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Congestive Heart Failure
Congestive heart failure (CHF) occurs when the heart muscle (“myocardium”) becomes weak and is no longer able to adequately pump blood around the body.
Symptoms of CHF
The resulting decrease in cardiac output can cause symptoms that include shortness of breath (“dyspnea”), fatigue, dizziness, weakness, swelling (“edema”) in the lower extremities, cough, wheezing, rhythm disturbances (“arrhythmia”), and chest pain (with coronary artery disease).
Doctors measure the heart's cardiac output by calculating the “ejection fraction,” which is the percentage of blood that the pumping chambers (“Ventricles”) pump out with each contraction. A normal ejection fraction should be at least 50%, meaning that more than half of the blood that fills the ventricle is pumped out with each contraction.
While most patients with congestive heart failure have low ejection fractions, that is not necessarily the case with all patients with CHF, such as when the heart muscle becomes stiff and cannot fill or eject the blood properly. One common cause of heart “stiffness” is high blood pressure (“hypertension”). Patients with hypertension can develop CHF even when their ejection fraction is normal.
Causes of CHF
Any condition that weakens the heart muscle may lead to the development of congestive heart failure. The most common medical conditions that give rise to CHF include hypertension, coronary artery disease, cardiomyopathy, defective heart valves, cardiac arrhythmias (especially atrial fibrillation), diabetes mellitus, thyroid disorders, hemochromatosis, amyloidosis, viral infections that affect the heart (“myocarditis”), blood clots in the lungs (“pulmonary emboli”), certain medications, and others (including alcohol, tobacco, and drug use).
The Centers for Disease Prevention and Control (CDC) estimates that 5.8 million people in the United States have CHF. Most CHF hospitalizations are for those aged 65 and over, but the proportion under age 65 has increased significantly from 23% in 2000 to 29% in 2010.
Diagnosis of CHF
The diagnosis of congestive heart failure is typically made by a cardiologist. There are many diagnostic tools that are used to diagnose CHF. They include blood tests, such as a BNP, which checks the level of a hormone in the blood that rises during heart failure, and procedures that include electrocardiogram (EKG), chest x-ray, echocardiogram, doppler ultrasound scan, Holter monitor for arrhythmias, nuclear heart scan, cardiac catheterization, coronary angiogram, cardiac stress test, and cardiac MRI.
Lifestyle modification. Patients with congestive heart failure are often instructed to exercise appropriately, reduce sodium in their diets, manage stress properly, and lose weight.
Control underlying medical conditions. If there are underlying medical conditions that may be contributing to congestive heart failure, such as coronary artery disease, high blood pressure, diabetes, or obesity, it is important to treat and monitor those conditions.
The National Institutes of Health (NIH) has summarized the medicationsthat are typically used in the treatment of congestive heart failure. They include the following.
ACE inhibitors lower blood pressure and reduce strain on your heart. They also may reduce the risk of a future heart attack.
Aldosterone antagonists trigger the body to remove excess sodium through urine. This lowers the volume of blood that the heart must pump.
Angiotensin receptor blockers relax your blood vessels and lower blood pressure to decrease your heart's workload.
Beta blockers slow your heart rate and lower your blood pressure to decrease your heart's workload.
Digoxin makes the heart beat stronger and pump more blood.
Diuretics (water pills) help reduce fluid buildup in your lungs and swelling in your feet and ankles.
Isosorbide dinitrate/hydralazine hydrochloride helps relax your blood vessels, so your heart doesn't work as hard to pump blood.
Medical Proceduresthat are used to treat progressive forms of congestive heart failure include the following.
Cardiac pacemaker. In heart failure, the right and left sides of the heart may no longer contract at the same time. This disrupts the heart's pumping. To correct this problem, an implantable cardiac pacemaker helps both sides of the heart to contract at the same time.
Defibrillator. Some people who have heart failure have very rapid, irregular heartbeats. Without treatment, these heartbeats can cause sudden cardiac arrest. An implantable cardioverter defibrillator (ICD) checks the heart rate and uses electrical pulses to correct irregular heart rhythms.
Mechanical heart pump. A left ventricular assist device helps pump blood from the heart to the rest of the body.
Heart transplant. Heart transplants are done as a life-saving measure for end-stage heart failure when medical treatment and less drastic surgery have failed. A noteworthy example of a successful heart transplant is Former vice-president Dick Cheney.
The New York Heart Association (“NYHA”) Classification of the stages of heart failure are as follows.
Class I means no symptoms and no limitation in ordinary physical activity (e.g. no shortness of breath when walking, climbing stairs etc.).
Class II means mild symptoms (e.g. mild shortness of breath and/or angina) and slight limitation during ordinary activity.
Class III means marked limitation in activity due to symptoms, even during less-than-ordinary activity, (e.g. walking short distances (20—100 m). Comfortable only at rest.
Class IV means severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.
Patients whose NYHA classification is class III or IV have a significantly lower survival rate than patients in class I or II. The prognosis of patients with CHF due to underlying coronary artery disease or primary cardiomyopathy is typically poorer when compared with patients who had other types of heart disease. [Ref: Maroba M, et al. “Long-term prognosis of patients with congestive heart failure.” Jpn Circ J. 1990 Jan;54(1):57-61.]
Stem Cell Therapy for Congestive Heart Failure
Stem cells have the capacity to travel from the bone marrow to the heart when an injury to the heart occurs, such as a myocardial infarction (“heart attack”). By secreting hormones at the site of the injury, stem cells help to heal damaged heart cells and can turn into heart muscle cells themselves. However, the benefit is modest because after a week or so, the stem cells seem to stop helping and no further repair occurs.
Researchers at the Cleveland Clinical have pointed out that at present, stem cell therapy for damaged hearts is not yet ready for “prime time,” because it has not been perfected as a clinical treatment modality. For now, the use of stem cells is best reserved for randomized clinical trials at medical centers, where further research can be done. [Ref: https://my.clevelandclinic.org/health/diseases/17508-stem-cell-therapy-for-heart-disease]