Congestive Heart Failure

Congestive Heart Failure /Cardiomyopathy 

What is Congestive heart failure ?- Congestive heart failure is a clinical syndrome. Syndrome means a clinical presentation of signs and symptoms that the patient will manifest from either functional or structural impairment of the heart . Congestive heart failure can be caused by  many different conditions. The most common one being coronary artery disease. Other common ones include hypertensive heart disease, infiltrative heart diseases like sarcoid, amyloid etc

What are the common types? 

This is mainly classified based on your ejection fraction (EF) . EF in simple terms means the pumping capacity of the heart. Normal EF is usually >55% . That is important to know as normal is not 100% in this case. Based on that heart failure can be classified as 

Hfref ( heart failure with reduced ejection fraction) - EF <40% 

Hfmref ( heart failure with mildly reduced ejection fraction)- EF 41-49% 

Hfpef (heart failure with preserved ejection fraction) - EF 50% and higher.

This is important as the treatment and medications used to treat heart failure changes based on this classification.

What do we mean by Stages of heart failure? The stages of heart failure as defined by the American college of cardiology, have to do with the structural/functional  damage that may have occurred to the heart leading to the clinical syndrome of heart failure or lead to cardiomyopathy. 

Stage A -  At risk- this means you have risk factors like Hypertension, obesity etc which can lead to the syndrome of heart failure. 

Stage B-. Simply put, at this stage  there is structural evidence of cardiomyopathy (heart damage ) but no evidence of signs or symptoms.  There are other ways this can be defined but that may be a little too complex for the scope of this discussion. Example evidence of decreased heart function, valvular heart disease. Hopefully at this stage you are already under the care of a cardiologist. 

Stage C- There is structural evidence of cardiomyopathy with prior or current symptoms. These are commonly patients who will be on  guideline directed medical therapy which we will talk about. 

Commonly Stage B and Stage C are managed by a cardiologist/ heart failure specialist.

Stage D- refractory heart failure not controlled by just medications and may need further advanced therapies . These patients definitely should be seeing a heart failure specialist and should discuss individual care with their physicians. 

The goal obviously is not to progress forward in the stages of heart failure. 

What are the classes of heart failure? The classes of heart failure identify to an extent the symptom burden of the patient or in other words how much is the syndrome of heart failure affecting your daily activity status.  It is possible to go up and down the 4 classes of heart failure depending on the degree of control of the condition.

Class I - No symptoms at regular levels of tolerated activity

Class II - Symptoms which occur with otherwise perceived normal levels of activity. 

Class III - Symptoms at less than routine physical activity. 

Class IV- Symptoms at rest 

What causes congestive heart failure? The most common causes of heart failure include ischemic heart disease, myocardial infarction ( ‘heart attack’) , hypertension, valvular heart disease, infiltrative heart disease. However there are a variety of other causes that can cause both Hfref and Hfpef. 

What are the signs and symptoms of heart failure? The cardinal symptom is shortness of breath. This may start as shortness of breath with physical activity as detailed above and can progress to shortness of breath with rest. Other commonly encountered symptoms include orthopnea( shortness of breath on lying down flat). People may describe this as ‘drowning in fluid on laying down. Paroxysmal nocturnal dyspnea - means people get up feeling short of breath in the middle of night or it wakes them up suddenly from sleep. 

Other symptoms may include lower extremity edema, palpitations, chest pain, dizziness or tiredness on walking depending on the cause and degree of cardiomyopathy. 

What can you do to prevent the development of heart failure?

From a patient perspective a lot of it has to do with concentrating on the risk factors which can lead to the development of heart failure and working on preventing their progression. This would include optimal control of blood pressure within goal, control of diabetes, losing weight if there is a component of obesity, watching salt intake and regular physical exercise. Prevention and control of coronary artery disease would also help reduce the chances of developing heart failure.

If you have congestive heart failure what can you do to prevent yourself from going into the hospital again and again?

This remains an important conundrum to deal with around the world as heart failure admissions and readmissions continue to stay high. Besides, hospital readmissions are also an indicator of overall poor prognosis. The goal is to keep the fluid off the patient to prevent readmissions. This can be done in a few ways. One is watching your salt and fluid intake ( though salt intake restriction  is more important as salt holds onto fluid. Ideally salt intake should be less than 2g/day as a general rule. This requirement may differ based on your clinical condition. 

In terms of medications, we may prescribe a diuretic/ fluid pill) to keep the fluid off. However these only work in conjunction with patient measures like watching salt intake and dietary restrictions. If you keep taking things that accumulate fluid on you, then there is only so much that medicines can do. 

If the patient has Hfref then they may be on a variety of medications to help make the heart pump stronger and compliance to these medications is key to staying out of the hospital too. 

What are the treatment options?

Depending on the stage and type  of heart failure, nowadays a variety of medications are available which may help to improve the heart function, keep patients out of the hospital, treat symptoms and also help patients live longer if taken in a correct manner as prescribed by your physician/cardiologist. Thus it is imperative to establish care with a cardiologist and continue to follow up regularly as instructed. This is crucial to having an improved quality of life. 

Advanced stages of heart failure ( Stage D) may require interventions and procedures in addition to medications. These patients need to be under the care of an advanced heart failure specialist.