Shopping on line can be easy, simple and save you lots of money. It can also take a lot of your time, frustrate you, and result in unwanted purchases. Now the same can be said for regular high street shopping, but with the vast opportunity presented by the Internet it will pay you to spend a few minutes reading this and understanding how to better optimize your Congestive Heart Failure shopping experience:

1. Compare - without doubt the biggest advantage that the Congestive Heart Failure offers shoppers today is the ability to compare thousands of Congestive Heart Failure at a time. This is a great thing, but not necessarily all the time! Too much can be daunting at times so take advantage of the great comparison sites and where possible let them do the hard work for you.

2. Research - if it has been said it will be on the internet. Ignorance is no longer a justifiable reason for buying the wrong thing. Take the time to research in detail everything that you could possible want to know about

3. Testimonials - don't know anybody that has bought a Congestive Heart Failure? Wrong! If the Congestive Heart Failure is good the internet will let you know. Use the Internet as a friend and get testimonials before you buy.

4. Questions - Got a question about Congestive Heart Failure then search the Forums, FAQ's, Blogs etc. Don't be afraid to ask .....

5. Reputation - Never heard of the company selling Congestive Heart Failure? Don't worry, no reason why you should know every company in the world, but you know someone that does! Use the internet to find out what people are saying about Congestive Heart Failure and build up a picture of their reputation for sales, returns, customer service, delivery etc.

6. Returns - still worried that even after all of the above your Congestive Heart Failure wont be what you want? Check out the returns policy. There is so much competition now that someone, somewhere is bound to offer the terms that you are comfortable with.

7. Feedback - happy with your Congestive Heart Failure then let people know, after all you are depending on others people input in your buying decision, so why not give a little back.

8. Security - check for the yellow padlock on the Congestive Heart Failure site before you buy, and the s after http:/ /i.e. https:// = a secure site

9. Contact - got a question about Congestive Heart Failure, or want to leave a comment then check out the sites contact page. Reputable companies have them and respond.

10. Payment - ready to pay for your Congestive Heart Failure, then use your credit card or PayPal! Be aware of companies that don't accept them, there may be genuine reasons but given the huge amount of choice you have when buying online there is no reason at all not to buy via credit card or PayPal.

{{Infobox_Disease | Name = Heart failure | Image = | Caption = | DiseasesDB = 16209 | ICD10 = {{ICD10|I|50|0|i|50--> | ICD9 = {{ICD9|428.0--> | ICDO = | OMIM = | MedlinePlus = 000158 | eMedicineSubj = med | eMedicineTopic = 3552 | MeshID = D006333| -->

Congestive heart failure (CHF), also called congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood through the body. It is not to be confused with "cessation of heartbeat", which is known as asystole, or with cardiac arrest, which is the cessation of normal cardiac function with subsequent hemodynamic collapse leading to death. Because not all patients have Hypervolemia at the time of initial or subsequent evaluation, the term "heart failure" is preferred over the older term "congestive heart failure".

Congestive heart failure is often undiagnosed due to a lack of a universally agreed definition and difficulties in diagnosis, particularly when the condition is considered "mild". Even with the best therapy, heart failure is associated with an annual mortality of 10%. It is the leading cause of hospitalization in people older than 65.

Signs and symptoms Symptoms The symptoms depend largely on the side of the heart which is failing predominantly. If both sides are functioning inadequately, symptoms and signs from both categories may be present.

Given that the left side of the heart pumps blood from the lungs to the organs, failure to do so leads to congestion of the lung veins and symptoms that reflect this, as well as reduced supply of blood to the tissues. The predominant respiratory symptom is shortness of breath on exertion (dyspnea, dyspnée d'effort) - or in severe cases at rest - and easy fatigueability. Orthopnea is increasing breathlessness on reclining, measured in the number of pillows required to lie comfortably. Paroxysmal nocturnal dyspnea is a nighttime attack of severe breathlessness, usually several hours after going to sleep. Poor circulation to the body leads to dizziness, confusion and diaphoresis and cool extremities at rest.

The right side of the heart pumps blood returned from the tissues to the lungs to exchange carbon dioxide for oxygen. Hence, failure of the right side leads to congestion of peripheral tissues. This may lead to peripheral edema or anasarca and nocturia (frequent nighttime urination when the fluid from the legs is returned to the bloodstream). In more severe cases, ascites (fluid accumulation in the abdominal cavity) and hepatomegaly (painful enlargement of the liver) may develop.

Heart failure may decompensate easily; this may occur as the result of any intercurrent illness (such as pneumonia), but specifically myocardial infarction (a heart attack), anaemia, hyperthyroidism or cardiac arrhythmia. These place additional strain on the heart muscle, which may cause symptoms to rapidly worsen. Excessive fluid or salt intake (including intravenous fluids for unrelated indications), and medication that causes fluid retention (such as Non-steroidal anti-inflammatory drug and thiazolidinediones), may also precipitate decompensation.

Signs In examining a patient with possible heart failure, a health professional would look for particular medical sign. General signs indicating heart failure are a laterally displaced apex beat (as the heart is enlarged) and a gallop rhythm (additional heart sounds) in case of decompensation. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of the heart failure.

Predominant left-sided clinical signs are pulmonary edema (abnormal lung sounds due to fluid accumulation), evidence for pleural effusions (fluid collection in the pleural cavity), and cyanosis (due to poor absorption of oxygen by fluid-filled lungs).

Right-sided signs are peripheral edema, ascites and hepatomegaly, an increased jugular venous pressure and Abdominojugular test and parasternal heave.

Diagnosis Imaging Echocardiography is commonly used to support a clinical diagnosis of heart failure. This modality uses ultrasound to determine the proportion of blood entering the heart that is pumped by each heartbeat, the ejection fraction. Echocardiography can also identify valvular heart disease and assess the state of the pericardium (connective tissue sac surrounding the heart). Echocardiography may also aid in deciding what treatments will help the patient, such as medication, insertion of an implantable cardioverter-defibrillator or cardiac resynchronization therapy.

Chest X-rays are frequently used to aid in the diagnosis of CHF. In the compensated patient, this may show cardiomegaly (visible enlargement of the heart), quantified as the cardiothoracic ratio (proportion of the heart size to the chest). In left ventricular failure, there may be evidence of vascular redistribution ("upper lobe blood diversion"), Kerley lines, cuffing of the areas around the bronchi, and interstitial edema.

Electrophysiology An electrocardiogram (ECG/EKG) is used to identify arrhythmias, ischemic heart disease, Right ventricular hypertrophy and left ventricular hypertrophy, and presence of conduction delay or abnormalities (e.g. left bundle branch block).

Blood tests Blood tests routinely performed include electrolytes (sodium, potassium), measures of renal function, liver function tests, thyroid function tests, a complete blood count, and often C-reactive protein if infection is suspected. A specific test for heart failure is Brain natriuretic peptide (BNP), which is found to be elevated in heart failure. BNP can be used to differentiate between causes of dyspnea due to heart failure from other causes of dyspnea. If myocardial infarction is suspected, various cardiac markers may be used.

Angiography Heart failure may be the result of coronary artery disease, and its prognosis depends in part on the ability of the coronary artery to supply blood to the myocardium (heart muscle). As a result, coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or Coronary artery bypass surgery.

Monitoring Various measures are often used to assess the progress of patients being treated for heart failure. These include fluid balance (calculation of fluid intake and excretion), monitoring body weight (which in the shorter term reflects fluid shifts).

Diagnostic criteria No system of diagnostic criteria has been agreed as the Gold standard (test) for heart failure. Commonly used systems are the "Framingham criteria" (derived from the Framingham Heart Study), the "Boston criteria", the "Duke criteria", and (in the setting of acute myocardial infarction) the "Killip class".

Functional classification is generally done by the New York Heart Association Functional Classification.Criteria Committee, New York Heart Association. Diseases of the heart and blood vessels. Nomenclature and criteria for diagnosis, 6th ed. Boston: Little, Brown and co, 1964;114. This score documents severity of symptoms, and can be used to assess response to treatment. While its use is widespead, the NYHA score is not very reproducible and doesn't reliably predict the walking distance or exercise tolerance on formal testing. The classes (I-IV) are:

• Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
• Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
• Class III: marked limitation of any activity; the patient is comfortable only at rest.
• Class IV: any physical activity brings on discomfort and symptoms occur at rest.

In its 2001 guidelines, the American College of Cardiology/American Heart Association working group introduced four stages of heart failure:

• Stage A: a high risk HF in the future but no structural heart disorder;
• Stage B: a structural heart disorder but no symptoms at any stage;
• Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment;
• Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

Classification There are many different ways to categorize heart failure, including:

• the side of the heart involved, (left heart failure versus right heart failure)
• whether the abnormality is due to contraction or relaxation of the heart (systolic dysfunction vs. diastolic dysfunction)
• whether the abnormality is due to low cardiac output or high systemic vascular resistance (low-output heart failure vs. high-output heart failure)
• the degree of functional impairment conferred by the abnormality (as in the NYHA functional classification)

Causes Causes and contributing factors to congestive heart failure include the following:

{| class="wikitable"|-! colspan="2" | Causes of heart failure|-|align="center"| Left-sided: hypertension (high blood pressure), aortic valve and mitral valve Valvular heart disease, aortic coarctation (e.g. due to chronic lung disease), [pulmonary valve or Tricuspid valve Valvular heart disease|-|colspan="2" align="center"| May affect both sides: Ischemic heart disease (due to insufficient vascular supply, usually as a result of coronary artery disease); this may be chronic or due to myocardial infarction (a heart attack), Cardiac arrhythmia (e.g. atrial fibrillation), cardiomyopathy of any cause, cardiac fibrosis, chronic severe anemia, thyroid disease (hyperthyroidism and hypothyroidism)|}

Treatment The treatment of CHF focuses on treating the symptoms and signs of CHF and preventing the progression of disease. If there is a reversible cause of the heart failure (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, or hypertension), that should be addressed as well. Reversible cause treatments can include exercise, eating healthy foods, reduction in salty foods, and Wiktionary:abstinence of smoking and drinking alcohol.

Non-pharmacological measures Patients with CHF are educated to undertake various non-pharmacological measures to improve symptoms and prognosis. Such measures include:Smith A, Aylward P, Campbell T, et al. Therapeutic Guidelines: Cardiovascular, 4th edition. North Melbourne: Therapeutic Guidelines; 2003. ISSN 1327-9513

• Moderate physical activity, when symptoms are mild or moderate; or bed rest when symptoms are severe.
• Weight reduction – through physical activity and dietary modification, as obesity is a risk factor for heart failure and ventricular hypertrophy.
• Monitor weight - Weight gain of more than 2 pounds is associated with admission to the hospital for heart failure
• Sodium restriction – excessive sodium intake may precipitate or exacerbate heart failure, thus a "no added salt" diet (60–100 mmol total daily intake) is recommended for patients with CHF. More severe restrictions may be required in severe CHF.
• Fluid restriction – patients with CHF have a diminished ability to excrete free water load. They are also at an increased risk of hyponatremia due to the combination of decreased sodium intake and diuretic therapy. Generally water intake should be limited to 1.5 L daily or less in patients with hyponatremia, though fluid restriction may be beneficial regardless in symptomatic reduction.

Pharmacological management There is a significant evidence–practice gap in the treatment of CHF; particularly the underuse of ACE inhibitors and beta-blocker and aldosterone antagonists which have been shown to provide mortality benefit.Jackson S, Bereznicki L, Peterson G. Under-use of ACE-inhibitor and β-blocker therapies in congestive cardiac failure. Australian Pharmacist 2005;24(12):936. Treatment of CHF aims to relieve symptoms, maintain a euvolemia state (normal fluid level in the circulatory system), and to improve prognosis by delaying progression of heart failure and reducing cardiovascular risk. Drugs used include: diuretic agents, vasodilator agents, positive inotropes, ACE inhibitors, beta blockers, and aldosterone antagonists (e.g. spironolactone). It should be noted that while intuitive, increasing heart function with some drugs, such as the positive inotrope Milrinone, leads to increased mortality.

Angiotensin-modulating agents ACE inhibitor (ACE) therapy is recommended for all patients with systolic heart failure, irrespective of symptomatic severity or blood pressure.National Institute for Clinical Excellence. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 5. London: National Institute for Clinical Excellence; 2003 Jul. Available from: www.nice.org.uk/pdf/CG5NICEguideline.pdf ACE inhibitors improve symptoms, decrease death and reduce ventricular hypertrophy. Angiotensin II receptor antagonist therapy (also referred to as AT1-antagonists or angiotensin receptor blockers), particularly using candesartan, is an acceptable alternative if the patient is unable to tolerate ACEI therapy.

Diuretics Diuretic therapy is indicated for relief of congestive symptoms. Several classes are used, with combinations reserved for severe heart failure:

• Loop diuretics (e.g. furosemide) – most commonly used class in CHF, usually for moderate CHF.
• Thiazide diuretics (e.g. hydrochlorothiazide) – useful for mild CHF.
• Potassium-sparing diuretics (e.g. amiloride) – used first-line use to correct hypokalaemia.
• Spironolactone is used as add-on therapy to ACEI plus loop diuretic in severe CHF.
• Eplerenone is specifically indicated for post-MI reduction of cardiovascular risk.

Beta blockers Until recently, beta blockers were contraindicated in CHF, owing to their negative inotropic effect and ability to produce bradycardia – effects which worsen heart failure. However, current guidelines recommend β-blocker therapy for patients with systolic heart failure due to left ventricular systolic dysfunction after stabilization with diuretic and ACEI therapy, irrespective of symptomatic severity or blood pressure. As with ACEI therapy, the addition of a β-blocker can decrease mortality and improve left ventricular function. Several β-blockers are specifically indicated for CHF including: bisoprolol, carvedilol, and extended-release metoprolol.

Positive inotropes Digoxin, once used as first-line therapy, is now reserved for control of ventricular rhythm in patients with atrial fibrillation; or where adequate control is not achieved with an ACEI, a beta blocker and a loop diuretic. There is no evidence that digoxin reduces mortality in CHF, although some studies suggest a decreased rate in hospital admissions. It is contraindicated in cardiac tamponade and restrictive cardiomyopathy.

The inotropic agent dobutamine is advised only in the short-term use of acutely decompensated heart failure, and has no other uses.

Alternative vasodilators The combination of isosorbide dinitrate/hydralazine is the only vasodilator regimen, other than ACE inhibitors or angiotensin II receptor antagonists, with proven survival benefits. This combination appears to be particularly beneficial in CHF patients with an African American background, who respond less effectively to ACEI therapy.

Devices and surgery Patients with New York Heart Association Functional Classification III or IV, left ventricular ejection fraction (LVEF) of 35% or less and a QRS interval of 120 millisecond or more may benefit from cardiac resynchronization therapy (CRT; pacing both the left ventricle and right ventricles), through implantation of an artificial pacemaker, or surgical remodelling of the heart. These treatment modalities may make the patient symptomatically better, improving quality of life and in some trials have been proven to reduce mortality.

The COMPANION trial demonstrated that CRT improved survival in individuals with New York Heart Association Functional Classification III or IV heart failure with a widened QRS complex on EKG. The CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all cause mortality, and a reduction in cardiovascular-related hospitalization.

Patients with New York Heart Association Functional Classification II, III or IV, and LVEF of 35% (without a QRS requirement) may also benefit from an implantable cardioverter-defibrillator (ICD), a device that is proven to reduce all cause mortality by 23% compared to placebo. This mortality benefit was observed in patients who were already optimally-managed on drug therapy.

Another current treatment involves the use of left ventricular assist devices (LVADs). LVADs are battery-operated mechanical pump-type devices that are surgically implanted on the upper part of the abdomen. They take blood from the left ventricle and pump it through the aorta. LVADs are becoming more common and are often used by patients who have to wait for heart transplants.

The final option, if other measures have failed, is heart transplantation (heart transplant) or implantation of an artificial heart. A radical new type of surgery, which is largely untested and is still in its first stages of development, was invented by Brazilian doctor Randas Batista in 1994. It involves removal of a swath of the left ventricle, to make contractions more efficient and prevent backflow of blood into the left atrium through the bicuspid valve.

Palliative care and hospice The growing number of patients with Stage D heart failure (intractable symptoms of fatigue, shortness of breath or chest pain at rest despite optimal medical therapy) should be considered for palliative care or hospice, according to American College of Cardiology/American Heart Association guidelines.

Prognosis Among several clinical prediction rules for prognosing acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying patients and identifying those at low risk of death during hospitalization or within 30 days. Easy methods for identifying low risk patients are:

• ADHERE Tree rule indicates that patients with blood urea nitrogen < 43 mg/dl and systolic blood pressure at least 115 mm Hg have less than 10% chance of inpatient death or complications.
• BWH rule indicates that patients with systolic blood pressure over 90 mm Hg, respiratory rate of 30 or less breaths per minute, serum sodium over 135 mmol/L, no new ST-T wave changes have less than 10% chance of inpatient death or complications.

References See also

• Cardiogenic shock
• Heart transplant
• Dor procedure
• ACE inhibitor
• Isosorbide dinitrate/hydralazine
• Killip class
• Ventricular remodeling

External links

• American Heart Association's Heart Failure web site - information and resources for treating and living with heart failure.
• Heart Failure Matters, patient information website of the Heart Failure Association of the European Society of Cardiology
• Congestive Heart Failure information from Seattle Children's Hospital Heart Center
• www.heartfailure-europe.com Patient information website of SHAPE (Study Group on Heart failure Awareness and Perception in Europe)

{{Infobox_Disease | Name = Heart failure | Image = | Caption = | DiseasesDB = 16209 | ICD10 = {{ICD10|I|50|0|i|50--> | ICD9 = {{ICD9|428.0--> | ICDO = | OMIM = | MedlinePlus = 000158 | eMedicineSubj = med | eMedicineTopic = 3552 | MeshID = D006333| -->

Congestive heart failure (CHF), also called congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood through the body. It is not to be confused with "cessation of heartbeat", which is known as asystole, or with cardiac arrest, which is the cessation of normal cardiac function with subsequent hemodynamic collapse leading to death. Because not all patients have Hypervolemia at the time of initial or subsequent evaluation, the term "heart failure" is preferred over the older term "congestive heart failure".

Congestive heart failure is often undiagnosed due to a lack of a universally agreed definition and difficulties in diagnosis, particularly when the condition is considered "mild". Even with the best therapy, heart failure is associated with an annual mortality of 10%. It is the leading cause of hospitalization in people older than 65.

Signs and symptoms Symptoms The symptoms depend largely on the side of the heart which is failing predominantly. If both sides are functioning inadequately, symptoms and signs from both categories may be present.

Given that the left side of the heart pumps blood from the lungs to the organs, failure to do so leads to congestion of the lung veins and symptoms that reflect this, as well as reduced supply of blood to the tissues. The predominant respiratory symptom is shortness of breath on exertion (dyspnea, dyspnée d'effort) - or in severe cases at rest - and easy fatigueability. Orthopnea is increasing breathlessness on reclining, measured in the number of pillows required to lie comfortably. Paroxysmal nocturnal dyspnea is a nighttime attack of severe breathlessness, usually several hours after going to sleep. Poor circulation to the body leads to dizziness, confusion and diaphoresis and cool extremities at rest.

The right side of the heart pumps blood returned from the tissues to the lungs to exchange carbon dioxide for oxygen. Hence, failure of the right side leads to congestion of peripheral tissues. This may lead to peripheral edema or anasarca and nocturia (frequent nighttime urination when the fluid from the legs is returned to the bloodstream). In more severe cases, ascites (fluid accumulation in the abdominal cavity) and hepatomegaly (painful enlargement of the liver) may develop.

Heart failure may decompensate easily; this may occur as the result of any intercurrent illness (such as pneumonia), but specifically myocardial infarction (a heart attack), anaemia, hyperthyroidism or cardiac arrhythmia. These place additional strain on the heart muscle, which may cause symptoms to rapidly worsen. Excessive fluid or salt intake (including intravenous fluids for unrelated indications), and medication that causes fluid retention (such as Non-steroidal anti-inflammatory drug and thiazolidinediones), may also precipitate decompensation.

Signs In examining a patient with possible heart failure, a health professional would look for particular medical sign. General signs indicating heart failure are a laterally displaced apex beat (as the heart is enlarged) and a gallop rhythm (additional heart sounds) in case of decompensation. Heart murmurs may indicate the presence of valvular heart disease, either as a cause (e.g. aortic stenosis) or as a result (e.g. mitral regurgitation) of the heart failure.

Predominant left-sided clinical signs are pulmonary edema (abnormal lung sounds due to fluid accumulation), evidence for pleural effusions (fluid collection in the pleural cavity), and cyanosis (due to poor absorption of oxygen by fluid-filled lungs).

Right-sided signs are peripheral edema, ascites and hepatomegaly, an increased jugular venous pressure and Abdominojugular test and parasternal heave.

Diagnosis Imaging Echocardiography is commonly used to support a clinical diagnosis of heart failure. This modality uses ultrasound to determine the proportion of blood entering the heart that is pumped by each heartbeat, the ejection fraction. Echocardiography can also identify valvular heart disease and assess the state of the pericardium (connective tissue sac surrounding the heart). Echocardiography may also aid in deciding what treatments will help the patient, such as medication, insertion of an implantable cardioverter-defibrillator or cardiac resynchronization therapy.

Chest X-rays are frequently used to aid in the diagnosis of CHF. In the compensated patient, this may show cardiomegaly (visible enlargement of the heart), quantified as the cardiothoracic ratio (proportion of the heart size to the chest). In left ventricular failure, there may be evidence of vascular redistribution ("upper lobe blood diversion"), Kerley lines, cuffing of the areas around the bronchi, and interstitial edema.

Electrophysiology An electrocardiogram (ECG/EKG) is used to identify arrhythmias, ischemic heart disease, Right ventricular hypertrophy and left ventricular hypertrophy, and presence of conduction delay or abnormalities (e.g. left bundle branch block).

Blood tests Blood tests routinely performed include electrolytes (sodium, potassium), measures of renal function, liver function tests, thyroid function tests, a complete blood count, and often C-reactive protein if infection is suspected. A specific test for heart failure is Brain natriuretic peptide (BNP), which is found to be elevated in heart failure. BNP can be used to differentiate between causes of dyspnea due to heart failure from other causes of dyspnea. If myocardial infarction is suspected, various cardiac markers may be used.

Angiography Heart failure may be the result of coronary artery disease, and its prognosis depends in part on the ability of the coronary artery to supply blood to the myocardium (heart muscle). As a result, coronary catheterization may be used to identify possibilities for revascularisation through percutaneous coronary intervention or Coronary artery bypass surgery.

Monitoring Various measures are often used to assess the progress of patients being treated for heart failure. These include fluid balance (calculation of fluid intake and excretion), monitoring body weight (which in the shorter term reflects fluid shifts).

Diagnostic criteria No system of diagnostic criteria has been agreed as the Gold standard (test) for heart failure. Commonly used systems are the "Framingham criteria" (derived from the Framingham Heart Study), the "Boston criteria", the "Duke criteria", and (in the setting of acute myocardial infarction) the "Killip class".

Functional classification is generally done by the New York Heart Association Functional Classification.Criteria Committee, New York Heart Association. Diseases of the heart and blood vessels. Nomenclature and criteria for diagnosis, 6th ed. Boston: Little, Brown and co, 1964;114. This score documents severity of symptoms, and can be used to assess response to treatment. While its use is widespead, the NYHA score is not very reproducible and doesn't reliably predict the walking distance or exercise tolerance on formal testing. The classes (I-IV) are:

• Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
• Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
• Class III: marked limitation of any activity; the patient is comfortable only at rest.
• Class IV: any physical activity brings on discomfort and symptoms occur at rest.

In its 2001 guidelines, the American College of Cardiology/American Heart Association working group introduced four stages of heart failure:

• Stage A: a high risk HF in the future but no structural heart disorder;
• Stage B: a structural heart disorder but no symptoms at any stage;
• Stage C: previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment;
• Stage D: advanced disease requiring hospital-based support, a heart transplant or palliative care.

Classification There are many different ways to categorize heart failure, including:

• the side of the heart involved, (left heart failure versus right heart failure)
• whether the abnormality is due to contraction or relaxation of the heart (systolic dysfunction vs. diastolic dysfunction)
• whether the abnormality is due to low cardiac output or high systemic vascular resistance (low-output heart failure vs. high-output heart failure)
• the degree of functional impairment conferred by the abnormality (as in the NYHA functional classification)

Causes Causes and contributing factors to congestive heart failure include the following:

{| class="wikitable"|-! colspan="2" | Causes of heart failure|-|align="center"| Left-sided: hypertension (high blood pressure), aortic valve and mitral valve Valvular heart disease, aortic coarctation (e.g. due to chronic lung disease), [pulmonary valve or Tricuspid valve Valvular heart disease|-|colspan="2" align="center"| May affect both sides: Ischemic heart disease (due to insufficient vascular supply, usually as a result of coronary artery disease); this may be chronic or due to myocardial infarction (a heart attack), Cardiac arrhythmia (e.g. atrial fibrillation), cardiomyopathy of any cause, cardiac fibrosis, chronic severe anemia, thyroid disease (hyperthyroidism and hypothyroidism)|}

Treatment The treatment of CHF focuses on treating the symptoms and signs of CHF and preventing the progression of disease. If there is a reversible cause of the heart failure (e.g. infection, alcohol ingestion, anemia, thyrotoxicosis, arrhythmia, or hypertension), that should be addressed as well. Reversible cause treatments can include exercise, eating healthy foods, reduction in salty foods, and Wiktionary:abstinence of smoking and drinking alcohol.

Non-pharmacological measures Patients with CHF are educated to undertake various non-pharmacological measures to improve symptoms and prognosis. Such measures include:Smith A, Aylward P, Campbell T, et al. Therapeutic Guidelines: Cardiovascular, 4th edition. North Melbourne: Therapeutic Guidelines; 2003. ISSN 1327-9513

• Moderate physical activity, when symptoms are mild or moderate; or bed rest when symptoms are severe.
• Weight reduction – through physical activity and dietary modification, as obesity is a risk factor for heart failure and ventricular hypertrophy.
• Monitor weight - Weight gain of more than 2 pounds is associated with admission to the hospital for heart failure
• Sodium restriction – excessive sodium intake may precipitate or exacerbate heart failure, thus a "no added salt" diet (60–100 mmol total daily intake) is recommended for patients with CHF. More severe restrictions may be required in severe CHF.
• Fluid restriction – patients with CHF have a diminished ability to excrete free water load. They are also at an increased risk of hyponatremia due to the combination of decreased sodium intake and diuretic therapy. Generally water intake should be limited to 1.5 L daily or less in patients with hyponatremia, though fluid restriction may be beneficial regardless in symptomatic reduction.

Pharmacological management There is a significant evidence–practice gap in the treatment of CHF; particularly the underuse of ACE inhibitors and beta-blocker and aldosterone antagonists which have been shown to provide mortality benefit.Jackson S, Bereznicki L, Peterson G. Under-use of ACE-inhibitor and β-blocker therapies in congestive cardiac failure. Australian Pharmacist 2005;24(12):936. Treatment of CHF aims to relieve symptoms, maintain a euvolemia state (normal fluid level in the circulatory system), and to improve prognosis by delaying progression of heart failure and reducing cardiovascular risk. Drugs used include: diuretic agents, vasodilator agents, positive inotropes, ACE inhibitors, beta blockers, and aldosterone antagonists (e.g. spironolactone). It should be noted that while intuitive, increasing heart function with some drugs, such as the positive inotrope Milrinone, leads to increased mortality.

Angiotensin-modulating agents ACE inhibitor (ACE) therapy is recommended for all patients with systolic heart failure, irrespective of symptomatic severity or blood pressure.National Institute for Clinical Excellence. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care. Clinical Guideline 5. London: National Institute for Clinical Excellence; 2003 Jul. Available from: www.nice.org.uk/pdf/CG5NICEguideline.pdf ACE inhibitors improve symptoms, decrease death and reduce ventricular hypertrophy. Angiotensin II receptor antagonist therapy (also referred to as AT1-antagonists or angiotensin receptor blockers), particularly using candesartan, is an acceptable alternative if the patient is unable to tolerate ACEI therapy.

Diuretics Diuretic therapy is indicated for relief of congestive symptoms. Several classes are used, with combinations reserved for severe heart failure:

• Loop diuretics (e.g. furosemide) – most commonly used class in CHF, usually for moderate CHF.
• Thiazide diuretics (e.g. hydrochlorothiazide) – useful for mild CHF.
• Potassium-sparing diuretics (e.g. amiloride) – used first-line use to correct hypokalaemia.
• Spironolactone is used as add-on therapy to ACEI plus loop diuretic in severe CHF.
• Eplerenone is specifically indicated for post-MI reduction of cardiovascular risk.

Beta blockers Until recently, beta blockers were contraindicated in CHF, owing to their negative inotropic effect and ability to produce bradycardia – effects which worsen heart failure. However, current guidelines recommend β-blocker therapy for patients with systolic heart failure due to left ventricular systolic dysfunction after stabilization with diuretic and ACEI therapy, irrespective of symptomatic severity or blood pressure. As with ACEI therapy, the addition of a β-blocker can decrease mortality and improve left ventricular function. Several β-blockers are specifically indicated for CHF including: bisoprolol, carvedilol, and extended-release metoprolol.

Positive inotropes Digoxin, once used as first-line therapy, is now reserved for control of ventricular rhythm in patients with atrial fibrillation; or where adequate control is not achieved with an ACEI, a beta blocker and a loop diuretic. There is no evidence that digoxin reduces mortality in CHF, although some studies suggest a decreased rate in hospital admissions. It is contraindicated in cardiac tamponade and restrictive cardiomyopathy.

The inotropic agent dobutamine is advised only in the short-term use of acutely decompensated heart failure, and has no other uses.

Alternative vasodilators The combination of isosorbide dinitrate/hydralazine is the only vasodilator regimen, other than ACE inhibitors or angiotensin II receptor antagonists, with proven survival benefits. This combination appears to be particularly beneficial in CHF patients with an African American background, who respond less effectively to ACEI therapy.

Devices and surgery Patients with New York Heart Association Functional Classification III or IV, left ventricular ejection fraction (LVEF) of 35% or less and a QRS interval of 120 millisecond or more may benefit from cardiac resynchronization therapy (CRT; pacing both the left ventricle and right ventricles), through implantation of an artificial pacemaker, or surgical remodelling of the heart. These treatment modalities may make the patient symptomatically better, improving quality of life and in some trials have been proven to reduce mortality.

The COMPANION trial demonstrated that CRT improved survival in individuals with New York Heart Association Functional Classification III or IV heart failure with a widened QRS complex on EKG. The CARE-HF trial showed that patients receiving CRT and optimal medical therapy benefited from a 36% reduction in all cause mortality, and a reduction in cardiovascular-related hospitalization.

Patients with New York Heart Association Functional Classification II, III or IV, and LVEF of 35% (without a QRS requirement) may also benefit from an implantable cardioverter-defibrillator (ICD), a device that is proven to reduce all cause mortality by 23% compared to placebo. This mortality benefit was observed in patients who were already optimally-managed on drug therapy.

Another current treatment involves the use of left ventricular assist devices (LVADs). LVADs are battery-operated mechanical pump-type devices that are surgically implanted on the upper part of the abdomen. They take blood from the left ventricle and pump it through the aorta. LVADs are becoming more common and are often used by patients who have to wait for heart transplants.

The final option, if other measures have failed, is heart transplantation (heart transplant) or implantation of an artificial heart. A radical new type of surgery, which is largely untested and is still in its first stages of development, was invented by Brazilian doctor Randas Batista in 1994. It involves removal of a swath of the left ventricle, to make contractions more efficient and prevent backflow of blood into the left atrium through the bicuspid valve.

Palliative care and hospice The growing number of patients with Stage D heart failure (intractable symptoms of fatigue, shortness of breath or chest pain at rest despite optimal medical therapy) should be considered for palliative care or hospice, according to American College of Cardiology/American Heart Association guidelines.

Prognosis Among several clinical prediction rules for prognosing acute heart failure, the 'EFFECT rule' slightly outperformed other rules in stratifying patients and identifying those at low risk of death during hospitalization or within 30 days. Easy methods for identifying low risk patients are:

• ADHERE Tree rule indicates that patients with blood urea nitrogen < 43 mg/dl and systolic blood pressure at least 115 mm Hg have less than 10% chance of inpatient death or complications.
• BWH rule indicates that patients with systolic blood pressure over 90 mm Hg, respiratory rate of 30 or less breaths per minute, serum sodium over 135 mmol/L, no new ST-T wave changes have less than 10% chance of inpatient death or complications.

References See also

• Cardiogenic shock
• Heart transplant
• Dor procedure
• ACE inhibitor
• Isosorbide dinitrate/hydralazine
• Killip class
• Ventricular remodeling

External links

• American Heart Association's Heart Failure web site - information and resources for treating and living with heart failure.
• Heart Failure Matters, patient information website of the Heart Failure Association of the European Society of Cardiology
• Congestive Heart Failure information from Seattle Children's Hospital Heart Center
• www.heartfailure-europe.com Patient information website of SHAPE (Study Group on Heart failure Awareness and Perception in Europe)

Congestive Heart Failure
Explains this condition where the heart can't pump enough blood to the organs, what causes it, diagnosis, and treatment.

Heart Failure
Learn more about congestive heart failure, its treatment, and ways to cope with stress and the disease.

Congestive Heart Failure Recovery & Prevention
Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood (cardiac ischemia) to the body's other organs.

Heart failure - Wikipedia, the free encyclopedia
Heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with blood or pump a sufficient ...

Congestive Heart Failure (CHF) Symptoms, Causes, Diagnosis, and ...
Read about congestive heart failure symptoms like fatigue, abdomen, leg and ankle swelling, shortness of breath, sleeplessness, increased urination, nausea, abdominal pain, and ...

Definition: congestive heart failure from Online Medical Dictionary
The Online Medical Dictionary is a searchable dictionary of definitions from medicine, science and technology.

Congestive heart failure - What is it? - Introduction
Information on Congestive heart failure from NHS Choices including causes, symptoms, diagnosis, risks and treatment and with links to other useful resources

MedlinePlus Medical Encyclopedia: Heart failure
Alternative Names Return to top. CHF; Congestive heart failure. Definition Return to top. Heart failure, also called congestive heart failure, is a life-threatening condition ...

Congestive heart failure Causes - Health encyclopaedia - NHS Direct ...
Decreased heart function and clogging of the lungs ... In many cases, the cause of congestive heart failure is unknown. Suggested contributors are:

Congestive Heart Failure
Frequently Asked Questions. What is Congestive Heart Failure? What are the symptoms of Heart Failure? What tests will my doctor perform? What is SVR ...