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Understanding Heart Failure -- Diagnosis and Treatment

How Do I Know If I Have Heart Failure?

Doctors diagnose heart failure by taking a medical history and conducting a physical exam and tests.

During the medical history your doctor will want to know if:

During the physical, the doctor will check your blood pressure, use a stethoscope to hear sounds associated with heart failure in the heart and lungs, and look for swollen neck veins, an enlarged liver, and swollen feet.

What Tests Are Used to Diagnose Heart Failure?

Tests your doctor might order to diagnose heart failure include:

Blood tests to check for anemia, thyroid problems, and high cholesterol, conditions that can be related to heart failure. There is also a blood test for B-type natriuretic peptide (BNP), which can indicate active heart failure.

Urine tests to look for signs of kidney problems or diabetes, a cause of heart disease

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Electrocardiogram (ECG or EKG) to assess the heart rate and rhythm. This test can often detect heart disease, heart attack, an enlarged heart, or abnormal heart rhythms that may cause heart failure.

Chest X-ray to see if the heart is enlarged and if the lungs are congested with fluid.

Echocardiogram, an ultrasound test, to evaluate heart muscle function, to see how well the heart is pumping, and to detect problems with the heart valves that may cause heart failure. Ejection fraction (EF) also can be measured. EF is a measure of how much blood is pumped out of the heart with each beat, and how much blood pumps through the heart with each beat. A normal EF is generally greater than 50%, which means that over half of the blood volume in the heart's main pumping chamber is pumped out with each beat.

Radionuclide ventriculography to show the pumping function of the left and right ventricles (the heart's large pumping chambers) during heart contractions. This test can also measure EF. Rarely performed by itself, this test may be part of an exercise stress test.

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Cardiac MRIto distinguish scar from normal tissue and abnormalities in the heart muscle. This can also measure EF. This test is generally available only in large heart centers and is rarely used as a first step in heart disease diagnosis.

Exercise stress test, an ECG performed while either walking on a treadmill, riding a stationary bike, or using medications to simulate exercise to check for any heart function problems brought on by exercise, which may indicate coronary artery disease.

In addition, your doctor may perform a variety of more invasive tests, such as cardiac catheterization, to directly visualize the heart's chambers. This test can determine if coronary artery disease is present and can also provide a measure of EF.

What Are the Treatments for Heart Failure?

Treatment of heart failure focuses on slowing or reversing its progression. The earlier treatment starts, the better the outcome.

After a diagnosis, your doctor will recommend a series of lifestyle changes. You may be asked to reach and maintain a healthy weight, increase your activity level (as recommended by your doctor), restrict salt intake, restrict fluid intake, and avoid alcohol. If you smoke or chew tobacco, you'll be advised to stop. You will need to work with your doctor to find the right balance of rest and activity -- mobility is important to keep blood circulating. You will also need to weigh yourself daily and record your weight to detect fluid retention.

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Your doctor will also prescribe several medications to manage your heart failure or the underlying problem that caused the heart failure. Drugs used to treat heart failure, often in combination, include:

Diuretics or water pills can help reduce symptoms of heart failure or keep them from getting worse. For example, they may help make breathing easier by helping pull fluid out of the lungs. A diuretic makes you urinate a lot, especially when you first start taking it. The diuretics you're most likely to be started on for heart failure include bumetanide (Bumex), furosemide (Lasix),  and  torsemide (Demadex).

You may also be given a thiazide diuretic like chlorothiazide (Diuril) or metolazone (Zaroxolyn).  Another option is a mineralocorticoid receptor antagonist like eplerenone (Inspra) and spironolactone (Aldactone) that not only removes extra salt and fluid but also holds onto potassium.

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Potassium supplementsreplace the potassium that may be lost because of increased urination from diuretics.

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ACE inhibitors, which have a multitude of beneficial effects in patients with heart failure, including serving as vasodilators -- they expand blood vessels and increase blood flow, thus helping the heart pump more efficiently. ACE inhibitors are important heart failure drugs since they have been shown to significantly prolong life and improve the quality of life for most people with heart failure. ACE inhibitors include: captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil, Zestril), quinapril (Accupril), ramipril (Altace) and trandolapril (Mavik).

Angiotensin receptor blockers (ARBS) work in similar ways as ACE inhibitors. They are prescribed when patients develop side effects to ACE inhibitors, such al cough or high potassium levels. Examples of ARBs include: candesartan (Atacand), losartan (Cozaar) and valsartan (Diovan)

Angiotensin Receptor-Neprilysin Inhibitor (ARNs) is a combination of a neprilysin inhibitor and an ARB. Entresto (sacubitril/valsartan) is seen as a possible replacement for ACE inhibitors or other ARB.

Beta-blockerscan improve the heart's ability to relax, and decrease the production of harmful hormones produced by the body in response to heart failure. Beta-blockers used to treat heart failure include carvedilol (Coreg) and metoprolol.

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Digoxin, sold under the brand name Lanoxin, may improve heart pumping function and control certain heart rhythm problems. Digoxin is an older medication and not used as frequently as in the past, because many of the newer agents appear to have more profound effects on symptom control and overall outcome. Nevertheless, it may still be a reasonable add-on for those patients in whom symptoms don't improve with diuretics and ACE inhibitors.

Selective sinus node inhibitors is a class of drug which targets a specific area of the heart, the sinoatrial pacemakerIvabradine (Corlanor) lowers the heart rate and helps the lower left ventricle contract more efficiently.

Some of these drugs may cause unwanted side effects. Always discuss problems you may be experiencing with your doctor before stopping or decreasing the dose of any prescribed medications.

In some cases, when drugs don't improve heart function enough or cannot be tolerated, surgery or other intervention is necessary. Doctors recommend surgery for several major reasons: to correct certain problems that cause heart failure (such as coronary-artery bypass graft surgery), to repair or replace valves, to implant devices (such as an intra-aortic balloon pump, specialized pacemakers, ICDs, or ventricular-assist devices) to help the heart pump, or to transplant a new heart. Heart transplants are used to treat severe CHF.

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