Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
9 May 2007

CONGESTIVE HEART FAILURE - 1

             It is Thursday night about 11:00 p.m. and I am returning from Brookings, South Dakota where I have participated in the Public Broadcasting System Program called “On-Call”.  Dr. Rick Holm, who is an internist in Brookings, moderates this program once a week on Thursday’s at 7:00 p.m.  It is an excellent source of medical information.  Tonight, the topic was “Congestive Heart Failure”.  The program is designed basically as an open forum where questions can be asked of generalists and specialists on a given topic.  Tonight, the program included Dr. David Nagelhout, who is an excellent cardiologist with North Central Heart Institute in Sioux Falls.  Next Thursday night, on May 10^th, the program will include Dr. Rob Allison, an internist at Medical Associates Clinic in Pierre.  The topic then is supposedly open to anything you want to ask. 

            The first and most obvious question tonight was “What is congestive heart failure?”. To understand this, one first has to understand the normal function of the heart.  The heart is a bag made out of muscle.  It holds about two-thirds of a cup of blood and with each heart beat it pumps out about 65% of that blood.  One can easily calculate that if a normal heart beat is around 70 beats per minute, and each heart beat pumps 70 ml of blood, the heart beats about 4,900 ml of blood per minute.  This is just about five quarts of blood per minute in the resting state.  This is enough blood to satisfy the body’s need and keep things in working order. 

            If a person decides to exert such as jogging or running, the heart will beat faster, it will fill up with more blood and there will be more blood pumped out per minute.  Normal untrained individuals can pump 8-10 quarts of blood per minute for a brief period of time.  Trained athletes can pump 20 quarts of blood per minute for a short period of time.  Those individuals are world class athletes running the 220 or 440 yard dash. 

            If one harkens back to about the 5^th century BC, the Greeks defeated the Persians at the battle of Marathon.  For some reason, it was felt important that people in Athens know about this victory right away, so one poor soldier ran 26 miles from Marathon to Athens to tell the city that the Greeks had won.  Thus was born our famous “marathons”.  Unfortunately, he promptly died on arrival after he had given the news.  Thus he had heart failure of the worst kind.  But it wasn’t a disease state; he was simply asking his heart to do more work than it was originally designed to do.  That makes the point that heart failure implies a disease state in which the normal function of the heart is not equal for the body’s need.  A poor soldier running from Marathon to Athens obviously didn’t have a diseased heart although he did by the time he had finished running 26 miles.  Hearts can be overworked, worn out, and wrecked. 

            The most common cause of heart failure in the United States today is high blood pressure.  The pressure that the heart has to pump against to get blood out to the body is the measure of how hard the heart is working.  The higher the pressure, the more work the heart has to do.  Since hearts have a designed capacity, asking them to pump against too high a pressure too long wears them out, although not as quickly as that man running from Marathon to Athens who ruined his heart in a few hours.  Instead high blood pressure over years of time, finally makes the heart weaken and unable to carry on the normal functions to meet the body’s demands.  This would be heart failure and indeed it would be a diseased state. 
            Other causes of heart failure include situations in which the valves don’t work or that there is a hole within the heart so that blood leaks backward or conditions in which the muscle of the heart has a disease.   The second leading cause of heart failure in our society is heart attacks in which a piece of the heart muscle dies.  When this occurs, that muscle doesn’t grow back and instead, the person has to do all of the work of pumping blood to the body with less heart muscle.  Because of that increased load for that heart muscle that was left, it will fail in time.  This, too, is considered a diseased state.

            One of the most common questions asked on the program tonight was how to deal with heart failure.  My answer is easy.  Don’t get it to begin with.  Get blood pressures checked in the 3^rd, 4^th, and 5^th decade of your life and make sure that they stay down in the normal range.  A blood pressure of 120/80 is a normal blood pressure.  Higher than that, it is abnormal.  If the blood pressure tends up into the 130’s when people are in the 30 year age group, the likelihood is that it will go higher yet as age continues.  Thus, it is important to get blood pressures controlled at an early age so that heart failure never develops.

            A very common question asked during the program was how much water a person should drink.  I thought I had covered that in this column so many times that the question was answered but will reiterate.  The kidneys are a very smart organ and they understand and know how much water a person takes in, how much they lose through perspiration, or how much they might lose through diarrhea.  The kidneys can add all these numbers up; their job is put out whatever water the person doesn’t need.  The kidneys know just how to do this without your help.  The idea that a person needs to drink lots of water to “flush their kidneys” is an absolutely invalid idea.  The kidneys do not need to be flushed and more water doesn’t make them cleaner or better functioning.  A person should drink as much water as they need to deal with their thirst.  But the idea that a person should drink 8 glasses of water a day is a fallacy.

            An equal fallacy comes in those grotesque, horrible instruction sheets that come with drugs from the pharmacy.  Invariably they tell a person that they should “drink lots of water” with their pill.  Don’t do that.  Drink enough water to get your pill down but the idea that you have to drink 2 or 3 or 4 glasses of water because you taking a pill doesn’t make any sense.  Another common question on the TV program had to do with how much salt a person should take in.  A diet containing less than 6 grams of salt per day will taste more or less like cardboard.  A diet with more than 10 grams of salt per day is going to take a lot of chips, sauerkraut, hotdogs, ham and other salty foods.  Many times individuals with heart problems have lost their appetite and have enough trouble trying to get adequate nutrition.  Thus, I am not a strong advocate of stringent salt restriction to the expense that the person’s diet becomes unpalatable and they lose lean body mass.  If a person uses fresh or frozen vegetables and avoids the prepared meats such a bologna, brunsweiger, hot dogs, etc and leaves the salt shaker alone, they will have an adequately restricted salt diet. 

            I mentioned above that my definition of heart failure means that the person has a disease state that prevents their heart from pumping enough blood to meet the body’s need.  If one puts the word congestive in front of that so that the person has “congestive heart failure”, that means that the person has retained fluid to where their ankles are swelling, the fluid is backing up into the person’s lungs and thereby taking up air space that the lungs would normally need.  When the lungs become wet and swollen, there is not enough room to put air into them with each breath and this is usually a very distressful state.  Thus congestive heart failure requires that the person strongly cut back fluid intake and usually will require “water pills” to get the extra fluid off. 

            The TV program was only an hour long and there were still many, many questions that were not answered.  Most specifically, we talked very little about how to treat people once they have congestive heart failure.  That will be the topic of the column next week and I will go over the medications available and the steps and care that are important.