Congestive Heart Failure (CHF)

Congestive Heart Failure (CHF)

What is CHF?

Congestive Heart Failure (CHF) is a clinical syndrome where the heart’s blood pumping efficiently is decreased. The term “failure” is really is misnomer. Decreased Heart Pumping Efficiency is a more accurate description. This decreased efficiency leads to fluid (liquid part of blood) backing up; the lungs to start but people generally develop swelling in ankles and legs as it progresses. 

What’s wrong with the heart in CHF?

The heart is a springy muscle. Blood enters, compresses the spring and as rebounds the muscle contracts pumping blood from the heart. CHF can be thought as a problem with the spring and come in 2 primary types. A normal heart beats 60-65% of the blood out each beat.

  1. Systolic / Heart Failure with Reduce Ejection Fraction (HFrEF) – in this type of heart failure the heart muscle has grown weak. Once you ejection fracture < 50% we consider this HFrEF. Think of a spring which has been over stretched and loss its “springiness.” Each heart beats less blood is pumped out; if less exits; more backs up. 
  2. Diastolic / Heart Failure with Preserved Ejection Fraction (HFpEF) – in this type of heart failure the heart still beats 60-65%. However the muscle has become stiff, like a rusted spring. A rusted spring doesn’t compress or bounce back with normal “springiness.” Each heart beats less blood is pumped out; if less exits; more backs up. 
  3. As a sports analogy imaging passing a basketball. To catch your arms are partially extended and bent, so when you catch the ball your arms muscle decelerate the ball towards your chest absorbing energy. No play with arm cast; you can’t absorb the energy correctly; this is HFpEF. Passing the ball is like systolic (HFeEF); it’s just a weak pass; may get the job done, but not well.
  4. One can have both. Generally diastolic (HFpEF) come first; but as the wear wears out over time from poor pumping efficiency it becomes weak, and thus systolic (HFrEF); double trouble.

What are the statistics on CHF?

  1. Prognosis: In general the prognosis if CHF goes down 10% of year. So after 1 year, 90% of people with CHF are still alive, after 5 year 50% of people are still alive. While this can be bleak the improvement in CHF treatment had made it possible for people to live long beyond this. 
  2. Incidence: About 7 million people in the US each year have CHF. Risk increases as you get older; lifetime risk if 25% (1:4 people). 425,000 people die of CHF each year and thus CHF accounts of 1/2 of cardiovascular deaths. Somewhat ironically, death certificates in Virginia do not permit listing as heart failure as a cause of death.
  3. Hospital Readmission: CHF is the most common cause of hospitalization in the US for people older than 65 years of age. It has the highest 30-day re-hospitalization rate among medical and surgical conditions, accounting for up to 27% of the total readmission rates.

Congestive Heart Failure requires a multi-pronged approach. Diet, exercise, medications, doctors visits, home monitoring, and sometimes advanced invasive procedures are all part of a comprehensive treatment plan. 

  1. Diet – lower salt diet. Not NO salt. I tell patient’s to spare the salt shaker and avoid foods which are highly salt containing (soup, TV dinners, some Asian cuisine). 
  2. Fluid intake – if you have swelling (edema) from CHF you need to watch how much fluid to take in. Too much just ends up in your skin. General rule is 2000 ml (2L or 64 oz) / day. All fluid counts: tea, water soda, etc. If it’s wet and you drink it count it towards total.
  3. Exercise – exercise is good for CHF; it can help it improve. Referral to Cardiac Rehab is just that; gradual exercise increase under the watchful eye of a physical therapist. If you don’t have cardiac rehab available progressive walking is a good start. Every day you walk try to go a little further. 
  4. Medications – this section could be a book until itself. All medications come with benefits and side effects. I try to get people on the “best” combination; however, each patient has limiting factors (blood pressure, heart beat, kidney function, electrolytes, interactions with other medications, cost, etc) which mean they cannot take them all. The “best” combination is the one the person can take, with little to no side effects.
    1. Beta-blockers – Common examples: metoprolol, carvedilol. These relax the heart muscle some and reduce blood pressure and heart rate
    2. ACE Inhibitors / ARB receptor – Common examples: losartan, lisinopril, valsartan.  These effect molecules released by the kidney and effect blood pressure, kidney function, and electrolytes.
    3. Entresto – this an ARB receptor combined with another medication. It is the only once in its class. 
    4. Mineralcorticoid antagonist – spironolactone and eplerenone. These block a hormone in the body which absorbs salt. Also effect how the heart reshapes itself over time
    5. SGLT2 Inhibitors – new kids on the block. Made as a medication for diabetes but studies show they can have beneficial effects on the heart. Very expensive because new.
    6. Diuretics “fluid pills” – all the backed up fluid in the lungs or legs needs to come out. Medications in this class increase urination and remove fluid. The downside is they can dehydrate you and your electrolytes (primarily potassium and magnesium) so they needing monitoring.
  5. Doctor’s Visits – Because CHF medications alter your blood pressure, heart rate, salt/water management and kidney function they are not set-and-forget. Like a tight-rope walker if things so going too far one way an adjustment is needed. Expect to have medications tweaked to optimize their effect. Consistent follow up with doctors is imperative to keeping you healthy and out of the hospital in CHF. 
  6. Home Monitoring – picking up on subtle changes in weight and extra edema early are key. This permits interventions that can steer the patient back on track before they get worse and admitted to the hospital. Weighing self most days of the week is a good start, you can’t gain pounds of fat in a few days, so if you weight increases it’s all water weight. Tracking your blood pressure and pulse is also important. Many doctor’s offices and home health agencies have special CHF programs. Be proactive and engaged in your health! “An ounce of prevention is worth a pound of cure” -Benjamin Franklin (1735),