especially important for those who cannot tolerate ACE inhibitors
• Beta-blockers such as such as carvedilol and metoprolol, which are particularly useful for those with a history of coronary artery disease

Certain medications may make heart failure worse and should be avoided. These include nonsteroidal anti-inflammatory drugs, thiazolidinediones, metformin, cilostazol, PDE-5 inhibitors (sildenafil, vardenafil), and many drugs that treat abnormal heart rhythms.

Valve replacements or repair coronary bypass surgery (CABG), and angioplasty may help some people with heart failure.

The following devices may be recommended for certain patients:

• A single or dual chamber pacemaker to help with slow heart rates or certain other heart signaling problems
• A biventricular pacemaker to help the left and right side of your heart contract at the same time.
• An implantable cardioverter-defibrillator to correct or prevent severe arrhythmias (abnormal heart rhythms)

Severe heart failure may require the following treatments:

• Intra-aortic balloon pump (IABP), a temporary device placed into the aorta
• Left ventricular assist device (LVAD), which takes over the role of the heart by pumping blood from the heart into the aorta; it's most often used by those who are waiting for a heart transplant.

Note: These devices can be life saving, but they are not permanent solutions. Patients who become dependent on circulatory support will need a heart transplant.

Heart failure symptoms may be improved with biventricular pacemaker or cardiac resynchronization therapy. Ask your provider if you are a candidate for this type of treatment.

Heart failure is a serious disorder. It is usually a chronic illness, which may get worse with infection or other physical stress.

Many forms of heart failure can be controlled with medication, lifestyle changes, and treatment of any underlying disorder.

• Irregular heart rhythms (can be deadly)
• Pulmonary edema
• Total heart failure (circulatory collapse)

Possible side effects of medications include:

• Cough
• Digitalis toxicity
• Gastrointestinal upset (such as nausea, heartburn, diarrhea)
• Headache
• Light-headedness and fainting
• Low blood pressure
• Lupus reaction
• Muscle cramps

Call your health care provider if weakness, increased cough or sputum production, sudden weight gain or swelling, or other new or unexplained symptoms develop.

Go to the emergency room or call the local emergency number (such as 911) if you experience severe crushing chest pain, fainting, or rapid and irregular heartbeat (particularly if other symptoms accompany a rapid and irregular heartbeat).

Follow your health care provider's treatment recommendations and take all medications as directed.

Keep your blood pressure , heart rate, and cholesterol under control as recommended by your doctor. This may involve exercise, a special diet, and medications.

Other important treatment measures:

• Do not smoke.
• Do not drink alcohol.
• Reduce salt intake.
• Exercise as recommended by your health care provider.

CHF; Congestive heart failure; Left-sided heart failure; Right-sided heart failure

Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. J Am Coll Cardiol. 2005;46:1-82.

Mann DL. Management of heart failure patients with reduced ejection fraction. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 25.

Hess OM and Carroll JD. Clinical assessment of heart failure. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Saunders; 2007: chap 23.

Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al. 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. Epub 2009 Mar 26.

Updated by: Alan Berger, MD, Assistant Professor, Divisions of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.