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Understanding Congestive Heart Failure

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What is Congestive Heart Failure?

Congestive heart failure (CHF) is synonymous with heart failure. It is a disease state in which the heart cannot normally fill with or eject blood.  In either case the heart does not symptoms of congestive heart failurepump out enough blood to meet the body’s demands for oxygen, nutrients, and removal of carbon dioxide. Additionally, it can’t pump out as much blood as it receives. This results in the accumulation of fluid in the heart, vessels and tissues. It can involve the left side, right side or both sides of the heart.

It is important to understand that heart failure does not mean the heart stops beating. The proper terminology for that phenomenon is cardiac arrest or asystole which can be a consequence. Asystole can also occur in the absence of CHF. It is also important to understand that although a heart attack can cause congestive heart failure it is not the same, and congestive heart failure can occur in the absence of a heart attack.

Systolic versus Diastolic Heart Failure

Systolic CHF is a result of the left ventricle being too weak to pump a normal amount of blood to the tissues of the body. The medical term for this state is systolic dysfunction. The accumulation of fluid resulting from the left ventricle’s inability to pump out as much blood as it receives causes fluid and pressure to build up in the heart as well as the vessels and tissues of the lungs. The accumulation of fluid in the lungs interferes with the transport of oxygen from the lungs into the bloodstream, which along with the decreased expulsion of blood, results in decreased oxygen delivery to tissues of the body.

Diastolic CHF results from the left ventricle being stiff and unable to normally relax while filling with blood. The term for this medical state is diastolic dysfunction. Diastolic dysfunction causes the heart to not be able to pump sufficient amounts of blood to tissues because it is not able to adequately fill with blood. The same fluid accumulation and pressure increase in the heart, blood vessels and lungs occurs because of the decreased ability of the heart muscle to relax while filling. That state of congestion has the same effect on oxygen exchange between the lungs and bloodstream as in the case of systolic heart failure.

Left Sided versus Right Sided Heart Failure

CHF can involve the left ventricle, the right ventricle, or both chambers. It most commonly begins with the left ventricle, but can eventually involve the right ventricle depending upon the amount and degree of fluid backup. When right sided heart failure is present the right ventricle is not able to pump sufficient amounts of blood to the lungs and there is fluid backup into the abdomen, lower limbs and liver.

Congestive Heart Failure Symptoms

There are three categories of congestive heart failure symptoms. Those categories are: the one related to the decreased amount of blood the heart pumps out, the one associated with decreased oxygen in the blood stream and tissues, and the one having to do with the accumulation of fluid in the heart, blood vessels and tissues.

Cardiac output is the medical term for the volume of blood the heart pumps out in one minute. Symptoms due to reduced cardiac output are fatigue and generalized weakness. If the reduced cardiac output results in the blood pressure being too low it can also cause lightheadedness or fainting.

Symptoms due to reduced oxygen in the blood stream and tissues are shortness of breath, fatigue and generalized weakness. In the early stages the shortness of breath is noticed primarily during exertion, but as the disease worsens victims experience shortness of breath with decreasing degrees of exertion, and sometimes even at rest. One of the differences between the shortness of breath associated with CHF and that which occurs with other conditions is its onset while lying flat without elevation of the head (orthopnea). In contrast to other causes of shortness of breath CHF is also oftentimes associated with paroxysmal nocturnal dyspnea.

Symptoms due to the accumulation of fluid in the heart, blood vessels and tissues, depends upon the degree of accumulation and where it occurs. If what many call fluid on the lungs (pulmonary edema) is present, the shortness of breath is usually worse and coughing is common. The accumulation of fluid in the pleural space (pleural effusion) can also cause greater degrees of shortness of breath. The buildup of fluid in the liver or veins of the liver and other organs in the abdomen can cause nausea, vomiting and abdominal discomfort. Excessive fluid in the abdomen or tissues of the lower limbs might cause varying degrees of discomfort due to swelling.

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Signs of Heart Failure

Much like with symptoms, there are three categories of congestive heart failure signs which medical personnel and others can observe. Signs of reduced cardiac output are hypotension and tachycardia. Tachycardia is the body’s attempt to compensate for the blood pressure being too low. Oftentimes, if the blood pressure is very low the skin may be cool to touch and there might be alteration of consciousness.

A bluish discoloration of the skin or mucous membranes (cyanosis) is a common sign of low oxygen levels in tissue. The lack of oxygen in the body causes more rapid breathing and an increased heart rate in an attempt to compensate for the deficit. Decrease oxygen levels in brain tissue might also cause alteration of mental status.

The accumulation of fluid in the lung tissue or in the pleural space causes rapid breathing and in many instances is associated with labored breathing. The buildup of fluid in the left ventricle can cause an abnormal heart sound (S3 gallop) which a doctor can hear with a stethoscope. A doctor can also hear crackles in the lung fields when he listens to the chest with a stethoscope if pulmonary edema is present. Peripheral edema of the lower extremities is present if there is significant buildup of fluid in those tissues. A physician might observe a fluid wave or other evidence if there is fluid collection in the abdomen. A physician can actually feel enlargement of the liver if fluid has accumulated in that organ. Another sign of right sided heart failure is bulging of the veins in the neck which drain blood from the head back into the right side of the heart. If distended neck veins are not visible, but there is congestion of the liver pressing on the liver can cause bulging veins to appear.  Doctors call it hepatojugular reflux.

Causes of Congestive Heart Failure

It is beyond the scope of this article to try to cover all of the causes of congestive-heart-failure. But to simplify matters and make the information most useful to you, there are generally four categories of causes. They are: injury to the heart muscle, disease of the heart muscle, valvular heart disease and factors outside of the heart.

When considering injury to the heart, we are basically talking about a heart attack (myocardial infarction). Less common causes include blunt trauma to the chest wall, overwhelming bloodstream infection, electrocution, etc.

CHF resulting from valvular heart disease is not an injury in the strictest sense of the word, but can be viewed as a type of self-injury, inasmuch as the abnormal flow of blood within the heart caused by an abnormal valve results in structural changes within the heart that affect its ability to pump blood.

The correct medical term for disease of the heart muscle is cardiomyopathy. There are many causes, but the most common known ones are ischemia, hypertension, alcohol, and viral infection. Ischemic cardiomyopathy can be the result of coronary artery disease or disease in very small vessels which would not show up on coronary angiography. The cardiomyopathy caused by hypertension is one in which the heart muscle is thickened. It is termed hypertrophic cardiomyopathy. This type of heart muscle disease causes decreased relaxation rather than weakness of the left ventricle. Therefore, it usually results in diastolic heart failure rather than systolic heart failure. The term for heart muscle disease caused by a viral infection is myocarditis. The most common cardiomyopathy is idiopathic dilated cardiomyopathy. It is associated with enlargement and weakness of the left ventricle. Idiopathic means the cause is unknown.

Factors outside of the heart which result in CHF are those which cause the organ to overwork. A common cause of the heart having to overwork is volume overload. One of the more common causes of volume overload is kidney failure, because normally functioning kidneys are necessary for the body to eliminate excess fluid. Extremely elevated blood pressure can cause CHF, even if it has not been existent long enough for hypertrophic cardiomyopathy to develop. The reason is the increased pressure that the left ventricle has to pump against to eject blood places a strain on the heart.  The heart might also have to overwork when it is trying to compensate for severe anemia. In this case it is termed high output CHF. Another form of high output CHF is that associated with an overactive thyroid gland.

Heart Failure Diagnosis

CHF is not a simple straight forward easily diagnosed disease in which a test, symptom or sign proves the diagnosis in all cases. This is because of its different forms and the fact that it differs in how it manifests in various individuals. Signs and symptoms alone can sometimes yield a diagnosis. In some cases though, tests are also required.

Two of the more useful tests for diagnosing CHF are echocardiography and brain natriuretic peptide. If a person has signs and symptoms of CHF an echocardiogram with Doppler confirms the diagnosis of systolic failure if it reveals an ejection fraction of less than 50%. On the other hand, if the ejection fraction is 50% or greater but it shows diastolic dysfunction the diagnosis is diastolic heart failure. Similarly, if there is evidence of CHF but the natriuretic peptide is below a certain level (the cutoff point) diastolic failure is the diagnosis. If left and right sided heart failure are present an echocardiogram with Doppler will most likely show a low ejection fraction and diastolic dysfunction.

Acute versus Chronic Heart Failure

Finally, it is important to understand the difference between acute and chronic failure. This is because after the ICD 10 transition, patients will need to be able to provide doctors with the necessary information for proper billing. Under the new coding system doctors will have to not only use the proper code to show whether or not the condition is acute, chronic, or acute on chronic. They will also have to provide documentation in the form of patient symptoms, signs and test results, if needed, to support the diagnosis.

First of all, acute and chronic refer to how fast signs and symptoms develop and whether they are stable – not necessarily the severity. Signs and symptoms of acute CHF can develop within minutes to a few hours and most commonly occur with a heart attack. Chronic CHF signs and symptoms on the other hand, might develop over several days, weeks or months. Signs and symptoms of chronic CHF can be stable, but if they worsen to a degree that urgent treatment is needed CHF with decompensation exists. According to the ICD 10 CM coding system the latter state requires the use of the acute on chronic CHF code.

Patients are not required to know diagnosis codes. But they do need to be able to tell doctors whether or not they have experienced certain signs and symptoms of CHF and approximately when they began to occur. It would be in the best interest of individuals with chronic heart failure to keep a diary or personal health record of their signs and symptoms. That information would help physicians make the correct diagnosis and provide the best treatment.

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