American College of Cardiology

Causes of CHF
Treating CHF
New Surgeries and Medications

Howard Hanson had never been sick a day in his life, but, in 1949, he began to notice that he got short of breath when climbing stairs or while mowing his lawn.

"You need to make an appointment with Dr. Ruel, Howard," his wife Betty told him. Dr. Ruel, their family doctor, was known as a "heart doctor."

At the doctor’s office, Howard described his symptoms. "I'm having trouble breathing," Howard explained, "and every now and then I have pressure in my chest."

"Have you ever had rheumatic fever?" Dr. Ruel asked. At the time, rheumatic fever was the leading cause of valvular heart disease and congestive heart failure.

"I don't believe so," Howard replied.

Dr. Ruel heard a loud heart murmur through his stethoscope when he listened to Howard’s heart. An electrocardiogram (ECG) indicated that Howard had an enlarged heart. A fluoroscopy—an X-ray picture of heart structures—revealed calcification, causing narrowing of the aortic valve, a condition called aortic stenosis.

Dr. Ruel told Howard what he’d learned from the tests. "Your aortic valve is diseased," Dr. Ruel explained. "It isn’t opening fully, and your heart is forced to work much harder than it should to circulate blood. You have congestive heart failure."

Congestive heart failure (or CHF) is a debilitating disease often caused by a weakened heart muscle that is unable to pump enough oxygen-rich blood for the body. When the heart can’t pump enough blood, fluid accumulates in the lungs and other organs. Howard and most Americans became familiar with CHF when it killed President Franklin D. Roosevelt in 1945. President Roosevelt’s CHF was a result of long-term, severe, uncontrolled high blood pressure. In Howard’s case, a narrowed aortic valve was at fault.

When Howard fainted a few weeks later, Dr. Ruel had to tell his patient that he could die in as few as three years. Although there was little a doctor could do for a patient with CHF in 1949, Dr. Ruel prescribed the mainstay of therapy, digitalis, the cardiac muscle stimulant used at the time.

"You’re going to have to quit your job, Howard, and curtail your everyday activities," Dr. Ruel cautioned. "And I want you to reduce your salt and fluid intake. CHF decreases the flow of blood from your heart to vital body organs and that decrease tells your kidneys—mistakenly—that you’re dehydrated. The kidneys hang on to salt and water, which produces fluid in the lungs and ankle swelling called ‘edema.’"

Howard Hanson died suddenly two years later during an evening walk with Betty—just a few years before key developments signaled a new era for surgically treating valvular heart disease.

Nearly 5 million people in the United States have congestive heart failure (CHF). In the most serious form of CHF, the patient feels shortness of breath while resting and has severe limitation during physical activity. More older patients than young have CHF. In fact, CHF is the leading cause of hospitalization among older Americans.

Causes of CHF
"Heart failure. The term sounds alarming. Fortunately, in patients with this condition, the heart doesn’t usually stop working completely; instead, the heart does not work enough to deliver all of the oxygen-rich blood the body needs," explained Denton A. Cooley, MD, president and surgeon-in-chief at the Texas Heart Institute in Houston. Congestive heart failure can arise from many conditions. Chief among them are—

• valvular heart disease from rheumatic fever or congenital defects. Although antibiotics have made rheumatic fever nearly disappear, other causes of heart valve disease still present serious risks:
• calcification, a calcium buildup on the valves,
• congenital defects that cause irregularly shaped valves, and
• infective endocarditis, an infection of the lining of heart valves.
• weakened heart muscle from a heart attack, or from high blood pressure (hypertension) that has been long standing or poorly controlled.
• cardiomyopathy, a degeneration of the heart muscle linked to heredity, excessive alcohol intake, infections, and other known and unknown causes.

Treating CHF
Prevention and early treatment are the keys to conquering CHF. "Treating this complex condition can be challenging. But the sooner a diagnosis is made and treatment undertaken, the more likely the weakened heart will be able to function more efficiently, and the patient will live longer," Dr. Cooley observed. "For most of us, how we live our lives in our first 50 years can greatly reduce our risk for developing the conditions that can lead to heart failure later in life."

One precursor to congestive heart failure, hypertension or high blood pressure, is the most prevalent cardiovascular condition today. It occurs when the tiny blood vessels (arterioles) that control blood pressure become narrowed, making the heart work harder to force blood through the arteries.

The American Heart Association warned in 1997 that awareness of high blood pressure has started to decline among U.S. adults—fewer than one in three patients have their hypertension successfully under control. The high incidence of uncontrolled high blood pressure is, in turn, triggering a rise in the numbers of patients with CHF.

New Surgeries and Medications To Treat CHF
Fifty years ago, cardiovascular surgery was still in its infancy; operations were very risky and not widely available. In 1948, cardiovascular surgeons Dwight Harken in Boston and Charles Bailey in Philadelphia performed surgery to open closed valves in patients with mitral stenosis from rheumatic fever. But it wasn’t until 1958 that Charles Hufnagel, MD, reported success with a plastic ball-valve implant. In 1960, Dr. Harken performed the first successful totally artificial aortic heart valve replacement, and Albert Starr introduced the first artificial mitral valve. Today, surgeons can repair or replace faulty valves using artificial mechanical valves or a "bio" prosthesis, a valve obtained from an animal. Patients with artificial valves have prompt relief of symptoms and many are restored to a normal life span.

For patients whose major problem is a weak heart muscle from a heart attack or cardiomyopathy, modern medications can dramatically lessen symptoms and prolong life. Most important, ACE (angiotensin-converting enzyme) inhibitors, a class of drugs developed in the 1980s, have become a cornerstone in treating heart failure. A new class of drugs, angiotensin II receptor blocking drugs, offers similar promise as a treatment for CHF, without the side effect of coughing sometimes caused by ACE inhibitors. Recently, studies have shown that beta blockers also improve heart function and prolong life expectancy. Furosemide (commonly known as lasix) is also a valuable drug for treating CHF because it eliminates excess water and salt from the body by altering kidney function and thereby increasing urine output. Digitalis is effective in strengthening the heart’s contraction. And dobutamine, which is given intravenously, may improve heart function for weeks or months.

In addition, cardiovascular specialists have had remarkable successes in cardiac transplantation—replacing the defective heart with a healthy one from someone who has died of other causes and "literally giving patients a new life," Dr. Cooley observed. And the availability of drugs such as cyclosporin to suppress rejection has significantly enhanced the success of cardiac transplantation. But the need for donor hearts far exceeds the supply. "Therefore," Dr. Cooley added, "development of mechanical assist devices, such as the intra-aortic balloon pump, and totally artificial hearts remains invaluable."

Dr. Cooley summarized the recent surgical and medical strides in this way: "These advances in medical science combined with the individual responsibility in preventing the major causes of heart failure can provide the most positive outcome: a healthy heart."

When Howard’s grandson, Howard (Howie) Hanson III, developed progressive fatigue and had difficulty breathing accompanied by pressure in his chest, he wasn’t taking any chances. Howie saw his primary care physician, who referred him to Dr. Brown, a cardiologist.

After taking Howie’s family and medical history and doing a physical exam, Dr. Brown performed an echocardiogram and confirmed that Howie also had severe congenital aortic stenosis.

"I’d like to do a cardiac catheterization and coronary angiography," Dr. Brown told Howie and his wife, Jean, who was sitting in on the consultation. "These tests will give me a better understanding of the severity of your problem. If necessary, we may need to do heart surgery."

The test results confirmed that Howie’s problem was a result of severe aortic stenosis due to calcium deposits occurring on a misshapen aortic valve at birth, a form of congenital heart disease. Dr. Brown scheduled Howie for surgery. During the procedure, Howie’s faulty aortic valve was replaced with a metal-and-plastic artificial valve. Dr. Brown prescribed warfarin, an anticoagulant that helps prevent blood clots, and Howie went home five days after his surgery.

Howie returned to work after two months, but only after enrolling in a cardiac rehabilitation program at his nearby community hospital. There, he and Jean learned proper exercises, weight control, and preventive measures to keep the whole family healthy.