I would like to take some time in this video to explain a medical condition called congestive heart failure.
This is actually not one condition alone, but rather an end result of a few different disease processes. Most people with congestive heart failure are likely to have a history of heart disease, high blood pressure, or atrial fibrillation – though there are a number of other causes as well.
Heart failure sounds like a terrible diagnosis, but in reality most cases can be managed in a way that can keep a person living every bit as long as those around them. To be honest, a better term for this would probably be something like “heart weakness”. So, to understand what is going on here, I’ll first explain how the heart normally works:
Think of the heart as a pump. Any well-functioning pump requires a successful filling stage and then an ejection phase: an ideal pump will fill and empty with a regular rhythm. If there’s a problem with the filling or emptying phase of the pump, there can be a backlog (in the heart’s case this would be a backlog of blood that does not get circulated throughout the body efficiently). That backlog of blood squeezes out into the tissues as extra fluid and can accumulate in several different places in the body, but the two most common types of congestion happen in the lungs and in the lower legs.
If the left side of the heart cannot keep up, fluid would accumulate in the lungs, whereas fluid would accumulate in the legs if it’s the right side of the heart that’s not pumping blood efficiently.
Why does this happen? Well, a heart that has lost some of its flexibility or stretch will become stiff and therefore may not fill properly. Or, a heart that beats too fast may not be allowing enough time to fill properly, and that reduces the amount that can get pumped out. It’s also common that after heart muscle gets damaged or stretched out, the actual strength of the heart is insufficient to empty the heart as much as before, leading to backlog.
Ordinarily, if the body accumulated fluid the kidneys would get rid of that extra fluid. However, with heart failure the kidneys often do not do what’s best for you (due to a hormonal misunderstanding between the heart and the kidneys) and instead contribute to fluid being retained.
The medications that we commonly use to treat heart failure include beta-blockers, ACE inhibitors or ARB’s, and water pills like spironolactone or furosemide. I will get into how and why each of these is used, but I do first want to talk about how you can monitor the situation to help keep things under control.
All of the medications used to treat heart failure affect your blood pressure, and some of them affect your heart rate, so knowing your typical and recent blood pressure and heart rate is essential for allowing us to adjust your medication.
The point here is not necessarily to get your blood pressure and heart rate below a certain number, though that is part of it, but to make sure we can get you at what are called “target doses” of these medications: doses that have been shown to prolong life and reduce the risk of you having to go to the hospital. But it is difficult for us to recommend using these medications, and/or increasing them, when we do not know what your blood pressure and heart rate is doing.
Given that, for some of us, accumulated fluid in the legs or in the chest is not obviously noticeable, one of the most sensitive ways to figure out whether or not you are accumulating fluid is simply by hopping on a scale every day. If you gain or lose 5 or 10 pounds over a few months, that could very well be related to eating too much or not exercising enough. But gaining 3 to 5 pounds or more in as many days will usually indicate a fluid change, and this should be addressed quickly. So, you should always let us know ASAP if you change weight that fast.
It’s helpful to know some of the different medications for congestive heart failure, and how they work:
Beta-blockers like metoprolol and bisoprolol help the heart pump slower, which gives it more time to fill, and helps it work more efficiently and effortlessly than would be possible if it were going too fast. It’s not unusual for us to aim for heart rates below 50.
ACE inhibitors like ramipril or perindopril, or ARB’s like irbesartan or candesartan, help the heart and kidneys work better together (as the communication system between these important organs sometimes gets mixed up) and also lower blood pressure: all of which helps improve the effectiveness of the heart.
Diuretics like spironolactone help the kidneys manage salt and fluids better over the long run, while a diuretic like furosemide is often used to get rid of excess fluid when the above medications happen to not be working very well (either temporarily, or sometimes long-term).
And lastly, there is another class of medication that actually comes from the world of diabetes but can be used for the treatment of congestive heart failure: drugs like empagliflozin or canagliflozin.
I should, however, mention at this point that medications are not the only thing that can help with chronic congestive heart failure. Dietary strategies need to be considered as well.
The two dietary strategies I want to highlight involve fluid consumption and salt intake.
One of the most important things you can do to avoid overloading your body with fluid is to not overload your body with fluid! What I mean is, if you drink a lot of water or other fluids every day, you really put a strain on your heart and kidneys that puts you at higher risk of accumulating too much fluid in your body, and that would lead to swollen legs or feet, and fluid in the chest.
Slightly more controversial is dietary advice about salt. When I was in medical school more than 15 years ago, we were taught to remind people to really limit their salt intake, but we know that some salt is still important. So, I would advise you to consider not adding extra salt at the dinner table to your meals, and assume they started with enough salt to begin with. A lot of pre-prepared foods at the grocery store, as well as frozen meals and food eaten out at restaurants, will all be quite high in salt, and that salt load can absolutely cause a worsening of swelling with congestive heart failure.
Other than the strategies I’ve discussed, how much monitoring should be done? That’s often a more individually tailored answer, so please feel free to discuss this at any upcoming visit. But here are some general guidelines:
At least every year or so, once you are stable, and perhaps more often if a lot of changes are being made to your medications, it would be important to get some blood work done. I would say an annual ECG would make sense as well. Echocardiograms are ultrasounds of the heart that allow us to assess heart function, but I do not think they necessarily need to be repeated annually in most cases (at least every three years would make sense).
Some people also wonder if they should be followed by a heart function program or a specialist. We happen to have access to our local family health team’s heart function program for all of our patients, and this added layer of support would ensure that you have regular follow-up with a specialist supervised nurse or nurse practitioner, so do let us know if you are interested in that.
Furthermore, seeing an internist locally, or following up with a cardiologist (though you would have to drive to Barrie for that) are also options that we are happy to discuss with you at your request.
Sometimes, we will suggest one or both of these options if we anticipate that you might need more specialized support, due to the complexity or severity of your situation.
Before I sign off, I do want to make sure that in addition to getting in touch with our office if you find that your symptoms have changed suddenly or recently (whether shortness of breath, coughing, or fast weight gain) you should also remember that the emergency room is an option if you are really short of breath, or you find it difficult to talk or sleep without getting short of breath.
On a more positive note, most of our patients with congestive heart failure, who follow-up with us regularly to make sure we keep their medications optimized, do not end up going to the hospital regularly, and are able to live long and healthy lives.
I hope that this has explained some of the key concepts related to heart failure in a way that will enable you to make better decisions about your health going forward.
