Heart failure

Signs and Symptoms

You may experience one or more of the following symptoms of chronic heart failure:

• Swollen feet, ankles, and sometimes abdomen
• Weight gain from fluid retention
• Shortness of breath and cough
• Racing or skipping heartbeat (palpitations)
• Stomach upset, nausea and vomiting, and loss of appetite
• Difficulty sleeping
• Fatigue, weakness, and a reduced ability to exercise
• Lightheadedness
• Difficulty concentrating or staying alert

The more advanced your heart failure, the more likely you are to have symptoms.

Acute heart failure occurs when something suddenly damages your heart (such as a heart attack, blood clot in the lungs, allergic reaction, or severe infection). Symptoms are similar to those for chronic heart failure, but they are more serious and get worse quickly. Acute heart failure is life threatening and requires immediate emergency medical attention.

Causes

The most common causes of heart failure are high blood pressure and coronary artery (heart) disease. Other causes of heart failure include:

• Heart attack
• Damaged heart valves (valves separate the chambers of the heart and keep blood flowing in the right direction)
• Cardiomyopathy (weakening of the heart muscle, which may be from infection, diseases such as rheumatoid arthritis or lupus, alcohol or drug abuse, or unknown reasons)
• Congenital heart disease (heart defects at birth)
• Myocarditis (inflammation of the heart from a virus)
• Abnormal heart rhythms (arrhythmias)

Risk Factors

You are at risk for developing heart failure if you:

• Have high blood pressure
• Have diabetes
• Have had a heart attack or have heart disease of any kind
• Have high blood pressure or diabetes
• Are overweight
• Have sleep apnea
• Take certain medications, including bisphosphonates
• Abuse alcohol, smoke cigarettes, or use cocaine
• Post traumatic stress disorder

Diagnosis

Your health care provider will take a detailed medical history and perform a physical exam. Your provider will examine your heart and lungs, checking for enlargement of the heart and fluid in the lungs. Other signs of heart failure that your provider will look for include enlarged neck veins, swelling in your legs or abdomen, and tenderness of the liver. A chest x-ray can help determine if there is fluid on your lungs or enlargement of your heart, two factors that often go along with heart failure.

After the initial diagnosis, your provider will look for the underlying cause of heart failure. Your provider may order these tests:

• Blood tests, to check kidney or thyroid function
• Echocardiogram, to determine systolic heart failure or diastolic heart failure
• Ejection fraction, to see how much blood your heart is pumping out
• Electrocardiogram (ECG), to look for heart rhythm problems
• Coronary catheterization (angiogram), to look for narrowed arteries

Treatment Approach

With proper treatment, you can control symptoms of heart failure and improve your health. Lifestyle changes, such as losing weight, cutting down on salt, and exercising regularly, can improve your condition. Medications are also available to help your heart better pump blood. Complementary and alternative therapies can be helpful, too, when used along with standard medical treatment. Heart failure is a serious condition and you should always seek medical care. DO NOT take any herbs or supplements without your doctor's supervision.

Lifestyle

Carefully monitoring your health and helping to manage your condition makes a big difference in managing heart failure. The results of one study found that healthy lifestyle habits (normal body weight, not smoking, regular exercise, moderate alcohol intake, and consumption of breakfast cereals, and fruits and vegetables) were associated with a lower risk of heart failure. The highest risk was in men adhering to none of the 6 lifestyle factors, and the lowest was among men adhering to 4 or more healthy lifestyle factors. To do this, track your weight on a daily basis. Weight gain can be a sign that you are retaining fluid and that the pump function of your heart is getting worse. Make sure you weigh yourself at the same time each day and on the same scale.

Other important measures include:

• Take your medications as directed. Carry a list of medications with you wherever you go.
• Cut down on salt. People with heart failure should consume no more than 2,000 mg of sodium per day. Keep in mind that most salt in your diet does not come from the salt shaker. Most salt comes from processed foods that already contain high levels of sodium.
• If you smoke, quit.
• Exercise and stay active. Walk or ride a stationary bicycle, for example. One study showed that a walking program was safe for people with heart failure and helped improve symptoms. Another study found that a regular tai chi practice improved quality of life and mood in patients with chronic heart failure. Talk to your doctor before starting new exercise program.
• Lose weight if you are overweight.
• Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest, too. Keep your feet elevated to decrease swelling.
• Manage your stress and stay connected to others. One study found that patients who attend an 8-week support group that included mindfulness had less depression and anxiety and fewer physical symptoms a year later.
• Eat an antioxidant-rich diet. Studies show that diets high in antioxidants are associated with a lower risk of heart failure.

Tips to lower your sodium intake

• Look for foods 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.
• DO NOT cook with salt or add salt to what you are eating. Use pepper, garlic, lemon, or other spices for flavor instead. Be careful of packaged spice blends as these often contain salt or salt products (such as monosodium glutamate).
• Avoid foods that are naturally high in sodium, such as anchovies, meats (particularly cured meats, bacon, hot dogs, sausage, bologna, ham, and salami), olives, pickles, sauerkraut, soy and Worcestershire sauces, 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 instead of bottled dressings on salads.
• Eat fresh fruit or sorbet when having dessert.

Medications

Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors widen blood vessels and make it easier for your heart to pump blood. Side effects can include chronic cough. ACE inhibitors include:

• Benazepril (Lotensin)
• Captopril (Capoten)
• Fosinopril (Monopril)
• Lisinopril (Zestril)
• Enlapril (Vasotec)

Angiotension II receptor blockers (ARBs). ARBs also dilate blood vessels and may be used in people who cannot take ACE inhibitors. They include:

• Irbesartan (Avapro)
• Candesartan (Atacand)
• Losartan (Cozaar)
• Valsartan (Diovan)

A combination of ACE and ARB, called Entresto, is also available for a subset of patients. This new drug has shown promise in further reducing the risk of cardiac events among heart failure patients.

Digoxin (Lanoxin). Helps your heart pump more blood by increasing the strength of its contractions.

Beta-blockers. Slow heart rate and lower blood pressure. Beta-blockers include:

• Acebutolol (Sectral)
• Atenolol (Tenormin)
• Bisoprolol (Zebeta)
• Carvedilol (Coreg)
• Propanolol (Inderal)
• Metoprolol (Lopressor, Toprol-XL)

Diuretics (water pills). Keep fluid from building up in your body by making you urinate more. There are different types of diuretics that can affect potassium and magnesium levels in your body, so your doctor will check your levels frequently.

Isosorbide dinitrate and hydralazine hydrochloride (BiDil). BiDil combines two drugs that dilate blood vessels. It is approved for use in African Americans who have heart failure as an addition to standard therapy.

Nutrition and Dietary Supplements

Heart failure is a serious medical condition and should be treated by conventional medicine. You should never add supplements or complementary and alternative medicine therapies to your regimen unless specifically instructed to do so by your physician. It is best to work with a health care provider trained in the use of nutritional medicine. Many people with heart conditions take multiple medications, including blood-thinning medications, blood pressure medications, and others. The supplements below can interact with these and many other medications and may not be right for people with certain medical conditions. You should use the supplements listed below only under the supervision of your cardiologist, and a doctor who understands the contraindications and interactions associated with these supplements.

• Magnesium. Magnesium is essential to heart health. This mineral is particularly important for maintaining a normal heart rhythm and is often used by physicians to treat irregular heartbeat (arrhythmia). People with heart failure are often at risk for developing an arrhythmia. In addition, some diuretics (water pills) may cause your body to lose too much magnesium. For this reason, your doctor may recommend a supplement. Magnesium can interact with a number of heart medications. Always ask your doctor before taking a magnesium supplement if you have heart failure.
• Carnitine. Some studies suggest that L-carnitine supplements may reduce your chances of developing heart failure after a heart attack and improve exercise capacity if you already have heart failure. Carnitine is a nutrient that helps the body convert fatty acids into energy. This energy is used primarily for muscular activities throughout the body. Most studies used a special form of carnitine called propionyl-L-carnitine. Carnitine may affect thyroid medication, and may interact with blood-thinning medications, such as coumadin (Warfarin), aspirin, and others. Speak with your physician.
• Coenzyme Q10 (CoQ10). Levels of CoQ10 can be low in people with heart failure. Several studies suggest that CoQ10 supplements can help reduce swelling in the legs, enhance breathing by reducing fluid in the lungs, and increase exercise capacity in people with heart failure. However, not all studies agree. More research is needed to see if CoQ10 has any real benefit. In the meantime, talk to your doctor about whether this supplement is right for you. CoQ10 may negatively interact with blood-thinning medications, such as coumadin (Warfarin), aspirin, and others, as well as blood pressure medications and chemotherapy agents.
• Creatine. Creatine is a naturally-occurring amino acid (protein building block) found mainly in muscles. In a few studies of people with heart failure, injections of creatine (in addition to standard medical care) improved heart function and ability to exercise compared to those who received placebo. Taking creatine orally improved muscle function and endurance. More studies are needed to determine whether oral creatine has any benefit for people with heart failure. People with kidney issues, or those who take medications that are potentially harmful to the kidneys, should use caution when taking creatine. Speak to your physician.
• Vitamin B1 (Thiamine). Thiamine may be related to heart failure in several ways. First, low levels of thiamine can contribute to the development of heart failure. On the flip side, people with severe heart failure can lose a significant amount of weight, including muscle mass (called cachexia), and become deficient in many nutrients, including thiamine. In addition, diuretics (water pills) can cause your body to lose too much thiamine. Talk to your doctor about measuring your level of vitamin B1 and whether you should take thiamine.

Amino acids. A few small studies suggest these amino acids might be helpful for heart failure. More research is needed:

• Arginine (needed for the body to make nitric oxide, which helps blood flow). Arginine can lower blood pressure, and may be unsafe to take with blood pressure medications. It may also interact negatively with medications that increase blood flow, such as nitrates, as well as medications used to treat erectile dysfunction.
• Taurine (helps the heart muscle contract). Taurine can interact with lithium, and may be unsafe in people with bipolar disorder.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. However, herbs can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, you should take herbs only under the supervision of a health care provider. Many people with heart conditions take blood-thinning medications and blood pressure medicines, among others. The supplements below can interact with these and many other medicines, and may not be right for people with certain conditions. These should be used only under the supervision of your cardiologist, and a doctor who understand the contraindications and interactions associated with these supplements.

• Hawthorn. Hawthorn (Crataegus spp.), a member of the rose family, was used by physicians in the early 1800s to treat circulation and respiration (breathing) problems. The flowers and berries have been used traditionally to treat irregular heartbeat, high blood pressure, chest pain, atherosclerosis (hardening of the arteries), and heart failure. Several scientific studies suggest that hawthorn improves the heart's ability to pump blood in people with heart failure. It also significantly improved symptoms (like reduced shortness of breath and fatigue) and helped people exercise longer. There is not enough research to determine definitively whether hawthorn can work safely with other medications, or how it compares to drugs such as ACE inhibitors. Hawthorne may potentially interact with a variety of medications. Talk to your doctor to see if hawthorn is right for you.
• Berberine. Berberine, an active ingredient of goldenseal (Hydrastis canadensis) and other herbs, can dilate blood vessels. In one study, people who took berberine for 8 weeks had better heart function and were more able to exercise than those who took placebo. A few other studies suggest that when berberine is combined with standard medicines for heart failure, it can improve heart function and quality of life. Talk to your doctor about whether it is safe and appropriate for you to take berberine in addition to your usual care. Berberine can potentially interact with a number of medications.

Prognosis and Complications

Heart failure is a serious disorder that leads to a lower life expectancy. It is generally a chronic illness. But many forms of heart failure can be controlled by treating the underlying causes, making lifestyle changes, and taking medication.

Potential complications include:

• Pulmonary edema (fluid buildup in the lungs)
• Total failure of the heart to function (circulatory collapse or shock)
• Arrhythmias (irregular heart rhythm) including fatal arrhythmias
• Cognitive impairment is common in older adults hospitalized for heart failure

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