n the United States alone, some five million people are affected by heart failure, with a half million new cases diagnosed each year. Below, cardiologists from New York Presbyterian Hospital, Dr. Simon Maybaum and Dr. Ainat Beniaminovitz, discuss how heart failure happens, and its effects on the body.
Can you give us a detailed description of what congestive heart failure is, and does that term refer to all heart failures?
SIMON MAYBAUM, MD: Heart failure and congestive heart failure are a very serious problem. Certainly, we're now becoming more aware of how serious it is in our community.
As the name suggests, heart failure is essentially a disease of the heart muscle or the valves of the heart, which make it weak or fail. In this state, the heart cannot continue to perform its normal function. In its normal state, the heart pumps blood through the body and then returns it through the lungs. When the heart fails and the muscle becomes weak, or the valves become ineffectual, the heart enlarges. Blood accumulates in the heart, and then eventually in other parts of the body.
Heart failure can start from an unnoticeable condition, that which we call asymptomatic, and progress to a severely debilitating disease; one which mimics, in some ways, cancer where the patients are really bed bound and have very little hope for the future. So, it's a very wide range of presentations.
When we refer to congestive heart failure, what does that mean exactly? At what point does it become congestive heart failure?
AINAT BENIAMINOVITZ, MD: Congestive heart failure is really the body's response to a failing heart. There are various compensations that the body makes. As a consequence, the person experiences symptoms of congestion.
When the heart begins to fail because it can't pump enough blood to the whole body, one of the compensations it makes is to dilate, or enlarge. It can't pump efficiently as a muscle and the pump function decreases, so it makes itself bigger, and stretches way out. It becomes twice its size, and begins to displace the lungs. As a consequence, since there is a bigger volume, it can pump the same amount of blood, but at a cost. The blood starts to backup in the heart itself, then it starts backing up into the other areas-such as the lungs, the liver, and the legs-forming the syndrome of congestive heart failure. That's what congestion means. Blood is backing up rather than going forward.
Let's discuss the effect on some of the organs, starting with the kidneys.
SIMON MAYBAUM, MD: The kidneys see that the heart is not efficiently supplying them with blood. It thinks that, in some respects, there is too little blood on board, but in fact there is the usual amount of blood, but that blood is not flowing normally. So, the kidneys work to absorb more fluid. That just exacerbates the problem, and you get increased fluid retention in the kidneys.
When we talk about "fluid" in the body, we're actually talking about excess blood?
AINAT BENIAMINOVITZ, MD: Correct. When the kidneys tell the body to absorb more water in order to dilute that blood and help fill the very big, big sack of heart that now exists, what happens is that the arteries can only hold so much blood. It starts seeping out. The blood that seeps out is called "water" because it's not quite blood, but it's a big composition of blood and water that leaks into places that it shouldn't be, such as in the lungs, in the liver, and in the legs. So, it is no longer in the arteries where blood typically flows, but in other places because the arteries can't hold as much.
What are the most common symptoms of this fluid backup?
SIMON MAYBAUM, MD: One of the most common symptoms is shortness of breath. It is related, in part, to a collection of fluid or blood-like fluid in the lungs. The patient not only cannot perform normal exertion, but also eventually cannot lie flat. We often see that patients with advanced heart failure are sleeping in a chair at night, or sleeping on three or four pillows, and when they wake at night they are very short of breath.
The second main symptom is fatigue. Patients feel tired and worn out, and eventually, they cannot perform normal daily activities.
Patients can experience swelling of the ankles, which is fluid collecting in the legs. They can also have abdominal pain, as the liver fills with fluid, or as the abdominal cavity fills with fluid. Some patients have no shortness of breath, but just abdominal pain.
Who is most at risk for heart failure? Is it mostly elderly people who get this?
AINAT BENIAMINOVITZ, MD: No. It's typically associated with the elderly because they are, by the time they arrive at an older age, more symptomatic, and have developed actual congestive heart failure. But it can attack anyone at any age, and when a problem arises in the heart, it can happen in a number of ways. The way people manifest in congestive heart failure is very varied and is not age dependent. So, someone who is twenty-years-old and had a virus attack their heart muscle-resulting in a weakening of the heart muscle-can be ten times as debilitated as an older person who has had congestive heart failure for a long time. It just depends on the severity and the rapidity with which the heart muscle declines.
SIMON MAYBAUM, MD: As many as 20 million people in the United States actually have defective hearts, and may have congestive heart failure, but not know it. We think there are a lot of people walking around with abnormal cardiac function who will, eventually, if untreated, progress to symptoms and signs of congestive heart failure. Most of us in the heart failure community believe that early intervention of these patients would probably slow or stop the progression of congestive heart failure. However, identifying these patients is much more problematic.
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