be informed about... Heart Failure Information for patients Heart failure is a condition in which the heart has become weak or stiff and is having trouble pumping enough blood to meet the body s needs. This pamphlet answers some questions you may have about heart failure.
What is heart failure? Although the term sounds frightening, heart failure is a condition that is usually treatable. It does not mean that your heart has stopped working. It means that the heart has become weakened or too stiff to pump enough blood to meet the body s needs. When the heart does not pump blood as well as it should, fluid tends to build up in the lungs and other parts of the body. The most common symptoms of heart failure are shortness of breath, swelling of the feet and legs, and fatigue. (See box for more signs and symptoms.) 2 Heart failure is common Heart failure is one of the most common reasons that people over age 65 go to the hospital. It affects an estimated 5 million Americans. Sometimes doctors classify heart failure as either systolic or diastolic. Systolic heart failure occurs when the heart enlarges, loses the ability to contract properly, and is unable to pump enough blood to the body. This is the more common type of heart failure. Diastolic heart failure occurs when the heart muscle is thick and stiff. As a result, the heart cannot relax and fill properly with blood. In either type, the heart s ability to pump blood is affected, leading to the signs and symptoms of heart failure. In most cases, heart failure can be effectively managed and treated. Although it can sometimes be cured, it is more common for heart failure to be a chronic condition one that you and your doctor can watch and manage so that you can live as full and active a life as possible. As you ll learn, you will play an important part in managing your heart failure by taking medications as prescribed, cutting down on salt, leading a healthy lifestyle, getting enough rest, and keeping regular appointments with your doctor. What causes heart failure? Heart failure often develops as a result of another condition that damages or strains the heart. The damage may cause the heart muscle to weaken or cause the pumping chambers (ventricles) to stretch (dilate or enlarge). Or the ventricles stiffen, preventing them from filling effectively with blood between heartbeats. Whatever the underlying cause, heart failure occurs when the heart just can t keep up with the body s demand for blood. What are the signs and symptoms of heart failure? Heart failure usually develops slowly over time, though in some cases it can come on more suddenly. Symptoms may include: shortness of breath at rest or with exertion, or shortness of breath when lying down a tired, run-down feeling swelling in the feet, ankles, or legs unexplained weight gain swollen abdomen, nausea, and loss of appetite confusion or inability to think clearly cough (usually dry or wheezing) inability to sleep unless propped up frequent urination, especially at night being unable to exercise as much as usual Conditions that may cause or contribute to heart failure include: coronary artery disease plaque in the arteries that feed the heart muscle heart attack damage to the heart muscle from lack of blood flow high blood pressure, which can lead to an enlarged heart or a thickening of the heart muscle damaged heart valves leaking or stiffening of the valves that separate the heart s four pumping chambers (two ventricles and two atria) cardiomyopathy damaged or weakened heart muscle from infection or other causes myocarditis inflammation of the heart muscle birth defects involving the heart arrhythmias abnormal heart rhythms certain medications diabetes, which can be associated with high blood pressure or coronary artery disease certain lung diseases thyroid disease viral infections, which can sometimes damage the heart muscle excessive alcohol use or illicit drug use certain sleep disorders obesity advancing age
How is heart failure diagnosed? To diagnose heart failure, the doctor asks about symptoms and medical history, and performs a physical exam checking the heart, lungs, abdomen, and legs. Some of the following tests may be done to help confirm the diagnosis. Chest x-ray This can help assess the size and shape of the heart. It can detect fluid in the lungs. Electrocardiogram (ECG, or EKG) This is a painless, simple test in which patches with electrodes are attached to your skin to measure electrical impulses produced by the heart. These impulses are recorded as waves displayed on a monitor or printed out on graph paper. It shows how fast the heart is beating and its rhythm. It also records the timing of the electrical signals as they pass through each part of the heart. Echocardioagram This test uses ultrasound waves to create an image of the heart and the pattern of blood flow through it. An echocardiogram provides information about the size and shape of the heart and how well the heart chambers and valves are functioning. The test also can identify areas of poor blood flow through the heart, areas of the heart muscle that aren t contracting normally, and previous injury to the heart muscle caused by poor blood flow. The test is completely painless, and is done by placing a wand-like instrument on the outside of the chest. (It is the same technique used to perform sonograms in pregnant women.) Coronary catheterization This is a procedure in which a small plastic tube (catheter) is threaded into the heart from a blood vessel in the leg or arm. X-ray pictures help the doctor guide the catheter. The catheter is threaded into the chambers and the arteries of the heart. Coronary angiography can be done as part of the catheterization. This involves injecting dye through the catheter to make the arteries show up clearly on x-ray. If blockages are found in the arteries, they can sometimes be treated during the procedure using a balloon; a small stent (a tiny metal tube) can sometimes be inserted to keep the artery open. During the catheterization, the doctor can take measurements of the pressures inside the heart, which gives an indication of how well the heart is functioning. Stress test During a stress test, the patient exercises on a treadmill or stationary bicycle to make the heart work hard and beat fast. The heart rate, blood pressure, oxygen level, and ECG are measured during exercise. By watching these measurements, in combination with any symptoms, the doctor can get an idea of how the heart responds to the stress of exercise. Sometimes, pictures of the heart are taken as part of the stress test, using sound waves (stress echocardiogram) or a small amount of radioactive dye (cardiac perfusion scan). Ejection fraction The ejection fraction is not really a test, but a measurement. It indicates the amount (fraction) of blood pumped (ejected) from the heart with each beat. The measurement can be taken as part of an echocardiogram, stress test, or catheterization. A normal, healthy heart has an ejection fraction of around 60%. Patients with heart failure may have an ejection fraction that is lower than normal. (In some cases, patients with heart failure have an abnormally high ejection fraction, which can place more strain on the heart.) Not every patient needs every test to diagnose heart failure. Sometimes, additional tests are needed. Your doctor will explain what tests are best for you. Please be sure to ask any questions you may have. How is heart failure treated? In most cases, heart failure is a chronic condition that will require life-long management. Sometimes, this includes treating an underlying condition that is causing heart failure, such as abnormal heart rhythms, blocked arteries, or valve problems. The goals of treatment are centered around improving your symptoms so that you can lead a more active and comfortable life. Treatment options that may be prescribed include medications, implantable devices, or surgery. But the patient plays a particularly important role in the successful management of heart failure. Lifestyle changes, such as following a low-sodium diet, getting enough exercise, and quitting smoking will be critical to treatment success. Equally important are the self-management activities you ll be asked to carry out, such as weighing yourself each day, observing for fluid retention, and alerting your doctor at the earliest sign of a problem. (For more on when to call your doctor, please see list on page 7.) 3
Medications Most people who have been diagnosed with heart failure require multiple medications to improve their symptoms and their quality of life. It is important that you take all medications as prescribed. (But if you miss a medication, do not take extra later in the day or the next day.) If you think your medicines are not working as they should, or if you think they are causing a problem, please check with your doctor or nurse before stopping the medicine on your own. Here are some of the common types of medicines prescribed for heart failure. Some of the common side effects that you should report are included here. For a complete list of possible side effects, please refer to the information sheet you will be given with each prescription medication. In any emergency (chest pain, fainting, severe shortness of breath, allergic reaction), always call 911. ACE inhibitors This type of medicine has been shown to decrease hospitalizations for patients with heart failure and help them live longer. ACE inhibitors block hormones that can make your heart failure worse. It is usually started at a low dose and then increased as needed according to the patient s symptoms or signs of heart failure. If you experience dizziness or cough while taking an ACE inhibitor, please let your doctor or nurse know. If you experience swelling of your lips or throat, please get medical help right away. ACE inhibitors can lower your blood pressure so you will need to have your blood pressure checked frequently at the start of this drug therapy. Beta blockers This medication helps to improve the heart s function and has been shown to make heart failure patients feel better and live longer. Beta blockers block hormones that can make your heart failure worse. If you feel dizzy, short of breath, or notice fluid build up (weight gain, cough at night, swelling of your feet and ankles), please let your doctor or nurse know. Beta bockers can lower both your heart rate and blood pressure. You will have to have your heart rate and blood pressure checked frequently when this medicine is started or when the dose is increased. Digoxin This medication is to help the heart beat stronger and may help some patients breathe easier. This medication is not appropriate for all heart failure patients; however, studies have shown that, when used properly, it can help reduce hospitalizations. Digoxin levels are monitored by a blood test and the dose is adjusted as needed. Diuretics This type of medicine sometimes called water pills helps the body to get rid of extra fluid. Diuretics can lower your potassium levels; you may be asked to take a potassium replacement if you are on a diuretic. You should take this medication early in the day so that you are not urinating late at night. Aldosterone antagonists This type of medication blocks the hormone aldosterone that can make heart failure worse. Side effects may include breast enlargement or pain (primarily in men) and increased potassium blood levels. You will need to have your blood checked periodically. About medications Make sure your doctor knows about everything you are taking. This includes prescription medicines, non-prescription medicines, vitamins, herbs, and supplements. It is best to carry a list with you that includes the name, dose, and frequency of everything you take. As a general rule, patients with heart failure should NOT take: non-steroidal antiinflammatory pain relievers (NSAIDs), such as Motrin, Aleve, Naprosyn, ibuprofen, etc. ACE inhibitors Tell your doctor if you have... cough dizziness swelling of the lips or throat (get help right away if this occurs) Beta blockers Tell your doctor if you have... dizziness shortness of breath weight gain coughing at night swelling in the feet or ankles Diuretics Can lower your potassium levels. You may be asked to take a supplement. 4
Angiotensin receptor blocker (ARB s) This type of medication works in a similar way to ACE inhibitors and blocks harmful hormones that can make your heart failure worse. It is used less often than ACE inhibitors, and is usually used as a replacement in those patient who have had serious side effects on ACE inhibitors. Isosorbide and hydralazine These medications are usually used together to treat heart failure. They are vasodilators, meaning they relax the blood vessels to help ease the workload of the heart. This combination of medication works particularly well in African Americans and/or in patients in whom ACE Inhbitors/ARB s cannot be used. Anticoagulants These medications sometimes called blood thinners help to prevent the formation of blood clots. They are not used in all heart failure patients. They are used only when there is a risk of blood clot formation. Patients who may need anticoagulation include those with atrial fibrillation, patients with mechanical heart valves, or patients who have a known blood clot or have had one in the past. Patients on anticoagulants need frequent blood tests and dose adjustments. Implantable devices Implantable electronic devices are available that help some patients with heart failure. Some of these help treat an underlying problem; others help the heart pump more effectively. Implantable cardioverter-defibrillator (ICD). The device is programmed to detect life-threatening abnormal heart rhythms and to correct them by delivering a jolt of electricity. It is implanted under the skin in the upper chest near the shoulder, and wires run from the device to the heart. Cardiac resynchronization therapy (CRT). This involves implantation of a special kind of pacemaker that sends timed electrical impulses to the heart s lower chambers to help them pump in a synchronized manner. It can improve heart failure symptoms. It is implanted under the skin in the upper chest near the shoulder, and wires run from the device to the heart. This type of pacemaker may also include an implantable cardioverter-defibrillator (ICD), described above. Left ventricular assist device This is a mechanical pump that can be implanted in the chest or abdomen. It temporarily assists the heart s pumping action, making it stronger. The pump may take over the function of either or both ventricles (lower chambers) of the heart. In the past, these devices were used only for patients waiting for a heart transplant. More recently, they have emerged as long-term treatment options. Surgery Surgical treatments are appropriate for certain patients with heart failure. Some patients will benefit from surgery to treat an underlying condition that is causing or contributing to the heart failure. Other patients who have severe heart failure that is not responding to treatment may be offered a heart transplant. Coronary artery bypass graft (CABG). When heart failure is a result of blocked coronary arteries, correcting the blockages often makes the heart pump better, which helps improve symptoms of heart failure. In some patients, this is done through an operation called a coronary artery bypass graft (CABG) that creates a detour, or graft, around the blocked artery. Heart valve surgery When heart failure is caused by a defective or diseased heart valve, correcting the valve problem by repairing or replacing the valve often helps the heart pump better and improves symptoms. Heart transplant Heart transplant is sometimes an option for the most serious cases of heart failure in which other treatments have not been effective. The operation involves removing a diseased heart and replacing it with a healthy heart from a donor who has died. More than 2,000 heart transplants are performed each year in the U.S. Lifestyle changes You can make important changes in your life that will help make sure you stay as active and as healthy as you can. Lifestyle changes can also help prevent your heart failure from getting worse. Lifestyle changes that can help control heart failure are listed in the box, "You can make 5
a difference!" Some of the most important are managing your diet, not smoking, and getting the right exercise. Diet We know that excess salt (sodium) puts a strain on the heart in patients with heart failure. Even in people without heart failure, too much sodium can lead to or worsen health problems. The average American consumes 6,000 8,000 milligrams (mgs.) of sodium each day more than 4 times the recommended amount. Most patients with heart failure should have no more than 1,500 2,000 mgs. of sodium per day. Ask your doctor what a good target range is for you. Although cutting out table salt is one important step you must take, you will also need to cut back or eliminate many foods that are high in sodium, and to follow a diet that is heart-healthy. Be sure to read the information on heart-healthy food choices you were given with this brochure, which includes additional, detailed information on sodium in the diet. You will also be given a sheet where you can track your daily sodium intake to make sure you are not taking in too much. Ask your nurse or doctor for these materials if you don't have them. Please speak to your nurse for additional information. You can make a difference! Follow these guidelines to make sure you stay as healthy and active as you can. Don t smoke! Exercise regularly (with guidance from your doctor) Eat a low-salt, heart-healthy diet Do not drink more than 48-64 ounces of fluid a day. (Jell-O, ice cream, and soups count as fluids.) Limit or avoid alcohol Lose weight if needed Reduce stress and get enough rest Get a flu shot each year! Take all of your medicines as prescribed Weigh yourself daily; let your doctor know if you gain 3 or more pounds in 2 days, or 5 or more pounds in 5 days Report shortness of breath, swelling, or other symptoms to your doctor right away As you learn to enjoy food without salt, please note that many salt substitutes are high in potassium or other substances your doctor may not want you to have. Please check with your doctor before using a salt substitute. Smoking It is extremely important that patients with heart failure do not smoke. We encourage you to talk with your care team about ways to manage the challenge of not smoking so that they may provide further guidance and resources for you. Additionally, the National Cancer Institute s Smoking Quit Line provides live telephone support Monday-Friday 9:00 AM 4:30 PM in both English and Spanish. To reach the National Cancer Institute s Smoking Quit Line, call 1-877-448-7848 or find them on the web at www.smokefree.gov. Exercise and activity It is important that patients with heart failure keep active. Remaining active can help decrease your symptoms and may improve your heart s function. Before beginning an exercise program, it is important that you talk with your medical provider about the type and amount of exercise that is right for you. In most cases, patients may choose from any number of activities, such as walking, swimming, biking, bowling, or gardening (to name a few). Remember to keep the activity at a pace that is comfortable for you. If you are not accustomed to exercise, or if you have been sick, be sure to check with your doctor about the best way to start a safe exercise program. There are many benefits of exercise for patients with heart failure, including: increased blood circulation improvements in your heart rate and blood pressure at exercise and at rest improved weight management decreased blood cholesterol levels decreased blood sugar levels improved stress management improved overall fitness a decrease in lightheadedness with position changes 6
Self-management In most cases, heart failure is a condition that can be successfully managed using the tools above. But sometimes, your heart failure symptoms may return or worsen. It is very important that you learn to recognize the signs of worsening heart failure. Early treatment can help you avoid a more serious setback that could require another admission to the hospital. One of the most important signs of worsening heart failure is extra fluid in the body. When there is extra fluid, you may start to notice that your rings feel tight, you have more swelling in your feet or ankles, your abdomen feels bloated, or your appetite is decreased. But one of the best ways to watch your body s fluid balance is to weigh yourself every day. By watching for the weight gain that comes with extra fluid, you can alert your doctor at the earliest sign of a problem often before symptoms such as swelling are even noticed. Tips for exercise success! Pick an activity that you enjoy. Exercise one hour after eating a light meal do not exercise right after a heavy meal or on an empty stomach. Start slowly and exercise at a comfortable, steady pace. Make sure you can carry on a conversation while doing the activity. You may experience an increase in fatigue the day after you exercise. This is common and will get better over time. If you experience excessive, prolonged fatigue after exercising speak to your doctor. Pick a time of day that is convenient and when you feel most energetic. (Most patients with heart failure feel best in the morning.) You should not exercise if: You have more shortness of breath at rest then usual (get help if you are in distress) You have chest pain (get help right away) You have a fever or infection You feel exhausted Daily weights It is important that you weigh yourself every day at about the same time. It s best to weigh yourself first thing in the morning, after you urinate and before breakfast. If you gain 3 or more pounds in 2 days or 5 or more pounds in 5 days call your heart failure doctor. You may hear your doctor or nurse talk about your dry weight. This is the weight that you should be when you don t have any extra fluid in your body. If you were recently hospitalized for heart failure, your dry weight is probably the weight you were when you were sent home (or your weight the following morning). Please ask your doctor or nurse to tell you what your dry weight is. Use the chart provided (on pg. 8) to track your weight. When to call your doctor Knowing when to call for help is a very important part of your heart failure self-management. Please call your doctor if you notice any of these warning signs. For severe shortness of breath, new or worsening chest pain, passing out, or any other emergency, always call 911. weight gain of 3 or more pounds in 2 days, or 5 or more pounds in 5 days worsening shortness of breath that occurs while resting or with minimal activity waking up because of shortness of breath, dry cough, or wheezing increased swelling in your ankles, legs, abdomen, hands, or elsewhere pain or discomfort in your chest, arm, or jaw that becomes more frequent, more severe, or that occurs with minimal activity chest pain that is worse with coughing or deep breathing a persistent dry, hacking cough palpitations (pounding in chest) dizziness or fainting spells you feel extremely tired you get tired or winded more easily during exercise nausea, vomiting, or inability to eat any other symptom that concerns you 7
Daily weights My dry weight is:. Date Weight Date Weight Date Weight Date Weight 8 330 Brookline Avenue Boston, MA 02215 (617) 667-7000 Phone www.bidmc.org/cvi Revised 01/12 MC0900