Congestive Heart Failure

The patients of congestive cardiac failure present with features of left and right heart failure. The clinical manifestations are as below.

Features due to left heart failure:

• Dyspnea, orthopnea and paroxysmal nocturnal dyspnea: These symptoms develop due to congestion of the lungs. Sometimes chronic cough may also be seen.
• Fatigue and weakness: Fatigue and weakness result from decreased cardiac output to the skeletal muscles and the central nervous system.
• Nocturia: Nocturia occurs due to excretion of fluid retained during the day and increased renal perfusion in recumbent position at night.

Features due to right heart failure:

• Headache, insomnia and restlessness: These symptoms occur because of cerebral congestion.
• Anorexia, nausea and vomiting: Congestion of the portal system causes these symptoms.
• Pain in the right hypochondrium: Hepatic congestion causes stretching of the hepatic capsule which causes pain in the right hypochondrium.
• Oliguria and nocturia: These symptoms result from renal congestion.
• Peripheral edema: Edema develops in the feet in ambulatory patients and sacral edema in bed bound patients.

On examination, the findings include raised jugular pressure and positive hepatojugular reflex, tender hepatomegaly and features of heart disease.

Framignham criteria is used for the diagnosis of congestive cardiac failure. The presence of one major and two minor criteria is the minimal requirement for establishing the diagnosis.

The major criteria include:

• Paroxysmal nocturnal dyspnea
• Distention of neck veins
• Crepitations
• Cardiomegaly
• Acute pulmonary edema
• S3 gallop rhythm
• Increased venous pressure (greater than 16 cm of water)
• Positive hepatojugular reflux

The minor criteria include:

• Pedal edema
• Night cough
• Dyspnea on exertion
• Hepatomegaly
• Pleural effusion
• Tachycardia
• Vital capacity reduced by at least one third of normal

The main investigations in the diagnosis of congestive cardiac failure include the following.

• Electrocardiography (ECG): ECG may show signs of right and left ventricular enlargement, myocardial infarction and arrhythmias.
• X-ray of the chest: Possible findings include hilar congestion and bat wings appearance in the lungs, cardiomegaly, pleural effusion and evidence of pulmonary hypertension.
• Echocardiography: Echocardiography may demonstrate systolic or diastolic impairment of the left or right ventricle, valve diseases, motion abnormalities of the heart walls, cardiomyopathies, reduced ejection fraction and intracardiac thrombus.

The treatment strategy for congestive cardiac failure has three components; namely correction of the underlying cause(s), removal of the precipitating cause(s) and control of congestive cardiac failure.

The general measures for controlling the congestive cardiac failure include the following.

• Bed rest: Bed rest reduces the demands of the heart. Propping up of the head of the patient should be proposed to reduce lung congestion. 
• Diet: Diet low in salt, general good nutrition and weight reduction should be advised.
• Smoking: Complete cessation of smoking has to be ensured.
• Exercise: Adequate exercise within the limits of the symptoms is beneficial.

Medical therapy

Initially, angiotensin converting enzyme (ACE) inhibitors are given to the patient which reduce cardiac workload by causing vasodilation [3]. Captopril and lisinopril are the commonly used agents [4].

If ACE inhibitors alone are not effective, a combination of other vasodilators (such as nitrates, hydralazine and neseritide) and diuretics (such as loop diuretics, thiazide diuretics and potassium sparing diuretics) may be used [5] [6].

If adequate control is still not achieved, positive ionotropic agents such as digoxin and digitalis are useful [7] [8].

Cardiac transplantation

Cardiac transplantation is indicated in end stage cardiac disease that is refractory to other kinds of therapy. Ideal candidates should have age less than 60 years, adequate renal function and pulmonary vascular resistance less than 3 RU [9] [10].

The prognosis depends upon the extent of cardiac failure and the type of treatment given. Prognosis is poor when the underlying heart disease is not treatable. Other poor prognostic factors include left ventricular dysfunction with ejection fraction less than 20%, secondary renal insufficiency, hyponatremia and hypokalemia (with potassium less than 3 mEq/l).

Ventricular arrhythmias and pump failure are the leading causes of death in these patients.

Congestive cardiac failure results from the following types of conditions related to the heart.

Volume overload

• Aortic regurgitation
• Mitral regurgitation
• Atrial septal defect
• Tricuspid regurgitation

Pressure overload

• Systemic hypertension
• Aortic stenosis
• Pulmonary hypertension
• Pulmonary stenosis

Myocardial diseases

• Ischemic heart disease
• Cardiomyopathies
• Myocarditis
• Diabetes mellitus
• Alcohol toxicity
• Sarcoidosis

Heart failure is a relatively common outcome of various cardiac diseases. Approximately 0.67 million people are affected in the United States each year [1]. Out of these, 0.27 million die from it.

The increasing use of refined diets and higher incidence of hypertension and diabetes in developing countries is also causing a rise in the international incidence of cardiac failure [2].

Congestive cardiac failure usually involves failure of both the left and right side of the heart. The features of left sided heart cardiac failure are mainly due to congestion of the lungs. Dyspnea occurs because of the damming of blood in the lungs resulting in pulmonary venous congestion. Initially dyspnea occurs only at exertion. Later on orthopnea and paroxysmal nocturnal dyspnea also develop. Later on dyspnea occurs even at rest. Orthopnea refers to breathlessness on lying flat. It occurs because of the following two circulating changes when the person lies flat.

• There is redistribution of blood from the tissues into the plasma. Approximately half a liter of blood pooled in the leg veins during standing is returned to the heart increasing the venous return.
• In upright position, hydrostatic pressure helps in draining the upper lung zones into the left atrium. Respiration can continue in the upper zones even if the lower zones are congested. Upon lying flat, this hydrostatic effect is lost and the whole lung becomes congested causing severe breathlessness.

Paroxysmal nocturnal dyspnea results from the same two mechanisms above along with the following:

• Depression of the nervous system during sleep leads to reduced awareness of pulmonary congestion. The patient wakes up when extreme congestion and breathlessness have developed.
• The sympathetic system is also depressed during sleep which causes reduction in the heart rate causing further pooling of the blood in the pulmonary vessels. 

Later on, pulmonary edema also develops and causes persistent breathlessness.

Right sided heart failure mainly causes tissue congestion because of the inability of the heart to empty properly. Many organs including the brain, liver and kidneys are affected. In addition, generalized congestion develops which manifests as peripheral edema.

The causes that predispose to the development of myocardial or valvular diseases should be avoided. In case of active disease, early diagnosis and prompt treatment is necessary to reduce mortality.

Cardiac failure refers to the inability of the heart to maintain adequate cardiac output to meet the demands of the body. Depending upon the cause, there may be a failure of the left side or the right side of the heart; known as left and right sided cardiac failure respectively. The salient features are also different.

Biventricular cardiac failure is the condition in there is chronic failure of both the left and right sides of the heart. In most of the cases, right sided cardiac failure is a result of preexisting left sided cardiac failure.

Congestive cardiac failure refers to the failure of both sides of the heart. The blood is not adequately pumped by the heart. As a result, the organs of the body do not get sufficient amount of blood and damming of blood in the vessels also takes place. A healthy lifestyle and proper treatment prevents mortality from congestive cardiac failure.

1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation. Feb 1 2011;123(4):e18-e209
2. Stewart S, Wilkinson D, Hansen C, et al. Predominance of heart failure in the Heart of Soweto Study cohort: emerging challenges for urban African communities. Circulation. Dec 2 2008;118(23):2360-2367.
3. Cayley WE, Jr. Therapy with ACE inhibitors and ARBs in heart failure. American family physician. Jul 15 2004;70(2):261.
4. Ball SG, Julian DG. ACE inhibitors and heart failure. Lancet. Mar 14 1992;339(8794):687-688.
5. Jentzer JC, DeWald TA, Hernandez AF. Combination of loop diuretics with thiazide-type diuretics in heart failure. Journal of the American College of Cardiology. Nov 2 2010;56(19):1527-1534.
6. Miraglia G, Nava A, Dalla Volta S. [Clinical amd metabolic results of a particular combination thiazide-antialdosterone in heart failure]. La Clinica terapeutica. Mar 15 1974;68(5):445-451.
7. Batterman RC, De Graff AC. Comparative study on the use of the purified digitalis glycosides, digoxin, digitoxin, and lanatoside C, for the management of ambulatory patients with congestive heart failure. American heart journal. Nov 1947;34(5):663-673
8. Digitalis Investigation G, Ahmed A, Waagstein F, et al. Effectiveness of digoxin in reducing one-year mortality in chronic heart failure in the Digitalis Investigation Group trial. The American journal of cardiology. Jan 1 2009;103(1):82-87.
9. Villar E, Boissonnat P, Sebbag L, et al. Poor prognosis of heart transplant patients with end-stage renal failure. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. May 2007;22(5):1383-1389.
10. Hori M, Koretsune Y, Takemura K, et al. Prognosis of patients with severe congestive heart failure referred to the cardiac transplant program. Osaka University Cardiac Transplant Program. Japanese circulation journal. Jun 1994;58(6):395-402.

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