Congestive Heart Failure (CHF) Symptoms, Stages, and Prognosis

  • Medical Author:
    Daniel Lee Kulick, MD, FACC, FSCAI

    Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

  • Medical Author: Benjamin Wedro, MD, FACEP, FAAEM
    Benjamin Wedro, MD, FACEP, FAAEM

    Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

  • Medical Editor: Charles Patrick Davis, MD, PhD
    Charles Patrick Davis, MD, PhD

    Charles Patrick Davis, MD, PhD

    Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

Shortness of breath is one symptom of congestive heart failure.

Congestive heart failure facts

  • Congestive heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs.
  • Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure.
  • The symptoms of congestive heart failure vary, but can include:
  • The diagnosis of congestive heart failure is based on knowledge of the individual's medical history, a careful physical examination, and selected laboratory tests.
  • The treatment of congestive heart failure can include lifestyle modifications, addressing potentially reversible factors, medications, heart transplant, and mechanical therapies.
  • The course of congestive heart failure in any given patient is extremely variable.

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Congestive Heart Failure Symptoms

An early symptom of congestive heart failure is fatigue. While fatigue is a sensitive indicator of possible underlying congestive heart failure, it is obviously a nonspecific symptom that may be caused by many other conditions. The person's ability to exercise may also diminish.

A life-like model of a human heart.

What is congestive heart failure (CHF)?

Heart failure describes the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and nutrients. This decrease in cardiac output, the amount of blood that the heart pumps, is not adequate to circulate the blood returning to the heart from the body and lungs, causing fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may include shortness of breath, weakness, and swelling.

Understanding blood flow in the heart and body

The right side of the heart pumps blood to the lungs while the left side pumps blood to the rest of the body. Blood from the body enters the right atrium though the vena cava. It then flows into the right ventricle where it is pumped to the lungs through the pulmonary artery, which carries deoxygenated blood to the lungs. In the lungs, oxygen is loaded onto red blood cells and returns to the left atrium of the heart via the pulmonary veins. Blood then flows into the left ventricle where it is pumped to the organs and tissues of the body. Oxygen is downloaded from red blood cells into the various organs while carbon dioxide, a waste product of metabolism, is added to be removed in the lungs. Blood then returns to the right atrium to start the cycle again. The pulmonary veins are unusual in that they carry oxygenated blood, while the pulmonary artery carries deoxygenated blood. This is a reversal of duties versus the roles of veins and arteries in the rest of the body.

Picture of a cross section of the heart.
Picture of a cross section of the heart.

Left heart failure occurs when the left ventricle cannot pump blood to the body and fluid backs up and leaks into the lungs causing shortness of breath. Right heart failure occurs when the right ventricle cannot adequately pump blood to the lungs. Blood and fluid may back up in the veins that deliver blood to the heart. This can cause fluid to leak into tissues and organs.

It is important to know that both sides of the heart may fail to function adequately at the same time and this is called biventricular heart failure. This often occurs since the most common cause of right heart failure is left heart failure.

A nurse performs an EKG exam on a senior patient.

What causes congestive heart failure?

Many disease processes can impair the pumping efficiency of the heart to cause congestive heart failure. In the United States, the most common causes of congestive heart failure are:

Less common causes include viral infections of the stiffening of the heart muscle, thyroid disorders, disorders of the heart rhythm, and many others.

It should also be noted that in patients with underlying heart disease, taking certain medications can lead to the development or worsening of congestive heart failure. This is especially true for those drugs that can cause sodium retention or affect the power of the heart muscle. Examples of such medications are the commonly used nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Motrin and others) and naproxen (Aleve and others) as well as certain steroids, some medication for type 2 diabetes, for example, rosiglitazone (Avandia) or pioglitazone (Actos), and some calcium channel blockers (CCBs).

View Heart Disease (Coronary Artery Disease) Slideshow Pictures
Angina or chest pain is a symptom of congestive heart failure.

What are the signs and symptoms of congestive heart failure?

Shortness of breath

The hallmark and most common symptom of left heart failure is shortness of breath and may occur.

  • while at rest
  • with activity or exertion
  • while lying flat (orthopnea)
  • while awakening the person from sleep (paroxysmal nocturnal dyspnea); or
  • due to fluid (water, mainly) accumulation in the lungs or the inability of the heart to be efficient enough to pump blood to the organs of the body when called upon in times of exertion or stress.

Chest Pain

Chest pain or angina may be associated, especially if the underlying cause of the failure is atherosclerotic heart disease.

Right heart failure, left heart failure, or both

  • Patients with right heart failure leak fluid into the tissue and organs that deliver blood to the right heart through the vena cava.
  • Back pressure in capillary blood vessels cause them to leak water into the space between cells and commonly the fluid can be found in the lowest parts of the body.
  • Gravity causes fluid to accumulate in the feet and ankles but as more fluid accumulates, it may creep up to involve all of the lower legs.
  • Fluid can also accumulate within the liver causing it to swell (hepatomegaly) and also within the abdominal cavity (ascites).
  • Ascites and hepatomegaly may make the patient feel bloated, nauseated, and have abdominal pain with the feeling of distension.
  • Depending upon their underlying illness and the clinical situation, patients may have symptoms of right heart failure, left heart failure, or both.
Fatigue is a symptom of congestive heart failure.

What are the functional classifications of heart failure?

The New York Heart Association has developed a scale that is commonly used to determine the functional capabilities of a patient with heart failure.

New York Heart Association (NYHA) Functional Classification of Heart Failure

  • Class I - Patients without limitation of physical activity.
  • Class II - Patients with slight limitation of physical capacity, in which marked increase in physical activity leads to fatigue, palpitations, dyspnea, or angina pain; they are comfortable at rest.
  • Class III - Patients with marked limitation of physical activity in which minimal ordinary activity results in fatigue, palpitation, dyspnea, or angina pain; they are comfortable at rest.
  • Class IV - Patients who are not only unable to carry on any physical activity without discomfort but who also have symptoms of heart failure or the angina syndrome even at rest; the patient's discomfort increases if any physical activity is undertaken.
High cholesterol and blood pressure are risk factors for congestive heart failure.

What are the risk factors for congestive heart failure?

Congestive heart failure is often a consequence of atherosclerotic heart disease and therefore the risk factors are the same: poorly controlled high blood pressure, high cholesterol, diabetes, smoking, and family history. Heart valve disease becomes a risk factor as the patient ages.

Other causes of heart failure have their own set of risk factors and predispositions and it becomes a complication of those diseases. Such causes may include obstructive sleep apnea, alcohol and drug abuse, infections, and connective tissue disorders like systemic lupus erythematosus, sarcoidosis, and amyloidosis.

Many patients have stable congestive heart failure but can decompensate when a change occurs to their body. For example, a patient with congestive heart failure may be doing well but then develops pneumonia, an infection of the lungs, or suffers a heart attack. The patient's heart may not be able to react to the body's changing environment and does not have the capability or reserve to meet the body's energy needs. As well, acute decompensation may occur if the patient drinks excess fluid, has a large intake of salt that can retain water in the body, or forgets to take their routine medication.

Diagnosis of congestive heart failure includes a physical exam.

How is congestive heart failure diagnosed?

Diagnosis of congestive heart failure is able to be accomplished by history and physical examination. The health care professional often will ask question about the symptoms like shortness of breath, swelling in the legs, chest pain, and what the patient does to make them better (sit down, rest). It will also be important to know whether the symptoms have come on gradually or over a shorter period of time.

Past medical history, medication history, diet, and social history including alcohol and drug use are all important to share. Should congestive heart failure be thought to be caused by atherosclerotic heart disease, risk factors for heart disease may be explored.

Physical examination begins with observing the patient to decide how comfortable they are at rest and whether the walk to the exam area made them short of breath. Vital signs including blood pressure, pulse rate, respiratory rate, oxygen saturation, and body weight may be helpful to assess how ill the patient might be. The exam often concentrates on the heart and lungs.

When examining the lungs, the health-care professional determines if there is good air entry in both sides of the chest or if there are extra sounds that might be heard when fluid is present. Tapping on the chest (percussion) can uncover a fluid buildup.

Heart exam includes feeling for the apex beat, the heart beat that can be felt through the chest wall. If it is displaced in the direction of the armpit, it may be a sign that the heart is enlarged. Listening to the heart sounds may uncover abnormal beats called gallops that are heard in heart failure. Murmurs may help diagnose heart valve disease. Rubs are noises made when the pericardium or fibrous sac covering the heart has become inflamed or enlarged.

The neck may be examined looking for jugular venous distention. The jugular veins will dilate if there is extra fluid in the body and may be a sign of right heart failure. Peripheral edema (tissue swelling) is also found in right heart failure. The doctor will often look at the feet and ankles first to see if they are swollen. The abdominal examination may reveal an enlarged liver or ascites (fluid accumulation in the abdominal cavity).

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Images of the heart using various techniques.

What tests diagnose congestive heart failure?

Congestive heart failure can be a medical emergency, especially if it acutely decompensates and the patient can present extremely ill with the inability to breathe adequately. In this situation, the ABCs of resuscitation (Airway, Breathing, Circulation) need to be addressed while at the same time, the diagnosis of congestive heart failure is made.

Common tests that are done to help with the diagnosis of congestive heart failure include the following:

  • Electrocardiogram (EKG, ECG) to help assess heart rate, rhythm, and indirectly, the size of the ventricles and blood flow to the heart muscle.
  • Chest X-ray to look at heart size and the presence or absence of fluid in the lungs.
  • Blood tests may include a complete blood count (CBC), electrolytes, glucose, BUN, and creatinine (to assess kidney function).
  • B-type natriuretic peptide (BNP) may be helpful in deciding if a patient has shortness of breath from congestive heart failure or from a different cause. It is a chemical that is located in the heart ventricles and may be released when these muscles are overloaded.
  • Echocardiography or ultrasound testing of the heart is often recommended to assess the anatomy and the function of the heart. In addition to being able to evaluate the heart valves and muscle, the test can look at blood flow within the heart, watch the chambers of the heart contract, and measure the ejection fraction (percentage of blood ejected with each beat - normal = 50% to 75%).

Other tests may be considered to evaluate and monitor a patient with suspected congestive heart failure, depending upon the clinical situation.

A man picks up his prescription for congestive heart failure at a pharmacy.

What is the treatment for congestive heart failure?

The goal of treatment for congestive heart failure is to have the heart beat more efficiently so that it can meet the energy needs of the body. Specific treatment depends upon the underlying cause of heart failure.

Treatment may try to decrease fluid within the body so that the heart does not have to work as hard to circulate blood through the blood vessels in the body.

Fluid restriction and a decrease in salt intake may be very helpful. Diuretic medications (water pills) may be prescribed if appropriate. Common diuretics include furosemide (Lasix), bumetanide (Bumex), and hydrochlorothiazide.

Medications are available that can make the heart pump more efficiently, increase cardiac output, and increase ejection fraction, as well as improve long-term survival

ACE inhibitors (angiotensin converting enzyme inhibitors) and ARBs (angiotension receptor blockers) are medicines that are also shown to increase survival by decreasing systemic resistance and favorable altering the hormonal milieu, which affects the cardiac performance; they are often used with other drugs. Beta blockers may control heart rate and increase cardiac output and ejection fraction, and provide a beneficial response to circulating epinephrine ("adrenalin"). Digoxin (Lanoxin) is an older medicine that may help increase cardiac output and control symptoms.

A very mild newer diuretic, spironolactone, has been shown to be of long-term benefit as well.

Cardiac risk factor modification is the cornerstone of prevention but may also benefit patients with established congestive heart failure.

Weight loss, establishing an exercise program, stopping smoking, and controlling high blood pressure, high cholesterol, and diabetes may help in the management of congestive heart failure.

End stage congestive heart failure (NYHA stage IV) patients may require aggressive treatments including left ventricular assist devices (LVAD), an implanted pump that helps increase the heart's ability to squeeze, or even heart transplantation. In older patients, not considered transplant candidates, LVAD may be a permanent treatment.

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Sodium or salt, increases fluid accumulation in the body.

What about diet, exercise, fluid management, and weight control?

After congestive heart failure is diagnosed, treatment should be started immediately. Lifestyle modification is one of the most important aspects a patient can incorporate to treat congestive heart failure. Some of these lifestyle changes include diet, exercise, fluid regulation, and weight maintenance.

Diet

Sodium: Sodium causes an increase in fluid accumulation in the body's tissues. Because the body is often congested with excess fluid, patients become very sensitive to the levels of intake of sodium and water.Restricting salt and fluid intake is often recommended because of the tendency of fluid to accumulate in the lungs and surrounding tissues.

  • A "no added salt" diet can still contain 4 to 6 grams (4000 to 6000 milligrams) of sodium per day.
  • In individuals with congestive heart failure, an intake of no more than 2 grams (2000 milligrams) of sodium per day is generally advised.
  • Reading food labels and paying close attention to total sodium intake is very important. Severe restriction of alcohol consumption also is advised.
View Heart Disease (Coronary Artery Disease) Slideshow Pictures
Exercise provides benefits to people with congestive heart failure.

Exercise

Aerobic exercise, once discouraged for congestive heart failure patients, has been shown to be beneficial in maintaining overall functional capacity, quality of life, and perhaps even improving survival. Each person's body has its own unique ability to compensate for the failing heart. Given the same degree of heart muscle weakness, individuals may display widely varying degrees of limitation of function. Regular exercise, when tailored to the person's tolerance level, appears to provide significant benefits and should be used only when the individual is compensated and stable.

Addressing potentially reversible factors

Depending on the underlying cause of congestive heart failure, potentially reversible factors should be explored. For example:

  • In certain persons whose congestive heart failure is caused by inadequate blood flow to the heart muscle, restoration of the blood flow through coronary artery surgery or catheter procedures (angioplasty, intracoronary stenting) may be considered.
  • Congestive heart failure that is due to severe disease of the valves may be alleviated by valve surgery in appropriate patients.
  • When congestive heart failure is caused by chronic, uncontrolled high blood pressure (hypertension), aggressive blood pressure control will often improve the condition.
  • Heart muscle weakness that is due to long-stand, severe alcohol abuse can improve significantly with abstinence from drinking.
  • Congestive heart failure that is caused by other disease states may be similarly partially or completely reversible by appropriate measures.
Diuretics can help in the elimination of excess fluid in the body.

Fluid regulation

The total amount of fluid a patient consumes must be regulated. Although many people with congestive heart failure take prescription diuretics to aid in the elimination of excess fluid, the action of these medications can be overwhelmed by an excess intake of water and other fluids. The maxim that "drinking eight glasses of water a day is healthy" certainly does not apply to patients with congestive heart failure. Patients with more advanced cases of congestive heart failure are often advised to limit their total daily fluid intake from all sources to 2 quarts.

The above guidelines for sodium and fluid intake may vary depending on the severity of congestive heart failure in any given individual and should be discussed with their physician.

Weight maintenance

An important tool for monitoring an appropriate fluid balance is the frequent tracking of the patient's body weight. An early sign of fluid accumulation is an increase in body weight. This may occur even before shortness of breath or swelling in the legs and other body tissues (edema) is detected. A weight gain of 2 to 3 pounds over 2 to 3 days should prompt a call to the physician, who may order an increase in the dose of diuretics or other methods designed to stop the early stages of fluid accumulation before it becomes more severe.

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The outlook for someone with congestive heart failure depends on several factors.

What is the long-term prognosis for patients with congestive heart failure?

Congestive heart failure is generally a progressive disease with periods of stability punctuated by episodic clinical exacerbations. The course of the disease in any given individual, however, is extremely variable. Factors involved in determining the long term outlook (prognosis) for a given patient include:

  • the nature of the underlying heart disease;
  • the response to medications;
  • the degree to which other organ systems are involved and the severity of other accompanying conditions;
  • the person's symptoms and degree of impairment; and
  • other factors that remain poorly understood.

With the availability of newer drugs to potentially favorably affect the progression of disease, the prognosis in congestive heart failure is generally more favorable than that observed just 10 years ago. In some cases, especially when the heart muscle dysfunction has recently developed, a significant spontaneous improvement is not uncommonly observed, even to the point where heart function becomes normal.

Heart failure is often graded on a scale of I to IV based on the patient's ability to function.

  1. Class I includes patients with a weakened heart but without limitation or symptoms.
  2. Class II describes patients whose only limitation is heavier workloads.
  3. Class III includes patients who experience limitation with everyday activity.
  4. Class IV describes patients with severe symptoms at rest or with any degree of effort.

The prognosis of heart failure patients is very closely associated with the functional class.

An important issue in congestive heart failure is the risk of heart rhythm disturbances (arrhythmias). Of those deaths that occur in individuals with congestive heart failure, approximately 50% are related to progressive heart failure. Importantly, the other half are thought to be related to serious arrhythmias. A major advance has been the finding that nonsurgical placement of automatic implantable cardioverter/defibrillators (AICD) in individuals with severe congestive heart failure (defined by an ejection fraction below 30% to 35%) can significantly improve survival, and has become the standard of care in most such individuals.

In some people with severe heart failure and certain ECG abnormalities, the left and right side of the heart don't beat in rhythm, and inserting a device called a biventricular pacer can significantly reduce symptoms.

Congestive heart failure can be prevented by not smoking.

Can congestive heart failure be prevented?

Congestive heart failure is the result of an underlying illness, often atherosclerotic heart disease. Controlling those risk factors may help with congestive heart failure prevention. These include lifelong control of high blood pressure, high cholesterol, and diabetes and smoking cessation. High blood pressure and diabetes are independent risks for congestive heart failure. Alcohol and drug abuse may be a cause of heart failure.

Diastolic dysfunction: This is a form of CHF in which the heart muscle may be stiff, most often from hypertension or normal aging. The ejection fraction is normal and the prognosis is excellent. The problem is that a stiff heart muscle fills with blood at a higher pressure, which is transmitted to the lungs resulting in shortness of breath. It must be emphasized that the long-term outlook for patients with this condition is excellent.

How does someone cope with congestive heart failure?

Resources available for patients trying to cope with the long-term challenges of congestive heart failure include

  • local support groups;
  • cardiac rehab programs designed for congestive heart failure (covered by many types of insurance); and
  • self-monitoring of weight and fluid intake.

Quick GuideAm I Having a Heart Attack? Symptoms of Heart Disease

Am I Having a Heart Attack? Symptoms of Heart Disease
Reviewed on 8/11/2017
References
REFERENCES:

Roger, Veronique L., et al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. "Heart disease and stroke statistics -- 2011 update: a report from the American Heart Association." Circulation 123.4 (2011): e18-e209.

Ho, K. K., et al. "The epidemiology of heart failure: the Framingham Study." Journal of the American College of Cardiology 22.4 Suppl A (1993): 6A-13A.

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