Though she lived a very public life growing up on the silver screen, Elizabeth Taylor was given the dignity of passing away quietly surrounded by family. Unfortunately, she had to spend part of the last weeks of her life in a hospital being treated for congestive heart failure (CHF), a disease that causes fluid to build up and cause congestion in the organs of the body, especially in the lungs.
Ms. Taylor was one of the millions of Americans with CHF who suffer with the symptoms of shortness of breath on exertion, difficulty lying flat, and swollen legs. When the heart muscle weakens and can't pump hard enough to push blood through the body, a couple of things happen. First, not enough oxygen gets delivered to the body, so muscles that don't get enough oxygen tire more quickly and it's harder to walk or climb stairs. Brain cells need oxygen to function and perhaps the patient may become less sharp. Every organ in the body needs adequate oxygen supply and blood circulation, and when the heart fails to meet those needs, the body gradually shuts down. Fluid starts backing up because the pump (the heart) can't keep it moving. It's no different than a failed oil pump in a car or a sump pump in a basement. But in the body, the fluid backs up into the lungs, causing shortness of breath, or the fluid backs up into the peripheral tissues, causing edema, where feet, ankles, and legs can swell.
Usually, CHF is the end result of gradual loss of heart muscle due to gradual blockage of the arteries that supply the heart muscle (coronary artery disease). Heart muscle cells lose their blood supply and die and the muscle is replaced by scar tissue, which does not help with the heart pumping function. Damage to heart valves, infections of the heart muscle or valves, and uncontrolled high blood pressure are other reasons why the heart loses its pumping ability. Ultimately, the heart enlarges as the muscle becomes floppy and less able to pump. The heart function is often evaluated by an echocardiogram or ultrasound of the heart, but the diagnosis can usually be made at the bedside by the care provider who understands the patient's symptoms and has performed a physical examination. As the symptoms of CHF increase as the pumping decreases, the diagnosis becomes easier to make.
Shortness of breath is a terrible symptom to endure, and fortunately, there are medications to help the heart beat more effectively and efficiently. Diuretics or water pills can remove some of the excess fluid from the bloodstream, decreasing the work that the heart has to do. The treatment options are tailored to the individual patient and some medications for CHF do double duty treating high blood pressure and angina. Sometimes, the symptoms of CHF can acutely worsen and hospital treatment is needed to help with symptoms while medications are adjusted and the reason for the flare-up of the disease is found. Congestive heart failure should be considered a disease that is controlled but not cured.
While medication can control the disease, CHF remains a leading cause of death. Some patients gradually get sicker as their heart pumping function weakens and they pass away slowly. However, about half of CHF patients can have sudden death where the electrical system of the heart short-circuits and develops ventricular fibrillation, a fatal heart rhythm causing the heart to stop beating efficiently enough to pump blood.
Prevention remains the key to treating CHF. Antibiotic treatment of strep throat made rheumatic heart valve disease a rare event. The goal is to prevent coronary artery disease and heart attacks. The big four risk factors are all controllable, including stopping smoking and keeping blood pressure, cholesterol, and diabetes within normal limits. It takes a lifetime commitment to protect the heart, but without that care and effort, the alternatives can make it hard to take a deep breath.
Tintinalli, J.E., et al. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill, 2003.