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Congestive Heart Failure (CHF)

Introduction

What should I know about Congestive Heart Failure?

The heart, our hardest working organ, is a pump made of muscle. It is the most efficient muscle in the body. Generating its own electrical impulses, the heart beats continuously without rest for as long as we live. Congestive heart failure is a health condition in which the pumping ability of the heart becomes weak. (1) The heart just doesn’t have the oomph it used to. It no longer beats with enough force to properly circulate blood throughout the body. When the heart loses pumping strength, excess sodium and water may accumulate in the tissues, causing "congestion" of fluid that puts an even greater burden on the circulatory system. People sometimes have signs of congestive heart failure without any symptoms of congestion, however, so doctors now prefer the term "heart failure." Heart failure can be caused by a variety of cardiac disorders, so it is actually a clinical syndrome rather than a specific disease. (2)

Doctors use the term "ejection fraction" to describe the amount of blood propelled out from the heart to the body. The heart normally ejects about 60% of its blood volume in one beat. With heart failure it may pump as little as 20 to 30 percent. The entire circulatory system becomes sluggish, putting more strain on the weak heart. With the circulatory system overloaded like this, the volume of blood returning to the heart through the veins increases. A normal heart responds by increasing the force of its contractions. In heart failure, the heart is simply not up to the task.

Doctors speak about the "contractility" of the heart when describing the shortening and lengthening of it’s muscle fibers as it beats. When the heart muscle fails to function properly, contractility drops off. A number of heart-related problems can cause a loss of contractility, including heart attacks, coronary artery disease, rheumatic heart disease, and persistent irregular heartbeat. Certain medications, beta-blockers and duanorubicin, for example, can impact contractility too.

As the heart muscle loses strength, it tries to compensate in an effort to keep moving blood through its chambers and out to the body. One of the ways it does this is to beat faster, in response to prodding from the body. Here is how this works. Low blood output from the heart results in reduced blood circulation to the tissues. Tissues and cells are deprived of the oxygen they need. The body then sends an alarm signal to the heart in an attempt to give it a kick. This signal is delivered by the hormone norepinephrine, which speeds up the heartbeat. (Norepinephrine works with the sympathetic nervous system, the body’s "fight or flight mechanism that is designed to gear us up in the face of stress.) When the sympathetic nervous system activates, the heart pumps more blood so the body has the oxygen it needs to jump into action. Unfortunately, noepinephrine constricts blood vessels in the skin, the digestive system, and kidneys, choking off their blood supply.

This extra demand on the heart to beat faster has additional consequences that compound the heart’s predicament. Timing between the heart’s contractions and relaxations--called "systole and diastole"--is thrown off. (When you have your blood pressure taken, the "systolic" pressure is the contraction and the "diastolic" pressure is the relaxation.) In heart failure, the muscle has less time to relax between beats. Diastole is shorter, and the heart cannot fill up with returning venous blood as it should. This ultimately makes it harder for the heart muscle fibers to relax. In order for a muscle cell to relax it has to move calcium inside the cell to the outside. Heart cells have a more difficult time doing this when diastole shortens. The muscle fibers cells also need more oxygen when all this is happening. Not a very pretty picture for a worn out heart.

And there is more. In heart failure, less blood circulates through the kidneys. They react by releasing a protein called "rennin" that causes retention of sodium and water. Excess fluid accumulates in the tissues surrounding blood vessels, increasing blood pressure and the heart’s workload. A normal heart has an extra capacity for harder work in response to increased blood volumes returning by way of the veins. In heart failure, this reserve is exhausted.

The body responds to any loss of blood output from the heart by constricting the blood vessels. In addition to norepinephrine, a number of other hormones participate in this process. The body redistributes blood to make sure the brain and heart have enough to keep us alive. This is a normal body function, but in heart failure it only compounds the problem by making the heart fight harder to keep up. It is easy to see that heart failure is a vicious circle for the weary heart.

In chronic (long-term) heart failure, the heart muscle adapts by becoming thicker. Doctors call this "ventricular hypertrophy." But thicker does not mean stronger. Just the opposite, the abnormally thick heart wall is stiff and dysfunctional.

Statistic

World Health Organization, 1995.

  • More than 22 million people worldwide suffer from congestive heart failure (CHF).

National Heart Association of Malaysia, 2007.

  • Heart failure accounts for 10% of medical admissions in Malaysia.

National Heart, Lung & Blood Institute, National Institute of Health Data Fact Sheet, 1996.

    It is estimated that 4.8 million Americans have CHF. 1/2 the patients diagnosed with CHF will die within 5 yrs. The annual number of deaths from CHF increased from 10,000 in 1968 to 42,000 in 1993,with another 219,000 deaths related to CHF. CHF is the first-listed diagnosis in 875,000 hospitalizations and the most common diagnosis in hospital patients age 65 yrs. and older.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

People with heart failure commonly have symptoms resulting from fluid build-up in the tissue and the lungs. Breathing may be difficult and painful. They become short of breath with even normal exertion like walking, climbing stairs, and ordinary daily activities like running the sweeper. It is even harder to breath lying down, making sleep difficult. The sufferer may need to use more pillows when sleeping and often wakes up after two to four hours with a feeling of suffocation. Sitting up for twenty to thirty minutes brings relief. It can feel like he/she is suffocating or drowning, terrifying, to say the least. Fluid congestion in the lungs can cause coughing and blood may be present in the sputum.

Water retention in the lower legs and around the ankles, known as "edema," is a common result of heart failure. (Some people may gain 10 pounds before this is noticeable). Other symptoms include abdominal pain, bloating, nausea, and constipation. This person with heart failure may lose interest in eating, even to the point of becoming anorexic. The jugular vein may be distended and the liver can even become enlarged.

Most people with heart failure complain of feeling weak and fatigued all the time.

General

  • Weakness
  • Fatigue
  • Exercise intolerance
  • Increased urination at night
  • Increased heart rate
  • Pale appearance
  • Cold, blue fingers and toes

Left Ventricular Failure

  • Shortness of breath with daily activity
  • Shortness of breath upon lying down
  • Awakening form sleep short of breath
  • Rapid breathing
  • Cough, may contain streaks of blood
  • Fluid in the lungs

Right Ventricular Failure

  • Abdominal pain
  • Loss of appetite
  • Nausea
  • Bloating
  • Constipation
  • Fluid build-up in the abdominal area
  • Fluid build-up in the ankles and feet

Treatment Options

Conventional

If your doctor suspects you have heart failure, determining the cause is the first step. He probably will advise you to restrict your salt (sodium) consumption. Americans typically consume 3 to 6 grams of sodium a day, so your doctor will likely recommend cutting your salt intake in half. The goal is to reduce your symptoms as much as possible, improve your quality of life, slow the disease process, and prolong survival.

Based on the specific diagnosis as to the cause of the condition and the surrounding complications, a number of different medications may be prescribed for heart failure. These most common drugs used are vasodilators, nitrates, diuretics, digitalis, and beta blockers. Others may also be tried, such as angiotensin II antagonsists, calcium channel blockers, and drugs to regulate heart rhythm.

Nutritional Suplementation


Coenzyme Q10 (CO-Q10)

Coenzyme Q10 (CoQ10) is a naturally occurring vitamin-like nutrient that helps improve function of the heart muscle. Available over-the-counter as a dietary supplement, CoQ10 has been shown in numerous research studies to have benefits in the treatment of heart failure. Clinical trials indicate that CoQ10 can improve quality of life and reduce the need for drugs. CoQ10 also decreases hospitalizations and the frequency of life-threatening complications in heart patients. (3)

CoQ10 is a co-enzyme (its full name is "coenzyme Q10") found in virtually all our cells. Every cell contains its own internal power generator, a microscopic structure called the "mitochondrion" (plural mitochondria). The energy that powers cell functions, and thus keeps us alive, is produced inside the mitochondrion. CoQ10 plays an essential role in this process. Cells that have high energy requirements contain lots of mitochondria, and they need lots of CoQ10. The heart, as the body’s hardest working muscle, is especially dependent on CoQ10, and the most vulnerable to CoQ10 deficiency. A lack of CoQ10 can impair the heart’s pumping ability.

In one study, patients with CHF were given 100 mg of CoQ10 daily. Along with congestive heart failure patients, people with "ischemic heart disease," where the heart muscle is starved for oxygen because of a blockage in one or more coronary arteries, also took part in this study. CoQ10 produced a good response in 69 percent of the people with heart failure, and 43 percent of those with ischemic heart disease. These results were so impressive that the authors of the study called coenzyme Q10, "A scientific breakthrough in the management of chronic heart failure." (4)

Some prescription drugs may impair the body’s ability to produce CoQ10. Drugs that can reportedly deplete the body’s CoQ10 supply include sulfonylureas, biguanides, beta-blockers, hydralazine-containing vasodilators, thiazide diuretics, centrally acting antihypertensives (blood pressure medications) (clonidine and methyldopa), the "statin" cholesterol lowering drugs, tricyclic antidepressants, and phenothiazines. (5) CoQ10 may interact with warfarin causing an alteration in blood clotting times.


Magnesium

In general, magnesium plays a critical role in regulating the heart muscle. Magnesium deficiency frequently occurs in patients with congestive heart failure, which can result in irregular heartbeat. It has also been determined that a magnesium deficiency can lead to a coronary artery spasm, which is a common cause of fatal heart attack. (6) Magnesium influences many aspects of heart function and works a lot like many of the most frequently used cardiovascular drugs.


L-Carnitine

L-Carnitine, often referred to as an amino acid, plays a key role in the metabolic functions of heart muscle cells. Heart cells use carnitine to produce energy, and carnitine deficiency may be linked to congestive heart failure. Carnitine helps the cell metabolize fat as an energy source, which may help make up for the low oxygen supply in heart cells that occurs in congestive heart failure. Carnitine appears to help the heart use oxygen more effectively. In one study, treatment with carnitine resulted in increased peak oxygen consumption by 45 percent, exercise time by 21 percent, and peak exercise heart rate by 12 percent. These results indicate that L-carnitine is valuable in the treatment of congestive heart failure and that it can be used in combination with traditional cardiovascular drugs. (7)


Taurine

Taurine is an amino acid that helps to protect heart muscle cells from a variety of damaging conditions. Studies have reported some success in treating congestive heart failure with oral taurine. Studies have shown that when the heart cell contains more taurine, the mechanisms that keep mineral such as sodium and calcium moving in and out of the cell work better. This flow of minerals from the inside of a cell to the outside is a key to health and function of the heart muscle. Increasing the amount of taurine in the heart cells may help reduce damage to the heart muscle during heart surgery. (8)


Potassium

Potassium is another important nutritional mineral in congestive heart failure. People with heart failure frequently lose potassium more easily than normal people. Potassium helps regulate the electrical activity that keeps the heart beating normally and it reduces the danger of severe disturbances in heart rhythm. Potassium also acts as a natural diuretic. (9) Commonly prescribed cardiovascular drugs, such as the loop diuretics, thiazide diuretics, and some of the calcium channel blocking drugs, are known to cause potassium depletion. (10) , (11) , (12) Because low blood potassium levels make people more susceptible to irregular heart rhythms, doctors usually monitor patients closely in an effort to maintain blood potassium at the right level. (13)


Arginine

Arginine is another amino acid that helps to regulate some aspects of cardiovascular function. Arginine is required for the production of nitric oxide, which helps increase circulation by dilating blood vessels. Research has shown that blood vessels of congestive heart failure patients have a harder time dilating normally when the metabolic process that utilizes arginine to make nitric oxide begin to shut down. (14) , (15) Giving L-arginine to patients with congestive heart failure results in increased production of nitric oxide, relaxation of blood vessels in the periphery of the body, and increased output of blood from the heart. (16)

Herbal Suplementation


Hawthorn

Hawthorn has a long history as a herbal tonic for the heart. Modern research has shown that hawthorn stimulates circulation and promotes blood vessel relaxation. Hawthorn, in the form of a standardized extract, has widely been used by doctors in Europe for a variety of heart-related health and circulatory conditions. Its combination of effects on the heart leads to its use as a tonic, especially for the elderly, who may have minor heart failure or stiffening of the heart valves. Studies have reported a reduction in blood pressure due to hardening of the arteries and also kidney disease with the use of hawthorn. (17) It is also used for circulatory disorders such as Raynaud’s disease. Hawthorn is reported to have the ability to regulate both low and high blood pressure. The bioflavanoid components in hawthorn reportedly have a relaxing effect on blood vessels, both in the heart and extremities. (18) For this reason, hawthorn is considered useful for decreasing angina attacks. Angina is a heart condition that causes severe, strangling pain in the chest due to reduced oxygen in the heart muscle. Hawthorn also has a slight diuretic effect, which may help lower high blood pressure. Hawthorn contains substances called proanthocyanidins, commonly known as "PCOs or "OPC." These substances, it is believed, may help counteract coronary artery spasm. (19) PCOs also seem to improve circulation and increase force of the heartbeat. Laboratory studies have reported that proanthocyanidins may actually aid in reversing plaque build-up in the arteries. (20)


Cordyceps

Cordyceps is a unique black mushroom that extracts nutrients from and grows only on a caterpillar found in the high altitudes of Tibet and China. Cordyceps is one of the most valued medicinal agents in Chinese medicine. Cordyceps has been used in traditional Chinese medicine as the herb of choice in lung and kidney problems, and as a general tonic for promoting longevity, vitality, and endurance. (21) Cordyceps is beneficial in helping individuals with decreased energy restore their capacity to function at a greater level of activity.

Cordyceps has been used in humans for centuries as a tonic for improving performance and vitality. Cordyceps is believed to work by helping the heart use oxygen more effectively when it is under stress. It also seems to help maintain a constant energy supply. Cordyceps also appears to support immune and glandular function, increasing physical strength and endurance. (22) , (23)


Dandelion Leaf

Dandelion has historically been used as a food and medicinal agent. The leaf contains a high content of vitamins and minerals, including: vitamin A (14,000 IU/100gm fresh leaf) and potassium (297mg/100gm dried leaf). (24) , (25) Dandelion leaf is reported to posses diuretic properties, and the herb helps the body retain potassium. (26) Although studies on humans do verify this have yet to be done, many years of positive use by physicians around the world justify further research. In experiments on laboratory animals, a fluid extract (1:1w/v) of dandelion leaf (corresponding to 8gm of dried leaf/kg body weight) was reported to be as effective as the diuretic drug furosemide (80mg/kg body weight). (27) A most promising point of this study was that the usual potassium loss seen in many conventional diuretics was not seen in dandelion’s use, due to the high potassium content in the leaves.

Diet & Lifestyle

    Reduce foods that are high in sodium. Increase intake of fresh fruits and vegetables.

References

  1. Colucci WS, Braunwald E. Pathophysiology of congestive heart failure. In Braunwald E, ed. Heart Disease, A Textbook of Cardiovascular medicine. Philadelphia: Saunders; 1997:394-420.
  2. Johnson JA, Parker RB, Geraci SA, Heart Failure In DiPiro JT, et al, eds. Pharmacotherapy, A Pathophysiologic Approach 4th edition. Stamford, Conn: Appleton and Lange; 1999:153-181.
  3. View Abstract: Morisco C, et al. Effect of coenzyme Q10 therapy in patients with congestive heart failure: a long-term multicenter randomized study. Clin Investig. 1993;71(8 Suppl):S134-6.
  4. View Abstract: Mortensen SA, et al. Coenzyme Q10: clinical benefits with biochemical correlates suggesting a scientific breakthrough in the management of chronic heart failure. Int J Tissue React. 1990;12(3):155-62.
  5. Pelton R. The Drug-Induced Nutrient Depletion Handbook. Hudson, OH: Lexi-Comp; 1999.
  6. View Abstract: Siembab L, et al. Current views on the clinical significance of coronary artery spasm. Przegl Lek. 1995;52(8):395-9.
  7. View Abstract: Anand I, et al. Acute and chronic effects of propionyl-L-carnitine on the hemodynamics, exercise capacity, and hormones in patients with congestive heart failure. Cardiovasc Drugs Ther. Jul1998;12(3):291-9.
  8. Chapman RA, et al. Taurine and the Heart. Cardiovascular Research. 1993:27:358-363.
  9. View Abstract: Packer M. Potential role of potassium as a determinant of morbidity and mortality in patients with systemic hypertension and congestive heart failure. Am J Cardiol. Mar1990;65(10):45E-52E.
  10. View Abstract: Lindeman RD. Hypokalemia: Causes, Consequences and Correction. Am J Med Sci. Aug 1976;272(1):5-17.
  11. View Abstract: Petri M, et al. The Metabolic Effects of Thiazide Therapy in the Elderly: A Population Study. Age Ageing. May1986;15(3):151-55.
  12. View Abstract: Tishler M, Armon S. Nifedipine-induced Hypokalemia. Drug Intell Clin Pharm. May 1986;20(5):370-71.
  13. View Abstract: Francis GS. Interaction of the sympathetic nervous system and electrolytes in congestive heart failure. Am J Cardiol. Mar1990;65(10):24E-27E, 52E.
  14. View Abstract: Katz SD, et al. Decreased activity of the L-arginine-nitric oxide metabolic pathway in patients with congestive heart failure. Circulation. Apr1999;99(16):2113-7.
  15. View Abstract: Bednarz B, Jaxa-Chamiec T, Gebalska J, Herbaczynska-Cedro K, Ceremuzynski L. L-arginine supplementation prolongs duration of exercise in congestive heart failure. Kardiol Pol. Apr2004;60(4):348-53.
  16. View Abstract: Koifman B, et al. Improvement of cardiac performance by intravenous infusion of L-arginine in patients with moderate congestive heart failure. J Am Coll Cardiol. Nov1995;26(5):1251-6.
  17. Racz-Kotilla E, et al. Salidiuretic and Hypotensive Action of Ribes-Leaves. Planta Medica. 1980;29:110-14.
  18. Wagner H, et al. Cardioactive Drugs IV. Cardiotonic Amines from Crataegus oxyacantha. Planta Medica. 1982;45:99-101.
  19. Rewerski W, et al. Some Pharmacological Properties of Flavan Polymers Isolated from Hawthorn. Arzneim-Forsch/Drug Res. 1967;17:490-91.
  20. View Abstract: Wegrowski J, et al. The Effect of Procyanidolic Oligomers on the Composition of Normal and Hypercholesterolemic Rabbit Aortas. Biochem Pharm. 1984;33:3491-97.
  21. Sun YH. Cordyceps sinensis and Cultured Mycelia. Chung Yao Tung Pao. Dec1985;10(12):3-5.
  22. Bao TT, et al. Pharmacological actions of Cordyceps sinensis. Chung Hsi I Chieh Ho Tsa Chih. Jun1988;8(6):352-54.
  23. Chen YP. Studies on Immunological Actions of Cordyceps sinensis. I. Effect on Cellular Immunity. Chung Yao Tung Pao. Sep1983;8(5):33-35.
  24. Bradley PR, ed. British Herbal Compendium, vol 1. Bournemouth: British Herbal Medicine Association; 1992:73-74.
  25. Popov AL, et al. Mineral Components of Dandelion Leaves. Vopr Pitan. 1993;3:57-58.
  26. Newall CA, et al. Herbal Medicines: A Guide for Health Care Professionals. London: The Pharmaceutical Press; 1996:96-97.
  27. Racz-Kotilla E, et al. The Action of Taraxacum officinale Extracts On the Body Weight and Diuresis of Laboratory Animals. Planta Med. Nov1974;26(3):212-17.