Diseases

• The best way to prevent heart failure is to never have a heart attack, but if you do, there still are treatments. The Lyon Heart study demonstrated that a Mediterranean diet can prevent heart failure among people who have had a heart attack.
• Following other healthy lifestyle recommendations such as not smoking, not abusing alcohol, eating a plant-based diet, eating a diet that is anti-oxidant rich, eating an anti-inflammatory diet such as a Mediterranean diet, and being physically active every day may also help prevent heart failure.
• Treating early signs of heart failure and risk factors such as high blood pressure, being overweight or obese, and hardening of the arteries (atherosclerosis) are also strategies to prevent congestive heart failure.
• Stress raises blood pressure, worsens diabetes, and causes coronary artery disease. Learning stress resiliency techniques such as Transcendental Meditation, Yoga, or meditation can reduce the risk of many types of cardiovascular disease by 48%.

• Heart failure can be diagnosed by physical exam, reported symptoms, or chest X-ray.
• An echocardiogram test can identify a low ejection fraction or a thickened, stiff heart muscle.
• Echocardiograms may be used to distinguish between systolic and diastolic types of heart failure.
• Blood tests such as BNP (beta naturetic peptide) suggest heart failure.
• Algorithms and guidelines exist to score and weigh signs and symptoms to help make the diagnosis.

While doctors define heart failure in stages or classifications, it represents a progression of heart muscle weakness. Sometimes people refer to this process as chronic heart failure but technically that term isn't correct. The New York Heart Association (NYHA) puts the stages of heart failure into four classifications:

• Class I: no limitations in activity. Normal activities can be performed.
• Class II: mild limitations and mild symptoms with activity; no symptoms at rest
• Class III: noticeable limitations in activity; only comfortable at rest
• Class IV: symptoms occur at any level of activity and uncomfortable even resting

The American Heart Association along with the American College of Cardiology grades heart failure in four stages, and takes into account that heart failure can be present even before symptoms appear:

• Stage A: No heart failure, but at high risk due to another medical condition that can lead to heart failure, such as high blood pressure, diabetes, obesity, or coronary artery disease.
• Stage B: The heart has been damaged by the patient's other medical condition(s) or other factors, but no symptoms are present yet.
• Stage C: The heart is damaged and the patient is experiencing heart failure symptoms.
• Stage D: The patient has severe heart failure that requires specialized care, despite receiving treatment (end-stage).

Symptoms of heart failure include:

1. Shortness of breath
2. Fatigue
3. Lightheadedness
4. Exercise intolerance
5. Loss of appetite
6. Nausea
7. Coughing (or chronic cough)
8. Wheezing
9. Pounding or racing heart
10. Excessive tiredness
11. Confusion
12. Problems thinking
13. Swelling in the ankles
14. Swelling in the abdomen
15. Chest pain

Symptoms are usually worse at night when lying flat. Symptoms are very similar for systolic and diastolic heart failure. Your doctor may need further testing to see which type you have.

The heart has four chambers through which blood pumps. Newly oxygenated blood is pumped from the lungs to the left atrium and left ventricle and out through the aorta to circulate through the rest of the body. After the oxygen has been used, the blood returns through the veins to the right atrium and right ventricle into the lungs to be re-oxygenated.

• Systolic heart failure (left-sided heart failure): When the heart loses strength on the left side (left ventricle) and cannot pump the blood into circulation, it is called systolic heart failure or left-sided heart failure. When this occurs, the heart becomes dilated and weak. The strength of the heart muscle can be measured with an echocardiogram that measures the ejection fraction. An ejection fraction of greater than 55% is normal. The term congestive heart failure, or CHF, refers to the accumulation of fluid in the tissues. Fluid can accumulate in the legs causing swelling (edema), into the lungs causing pulmonary edema, or into the abdomen where it is called ascites. A type of heart failure termed acute decompensated heart failure is an emergency.
• Diastolic heart failure (right-sided heart failure): The second type of heart failure is diastolic heart failure, characterized by the heart becoming thicker and stiffer. When this happens, the left ventricle cannot fill with sufficient blood, and not enough blood is pumped into circulation, even if the pumping action is still strong. This is why diastolic heart failure is sometimes referred to as heart failure with preserved ejection fraction (PEF), or right-sided heart failure. If the signs and symptoms of heart failure are present and the ejection fractions is greater than 50%, diastolic heart failure may be considered, especially if an echocardiogram shows the heart muscle is thickening.

The complications of heart failure include severe fatigue and weakness, inability to complete activities of daily living, kidney damage, and progressive heart failure that could ultimately require heart transplant.

The most common risk factors for heart failure include:

• Coronary artery disease
• Previous heart attack
• Heart valve problems
• Cardiomyopathy
• Other major risk factors include:
• High blood pressure
• Genetics (congenital heart defects)
• Infections (especially viral infections)
• Obesity

Less well recognized risk factors of heart failure include:

• Sleep apnea
• Nutrient deficiencies
• An unhealthy diet (low in antioxidant vegetables and high in animal fats)
• Stress
• Lack of exercise

All of these also contribute to coronary artery disease, which is a major risk factor for heart failure.

The cause of heart failure is a weakened or thickened cardiac muscle. For example, in chronic high blood pressure (hypertension), the heart must pump extra forcefully against the additional blood pressure. First it becomes enlarged and thickened. But over time, the heart weakens, scarring (fibrosis) develops, and it becomes less efficient at pumping. It can become larger (dilated) and weak or thickened and stiff. When the risk factors for heart failure are present, there usually is inflammatory stress, which further damages the cardiac muscle depleting cells of energy and antioxidants.

Many lifestyle and diet factors can improve, or even reverse, congestive heart failure. Cardiac rehabilitation programs can teach people how to make lifestyle changes, as can integrative cardiology clinics. Some of the lifestyle factors that make a difference include:

• Manage stress by doing mind-body practices such as Tai Chi, yoga, Qi Gong, and meditation
• Quit smoking or using tobacco
• Eliminate alcohol
• Eat a healthy Mediterranean, vegetarian, or vegan diet
• Be physically active and become stronger
• Get enough restful sleep
• Manage and treat sleep apnea
• Take dietary supplements including CoQ10, L-carnitine, Crataegus (hawthorne), magnesium, and fish oil
• Avoiding salt and excess fluids

Talk to your doctor before taking any herbs or supplements.

The term heart failure can be frightening, but in reality, it just means that the heart is not pumping as well as it could be. When the heart muscle is weak, blood cannot be pumped efficiently enough to get oxygen to all of the cells. Sometimes the heart becomes dilated and weak. Other times it may be stiff and thickened. Over time, the heart cannot keep up with its workload. When this happens, there isn't enough oxygenated blood reaching the brain and muscles, and fluid begins to backup in the lungs and other tissues. The lack of oxygen causes the main symptoms of heart failure such as fatigue, shortness of breath, and difficulty completing tasks that require exertion.

The course of heart failure is highly variable. People who address their risk factors and make lifestyle changes may never progress. However, if changes are not made, if medications are not taken, or if the underlying causes are not correctable, heart failure can become a progressive and eventually fatal condition. This means that the heart muscle will continue to get weaker and have more difficulty keeping up with the workload. Fortunately, many treatment options exist for heart failure.

Heart failure treatment options include making healthier decisions about lifestyle and diet, taking medications, and sometimes implanting devices. Heart transplant is sometimes considered for certain individuals. In acute or decompensated heart failure, the person may need hospitalization or even intravenous medications to help recover.

Medications help reduce the symptoms of congestive heart failure (CHF) and can actually improve heart muscle function. There are several main classes of medications that are used for treating a weak heart muscle. Your physician will choose medications based on your symptoms and whether your heart needs to be strengthened or relaxed. The types of medications commonly prescribed for heart failure include:

• Beta-blockers: carvedilol (Coreg), bisoprolol (Zebeta), metoprolol (Lopressor, Toprol), nebivolol (Bystolic), acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), carteolol (Cartrol), esmolol (Brevibloc), penbutolol (Levatol), nadolol (Corgard), pindolol (Visken), propranolol (Inderal, InnoPran), timolol (Blocadren), labetalol (Trandate, Normodyne)
• Diuretics (water pills): Thiazide diuretics: hydrochlorothiazide (Microzide, Hydrodiuril), chlorothiazide (Diuril), metolazone (Mykrox, Zaroxolyn, Diulo), methyclothiazide (Enduron), indapamide (Lozol), chlorothalidone (Hygrotron)
• Loop diuretics: furosemide (Lasix), bumetanide (Bumex), torasemide (Demadex), ethacrynate (Edecrin)
• Potassium sparing diuretics: spironolactone (Aldactone), triamterene (Dyrenium), eplerenone (Inspra), amiloride hydrochloride
• ACE (angiotensin converting enzyme) inhibitors: lisinopril (Prinivil, Zestril), benazepril (Lotensin), and captopril (Capoten), enalapril/enalaprilat (Vasotec oral and injectable), fosinopril (Monopril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), trandolapril (Mavik)
• ARBs (angiotensin receptor blockers): candesartan (Atacand), irbesartan (Avapro), olmesartan (Benicar), losartan (Cozaar), valsartan (Diovan), telmisartan (Micardis), eprosartan (Teveten)

In severe heart failure, devices can help the heart pump better. Left Ventricular Assist Devices (LVAD) are implanted mechanical pumps that are most commonly used when people are waiting for heart transplants. When medications and lifestyle haven't stopped the progression of heart failure, surgical transplantation of a donor heart can be lifesaving. Other surgical procedures can sometimes be performed earlier to address the risk factors and causes of heart disease such as coronary artery bypass, percutaneous coronary intervention, or angioplasty to open the blockages of coronary atherosclerosis.

You may initially see your primary care provider (PCP) such as a family practitioner or internist, and in a sudden or severe situation you may be seen by an emergency medicine specialist in a hospital's emergency department. You will be referred to a cardiologist, a specialist in disorders of the heart. You also may see some sub-specialties of cardiology, including a cardiac electrophysiologist, who specializes in electrical and heart rhythm problems, or a cardiothoracic surgeon if surgery is needed.