Congestive heart


Right or left Sided heart failure, Cardiomyopathy


Congestive heart failure is an abnormality of the heart functioning wherebyheart is unable to pump sufficient blood to the body tissues or has to compensate with increased pressure in the ventricle while pumping out blood.It is described as an end stage of cardiac disease.
Congestive heart failure contributes to significant disability and death worldwide with occurrence of new cases and of total number of all cases showing an increase. The incidence of the disease increases with age.  It is more commonly found in males than in females.  the American Heart association estimates a total of about 5.7 million with similar occurrence in western European countries.  In the Indian subcontinent, the prevalence is estimated at 18.8 million with new cases of about 1.57 million per year.


Increased pressure on the heart muscle leads to stretching and enlargement of the muscle cells, and this in turn weakens the heart muscles. The neuroendocrine system (deals with nervous and endocrine system) responds with release of hormones called epinephrine and norepinephrine and other substances, which leads to narrowing of the blood vessels which in turn increases  pressure on the smaller vessels of the arms and feet.  The amount of blood pumped out of the heart decreases overall.  This can result in rhythm changes of the heart and could lead to death. 
In right-sided heart failure, enzymes such as bilirubin and transaminases show moderate increase.  In left-sided heart failure, there is a marked increase of the same enzymes. 
Congestion leads to reduced blood reaching the kidney and activation of a hormonal cascade called the renin-angiotensin system (a hormonal system which helps to regulate the blood pressure).  Excessive accumulation of water in the body does not allow the accumulated sodium to be removed from the body.  The salt which would be normally excreted from the body through urine is not eliminated because of failure of the kidneys.    Excess salt can lead to imbalance of magnesium and potassium.  This causes further water retention and worsens the condition.

Common Causes:
  • Coronary artery disease
  • Cor pulmonale
  • Congenital heart failure
  •  Valvular heart disease
  •  Myocardial infections
Precipitating Factors:
  • Arrhythmias
  • Rheumatic heart disease
  • Myocardial ischemia
  • Thyrotoxicosis
  • Chronic obstructive pulmonary disease
  • Kidney failure
  • Pulmonary embolism
  • Hypertension
  • Diabetes
  • Systemic infections
  • Anemia


  • Fatigue, weakness
  • Cough, and shortness of breath, becoming severe at a later stage
  • Increased frequency of urination worsening at night.
  • Loss of appetite
  • Oedema of limbs
Crackling sounds may be heard on examining the chest.   This is commonly seen with left-sided heart failure. The other symptom is oedema of arms and feet with right-sided heart failure. The patient may appear to have gained weight suddenly. The heart sounds may be rapid or irregular in nature.


  • Chest x-ray indicates the presence of congestion of the lungs or enlargement of the heart.
  • An echocardiogram can determine abnormal rhythm .  To measure 24-hour electrical activity of the heart, a Holter monitor is used.
  • Cardiac catheterization involves inserting a catheter into a blood vessel in the groin or extremities and is pushed up all the way to the heart artery.  An opaque iodine-based contrast material is injected and then x-rayed to measure the severity of the disease. 
Other Tests:
  • Nuclear heart scans: This is similar to the cardiac catheterization procedure except that the contrast material used is a safe radioactive substance known as a tracer.  Two sets of pictures are taken, one set after a stress test (Exercise test where BP, Pulse rate, Respiratory rate etc. are continuously monitored.) and one set at rest. 
  • Kidney function tests:  To identify predictors of decreased kidney functions in patients progressing to cardiac failure.
  • Blood testing including complete blood count, creatinine, blood urea and electrolytes,
  • albumin, glucose, and thyroid and liver function tests.
Differential Diagnosis
  • Coronary artery disease
  • Ischemic heart disease
  • Idiopathic Cardiomyopathy
  • Valvular heart disease
  • Myocarditis – bacterial or parasitic
  • Collagen vascular disease
  • Granulomatous disease
  • Endocrinologic disease


General Treatment:
General measures include educating the patient about lifestyle modifications and the importance of adhering to medications.  Sodium restriction is important to prevent fluid build up.  If rapid weight gain occurs over 2 days, the patient should seek help from a physician.  Underlying conditions such as diabetes, hypertension, etc., should be monitored and treated.  Regular light exercise should be encouraged.

Medical Treatment:
  • Treatment with medications include use of
  • Vasodilators – These drugs dilate and reduce pressure from the vessel walls
  • Diuretics – They reduce swelling by removing retained fluid and reduce venous pressure
  • Anticoagulants – To prevent formation of blood clots
  • Betablockers – To lower blood pressure, vasodilation, and control ventricular rate
  • Digoxin – May help with increase in the volume of the blood being forced out of the left side of the heart
  • Angiotensin converting enzyme inhibitors – Removes excess water and relax the blood vessels.
Surgical Treatment:
  • Coronary artery bypass surgery (CABG) and angioplasty:  Angioplasty is a method of widening narrowed or obstructed blood vessels.  CABG is a procedure where new arterial routes are formed around narrowed and blocked arteries.
  • Pacemakers:  These are small devices that are placed in the chest to help control the rhythm of the heart and prevent abnormal heart beats.
  • Heart valve surgery: This may be required to replace diseased valves due to infections.
  • Heart replacement: In case of end-stage heart failure or severe coronary heart disease, this may be the last resort to saving a person’s life.


  • Narrowing of the blood vessels may cause poor blood supply to the heart  leading to angina or chest pain.  There may also be sharp neck or back pain or a feeling of pressure which is located in the centre of the chest or the breastbone.   
  • Arrhythmias or abnormal rhythms and congestion of the lungs can occur with edema.
  • Cardiac cachexia is a wasting disease that occurs even when the individual eats a high calorie diet but continues to lose weight. 
  • Kidney dysfunction is a condition where the normal functioning of the kidney is gradually lost with failure to remove toxic materials from the body with resulting water retention, increased blood pressure and retention of salts. 
  • Some patients can even present with depression occurring as a complication of congestive heart failure.


Heart failure is disease that occurs over a long duration.  People are at risk for developing problems with rhythms.  Long-term treatment and monitoring are the norm.  The 5-year survival rate for men is 25% and for women is 38%.


Smokers and those with concomitant diabetes, hypertension, and other chronic illnesses need regular monitoring and treatment.  Regular exercising, medications, and following a regular diet help in preventing development of end stage heart failure.


American Heart Association
Consult Treating Specialty

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