Congestive Heart Failure (CHF) Overview (cont.)
Benjamin Wedro, MD, FACEP, FAAEM
Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Charles Patrick Davis, MD, PhD
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
In this Article
- What is congestive heart failure (CHF)?
- What causes congestive heart failure?
- What are the signs and symptoms of congestive heart failure?
- What are the risk factors for congestive heart failure?
- How is congestive heart failure diagnosed?
- What is the treatment for congestive heart failure?
- What is the prognosis for congestive heart failure?
- Can congestive heart failure be prevented?
- Find a local Cardiologist in your town
What are the risk factors for congestive heart failure?
Congestive heart failure is often a consequence of atherosclerotic heart disease and therefore the risk factors are the same: poorly controlled high blood pressure, high cholesterol, diabetes, smoking, and family history. Heart valve disease becomes a risk factor as the patient ages.
Other causes of heart failure have their own set of risk factors and predispositions and it becomes a complication of those diseases. Such causes may include obstructive sleep apnea, alcohol and drug abuse, infections, and connective tissue disorders like systemic lupus erythematosus, sarcoidosis, and amyloidosis.
Many patients have stable congestive heart failure but can decompensate when a change occurs to their body. For example, a patient with congestive heart failure may be doing well but then develops pneumonia, an infection of the lungs, or suffers a heart attack. The patient's heart may not be able to react to the body's changing environment and does not have the capability or reserve to meet the body's energy needs. As well, acute decompensation may occur if the patient drinks excess fluid, has a large intake of salt that can retain water in the body, or forgets to take their routine medication.
How is congestive heart failure diagnosed?
Diagnosis of congestive heart failure is able to be accomplished by history and physical examination. The health care professional often will ask question about the symptoms like shortness of breath, swelling in the legs, chest pain, and what the patient does to make them better (sit down, rest). It will also be important to know whether the symptoms have come on gradually or over a shorter period of time.
Past medical history, medication history, diet, and social history including alcohol and drug use are all important to share. Should congestive heart failure be thought to be caused by atherosclerotic heart disease, risk factors for heart disease may be explored.
Physical examination begins with observing the patient to decide how comfortable they are at rest and whether the walk to the exam area made them short of breath. Vital signs including blood pressure, pulse rate, respiratory rate, oxygen saturation, and body weight may be helpful to assess how ill the patient might be. The exam often concentrates on the heart and lungs.
When examining the lungs, the medical caregiver determines if there is good air entry in both sides of the chest or if there are extra sounds that might be heard when fluid is present. Tapping on the chest (percussion) can uncover a fluid buildup.
Heart exam includes feeling for the apex beat, the heart beat that can be felt through the chest wall. If it is displaced in the direction of the armpit, it may be a sign that the heart is enlarged. Listening to the heart sounds may uncover abnormal beats called gallops that are heard in heart failure. Murmurs may help diagnose heart valve disease. Rubs are noises made when the pericardium or fibrous sac covering the heart has become inflamed or enlarged.
The neck may be examined looking for jugular venous distention. The jugular veins will dilate if there is extra fluid in the body and may be a sign of right heart failure. Peripheral edema (tissue swelling) is also found in right heart failure. The doctor will often look at the feet and ankles first to see if they are swollen. The abdominal examination may reveal an enlarged liver or ascites (fluid accumulation in the abdominal cavity).
Congestive heart failure can be a medical emergency, especially if it acutely decompensates and the patient can present extremely ill with the inability to breathe adequately. In this situation, the ABCs of resuscitation (Airway, Breathing, Circulation) need to be addressed while at the same time, the diagnosis of congestive heart failure is made.
Common tests that are done to help with the diagnosis of congestive heart failure include the following:
- Electrocardiogram (EKG) to help assess heart rate, rhythm, and indirectly, the size of the ventricles and blood flow to the heart muscle.
- Chest X-ray to look at heart size and the presence or absence of fluid in the lungs.
- Blood tests may include a complete blood count (CBC), electrolytes, glucose, BUN, and creatinine (to assess kidney function).
- B-type natriuretic peptide (BNP) may be helpful in deciding if a patient has shortness of breath from congestive heart failure or from a different cause. It is a chemical that is located in the heart ventricles and may be released when these muscles are overloaded.
- Echocardiography or ultrasound testing of the heart is often recommended to assess the anatomy and the function of the heart. In addition to being able to evaluate the heart valves and muscle, the test can look at blood flow within the heart, watch the chambers of the heart contract, and measure the ejection fraction.
Other tests may be considered to evaluate and monitor a patient with suspected congestive heart failure, depending upon the clinical situation.
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