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.

• 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

• Smoking
• High fat diet, excess body weight
• Alcohol abuse
• High sodium intake
• Influenza, pneumonia
• Noncompliance with prescribed medications or diet

• 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

• Cirrhosis
• Nephrotic syndrome
• Venous occlusive disease

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.

• 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

• 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

• X rays—show increased heart size and blood flow; indicates pulmonary, vascular, interstitial, and alveolar edema
• Radionuclide ventriculography—assesses ventricular function

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

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.

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

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.

• 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 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.

Constitutional homeopathy may be helpful for stimulating overall vitality and should be prescribed by an experienced homeopath.

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.

May be helpful for increasing circulation, diuresis, and cardiac strength.

May be helpful to increase lymphatic drainage and reduce edema.

Close and frequent monitoring (X rays, blood levels) may reduce the need for hospitalization.

Every effort must be made to prevent progression of disease. Avoiding risks (see above) and isometric exercise may help prevent CHF.

• Pulmonary edema—medical emergency
• Electrolyte disturbances
• Arrhythmias

• 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

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.

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.