December 17, 2001
According to Canobbio (1990), "it is estimated that as many as two million Americans suffer from congestive heart failure and that up to 29,000 die annually from this chronic disorder" (p. 103). From this statistic alone, it is evident that congestive heart failure is in need of attention. These numbers are going to continue to grow because congestive heart failure is a disease of civilization. A disease of civilization means that it is caused by the everyday lives of people in modern civilized society. What most people do not realize is that congestive heart failure is a syndrome that can be caused by multiple diseases. Once the causes are under control, congestive heart failure is more under control.
The human heart is probably the most reliable and most efficient pump ever devised. Although it is hardly bigger than a clenched fist, the heart in less than a second can squeeze out a third of a cup of blood with enough force to send it surging through more that 60,000 miles of blood vessels. It does this an average of 72 times a minute, 40 million times a year–and it’s been known to do this for more than a century without once failing its owner. The heart is the only organ in the body whose function is solely mechanical. It adds nothing to the blood that passes through it, takes nothing out, and makes no chemical changes in it. Its only purpose is to take the "used" blood that has coursed through the body and push it into the lungs, where its carbon dioxide wastes can be exchanged for fresh oxygen. It then thrusts this refreshed blood once again into the network of arteries that nourish every nook and cranny of the body. It is incredibly important that the heart continues perform this function day in and day out. A person cannot live without this vital organ (Toufexis, 1981).
Therefore, the heart backing up with excess fluid is a serious problem. Heart failure is a medical term that describes an inability of the heart to keep up its workload of pumping blood to the lungs and to the rest of the body. Although it sounds life threatening, heart failure is usually a treatable condition and compatible with survival for many years (Heart Home, 1989, p. 519).
All the symptoms of congestive heart failure result from the inability of the heart to pump enough blood to the tissues and the backup of blood into the veins, which allows fluid to collect in the organs and tissues of the body. This swelling is called edema. With mild degrees of congestive heart failure there may be only a mild swelling around the ankles and some shortness of breath during exertion. As heart failure worsens, more fluid retention occurs, leading to edema of the legs and hands (Silver, 1994). Fluid retention of the lungs can cause orthopnea, or the shortness of breath when lying flat. Persons with congestive heart failure often sleep on several pillows with the head of their bed propped up. Inadequate blood flow to the body results in shortness of breath with even mild exertion, such as walking across the room. In the most severe cases, congestive heart failure causes shortness of breath even at rest (Silver, 1994). The arms and legs become cool and pale from lack of blood flow. Cyanosis, or a bluish color, may be seen in the lips and fingernails from lack of oxygen. Cheyne-Stokes respiration, which is a pattern of alternating slow deep breathing, pauses, and rapid breathing, may develop. Blood flow to the kidneys is then reduced, resulting in further fluid accumulation. Paraoxysmal nocturnal dyspnea, which simply means sudden shortness of breath in the middle of the night, occurs during the first hours of sleep. The fluid that was retained in the abdomen and the lower extremities during the day is redistributed. The added volume in the blood vessels leads to increased congestion that may be relieved by sitting up for an hour or longer. Other signs and symptoms of congestive heart failure are fatigue or weakness, rapid or irregular pulse, a chronic dry or frothy cough that may be blood-tinged or resemble foam, increased urination at night, unexplained or unintentional weight gain, distended neck veins, loss of appetite or indigestion, and changes of behavior such as restlessness, confusion, and decreased attention span and memory (Mason, 1980). An interesting example showing many of these symptoms can be found in Appendix A.
There are many causes of congestive heart failure. Patients with family members that have one or more of these causes are likely to have congestive heart failure. Also, the body has not evolved to be able to handle current risks. Eaton and Eaton (1999) say "since the Industrial Revolution, genetic evolution has been unable to keep pace with cultural changes which have made modern human environments increasingly different from the Paleolithic" (1999, p. 252). The severity of the causes ranges from an inconvenience to life-threatening over time. Just a few of these causes are congenital heart disease, atherosclerosis, rheumatic fever, left or right-sided failure, and other contributors.
The first contributors to congestive heart failure in young people are present even before birth. According to Fisher, "congenital heart disease affects one out of every one thousand babies"(1981, p. 140 & 141). In these babies, the marvelously intricate combination of chambers, valves, and vessels making up the heart and circulatory system fails to form properly before birth or fails to undergo certain necessary changes soon afterward. Genetic flaws may be the reason for this. The defective gene is passed down through the generations (Fisher, 1981). Structural abnormalities in the heart are among the most common birth defects, but are usually treatable. Examples are conditions such as septal defects and some types of abnormal heart valves. Septal defects are some of the most severe congenital heart disorders. Atrial septal defect (ASD) is a hole between the atria and the ventricular septal defect (VSD) is a hole between the ventricles. Such holes allow oxygenated blood from the left side of the heart to enter the right side. If oxygenated blood recirculates to the lungs it can cause congestion (Silver, 1994). Surgery can correct these disorders.
Furthermore, atherosclerosis is the gradual clogging up of the arteries by fatty, fibrous deposits. These deposits are thought to begin building up in most Americans in early adulthood and perhaps even in childhood. Since people are eating less healthy foods, this problem is increasing (Canobbio, 1990). The digestive system may not have evolved to be able to handle such a high fat intake. Whether the deposits become dangerous depend on how fast they build up and where. Cholesterol begins accumulating in the damaged area creating a kind of yellowish streak that sets off a chain reaction. A tiny lump of fibrous tissue grows as the artery tries to repair the damage. Cells begin to die. More cholesterol accumulates and more fibrous tissue builds up. The growing mound of cholesterol, fibrous tissues, and dead cells is called plaque. The arteries are thickened and hardened making a loss of elasticity causing congestion.
One form of cardiovascular disease is coronary heart disease. This may result in insufficient blood supply to the heart. Damage occurs from lack of oxygen that may be caused by coronary thrombosis, or the formation of a blood clot in narrowed vessels (Coronary, 1969).
Also, strep throat from the streptococcal infection begins a disease process where the heart valves are damaged. This condition is called rheumatic heart disease and if it is not treated, can develop into rheumatic fever. Affecting many connective tissues, especially those of the heart, joints, brain, and skin, is the inflammatory disease rheumatic fever. It usually occurs in children from five to fifteen but the damage is life-long. Damaged heart valves can cause serious, even disabling problems. The most advanced condition is congestive heart failure. Prevention of rheumatic heart disease is achieved by treating strep throat before it leads to rheumatic fever. A person who has had rheumatic fever is likely to get it again. Continuous monthly or daily treatments are used to combat this situation (Canobbio, 1990).
Another cause of congestive heart failure occurs when the heart muscle is inflamed and does not work as well as it should. This condition is called cardiomyopathy. Dilated, or congestive, cardiomyopathy is the most common form. Stretching and enlarging of the heart cavity occurs making the heart weak so it does not pump correctly. Hypertrophic cardiomyopathy is when the septum thickens and can block the flow of blood from the left ventricle causing congestion for the lungs. Symptoms are shortness of breath on exertion, dizziness, fainting, and chest pain. It is treated by a drug called a beta blocker or a calcium channel blocker. Surgery may be needed if the drug treatment fails. Alcohol ablation is a nonsurgical treatment being developed. It involves injecting alcohol down a small branch of one of the heart arteries to the extra heart muscle. It is destroyed without being surgically cut (NOVA, 1997).
In addition, valve disorders occur when the flaps are scarred or deformed. Stenosis, or heart valves that stick shut, reduces blood flow through the valve. It is characterized by the thickening of the walls that makes the diameter of the valve smaller. Blood is trapped keeping the circulatory system from working. The pressure in the small arteries of the lungs is elevated. The right side of the heart tries to pump against the resistance of the lungs. Pressure increases in the veins and fluid retention occurs in the liver, legs, ankles, and sometimes the abdomen (Heartpoint Congestive, 1998). Mitral valve disorder occurs when the flaps on the opening between the left atrium and the left ventricle are slightly larger than normal and fail to close properly. Regurgitation occurs permitting blood to leak back into the chamber from which it came. Doctors closely monitor patients with diseased valves for any changes in symptoms. Valve disorders may not appear until adulthood, after years of wear on the deformed valve begin to affect the function.
Next, ventricular failure can be caused by ventricular aneurysms or weak spots in the ventricular walls. When extensive tissue damage or destruction leaves the wall so damaged that it bulges out it is called an aneurysm. An aneurysm can absorb much of the force of the heart contraction. It can also collect some blood keeping it from being pumped into the lungs or out into the body. The ventricle will eventually work until exhaustion.
Equally important, if one side of the heart is in more severe failure than the other it may be referred to as right-sided or left-sided heart failure. Left-sided failure causes
blood to back up in the lungs so that shortness of breath and orthopnea are the most prominent symptoms. The lungs swell yielding moist, noisy sounds when a person breathes. Tapping the base of the lungs sounds similar to tapping a barrel full of water. Right-sided failure causes more swelling of the extremities. Serious cases show the liver and internal organs swelling causing bloating and abdominal discomfort (Why, 1981).
Finally, some other contributors to congestive heart failure that are due to evolution are hypertension, a prolonged alcohol or drug addiction, a previous heart attack, diabetes, chronic rapid heartbeats, and sometimes the chemotherapeutic agents used to kill cancer. Hypertension is high blood pressure. It forces the heart to pump against greater arterial resistance. The muscle weakens and eventually gives out. The stress of an average person’s everyday life can build up contributing to hypertension (Brams, 1973). Substance abuse can break down the heart muscle, which may lead to congestive heart failure. Alcohol and other substances were not around in Paleolithic times, so it is possible that the human body is not prepared for them. A heart attack may kill too much of the heart leaving it unable to pump blood. An error in evolution is that the heart cannot regenerate muscle tissue. It would be a great advantage if the heart could regenerate new muscle tissue. Diabetes, chronic rapid heartbeats, and chemotherapeutic agents wear on the heart to exhaustion. It is important to note that even if there are no complications with causes in a person’s lifetime, they can still have congestive heart failure because of aging. It is natural for the body to break down over a long period of time (Why, 1981).
Since congestive heart failure is a syndrome, or collection of things, there is no single test that will diagnose it. The clinical symptoms may be different in each patient.
The goal is to determine the underlying cause. An extensive history check and physical will be performed. If close relatives have died during middle age or younger from complications of heart disease, it could mean that a tendency to the disease runs in the family. Taking advantage of the family history by heeding the warning and taking steps to reduce the risks is the key. The complete physical examination may reveal many things. The heart rate may be rapid or irregular, respiratory rate may be increased, skin may be cold or sweaty. The physician will listen to the patient’s chest with a stethoscope and may hear crackling sounds indicating fluid around the lungs (Why, 1981). Abnormal heart sounds may be heard. There may be blood pressure changes. An electrocardiogram can diagnose which portion of the heart wall is being injured or destroyed as a result of lack of blood flow. It is the most reliable test and is conducted over several days. It can identify the exact nature of any irregularities in heart rhythm such as arrhythmias (Heart, 1996). Arrhythmias occur when the organ’s electrical impulses are disrupted. Electric current flows from one part of the heart to another making millions of heart cells contact in a specific sequence. Abnormal rhythms can lead to a disorganized twitching of the heart muscle or fibrillation. A person with fibrillation may feel drowsy or go unconscious with the possibility of dying within minutes.
Heart imaging techniques such as chest x-ray, and echocardiography are done. The chest x-ray checks for enlargement of the heart and for fluid in and around the lungs. Echocardiography, or ultrasound imaging, is the most widely used noninvasive test. High frequency waves bounce off the heart the same way that surface ships search for submarines. A picture of the hearts interior and its chambers in motion is observed. It may also show decreased heart function and abnormalities. This procedure is done in fifteen to sixty minutes. Blockage of coronary arteries is also examined. Injected into the blood are radioactive isotopes with affinities for certain tissues. A scintillation camera picks up gamma rays emitted by isotopes. The computer then translates the information into pictures. This test is done first when exercising and then when resting (Mason, 1980).
If tests indicate blockage of coronary arteries, then cardiac catheterization is done by feeding a narrow tube through an artery in the groin or elbow into the blocked coronary vessel. A drug called steptokinase is injected that can dissolve a clot within an hour. The problem with this is the clot may not be found until it is too late and the heart is damaged. Blood and urine tests may be done and in rare cases a biopsy, or the removal of a small sample of the heart tissue for analysis, is completed (Toufexis, 1981).
When a treatable underlying cause of congestive heart failure exists, correcting the cause may resolve, or at least greatly improve, the degree of heart failure. For example, if a defective heart valve is responsible for heart failure, it may be treated by heart valve surgery. Surgical implantation of an artificial heart valve or valve repair may alleviate the problem. Angioplasty, which is catheterization using a balloon to flatten fatty deposits can be used to treat atherosclerosis or other condition with blocked arteries. An artery of an arm or leg is used to guide the catheter through to the blocked artery. An uninflated balloon on the top of a smaller tube is threaded through the larger tube and centered in the plaque–narrowed area. The balloon inflates squashing the plaque against the walls and increasing the open area (Heartpoint Angioplasty, 1998). This has a ninety percent success rate. If the vessel becomes clogged again, the procedure is done again. This is quicker and cheaper substitute for bypass surgery. High blood pressure can be controlled by changing eating habits such as reducing salt intake, reducing if overweight, and changing a stressful life style (Brams, 1973). Some general suggestions are to refrain from smoking; reduce fluid intake, especially alcohol; and leave time in the day for rest. A daily weighing is a necessity. "A gain of three pounds in one day or five in one week is a sure sign to call the doctor"(Toufexis, 1981, p. 55).
Heart failure is most often treated with drugs. It is necessary to keep in mind that the body may eventually develop a resistance to these drugs. The drugs lose their effectiveness over time because of changes in the body over time. Digitalis drugs have been prescribed for heart conditions for over two hundred years. They strengthen the heart’s contractions increasing blood flow. It can be taken orally or intravenously. Digitalis is given for rapid heart rate. Diuretic drugs increase the output of salt and water in urine. The side effects are loss of too much salt and water, and the depletion of the body’s mineral like potassium. Potassium supplements or potassium rich foods can combat the loss. It may be possible that the body is getting rid of the potassium for a reason and that taking supplements may discourage the rehabilitation of the patient (American Congestive, 2001). Weakness and the chance of toxicity when taken in combination with digitalis are other complications. No laxatives, headache preparations, or cough medicine that contain sodium should be used. They decrease swelling and make the person feel better, thus allowing the causes to go untreated. Vasodilators relax blood vessels which lowers the resistance to blood flow. More blood reaches the tissues and the heart works no harder than before. Another name for this drug is angiotensin converting enzyme (ACE) inhibitors. This drug does not affect permanently damaged coronary arteries, but other damaged vessels will dilate. The volume of the heart decreases because it does not have to expand as much. This also means that it does not use as much oxygen because it is not working as hard. The heart muscle is supplied with oxygen and does not cause the pain that is felt when being deprived of oxygen. The body may try to compensate when the blood pressure is lowered by accelerating the heart rate and the speed of contraction (Silver, 1994).
The body tries to overcome heart failure automatically but usually only worsens the condition. If the blood neglects less essential parts of the body and instead flows to the brain and other vital organs, the heart only has to work harder. Muscle tissues of the heart are not under voluntary control. When the activity of the heart is increased, a more forceful contraction causes an increased heart rate (Heart The, 1996). Ventricular hypertrophy occurs when the heart adapts by increasing its muscle mass to add a number of heart muscle units. The contraction force is strengthened allowing blood flow. However, the muscle can develop to the point where coronary circulation is no longer adequate and angina pectoris is sure to come. Through dilation the ventricle holds a greater volume of blood stretching the heart muscle. Therefore more force is necessary to pump the blood. The heart sends out a larger volume of blood with out a stronger contraction, only to have it accumulate and cause congestion.
Researchers today consider that a number of synthetic materials suitable for use on the heart have been developed. Silastic, for example, is a synthetic that will not trigger the body’s rejection response to a foreign substance. It is also smooth enough for the blood to flow over without damage and without stimulating clotting or friction. The material also appears strong enough to endure hydraulic pressure necessary for the heart pumping action and to last for years in spite of wear and tear and constant expansion and contraction. Prototypes of artificial hearts made of Silastic have already been transplanted in animals. A successful artificial heart must have the capacity to pump at varying rates according to the body’s needs. Since human responses to emotional stimuli vary from individual to individual, no artificial heart yet contemplated is capable of adjusting to emotional stress. Miniature timing devices and computers are necessary to meet these demands (American Circulation, 2001).
More information on congestive heart failure can be obtained by writing or calling the contacts located in Appendix B. These organizations have the answers to most questions concerning this topic.
In conclusion, congestive heart failure is often assumed
to be a disease when in fact it is a syndrome caused by multiple disorders.
Whether it is an uncontrollable cause or one that develops over time the
outcome is constant. People need to be aware of the many ways that congestive
heart failure occurs. Since congestive heart failure is a disease of civilization,
steps can be followed to improve one’s health. Only when the problem is
taken care of will the chance of heart failure decrease.
American Heart Association. Circulation. http://circ.ahajournals.org/, 2001.
American Heart Association. Congestive Heart Failure. http://www.americanheart.org/presenter.jhtml?identifier=1486, 2001.
Brams, William. (1973). How to Live with Your High Blood Pressure. New York: Arco Publishing Company.
Cannobbio, Mary. (1990). Cardiovascular Disorders. Missouri: C.V. Mosby Company.
Coronary Heart Disease. (1969). Illinois: National Dairy Council.
Eaton, S. & Eaton S. III. (1999). The Evolutionary Context of Chronic Degenerative Diseases. In S. Stearns (Ed.), Evolution in Health and Disease. (p. 251-259). Oxford, NY: Oxford University Press.
"Heart." (1989). Home Medical Encyclopedia.
"Heart." (1996 ed.) The World Book Encyclopedia.
Heartpoint. Angioplasty. http:/heartpoint.com/angioplasty.html, June 1998.
Heartpoint. Congestive Heart Failure. http://heartpoint.com/congheartfailuretellme.html, June 1998.
Fisher, Arthur. (1981). The Healthy Heart. Virginia: Time-Life Books Inc.
Mason, Dean. (1980). The American Heart Association Heartbook-Congestive Heart Failure. New York: E.P. Dutton.
NOVA Online. Cut to the Heart. http://www.pbs.org/wgbh/nova/heart/treating .html, 1997.
Silver, Marc A. (1994). Success with Heart Failure-Help and Hope for Those with Congestive Heart Failure. New York: Plenum Publishing Corporation.
Toufexis, Anastasia. (1981, June). Taming the No. 1 Killer. Times. pp. 50-60.
Why Risk Heart Attack. (1981). Texas: American
"Doctor, please come at once–my husband–he is very sick." The agitated voice over the phone belonged to Mrs. Steele, who was unusually calm. She was the wife of a friend of many years. I left for their home immediately. Mr. Steele was propped up on three pillows in a sitting position. His breathing was labored and rapid. I could hear a distinct wheeze each time he exhaled. He tried to speak but was too out of breath. Mrs. Steele laid a gentle hand on his shoulder, "Relax, John, let me tell the doctor what happened." It was a familiar story to doctors.
Mr. Steele had been working too hard for several months. He had remained at his office for long hours after others had left. Tax time was approaching, a strike was threatening, and needed merchandise had not arrived.
On examination, I heard rattling noises in the patient’s
chest, indicating severe congestion of the lungs. The heart action was
irregular and rapid. The blood pressure was far too high. I gave Mr. Steele
an injection to quiet his breathing and to allay his anxiety. I gave him
a diuretic pill to increase the output of unwanted body fluid by way of
urine, which as it did so, would drain the congestion from his lungs while
lowering his blood pressure. I then suggested that he be taken to a hospital
by ambulance. The patient received medicine to strengthen his heart and
slow its beat; oxygen and other measures brought improvement within several
hours. The immediate danger had been overcome. Now my efforts were directed
to the basic, the underlying condition: the high blood pressure, also called
hypertension (Brams, 1973, p. 8).
The American Heart Association
Toll free # 1-800-AHA-USA1
American Heart Association
7272 Greenville Avenue
Dallas, TX 75231
American Heart Association
Northwestern PA Chapter
3025 French St
Erie, PA 16504
American Geriatrics Society
770 Lexington Avenue
New Your, NY 10021
Council of Geriatric Cardiology
4101 Lake Boone Trail
Raleigh, NC 27607
American Association of Retired Persons
601 E Street NW
Washington, DC 20049