The death rate due to coronary artery disease has continued to decline with improvements in medications and cardiac therapies. However, more Americans are living with heart failure, also called congestive heart failure (CHF). In fact, it is one of the leading reasons for hospital admission in the United States. It seems that Americans are now surviving their heart attacks, only to face life with residual heart damage.

Heart failure occurs when one or both of the heart's two bottom chambers, called ventricles, become weakened and cannot appropriately squeeze blood.

The normal left ventricle pumps blood forward to perfuse the entire body with fully oxygenated blood, while the normal right ventricle pumps blood to the lungs where it is oxygenated. When the left ventricle becomes weakened, forward blood flow is reduced and backs up into the lungs. While a weakened right ventricle results in blood backing up into the veins of the legs and abdomen. The ventricles can become dysfunctional due to either poor squeezing function, called systolic dysfunction, or poor relaxing function, called diastolic dysfunction. This backed up blood results in retained fluid or congestion, hence the term congestive heart failure.

The final common pathway of all CHF is heart muscle damage. The most common cause is coronary artery disease. Blockages of the coronary arteries result in heart attacks and permanent damage to the heart muscle. While in some cases, the heart valves do not function properly, causing the heart to stretch, remodel inappropriately and become weakened.

In addition, long standing hypertension puts significant stress on the heart, which over time results in an unhealthy and dysfunctional increase in heart muscle size. There are some toxins and diseases that directly attack heart muscle. The most common toxins are recreational drugs and alcohol, rare environmental substances and some possibly toxic medications like chemotherapy. The diseases that can affect the heart include viral and bacterial infections, infiltrative diseases, primary lung diseases, thyroid dysfunction, diabetes and anemia.

Lastly, pregnancy has rarely been associated with irreversible heart muscle damage.

The symptoms of CHF tend to correspond to the chamber of the heart that is affected. Left ventricular CHF tends to present with fatigue, shortness of breath, an inability to exercise, sleeping in an up-right position and weight gain. While right ventricular CHF may also be associated with weight gain, but is more characterized by abdominal and lower extremity swelling, called edema. Although, CHF can be relatively stable and chronic, sudden and very dangerous exacerbations of CHF can occur. The “red flags” to look for are: abrupt weight gain, shortness of breath at rest or causing awakening, abdominal pain, inability to sleep flat, or a dry, hacking cough. The patient should weigh themselves daily and call the physician if there has been a 2 to 3 pound weight gain. Any signs of acute distress warrant an immediate call to EMS.

When a physician suspects heart failure, there are some tests that can make the diagnosis and help establish a therapy plan. Evaluation usually starts with basic blood work, chest X-ray and an electrocardiogram (EKG). This is followed with a non-invasive test called an echocardiogram, in which ultrasonic sound waves are bounced off the heart muscle and valves to assess structure and function. To evaluate the function and blood supply, a simple exam is a nuclear stress test. It can be performed on a treadmill or with a chemical infusion in those unable to exercise. The stress test assesses whether there is a lack of blood supply to the heart.

If necessary, a cardiac catheterization, also called a coronary angiogram can be done. In this hospital based procedure, a small tube is placed into an artery of the groin or wrist, allowing the cardiologist to directly inject contrast into the coronary arteries, as visualized by an X-ray camera. Due to the technical skill and invasive nature of the angiogram, it is performed at larger hospitals in both Syracuse and Rochester. More recently, a newly developed high resolution heart CT scan, called a 32 or 64 slice cardiac CT angiogram, has gained popularity. This non-invasive, outpatient test gives high quality images of the heart and direct visualization of the coronary arteries with only a simple IV.

Once the diagnosis of CHF is made, therapy can be initiated. This includes aggressive lifestyle modifications, which entails dietary changes, salt restriction, exercise, alcohol and smoking cessation and cardiac rehabilitation. As hypertension is the one of the most common causes of CHF, blood pressure control is essential. Additionally, opening blocked coronary arteries with balloons and stents or surgical bypass grafts and correction of valves can result in significant improvement.

The mainstay of CHF management is medical therapy. Most patient with CHF are on several medications, the most common being diuretics or “water pills,” ACE Inhibitors and ARBs, digoxin, beta and calcium channel blockers and occasionally blood thinners. These medications work in conjunction to optimize blood pressure, improve cardiac function and reduce overall work load of the weakened heart. Unfortunately, the number of pills can be daunting.

There are several medications that patients with CHF should absolutely avoid. One is the over-the-counter pain medication, non-steroidal anti-inflammatory drugs like Ibuprofen. Others include specific prescription diabetic medications and some medications for erectile dysfunction.

CHF can remain relatively stable with medical therapy and close physician supervision. However, like many life threatening diseases, CHF can worsen and ultimately progress into a medically refractory condition. This requires specialized therapy, including hospitalization for infusion of medications that directly increase the heart#'s squeezing function. Rarely, drug refractory CHF requires medical devices to remove the excess fluid.

In near end stage CHF, cardiologists at specialized heart centers can recommend mechanical circulatory support devices or lastly cardiac transplantation. There are three major types of devices, including specialized pacemakers/defibrillators, aortic balloon pumps and ventricular assist devices. Cardiac transplantation has an established record of improving the quality of life and survival in patient with end stage heart failure.

Sadly, the number of CHF candidates who actually make it to transplant is dismally low, estimated at only around 2000 transplants each year.

Managing heart failure isn't easy. The mainstay of therapy remains strict adherence to treatment regiment and close follow up with your treating physicians. However, the future is bright with improvements in medications, medical devices and advances in gene therapy.

Dr. David M. Donaldson is an Auburn native and currently a cardiologist at Massachusetts General Hospital in Boston.