Research and Literature

Congestive Heart Failure

January 11, 2017   /

Congestive heart failure is a diagnosis often seen in medical records. Heart failure is a life-threatening condition in which the heart can no longer pump enough blood to the body. As a result, organs do not receive enough oxygen and nutrients, which reduces their ability to function properly. Blood also can back up into other organs, including the liver, gastrointestinal tract, extremities, and lungs. Symptoms of heart failure include fatigue, shortness of breath (dyspnea), and fluid retention, resulting in edema.

Heart failure can result from any structural or functional disorder that impairs the ability of the ventricle to fill with or eject blood, including hypertension (HTN) and damage to the heart values or heart muscle. The majority of patients with heart failure have symptoms that are caused by an impairment of left ventricle myocardial function. A comprehensive discussion of heart failure, its causes, and its effects on the body is available at www.merck.com/mmpe/print/sec07/ch074/ch074a.html.

Heart failure affects more than 5 million Americans. The incidence of heart failure approaches 10 per 1000 in the population older than 65 years of age. In many cases, heart failure is considered a progressive disorder. It is thus categorized into four different stages, ranging from a person with risk factors (stage A) to persons with advanced heart failure (stage D). A discussion of the four stages is available at http://circ.ahajournals.org/cgi/content/full/112/12/1825.

The following table summarizes the four different stages.

Stage

Examples

Treatment Goals

Medical Therapy

Stage A

At high risk, but without structural heart disease or symptoms of heart failure

Patients with hypertension, atherosclerotic disease, DM, and metabolic syndrome

Treat underlying risk factors, including DM, HTN, obesity, and smoking

ACEI or ARB for vascular disease or DM

Stage B

Structural heart disease, but without signs or symptoms of heart failure

Patients with previous MI, asymptomatic valvular disease

All measures under stage A

ACEI or ARB in some patients

Beta-blockers in some patients

Stage C

Structural heart disease with prior or current symptoms of heart failure

Patients with known structural heart disease and shortness of breath and fatigue, and reduced exercise tolerance

All measures under stages A and B

Dietary salt restriction

Diuretics for fluid retention

ACEI

Beta-blockers

Other drugs for some patients*

Stage D
Refractory heart failure requiring specialized interventions

Patients with symptoms at rest, despite maximum medical therapy

Appropriate measures under stages A, B, and C

Decision for appropriate level of care

Compassionate end-of-life care

Extraordinary measures (heart transplant, permanent mechanical support, etc)

ACEI=angiotensin-converting enzyme inhibitors, ARB=angiotensin receptor blockers, DM=diabetes mellitus, MI=myocardial infarction

 

Medical nutrition therapy for heart failure involves management of risk factors in stages A and B, as well as treatment in stages C and D. For those in all stages of heart failure,  but especially stages A and B, a diet low in saturated fats, trans fats, and cholesterol and high in fiber, whole grains, fruits, and vegetables is suggested. For persons with HTN, the DASH diet is recommended. Heavy alcohol consumption is discouraged, but moderate alcohol intake may lower the risk for heart failure through the beneficial effects of alcohol on coronary artery disease.

When a patient becomes symptomatic (stages C and D), edema often is present, resulting from impaired cardiac function, inadequate blood flow to the kidneys, and secretion of aldosterone and antidiuretic hormone. These hormones act to conserve fluid, thus trying to restore blood flow. As a result, sodium and fluid accumulate in the tissue. Often sodium and fluid restriction are recommended, but no consensus exists on the optimal level of sodium restriction.

It appears that limiting sodium to no more than 2000 milligrams/day is an effective nutrition therapy to manage fluid retention and is a valuable tool in managing heart failure. According to Mahan and Escott-Stump, it is important to maintain a sodium-restricted diet even with low blood-sodium levels, because the sodium has shifted from the blood to the tissues. Serum sodium appears low in patients who are overloaded with fluid and are improved through diuresis by decreasing the amount of water in the vascular space. Fluid restriction sometimes is necessary, especially if hyponatremia is present. However, health care professionals should base fluid needs on presence of edema and urine output. Standard fluid restrictions are between 1500 and 2000 milliliters/day.

Reducing sodium in the diet is difficult for some patients, especially those who rely on convenience foods as a regular part of their daily diet. In addition, restricting sodium may, in some patients, result in decreased intake, which can contribute to unintended weight loss and cardiac cachexia. Health care professionals should prescribe the type of sodium restriction that is the least restrictive possible in order to achieve the desired results.

Some research suggests the control of congestive heart failure in older adults with the use of drug therapy and a mild sodium restriction of 4 to 6 grams (g)/day, instead of the 2-g sodium diet prescription. In the presence of stages C and D heart failure, it is important to weigh the risk/benefit of sodium and fluid restrictions against the patients’ wishes and quality-of-life issues.

Patients with active heart failure may tire easily. One approach is providing small, frequent meals to increase meal intake.

Implications for dietetics practitioners
Patients in all stages of heart failure can benefit from medical nutrition therapy. Patients with stages A and B heart failure require a diet to help prevent heart disease and control underlying risk factors. Those with active heart failure may require sodium and/or fluid restrictions.

 

References and recommended readings
Academy of Nutrition and Dietetics. Nutrition Care Manual®. Nutrition Care Manual Web site [by subscription]. www.nutritioncaremanual.org. Accessed December 26, 2013. 

Heart failure (HF): congestive heart failure. Merck Manuals Web site. www.merck.com/mmpe/print/sec07/ch074/ch074a.html. Updated October 2013. Accessed December 26, 2013.

Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on the Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005;112(12):1825-1852. http://circ.ahajournals.org/cgi/content/full/112/12/1825. Accessed December 26, 2013. 

Mahan KL, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed.St Louis, MO: Elsevier Saunders; 2012.

Niedert KC, American Dietetic Association. Position of the American Dietetic Association: liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc. 2005;105(12):1955-1965.

What is heart failure? National Heart, Lung, and Blood Institute, National Institutes of Health Web site. http://www.nhlbi.nih.gov/health/health-topics/topics/hf/. Accessed December 26, 2013.