Congestive Heart Failure

Description

Alternative Names

Lifestyle Changes

Between 30% to 47% of patients who require hospitalization for heart failure are back in the hospital again within six months. Many people return because of lifestyle factors, such as poor diet, failure to comply with medications, and social isolation.

Home Support and Rehabilitation Programs

In one study, elderly people who had no emotional support at home had triple the risk of a heart attack after hospitalization for heart failure than those who did have such support. (In women, this risk was eightfold.) In another study, the greatest risk factor for death and readmission to the hospital after a first hospitalization for heart failure was being single, regardless of the health of the patient at discharge. A third study confirmed that a strong marriage predicted long-term survival. Evidence continues to mount that programs that offer intensive follow-up to ensure that the patient complies with lifestyle changes and medication regimens at home are reducing rehospitalization and costs and improving survival. Patients without available rehabilitation programs should seek support from local and national heart associations and groups.

Monitoring Weight Changes

Heart failure patients should weigh themselves each morning and keep a record. Any changes are important:

• A sudden increase in weight of more than two or three pounds may indicate fluid accumulation and should prompt an immediate call to the physician.
• Rapid wasting weight loss over a few months is a very serious sign and may indicate the need for surgical intervention.

Dietary Factors

Mediterranean Diet. There is some evidence suggesting that the Mediterranean diet helps protect the heart and may even reduce the risk for heart failure after a first heart attack. Its emphasis on whole grains, fish, olive oil, garlic, and moderate, daily intake of wine may have many benefits for the heart. The diet recommends the following:

• A relatively high fat intake (about 35% to 45% of daily calories, mostly in monounsaturated and polyunsaturated fats.) The Mediterranean diet is known for its use of olive oil, but the greatest benefits found in a major study of this diet appeared to be derived from the use of canola oil, which is rich in omega-3 fatty acids. Olive oil, in fact, does not contain omega-3 fatty acids. On the other hand, olive oil may have beneficial effects independent from those on lipids, such as improving insulin and blood glucose levels and reducing blood pressure.
• Daily glass or two of wine.
• The same protein intake as the AHA, although fish is the primary source. (It avoids high-fat dairy and meat products.) In fact, one 2001 study suggested that fish-consumption, not wine, that is the heart-protective ingredient in this diet.
• Lower carbohydrate intake than AHA. Emphasizes not only fresh fruits and vegetables, but also higher amounts of nuts, legumes, beans, and whole grains.
• Foods seasoned with garlic, onions, and herbs.

DASH Diet. A diet known as Dietary Approaches to Stop Hypertension (DASH) is now recommended as an important step in managing blood pressure so it may be useful for many patients with heart failure. This diet is not only rich in important nutrients and fiber, but also includes foods that contain two and half times the amounts of electrolytes, potassium, calcium, and magnesium as are found in the average American diet.

Potassium-rich foods, which are important for patients with heart failure, include bananas, oranges, prunes, cantaloupes, carrots, spinach, celery, alfalfa, mushrooms, lima beans, potatoes, avocados and broccoli. It is important to note, however, that patients taking Aldactone, those with kidney dysfunction, and some of those taking ACF inhibitors may have to restrict their potassium intake.

The diet also stresses avoiding saturated fats, as any healthy diet does, although it includes calcium-rich dairy products that are no- or low-fat. When choosing fats, it also advises monounsaturated oils, and it stresses whole grains, fresh fruits and vegetables every day.

Salt Restriction. People with high blood pressure are generally urged to restrict salt, although certain people may be more susceptible to its effects. For example, a high intake of salt may be an independent risk factor for the development of heart failure in people who are overweight. All heart failure patients should limit their salt intake, and in severe cases, very stringent salt restriction may be necessary. Patients should not add salt to their cooking and their meals. They should also avoid foods high in sodium; these include ham, bacon, hot dogs, lunch meats, prepared snack foods, dry cereal, cheese, canned soups, soy sauce, and condiments. Some patients may need to reduce their water intake as well. People with high cholesterol levels or diabetes require additional dietary precautions. [For more information, seeWell-Connected Report #43, Heart-Healthy Diet.]

Exercise

Traditionally, people with heart failure were discouraged from exercising. Now, exercise, when performed under medical supervision, is proving to be extremely important for many patients with stable conditions. Studies have reported that patients with stable conditions who engage in regular moderate exercise (twice a week) experience a better quality of life and lower mortality rates than those who don't.

The following guidelines are critical:

• Experts warn that exercise is not appropriate for all heart failure patients. Physicians should always be consulted before any patient with heart failure starts an exercise program.
• People who are approved for exercise and not used to exercising should start with five to 15 minutes of easy exercise with frequent breaks. Although the goal would be to build to 30 to 45 minutes of walking, swimming, or low-impact aerobic exercises three to five times every week, even shorter times spent exercising is useful.

The following are some examples of studies reporting benefits from specific exercises.

• Progressive strength training may be particularly useful for heart failure patients since it strengthens muscles, which commonly deteriorate in this disorder. Strength training typically employs light weights, weight machines, or even the bodys weight (leg raises or sit-ups, for example). Even simply performing daily handgrip exercises can improve blood flow through the arteries.
• Patients who exercise regularly using supervised treadmill and stationary-bicycle exercises have increased exercise capacity by 14% to 36%. In one study, heart failure patients as old as 91 years old increased their oxygen consumption significantly after six months of supervised treadmill and stationary bicycle exercises. Exercising the legs may actually help correct problems in heart muscles in these patients. In one study, patients who did leg extension exercises for eight weeks had higher levels of an enzyme involved in forming new blood vessels. Exercise has also been associated with evidence of reduced inflammation in blood vessels.

Bed Rest

Bed rest may be required in cases of severe congestive heart failure. To reduce congestion in the lungs, the patients upper body should be elevated; for most patients, resting in an armchair is better than lying in bed. Relaxing and contracting leg muscles is important to prevent clots. As the patient improves, progressively more activity will be recommended.

Warm Baths and Saunas

Experts have traditionally recommended that people with heart failure avoid warm baths, which can increase the heart rate. Now, studies are reporting that carefully controlled bathing for short periods may not be harmful and, in fact, may be beneficial, reducing irregular heart beats and increasing cardiac output and ejection fraction. Warm water may behave like a vasodilating drug, opening up the vessels gently and improving circulation. The people in the study sat in water up to their chests at 106 F or in a dry sauna at 140 F. In both situations they sat for 10 minutes with their torsos tilted at 45 degrees. None of them experienced pain in the heart, shortness of breath, or irregular heart beats.

Warning Note: Prolonged periods in hot or even warm conditions can be dangerous, however. Any patient with heart failure should consult the physician first, not bathe unaccompanied, and be sure that the temperature does not go above those described in this report for either water bathing or dry saunas.

Stress Reduction

Stress reduction techniques may have direct physical benefits lowering stress hormones, including cortisol (which suppresses the immune system) and norepinephrine (also known as adrenaline), the chemical messenger associated with heart dysfunction. Many effective stress reduction techniques, including meditation and relaxation methods, are available.

Alternative Remedies

Patients with heart failure may resort to alternative remedies. It should strongly be noted that such remedies are not regulated. They are often ineffective or, worse, in some cases may have sever or toxic effects. Of particular note for patients with congestive heart failure is an interaction between St. John's wort, an herbal medicine used for depression, and digoxin. Taking St. John's wort can significantly interfere with the heart agent.

Arginine. Some evidence suggests that arginine (also called L-arginine) may have some benefit. This amino acid appears to reduce endothelin, a protein that causes blood vessel constriction and is found in high amounts in heart failure patients. It can have adverse effects, however, including gastrointestinal problems. It can also lower blood pressure and change levels of certain chemicals and electrolytes in the body. It may increase the risk for bleeding. Some people have an allergic reaction to it, which in same cases may be severe. It may worsen asthma.

Coenzyme Q10. Some small studies suggest that coenzyme Q10 (CoQ10) may have some value for patients with heart failure, particularly in combination with vitamin E. CoQ10 is a vitamin-like substance found in organ meats and soybean oil. More recent studies, however, have found no effect on the heart or the quality of life with CoQ10 or vitamin E.

Other Vitamins and Supplements. A wide array of additional vitamins (thiamin, B6, and C), minerals (calcium, magnesium, zinc, manganese, copper, selenium), nutritional supplements (carnitine, creatine phosphate), and herbal remedies (e.g., hawthorn) have been proposed as treatments for heart failure. None have been adequately tested. While it is probably wise to eat a nutrient-rich diet, it is important to stress that no supplement or diet can cure the condition.