Managing Congestive Heart Failure
Although good management can slow heart failure's progress, it is generally a progressive disease. As the patient's condition advances, the patient's healthcare team will intensity its efforts, adding or changing drugs or raising dosages and stressing the need for the patient to adopt a more healthful lifestyle.
Note: Certain types of heart failure actually can be reversed—not just slowed. For example, if serious valve disease caused the heart failure, surgery to fix the valve might "cure" the patient's heart failure. Similarly, when heart failure is the result of heavy drinking, stopping drinking can reverse the condition.
This section discusses:
- Your management team
- The stages of heart failure
- Medications
- Lifestyle-related goals
- When to call your doctor
- When to call 911 or go to the emergency room
- The years to come
More than two thirds of patients with heart failure are under the exclusive care of a primary-care physician. Most clinical guidelines recommend that patients also be monitored routinely by a cardiologist who specializes in heart failure, with help from nurses, dietitians, pharmacists, exercise specialists, and social workers as needed.
Managing congestive heart failure is as much the patient's as the physician's responsibility. Patients must take medications as directed, change their diet as necessary, cut back on fluids, exercise, quit smoking, make and keep follow-up appointments, and accurately report symptoms and any side effects of their medications to all doctors involved in their care. Also, while it may seem obvious, if you're not told when you should come again, ask--and make your next appointment before leaving the office.
The American Heart Association and the American College of Cardiology defined the specific stages of heart failure in 2001 to show patients where they stand and the range of therapies they can expect at that point. For their own purposes, physicians also refer to New York Heart Association clinical categories, which rank patients from Class I to IV according to functional limitations and the severity of symptoms.
Below are the AHA/ACC stages. The following therapies may or may not apply to you, depending on the cause of your heart failure and your specific medical condition. This guide is meant to assist you in discussing treatment options with your physician.
Stage A: No diagnosis or symptoms of heart failure, but the risk is high because of one or more of the following factors: hypertension; diabetes; known coronary artery disease and history of a heart attack; history of cardiotoxic drugs (therapeutic or recreational) or alcohol abuse; history of rheumatic fever; and family history of cardiomyopathy.
Usual therapies: Stop smoking and exercise. Treat hypertension and high blood levels of cholesterol and triglycerides. Stop use of alcohol and illicit drugs. Your doctor may prescribe an angiotensin-converting enzyme (ACE) inhibitor if you have had a previous heart attack, hypertension, or diabetes and a beta blocker if you have had a previous heart attack.
Stage B: Heart failure diagnosed by an ejection fraction (a test measuring the amount of blood pumped out of the main pumping chamber with each heartbeat) below 40 percent (compared with a normal 55 percent or more) but no past or current symptoms.
Usual therapies: All therapies in Stage A plus: Get a surgical consultation for coronary artery revascularization and valve repair or replacement (as appropriate). Your doctor should prescribe an ACE inhibitor and beta blocker (unless contraindicated).
Stage C: Heart failure diagnosed, with past or current symptoms, including shortness of breath, fatigue, and reduced exercise tolerance.
Usual therapies: All therapies in Stage A plus: All patients should take an ACE inhibitor and beta blocker. Your doctor may also prescribe a diuretic and digoxin, if appropriate. All patients should restrict their intake of salt, monitor their weight, and restrict fluid intake (as appropriate). Discontinue drugs that make the condition worse. Your doctor may prescribe spironolactone when symptoms remain severe with other therapies.
Stage D: Advanced symptoms of heart failure after receiving optimal medical care.
Usual therapies: All therapies in Stages A, B, and C plus: evaluation for other treatment options, such as a heart transplant, ventricular-assist device, other surgeries, continuous IV infusion of inotropic drugs, and research therapies.
Taking medications as prescribed is a vital part of managing heart failure. Many patients will take more than one medication. It is important to know the names of your medications, how they work, how much to take, and when to take them. Take your medications at the same time every day. Never stop your medications without speaking to your physician. Do not take over-the-counter or herbal medications without first asking your doctor.
Heart failure medications are used to strengthen the heart's pumping ability, expand the blood vessels, decrease the workload on the heart, and decrease water and sodium in the body. Other medications may be used to treat arrhythmias, high blood pressure, and coexisting medical conditions.
Common heart failure medications include:
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin II-receptor blockers (ARBs)
- Beta blockers
- Potassium or magnesium
- Digoxin
- Diuretics
- Vasodilators/nitrates
- Aldosterone inhibitors
- Inotropic therapy
- Calcium channel blockers (for diastolic dysfunction only)
Treating heart failure requires a team effort, which includes a commitment to adhering to a healthful lifestyle. Making these changes will help to improve symptoms, slow the progression of heart failure, and improve your daily life. The following are general guidelines; members of your healthcare team will discuss with you specific recommendations.
Diet:
- Restrict the sodium in your diet to less than 2,000 mg per day. Remove the saltshaker from the table, and learn to read food labels to make the best low-sodium choices. Many frozen, processed, and precooked foods from the supermarket as well as restaurant fast foods are high in sodium and fat.
- Increase your consumption of fiber by eating more whole grains, vegetables, and fruits.
- Carefully follow your fluid management guidelines. The general rule is to drink no more than 8 cups of fluid daily, including semiliquid foods such as yogurt and pudding, even if you feel thirsty.
- Eat a variety of foods to get all the nutrients you need.
- Consider consulting a dietitian or nutritionist to help with menu planning.
Weight: Maintain a healthy body weight. Drop extra pounds, and keep them off by limiting your total daily caloric intake, following a low-fat diet, and exercising on most days.
Alcohol: Your doctor may recommend limiting or avoiding alcohol. If alcohol is permitted, make it red wine, and have no more than 4 ounces a day (red wine has heart benefits).
Exercise: Regular exercise has many benefits. But always check with your doctor before starting an exercise program. Find out how often you should exercise, and ask for a list of exercises and activities that would be appropriate for you. If you feel more comfortable beginning to exercise in a supervised setting, ask your doctor for a cardiac rehabilitation program near you.
Enjoy life: Stay in touch with friends, and plan daily activities to get out of the house. Still, keep your activities within the limits set by your doctor. Listen to your body so you know when it is time to rest and rebuild your energy.
Tobacco: Do not smoke or chew tobacco. Tobacco increases your risk of heart disease by causing your blood pressure and heart rate to rise.If you need help to quit smoking, ask your healthcare team.
Control additional risk factors: If you have high blood pressure or diabetes, work with your healthcare team to achieve your goals.
Monitor your health: Weigh yourself at the same time every day, using the same scale, preferably in the morning after urinating and before dressing. Record your weight in a diary for your doctor to review at every visit. Call your doctor if you gain more than 3 pounds in one day or 5 pounds in one week.
Get the flu shot and pneumonia vaccine: Talk to your doctors about getting a pneumococcal vaccination every five years and an annual flu shot. Complications of respiratory problems can worsen heart failure.
Stay emotionally healthy: Learning that you have heart failure may provoke feelings of anxiety or depression. These feelings should fade as you begin to take charge of your health and make positive lifestyle changes. But if the negative feelings continue or prevent you from enjoying life, talk to your doctor.
If you experience any of the following symptoms, call your doctor. Do not wait until your next appointment to make the call, and do not change or stop taking your medications without first talking to your doctor. If your symptoms are discovered early, your doctor may be able to relieve your symptoms by changing your medications.
- Unexplained weight gain—3 or more pounds in one day or 5 or more pounds in one week
- Increased swelling in the ankles, feet, legs, or abdomen
- More-severe or more-frequent shortness of breath, especially on awakening
- Abdominal fullness or bloating
- Loss of appetite or nausea
- Extreme fatigue or decreased ability to undertake daily activities
- A respiratory infection or bad cough
- A resting heart rate of 120 beats or more per minute
- A new or more noticeably irregular heartbeat
- Chest pain or discomfort that is relieved with rest
- Difficulty breathing during regular activities or at rest
- Difficulty sleeping or needing much more sleep than usual
- Decreased urination
- Restlessness or confusion
- Dizziness or lightheadedness
- Excessive, unexplained perspiration
When to call 911 or go to the emergency room
Take immediate action if you experience any of the following:
- New, severe chest pain or discomfort, especially if you are short of breath, sweating, nauseated, or weak
- A fast heartbeat (more than 120 to 150 beats per minute), especially with shortness of breath
- Shortness of breath that is not relieved by rest
- Sudden weakness or inability to move your arms or legs
- Sudden onset of a severe headache
- A fainting spell with loss of consciousness
With the right care and teamwork, heart failure should not keep you from doing most of the things you enjoy. Your future health depends on how well your heart muscle functions, how well and how often you and your doctor work together to control and treat your symptoms, how well you follow your treatment plan, and how well your heart responds to care.
Whatever your medical condition—whether you and your heart are healthy or are beset by long-term, chronic heart failure—you should discuss with your doctor, family, and lawyer the kind and amount of intensive medical care you want when your life is ending. An "advanced directive" or "living will" is a good way to let everyone know your wishes. A living will spells out what medical treatments you do or don't want to prolong your life. Preparing and signing a living will while you are fully competent is in your best interests. There is always a possibility that you could be unable to make such decisions down the road. For help in this area, one good resource is the nonprofit group Aging with Dignity at agingwithdignity.org
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