Medically Reviewed On: May 07, 2008

PAUL J. MONIZ, MD:  I’m Paul Moniz.  Thank you for joining us on this webcast.  Today's topic is congestive heart failure.

Did you know congestive heart failure is the most common cardiac condition among the elderly.  In the United States, it effects some five million people, and each year more than half a million new cases are diagnosed.

The condition, known as CHF, refers to a poorly pumping heart that causes a fluid backup in the heart, lungs and other organs.  The result is shortness of breath, swelling in the body and debilitating fatigue.

Here to talk about this and explain more about this are two specialists in the field.  To my left is Dr. Simon Maybaum.  He is an attending cardiologist at the Heart Failure and Cardiac Transplant Program at New York Presbyterian Hospital.  Thank you for joining us.

SIMON MAYBAUM, MD:  Thank you.

PAUL J. MONIZ, MD:  Next to him, we have Dr. Ainat Benjaminovitz, who is a cardiologist at the same hospital, and who has agreed to be called Dr. B for the rest of the segment for my purposes.  We appreciate that.

Dr. Maybaum, let's begin with you.  Can you give us a more detailed description of what congestive heart failure is, and does it refer to all heart failures?

SIMON MAYBAUM, MD:  Well, I certainly would agree that heart failure and congestive heart failure is a very serious problem.  Certainly, we're becoming now more aware of how serious it is in our community.

Heart failure is essentially a disease of the heart muscle or the valves of the heart which make it weak or fail, as its name suggests.  So, the heart cannot continue to form its normal function.  As we know, the heart pumps blood through the body and then returns it through the lungs.  When the heart fails and the muscle becomes weak, or the valves become ineffectual, the heart enlarges.  Blood accumulates in the heart, and then eventually in other parts of the body.

Heart failure can start from an unnoticeable condition, that which we call asymptomatic, and progress to a severely debilitating disease; one which mimics, in some ways, cancer where the patients are really bed bound and have very little hope for the future.  So, it's a very wide range of presentations.

PAUL J. MONIZ, MD:  Dr. B, let's bring you into this.  When we refer to the congestive part of this, what does that mean exactly?  At what point does it become congestive heart failure?

AINAT BENJAMINOVITZ, MD:  As Dr. Maybaum was alluding, the first thing that happens is that congestive heart failure, as it stands, is really the body's response to a failing heart.  There are various compensatory mechanisms that come into play.  As a consequence, the person experiences symptoms of congestion.

For ease of illustration, I just wanted to bring this up in this model.  As you can see, here is a model of the heart.  Here are the lungs.  This is the left ventricle or the main pumping chamber of the heart itself.  This is what we talk about getting enlarged when the heart begins to fail, starting the syndrome of congestive heart failure.  So as you can see, this chamber is finite.  When the heart begins to fail because it can't pump enough blood to the whole body, one of the compensations that happens is the hearts, since it can't pump efficiently as a muscle and the pump function decreases, it begins to dilate.  It begins to enlarge.  This muscle stretches way out.  So, instead of the heart looking this big, it becomes twice its size, displacing the lungs.  As a consequence, since there is a bigger volume, it can pump the same amount of blood, but at a cost.  When the blood starts to backup in the heart itself, then it starts backing up into the other organs, such as the lungs, such as the liver, such as the legs, forming the syndrome of congestive heart failure.  That's what congestion means.  Blood is backing up rather than going forward.

PAUL J. MONIZ, MD:  What's interesting in this whole discussion is that the body has the ability to compensate as it does.  In some cases, this is a bad thing because it can make a patient think that nothing is wrong.  Let's first take the kidneys.  What happens, Dr. Maybaum, with the kidneys.

SIMON MAYBAUM, MD:  The kidneys see that the heart is not efficiently supplying them with blood.  It thinks that, in some respects, there is too little blood on board.  Even though there is a normal amount of blood on board, it's just not flowing normally.  So, the kidneys work to absorb more fluid.  That just exacerbates the problem, so you get increased fluid retention, which is a compensatory mechanism that is inappropriate in the setting of heart failure.  In fact, a lot of the medications work to regulate that compensatory mechanism.

PAUL J. MONIZ, MD:  Doctor, when we talk about fluid in the body, we're actually talking about excess blood.  Can you explain that to our audience?

AINAT BENJAMINOVITZ, MD:  Correct.  Basically, when we always say water in the lungs to patients with congestive heart failure, they'll come back and tell you, "Oh, I have water in my lungs."  Basically, what that is, is that you have a certain capacitance system in your body which are the veins and the arteries.  They can hold only so much blood.  When the kidneys tell the body to absorb more water to dilute that blood to help fill the very big, big sack of heart that exists, what happens is that the arteries can only withhold so much blood within them.  They start seeping out.  The blood that seeps out is termed water because it's not quite blood, but it's a big composition of blood and water that leaks into places that it shouldn't be, such as in the lungs, in the liver, like we said before, and in the legs.  So, they are no longer in the arteries where blood typically flows, but they are in other places because the arteries can't hold as much.

PAUL J. MONIZ, MD:  What are the most common symptoms of this?

SIMON MAYBAUM, MD:  I think that amongst the most common symptoms is really shortness of breath.  As Ainat was saying, that is related, in part, to a collection of fluid or blood-like fluid in the lungs.  The patient not only cannot perform normal exertion, but also eventually cannot lie flat.  We often see that patients with advanced heart failure are sleeping in a chair at night, or sleeping on three or four pillows, on waking at night are very short of breath.

Really, the second main symptom is fatigue.  Patients feel tired and worn out, and cannot perform eventually normal daily activities.  So, those are the two main symptoms.

In addition, there are other symptoms and signs of collection of fluid.  We talked about the swelling of the ankles, which is fluid collecting in the legs.  Patients can also have abdominal pain, as the liver fills with fluid, or as the abdominal cavity fills with fluid.  Some patients have no shortness of breath, but just abdominal pain.

PAUL J. MONIZ, MD:  So, it sounds like a lot of different symptoms depending on how the body is manifesting this congestion.  Who is most susceptible to this, doctor?

AINAT BENJAMINOVITZ, MD:  Most susceptible to the symptoms of heart failure.  That really is very individual.

PAUL J. MONIZ, MD:  Is it mostly elderly people who get this?

AINAT BENJAMINOVITZ, MD:  No.  It's typically more associated with the elderly because they have a lot more of the manifestations that have slowly taken apart their heart muscle and rendered them in congestive heart failure, but it can attack anyone at any age for a variety of reasons that attack the heart muscle itself.  The way people manifest in congestive heart failure is very varied and is not age dependent.  So, someone who is 20-years-old that had a virus attack the heart muscle, and now the heart muscle is very weak, can be ten times as debilitated as an older person who has had congestive heart failure for a long time.  It just depends on the severity with which, and the rapidity with which the heart muscle declines.

PAUL J. MONIZ, MD:  Before the show, both of you brought up a rather startling statistic that as many as 20 million people in the United States actually have defective hearts, and may have congestive heart failure but not know it.  So, what do you do?

SIMON MAYBAUM, MD:  That is very worrying.  Because initially when damage to the heart occurs, and patients lead full and normal lives, we think there are a lot of people walking around with abnormal cardiac function who will, eventually if untreated, progress to symptoms and signs of congestive heart failure.  Most of us in the heart failure community believe that early intervention of these patients would probably slow or stop the progression of congestive heart failure.  However, identifying these patients is much more problematic.

PAUL J. MONIZ, MD:  The gatekeeper, so to speak, is generally an internist.  Can the internist generally spot symptoms before things get too dangerous.

AINAT BENJAMINOVITZ, MD:  Well, the body does have cues to someone that is observing or examining to tell you or lead you on to the fact that there is something wrong with the heart, such as an extra heart sounds; perhaps a murmur.  Typically, when it no longer is symptom free and people are actually manifesting signs and symptoms of congestive heart failure, that is easy.  A patient comes in and tells you those signs and cues.  But, the subtle signs and cues are those that a physician can hear with his or her stethoscope and on a very cursory exam actually pick up that he veins will be backed up with fluid.  That will be a subtle sign or symptom that the patient may not even manifest.  Just the doctor looking at them may be able to disclose that.

PAUL J. MONIZ, MD:  If an internist or if another doctor that you go to suspects that you may have problems – or in this case, congestive heart failure – what is the first test that is performed.

SIMON MAYBAUM, MD:  On the assumption that most internists would probably do an electrocardiogram, I think the most useful test is an echocardiogram, which is essentially an ultrasound of the heart.  This is really very well developed now.  It allows us to look, not only at the cardiac function, the squeezing of the heart, but also at the size of the chambers, to interrogate the values and see that they're working properly.  It is a very useful tool for giving us clues as to why the heart failure occurred in the first place.  So, that would probably be the first important test that we do.

PAUL J. MONIZ, MD:  How effective is the test?  Is it painful at all?

AINAT BENJAMINOVITZ, MD:  It's very painless.  That's why it's very appealing.  It's much like having an ultrasound as a baby when you're going for a prenatal visit.  It's performed at most places, including physicians' offices.  You don't have to go somewhere special.  It's very informative.  You basically get the results right away as they are obtained.

PAUL J. MONIZ, MD:  Can it pick up blockages, as well?

AINAT BENJAMINOVITZ, MD:  Of the arteries, no.  But what it can allude to is whether or not there have been blockages in the arteries.  The heart muscle will become dysfunctional in only certain regions, rather than a global dysfunctional state, which clues you into the fact that only one artery was blocked, and only one part of the heart muscle died, not the whole heart muscle.  It tells you more.  It gives you clues and signs as to what the ideology or causal factor is.

PAUL J. MONIZ, MD:  There are a variety of causes.  What are we talking about?

SIMON MAYBAUM, MD:  I think the two big distinctions, as far as the etiology or cause of congestive heart failure, is whether it comes from a decrease or abnormal blood supply to the muscle, or whether it's a problem within the heart structure itself; the muscle or the valves.  A problem with blood supply to the heart muscle is what we call coronary artery disease.  This is a disease that gives us heart attacks and angina and chest pain.

AINAT BENJAMINOVITZ, MD:  It's known as ischemic cardiomyopathy.

SIMON MAYBAUM, MD:  The other is all the causes, which are unrelated to abnormal blood supply to the muscle.  There are many.  There are toxic agents such as alcohol and drugs and chemotherapeutic agents, and many others that can cause damage to the heart muscle.

Probably, we think the most common is viral infection.  We think that most of the cardiomyopathies or the diseases of the heart muscle that we see and find no cause for, have at some time, been related to a viral infection of the heart.

PAUL J. MONIZ, MD:  That leads us to prevention.  What can someone do to prevent this all together?  Also, does it run in families?

AINAT BENJAMINOVITZ, MD:  Simon was alluding to the various causes.  One of the causes which is actually preventable is high blood pressure, or hypertensive cardiomyopathy.  If you know that you have high blood pressure, getting it treated may save you a lot of pain and suffering later on by not allowing you to promote more heart failure.  Abstaining from alcohol if you've been diagnosed with heart failure.  Although we know in the press, alcohol has been touted to protect the coronary artery, it has a negative effect on the heart muscle itself.  It actually depresses heart function.  I'm talking about an excess, not in minute forms or moderation.

PAUL J. MONIZ, MD:  So, the one glass of wine with dinner is still okay?

AINAT BENJAMINOVITZ, MD:  Okay for people with coronary artery disease, but people who already have dysfunctional heart muscles, we ask to refrain from alcohol completely.  Even a small amount may be deleterious.  Those are things that you can do for prevention of potentially treatable or preventable causes of heart failure.

Sometimes the thyroid gets of out whack.  Treating that problem can prevent heart failure.  You were alluding to the non-treatable causes, basically, which are the ones that are inheritable.  Inherited conditions of the heart muscle itself.  Right now, we are just at the beginning, at the cutting edge of understanding what causes them; what gene defect causes this dysregulation of the heart muscle.  Until we're really good at fixing our genetic composition, we're not going to be able to prevent those complications, but just treat them expectantly.  So, that talks to the non-preventable causes of heart failure.

But there are things that you can do in terms of prevention or retarding the progression of heart failure.  There is a whole compendium of medications that we're fortunate to have currently to help retard the disease once it's come about.

PAUL J. MONIZ, MD:  Dr. Maybaum, we have just a short time for this segment.  In closing, what would you want the audience to know overall about congestive heart failure?

SIMON MAYBAUM, MD:  I think that we need to understand that it's a serious condition, which, if untreated can lead to progressive deterioration.  But, we are much better at identifying and treating patients with heart failure.  Hopefully, we're improving their quality of life and eventual survival.

PAUL J. MONIZ, MD:  All right.  We certainly appreciate your time.  Dr. Simon Maybaum, and Dr. Ainat Benjaminovitz, both of New York Presbyterian Hospital.

I'm Paul Moniz.  Thanks a lot for joining us.  Remember, if you have questions or think you may have some of these symptoms, contact your doctor.