CHF; Congestive heart failure

Definition Return to top

Heart failure, also called congestive heart failure, is a life-threatening condition in which the heart can no longer pump
enough blood to the rest of the body.

Causes Return to top

Heart failure is almost always a chronic, long-term condition, although it can sometimes develop suddenly. This condition
may affect the right side, the left side, or both sides of the heart.

As the heart's pumping action is lost, blood may back up into other areas of the body, including the:

• Gastrointestinal tract, arms, and legs (right-sided heart failure)

• Liver
• Lungs (left-sided heart failure)

Heart failure results in a lack of oxygen and nutrition to organs, which damages them and reduces their ability to function
properly. Most areas of the body can be affected when both sides of the heart fail.

The most common causes of heart failure are:

• Coronary artery disease

• High blood pressure

Other structural or functional causes of heart failure include:

• Cardiomyopathy
o Dilated cardiomyopathy
o Hypertropic cardiomyopathy
o Restrictive cardiomyopathy
• Congenital heart disease
• Heart valve disease
• Heart tumor
• Lung disease

Heart failure becomes more common with advancing age. You are also at increased risk for developing heart failure if you
are overweight, have diabetes, smoke cigarettes, abuse alcohol, or use cocaine.

Symptoms Return to top

• Cough
• Decreased alertness or concentration
• Decreased urine production
• Difficulty sleeping
• Fatigue, weakness, faintness
• Irregular or rapid pulse
• Loss of appetite, indigestion
• Nausea and vomiting
• Neck veins that stick out
• Need to urinate at night
• Sensation of feeling the heart beat (palpitations)
• Shortness of breath with activity, or after lying down for a while
• Swelling of the abdomen
 • Swelling of feet and ankles
• Weight gain

Infants may sweat during feeding (or other activity).

Some patients with heart failure have no symptoms. In these people, the symptoms may develop only with these
conditions:

• Abnormal heart rhythm (arrhythmias)

• Anemia
• Hyperthyroidism
• Infections with high fever
• Kidney disease

Exams and Tests Return to top

A physical examination may reveal the following:

• Fluid around the lungs (pleural effusion)

• Irregular heartbeat
• Leg swelling (edema)
• Neck veins that stick out (are distended)
• Swelling of the liver

Listening to the chest with a stethoscope may reveal lung crackles or abnormal heart sounds. Blood pressure may be
normal, high, or low.

The following tests may reveal heart swelling or decreased heart function:

• Cardiac MRI
• Chest CT scan
• Chest x-ray
• ECG, which may also show arrhythmias
• Echocardiogram
• Heart catheterization
• Nuclear heart scans

This disease may also alter the following test results:

• Blood chemistry
• BUN
• Complete blood count
• Creatinine
• Creatinine clearance
• Liver function tests
• Serum uric acid
• Serum sodium
• Urinalysis
• Urinary sodium

Treatment Return to top

If you have heart failure, your doctor will monitor you closely. You will have follow up appointments at least every 3 to 6
months and tests every now and then to check your heart function. For example, an ultrasound of your heart
(echocardiogram) will be done once in awhile to see how well your heart pumps blood with each beat.
You will need to carefully monitor yourself and help manage your condition. One important way to do this is to track your
weight on a daily basis. Weight gain can be a sign that you are retaining fluid and that the pump function of your heart is
worsening. Make sure you weigh yourself at the same time each day and on the same scale, with little to no clothes on.

Other important measures include:

• Take your medications as directed. Carry a list of medications with you wherever you go.
• Limit salt intake.
• Don’t smoke.
• Stay active. For example, walk or ride a stationary bicycle. Your doctor can provide a safe and effective exercise
plan based on your degree of heart failure and how well you do on tests that check the strength and function of
your heart. DO NOT exercise on days that your weight has gone up from fluid retention or you are not feeling well.
• Lose weight if you are overweight.
• Get enough rest, including after exercise, eating, or other activities. This allows your heart to rest as well. Keep
your feet elevated to decrease swelling.

Here are some tips to lower your salt and sodium intake:

• Look for foods that are labeled “low-sodium,” “sodium-free,” “no salt added,” or “unsalted.” Check the total sodium
content on food labels. Be especially careful of canned, packaged, and frozen foods. A nutritionist can teach you
how to understand these labels.
• Don’t cook with salt or add salt to what you are eating. Try pepper, garlic, lemon, or other spices for flavor instead.
Be careful of packaged spice blends as these often contain salt or salt products (like monosodium glutamate,
MSG).
• Avoid foods that are naturally high in sodium, like anchovies, meats (particularly cured meats, bacon, hot dogs,
sausage, bologna, ham, and salami), nuts, olives, pickles, sauerkraut, soy and Worcestershire sauces, tomato
and other vegetable juices, and cheese.
• Take care when eating out. Stick to steamed, grilled, baked, boiled, and broiled foods with no added salt, sauce,
or cheese.
• Use oil and vinegar, rather than bottled dressings, on salads.
• Eat fresh fruit or sorbet when having dessert.

Your doctor may consider prescribing the following medications:

• ACE inhibitors such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work
load of the heart
• Diuretics including thiazide, loop diuretics, and potassium-sparing diuretics to help rid your body of fluid and
sodium
• Digitalis glycosides to increase the ability of the heart muscle to contract properly and help treat some heart
rhythm disturbances
• Angiotensin receptor blockers (ARBs) such as losartan and candesartan to reduce the workload of the heart; this
class of drug is especially important for those who cannot tolerate ACE inhibitors
• Beta-blockers such as such as carvedilol and metoprolol, which are particularly useful for those with a history of
coronary artery disease

If you have sudden (acute) heart failure, you may be admitted to the hospital. Treatment may involve:

• Oxygen
• Medicines given through a vein, including dobutamine or milrinone, which help the heart pump blood
• A medication called nesiritide (Natrecor) to help dilate blood vessels

Swan-Ganz catheterization may be needed in some cases. If excessive fluid has gathered around the sac surrounding the
heart (pericardium), pericardiocentesis will be done.

Severe heart failure may require the following treatments:

• Thoracentesis to remove excess fluid

 • Implanted devices such as the intra-aortic balloon pump (IABP) and the left ventricular assist device (LVAD)

These devices can be life-saving, but they are not permanent solutions. Patients who become dependent on circulatory
support will need a heart transplant.

Heart failure symptoms may be improved with biventricular pacemaker or cardiac resynchronization therapy. Ask your
provider if you are a candidate for this type of treatment.

Outlook (Prognosis) Return to top

Heart failure is a serious disorder. It is usually a chronic illness, which may get worse with infection or other physical
stress.

Many forms of heart failure can be controlled with medication, lifestyle changes, and treatment of any underlying disorder.

Possible Complications Return to top

• Irregular heart rhythms (can be deadly)

• Pulmonary edema
• Total heart failure (circulatory collapse)

Possible side effects of medications include:

• Cough
• Digitalis toxicity
• Gastrointestinal upset (such as nausea, heartburn, diarrhea)
• Headache
• Light-headedness and fainting
• Low blood pressure
• Lupus reaction
• Muscle cramps

When to Contact a Medical Professional Return to top

Call your health care provider if weakness, increased cough or sputum production, sudden weight gain or swelling, or
other new or unexplained symptoms develop.

Go to the emergency room or call the local emergency number (such as 911) if you experience severe crushing chest
pain, fainting, or rapid and irregular heartbeat (particularly if other symptoms accompany a rapid and irregular heartbeat).

Prevention Return to top

Follow your health care provider's treatment recommendations and take all medications as directed.

Keep your blood pressure , heart rate, and cholesterol under control as recommended by your doctor. This may involve
exercise, a special diet, and medications.

Other important treatment measures:

• Do not smoke.
• Do not drink alcohol.
• Reduce salt intake.
• Exercise as recommended by your health care provider.
Alternative Names Return to top

Urinary tract infection - complicated; Infection - kidney; Complicated urinary tract infection; Pyelonephritis

Definition Return to top

Pyelonephritis is an infection of the kidney and the ducts that carry urine away from the kidney (ureters).

Causes Return to top

Pyelonephritis most often occurs as a result of urinary tract infection, particularly in the presence of occasional or
persistent backflow of urine from the bladder into the ureters or kidney pelvis (vesicoureteric reflux).

Pyelonephritis can be further classified as follows:

• Acute uncomplicated pyelonephritis (sudden development of kidney inflammation)

• Chronic pyelonephritis (a long-standing infection that does not clear)

Although cystitis (bladder infection) is common, pyelonephritis occurs much less often. The risk is increased if there is a
history of cystitis, renal papillary necrosis, kidney stones, vesicoureteric reflux, or obstructive uropathy.

The risk is also increased when there is a history of chronic or recurrent urinary tract infection and when the infection is
caused by a particularly aggressive type of bacteria.

Acute pyelonephritis can be severe in the elderly and in people who are immunosuppressed (for example, those with
cancer or AIDS).

Symptoms Return to top

• Flank pain or back pain

• Severe abdominal pain (occurs occasionally)
• Fever
o Higher than 102 degrees Fahrenheit
o Persists for more than 2 days
• Chills with shaking
• Warm skin
• Flushed or reddened skin
• Moist skin (diaphoresis)
• Vomiting, nausea
• Fatigue
• General ill feeling
• Painful urination
• Increased urinary frequency or urgency
• Need to urinate at night (nocturia)
• Cloudy or abnormal urine color
• Blood in the urine
• Foul or strong urine odor
• Mental changes or confusion *

* Sometimes in the elderly, mental changes or confusion are the only signs of a urinary tract infection.

Exams and Tests Return to top

An examination may show tenderness on palpation (pressing) over the kidney.

 • A urinalysis commonly reveals white blood cells (WBCs) or red blood cells (RBCs) in the urine.
• A urine culture from aclean catch or urine culture (catheterized specimen) may reveal bacteria in the urine.
• A blood culture may show an infection.
• An intravenous pyelogram (IVP) or CT scan of the abdomen may show enlarged kidneys with poor flow of dye
through the kidneys. IVP and CT scan of the abdomen can also indicate underlying disorders.

Underlying abnormalities of the kidney that put a patient at high risk for acute pyelonephritis may be discovered by
additional tests and procedures, including the following:

• Voiding cystourethrogram
• Renal ultrasound
• Renal scan
• Renal biopsy

Treatment Return to top

The goals of treatment are control of the infection and reduction of symptoms. Acute symptoms usually disappear within
48 to 72 hours after appropriate treatment.

Due to the high mortality rate in the elderly population and the risk of complications, prompt treatment is recommended.

After obtaining a urine culture to identify the bacteria, antibiotics are selected to treat the infection.

MEDICATIONS

Intravenous (IV) antibiotics may be used initially to control the bacterial infection if your infection is severe or you cannot
take antibiotics by mouth. In acute cases of pyelonephritis, you may receive a 10- to 14-day course of antibiotics.

Chronic pyelonephritis may require long-term antibiotic therapy. It is imperative that you finish taking the entire course of
prescribed antibiotics. Commonly used antibiotics include the following:

• Sulfa drugs such as sulfisoxazole/trimethoprim

• Amoxicillin
• Cephalosporins
• Levofloxacin and ciprofloxacin

Permanent kidney damage can rarely result from these infections when they are chronic, when they occur in a
transplanted kidney, or when multiple infections occur during infancy or childhood. Acute kidney injury (acute renal failure)
may occur when an infection is severe enough to result in shock (low blood pressure). Severe episodes of acute kidney
injury may result in permanent kidney damage and lead to chronic kidney disease.

The elderly, infants, and people with a compromised immune system are at increased risk for developing sepsis (a severe
blood infection) and shock. Often, these people will be admitted to the hospital to receive frequent monitoring for potential
problems and to receive IV antibiotics, additional IV fluids, and other medications as necessary.

MONITORING

In diabetic patients and pregnant women, as well as in people with spinal paralysis, follow-up should include a urine
culture at the completion of antibiotic therapy to ensure that bacteria are no longer present in the urine.

Outlook (Prognosis) Return to top

Most cases of pyelonephritis get better without complication after the treatment. However, the treatment may need to be
aggressive or prolonged. If sepsis occurs, it can be fatal.

Possible Complications Return to top

 • Recurrence of pyelonephritis
• Perinephric abscess (infection around the kidney)
• Sepsis
• Acute renal failure

When to Contact a Medical Professional Return to top

Call your health care provider if symptoms suggesting pyelonephritis occur.

If you have pyelonephritis, call your health care provider if new symptoms develop, especially decreased urine output,
persistent high fever, or severe flank pain or back pain.

Prevention Return to top

Prompt and complete treatment of cystitis (bladder infection) may prevent development of many cases of pyelonephritis.
Chronic or recurrent urinary tract infection should be treated thoroughly because of the chance of infection of the kidneys.

LIFESTYLE CHANGES

Preventive measures may reduce symptoms and prevent recurrence of infection. Keeping the genital area clean and
remembering to wipe from front to back may reduce the chance of introducing bacteria from the rectal area to the urethra.

Urinating immediately after sexual intercourse may help eliminate any bacteria that may have been introduced during
intercourse. Refraining from urinating for long period of time may allow bacteria time to multiply, so frequent urination may
reduce the risk of cystitis in those who are prone to urinary tract infections.

DIET

Increasing the intake of fluids (64 to 128 ounces per day) encourages frequent urination that flushes bacteria from the
bladder. Drinking cranberry juice prevents certain types of bacteria from attaching to the wall of the bladder and may
lessen the chance of infection.

Update Date: 7/25/2006