Chronic Heart Failure
The signs and symptoms of chronic heart failure are usually associated with comorbid chronic medical conditions including myocardial infarctions, hypertension, obesity, and diabetes mellitus. The term heart failure is defined as the inability of the heart to adequately supply the body with enough blood flow and oxygen to meet its needs. When the heart pump is not functioning adequately, changes occur within the body that lead to fluid accumulation within the lungs and other tissues that result, in part, from higher filling pressures within the heart chambers. Fluid accumulation within the legs leads to swelling, i.e., edema. When fluid accumulates in the lungs, patients experience shortness of breath with activity or, in severe cases, at rest. In acute heart failure, acute congestion of the lungs can lead to hypoxia (low oxygen levels) and subsequent respiratory and cardiac arrest. Autopsy findings may support this (acute severe worsening of pulmonary congestion – i.e., fluid buildup within the lungs) as the likely cause of death.
There are many important risk factors for heart failure such as prior myocardial infarctions, hypertension, obesity, and diabetes mellitus. Hypertension in particular, especially when poorly controlled, increases the risk of heart failure; this notion has been substantiated by several large clinical trials. More aggressive control of hypertension has been promulgated in recent years as important to minimize the risks for heart failure. Thus, consistent control of hypertension by careful medical adjustments is critically important to a patient’s wellness and to reducing the risk of heart failure. Hypertension often requires multiple medications for adequate control. When there are periodic and pronounced rises in blood pressure, a given patient’s regimen must be altered or augmented to help decrease blood pressure. In short, taking an added medication “as needed” for episodic very high blood pressure is completely insufficient to treat chronic hypertension. Patients exhibiting these intermittent and pronounced rises in blood pressure require permanent augmentation of their medical regimen to reduce the likelihood and frequency of such episodes.
Worsening heart failure is heralded by weight gain that results from increased fluid retention that is manifest in most patients by worsening lower extremity edema or swelling. When this occurs, several treatment options are available to medical providers. First and foremost, the provider needs to recognize worsening heart failure. Initial treatment will include increased diuretic therapy to help reduce swelling and improve shortness of breath. Lasix (aka furosemide) and spironolactone, are both agents that can help reduce fluid accumulation. Worsening edema, increased symptoms of generalized weakness, and easy fatigability necessitate augmented therapy. Usually, a provider will increase the dose of oral diuretic therapy. If this does not effect an improvement in symptoms and a reduction in weight and edema, hospitalization is then required where intravenous diuretics such as Lasix can be administered which is nearly always successful in reducing edema, decreasing weight, and improving symptoms. Without hospitalization and correct medical treatment, the lungs often will become more congested and patients will experience worsening shortness of breath. If lung congestion becomes worse, rapid respiratory muscle fatigue due to the high work of breathing follows that may ultimately lead to a cardiopulmonary arrest and death.
Some medications are known to increase blood pressure and the propensity for fluid retention and thus are relatively contraindicated in heart failure and difficult to control hypertension. For example, drugs commonly used to treat arthritis known as nonsteroidal anti-inflammatory drugs (NSAIDS) can cause blood pressure to rise due increased sodium and fluid retention by the kidney. By the same mechanism, they worsen edema thereby counteracting the effects of diuretics. The NSAID Voltaren is one such drug that can increase blood pressure (and as a result counteract the effects of blood pressure-lowering medications) and increase fluid retention (and as a result counteract the effects of diuretics).
A heart failure cardiologist is routinely referred patients with heart failure by other physicians. As such, they are able to recognize the presence of heart failure and, further, identify those who require transfer to the emergency department for urgent care. When a patient is hospitalized for heart failure, they are treated with intravenous diuretics, such as furosemide, that act on the kidney to increase sodium and water excretion and, in doing so, diminish lung and tissue congestion. In the course of such treatment, patients will often lose weight due to the loss of fluid. This is usually accompanied by a significant improvement in symptoms.