|
|
|
Overview |
|
|
Definition |
|
Congestive heart failure (CHF) occurs when the heart cannot pump out an
adequate supply of blood to meet the metabolic needs of the body. This condition
results in ventricular dysfunction that correlates with reduced exercise
capacity. Any form of heart disease may lead to CHF. End-stage CHF is
characterized by a large dilated heart, elevated left ventricular (LV) filling
pressure, reduced cardiac output, and peripheral and pulmonary edema. It is the
most common cause of death for people over 65 years, affecting 10% of the
geriatric U.S. population. |
|
|
Etiology |
|
- Hypertension
- Coronary artery disease
- Systolic dysfunction, diastolic dysfunction, or both
- Congenital heart disease
- Pericardial disease
- Tricuspid stenosis
- Pulmonary embolism
- Valvular function defects
- Myocardial infarction
- Myocarditis
- Arrhythmias
- Cardiomyopathy
- Anemia
- Thyrotoxicosis
|
|
|
Risk Factors |
|
- Smoking
- High fat diet, excess body weight
- Alcohol abuse
- High sodium intake
- Influenza, pneumonia
- Noncompliance with prescribed medications or
diet
|
|
|
Signs and Symptoms |
|
- Dyspnea
- Fatigue, exercise intolerance
- Pulmonary edema—audible rales
- Hemoptysis—rust-colored sputum
- Distended neck veins
- Orthopneic cough
- Nocturia
- Proteinuria
- Insomnia
- Nausea, vomiting
- Anorexia
- Anxiety
- Peripheral edema
|
|
|
Differential
Diagnosis |
|
- Cirrhosis
- Nephrotic syndrome
- Venous occlusive disease
|
|
|
Diagnosis |
|
|
Physical Examination |
|
No physical finding can confirm a diagnosis of CHF. Patients typically appear
pale and present with fatigue and dyspnea. Echocardiography is therefore
essential for early diagnosis. |
|
|
Laboratory Tests |
|
- Blood tests may indicate elevated serum creatinine, blood urea
nitrogen (BUN), erythrocyte sedimentation rate, enzymes
- Serial blood gas measurements may indicate carbon dioxide retention
with pulmonary edema
|
|
|
Pathology/Pathophysiology |
|
- Hypoperfusion
- Sodium and nitrogen retention from diminished renal
perfusion
- Inadequate tissue oxygen delivery
- Endothelial dysfunction
- Orthopnea from elevated jugular venous pressure
- Pulmonary edema—excessive elevation of
filling pressures results in aveolar flooding and gas exchange
disturbance
Resulting adaptive mechanisms include:
- Renin–angiotensin and adrenergic systems
activate causing arterial and venous vasoconstriction; arterial vasoconstriction
increases the afterload, venous vasoconstriction increases preload
- Increased LV mass (hypertrophy) and volume
(dilation)—contribute to dyspnea
- Increased sympathetic nervous system activity, resulting in systemic
vascular resistance increase
|
|
|
Imaging |
|
- X rays—show increased heart size and blood
flow; indicates pulmonary, vascular, interstitial, and alveolar edema
- Radionuclide ventriculography—assesses
ventricular function
|
|
|
Other Diagnostic
Procedures |
|
Diagnoses focus on identifying etiology and precipitating factors. Procedures
include blood tests and ECG.
- Electrocardiogram (ECG)—measures heart's
electrical activity; may be normal, or suggest ventricular dysrhythmias, left
ventricular hypertrophy/damage, and inadequate blood flow
- Echocardiogram—assesses ventricular
function; wall and valvular abnormalities; LV hypertrophy and abnormal filling
pressures suggest diastolic dysfunction, pericardial disease, and valvular
disease.
- Cardiac catherization—definitive diagnoses
of extent of damage
- Angiography—diagnoses coronary occlusion and
wall abnormalities
- Exercise stress test—assess blood pressure,
heart rate and rhythm, and oxygen consumption while
exercising
|
|
|
Treatment Options |
|
|
Treatment Strategy |
|
Immediate relief of the precipitating event. Typically, combined drug therapy
(e.g., vasodilator, diuretic, digitalis glycoside) is prescribed for CHF.
Mechanical or surgical therapies are added with severe CHF. Heart valve surgery,
revascularization, or cardiac transplantation as required and as available. Bed
rest and reduced activity are recommended until condition is stabilized. Oxygen
relieves dyspnea and pulmonary vasoconstriction. |
|
|
Drug Therapies |
|
Vasodilators—reduce arterial and venous
vasoconstriction (afterload/preload); shifts blood volume from the arterial to
the venous side of circulation; cornerstone of treatment; gradually titrate
Oral vasodilators:
- Angiotensin-converting enzyme (ACE) inhibitors (e.g., enalapril, 2.5
to 5.0 mg bid to qid); side effects—acute renal failure
(avoid potassium-sparing diuretics), cough, angioedema, hypotension
- Angiotensin II receptor antagonists (e.g., Losartan, 12.5 mg qid
titrated to 50 mg qid); monitor blood pressure
- Nitrates may relieve venous and pulmonary congestion
- Calcium-channel blockers and alpha- and beta-adrenergic receptor
antagonists—variable effects and potential serious
adverse effects
Parenteral vasodilators:
- Nitroglycerin—10 to 100 mg/min; tolerance
problems with long-term use
- Sodium nitroprusside—5 to 150 mg/kg/min;
thiocyanate and cyanide toxicity
For fluid control and sodium retention
- Restriction of dietary fluid and sodium (<2 g/day) reduces need
for diuretics.
- Maximum daily net fluid loss—0.5 to 1.0
liter/day to avoid serious complications (e.g., oliguria, impaired renal
function)
- Thiazide diuretics (e.g., chlorothiazide 500 to 1000 mg/day); loop
diuretics (e.g., furosemide 20 to 600 mg/day); potassium-sparing diuretics
(e.g., spironolactone 25 to 200 mg/day)
- Mechanical removal of fluid—phlebotomy,
thoracentesis, dialysis, paracentesis
- Digitalis glycosides—increase myocardial
contractile function; prevent rhythm disturbances by increasing cardiac output
and lowering filling pressures; digoxin—monitor closely
for toxicity (5% to 15% of patients) and drug interactions; 0.25 to 0.5 mg/day
then 0.25 mg every six hours to 1.0 to 1.5 mg
- Inotropic agents—for CHF unresponsive to
other therapies; poor long-term benefit (e.g., dopamine 1 to 3 mg/kg/min;
milrinone 50 mg/kg/min then 0.375 to 0.750 mg/kg/min); closely monitor for
tachycardia and arrhythmia
|
|
|
Complementary and Alternative
Therapies |
|
The true goal is to prevent the pathologies leading to congestive heart
failure. Nutrition and herbal medicine can play an important role in increasing
the strength of the heart without also increasing the workload. In addition,
treating the lungs with herbs and physical medicine may increase the comfort of
the patient and decrease pulmonary pathology. Mind-body techniques, such as
yoga, meditation, relaxation, and biofeedback show promise in increasing
cardiovascular health and increasing a sense of well-being. |
|
|
Nutrition |
|
- Antioxidants: vitamin C (1,000 mg tid), vitamin E (400 IU/day),
selenium (200 mcg/day)
- Coenzyme Q10: (30 to 50 mg tid) antioxidant, increases oxygenation of
tissue, including heart muscle
- Essential fatty acids: (1,500 mg bid) anti-inflammatory
- Garlic, ginger, and onions all have a beneficial effect on platelet
aggregation. Increase fiber (especially water-soluble), fruits, vegetables, and
vegetarian sources of protein. Increase potassium and decrease sodium in the
diet.
- Homocysteine metabolism: Folic acid (800 mcg/day), B6 (50 mg/day),
B12 (400 mg/day), betaine (200 to 1,000 mg/day)
- Magnesium: (500 mg) mild vasodilation, decreases vascular
resistance
- Taurine: (500 mg bid) enhances cardiac efficiency, mild
diuretic
- Carnitine: (750 to 1,500 mg bid) important in fatty acid metabolism,
increases efficiency of cardiac
function
|
|
|
Herbs |
|
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. of herb per cup of hot
water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes
for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination
as noted.
- Hawthorn (Crataegus monogyna): stabilizes collagen and
increases blood vessel integrity, prevents free radical damage, reduces
peripheral vascular resistance, and increases coronary and myocardial perfusion
without increasing cardiac load; historic use in CHF; dose is 3 to 5 g. This
dose is difficult to achieve in tea or tincture. Supplements or solid extract
are used.
- Mistletoe (Viscum album): mild antihypertensive,
antiatherosclerotic, historically for exhaustion and nervousness
- Linden (Tilia cordata): historic use as a hypotensive,
especially with digestive problems and nervousness
- Rosemary (Rosmarinus officinalis): increases coronary artery
blood flow, historically used to stimulate digestion and relieve nervous
tension
- Motherwort (Leonurus cardiaca): chronotropic, arrhythmias,
especially with nervousness
- Dandelion (Taraxacum officinale): potassium-sparing diuretic,
can be used as a coffee substitute
- Indian tobacco (Lobelia inflata): antispasmodic, stimulates
respiratory function, used in smoking cessation. May be toxic if used above
recommended doses.
- Lily of the valley (Convallaria majalis): specific for cardiac
insufficiency; exceeding recommended doses may lead to nausea, vomiting,
headache, stupor. Use no more than 30 drops/day.
- Horsetail herb (Equisetum arvense):
diuretic
Hawthorn should be included in any treatment. In addition, use a combination
of four to six of the above herbs at 1 cup tea tid or 30 to 60 drops tincture
tid. |
|
|
Homeopathy |
|
Constitutional homeopathy may be helpful for stimulating overall vitality and
should be prescribed by an experienced homeopath. |
|
|
Physical Medicine |
|
Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory.
Apply oil directly to chest, cover with a clean soft cloth (e.g., flannel) and
plastic wrap. Place a heat source (hot water bottle or heating pad) over the
pack and let sit for 30 to 60 minutes. For best results use three consecutive
days. Applied over the lungs, this will increase pulmonary function stimulating
drainage.
Contrast hydrotherapy. Alternating hot and cold applications to the chest
brings nutrients to the lungs and diffuses metabolic waste from inflammation.
The overall effect is decreased inflammation, pain relief, and enhanced healing.
Alternate three minutes hot with one minute cold. Repeat three times to complete
one set. Do two to three sets/day. For debilitated patients, use cool and warm
applications to decrease the contrast. |
|
|
Acupuncture |
|
May be helpful for increasing circulation, diuresis, and cardiac
strength. |
|
|
Massage |
|
May be helpful to increase lymphatic drainage and reduce
edema. |
|
|
Patient Monitoring |
|
Close and frequent monitoring (X rays, blood levels) may reduce the need for
hospitalization. |
|
|
Other
Considerations |
|
|
Prevention |
|
Every effort must be made to prevent progression of disease. Avoiding risks
(see above) and isometric exercise may help prevent CHF. |
|
|
Complications/Sequelae |
|
- Pulmonary edema—medical emergency
- Electrolyte disturbances
- Arrhythmias
|
|
|
Prognosis |
|
- 50% of patients die in four to five years
- 50% of those with advanced CHF live <1 year
- Diastolic dysfunction has better prognosis than
systolic
Independent predictors include:
- Elevated ventricular filling
- Extent of ventricular function impairment
- Reduced cardiac index
- Exercise capacity
|
|
|
Pregnancy |
|
Diuretics and sodium restriction are indicated. Anemia, infection, and
preeclampsia increase cardiac workload and must be treated vigorously. The first
two weeks postpartum is particularly dangerous for
CHF. |
|
|
References |
|
Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:218-219.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:120,142-144,162-163,171-172,197.
Brady JA, Rock CL, Horneffer MR. Thiamin status, diuretic medications, and
the management of congestive heart failure. J Am Diet Assoc.
1995;95:541-544.
Cecil RL, Plum F, Bennett JC, eds. Cecil Textbook of Medicine. 20th
ed. Philadelphia, Pa: WB Saunders Co; 1996.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co;
1998:779-781,932-923,1101-1103,1175-1176,1185-1187,1219-1221.
Murray MT. Encyclopedia of Nutritional Supplements. Rocklin, Calif:
Prima Publishing; 1996:378-379.
Schmidt U, Kuhn U, Ploch M, Hubner WD. Efficacy of the hawthorn (Crataegus)
preparation LI 132 in 78 patients with chronic congestive heart failure defined
as NYHA functional class II. Phytomedicine. 1994;1:17-24.
Washington University School of Medicine, Department of Medicine.
Washington Manual of Medical Therapeautics. 29th ed. Philadelphia, Pa:
Lippincott-Raven Publishers; 1998.
Werback MR. Nutritional Influences on Illness. New Canaan, Conn: Keats
Publishing, Inc;
1987:40-78,136-139,227-240. |
|
Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |