Heart Failure

Heart failure (HF) is a generalized term that describes a dysfunction in the pumping mechanism of the heart, and a failure to adequately maintain the circulation of blood. Although the term heart failure suggests a rapid cessation of cardiac function, in most cases it is refers to a progressive but gradual loss of the efficiency of the heart. A myocardial infarction or heart attack is an ischemic attack of the myocardium, and while it may cause sudden death, may also lead to progressive heart failure, often with repeated incidents. (Berkow 1992; Rubin and Farber 1990, 283-84; Zevitz et al 2005)

Anything that causes the heart to increase its workload for a prolonged period of time can result in heart failure. Heart failure can occur for several reasons, some which are intrinsic to the heart and some that are extrinsic. Intrinsic causes include a loss of the contractile force of the myocardium during systole, a failure of the myocardium to relax during diastole, or a failure of the heart valves to regulate the flow of blood through the heart (e.g. rheumatic fever). A common extrinsic cause of heart failure is hypertension (secondary to atherosclerosis), which increases intracardial pressure and promotes pathogenic changes in the pumping mechanism of the heart. Up to 80% of all cases of heart failure relate to an atherogenic process by which the coronary arteries become progressively occluded, causing myocardial ischemia and infarction. (Berkow 1992; Rubin and Farber 1990, 283-84; Zevitz et al 2005; Govan 1991, 245-53)

The term congestive heart failure (CHF) describes a pathological process that results in a build up of fluid in the lungs and other tissues. It is specifically related to a failure of the ventricles to sufficiently eject blood from the heart, increasing the volume of blood in the ventricles, causing a dilatation of the heart chambers, and elevating the intracardial pressure. Overtime the increase in pressure promotes mycocardial hypertrophy (i.e. an “enlarged heart”), a compensatory mechanism that allows the patient to tolerate this state for years. (Berkow 1992; Rubin and Farber 1990, 283-84; Zevitz et al 2005; Govan 1991, 245-53)

Broadly speaking, CHF can be classified on the basis of which ventricle is more affected, as either left-sided or right-sided heart failure. In most cases CHF relates to a left-sided heart failure, which in turn, can be classified into systolic heart failure or diastolic heart failure. Systolic heart failure refers to a loss of the contractile force of the left ventricle during systole to eject blood into the aorta, resulting in an increase in pulmonary venous pressure and pulmonary congestion and edema. Overtime the result is interstitial fibrosis in the lung, resulting in a loss of pulmonary function. Diastolic heart failure refers to a failure of the left ventricle to relax during diastole, either from a restrictive cardiomyopathy or ventricular tachycardia. (Berkow 1992; Rubin and Farber 1990, 283-84; Zevitz et al 2005; Govan 1991, 245-53)

Right-sided heart failure usually develops as a complication of the former, but can also occur secondary to chronic lung diseases such as lung fibrosis or chronic obstructive pulmonary disease (e.g. emphysema, asthma). The resulting pulmonary hypertension places a back pressure on the right ventricle leading to hypertophy, dilatation and an increase in pressure. As a consequence both the right atrial pressure and systemic venous pressure increase, resulting in jugular vein distension, edema of the lower extremities, and congestion of the liver and spleen. (Berkow 1992; Rubin and Farber 1990, 283-84; Zevitz et al 2005; Govan 1991, 245-53)

The basic signs and symptoms of CHF are as follows:

• Dyspnea: Patients with CHF have difficulty breathing, especially upon lying down, often interrupting normal sleeping patterns. The dyspnea is often associated with a non-production cough, and as the condition progress the patient may begin to cough up frothy, blood-tinged sputum.
  
• Exercise intolerance: Patients with CHF experience extreme fatigue and dyspnea, even with day-to-day activities such as sweeping, vacuuming, pushing a lawnmower, or even walking. Accumulation of fluid and swelling: With right-sided heart failure patients with CHF often experience a noticeable swelling in their legs, feet, and ankles, which can extend upwards to the waist, with hepatosplenomegaly and ascites.
  
• Cerebral symptoms: Eldery patients with CHF frequently experience confusion, memory impairment, anxiety, headaches, insomnia, nightmares, or in rare cases, psychosis with disorientation. (Berkow 1992; Rubin and Farber 1990, 283-84; Zevitz et al 2005; Govan 1991, 245-53)

The New York Heart Association (NYHA) classifies CHF into four basic groups:

• Class I: describes a patient who is not limited with normal physical activity by symptoms.
  
• Class II: occurs when ordinary physical activity results in fatigue, dyspnea, or other symptoms.
  
• Class III: characterized by a marked limitation in normal physical activity.
  
• Class IV: defined by symptoms at rest or with any physical activity.

Medical treatment

The focus of medical treatment in CHF is three-fold: to decrease pulmonary capillary hydrostatic pressure and fluid transudation into the pulmonary interstitium and alveoli; reduce systemic vascular resistance; provide ionotropic and chronotropic support. Typical therapies used to reduce lung congestion and edema include nitroglycerin (mostly for angina), diuretics (e.g. furosemide, bumetanide, torsemide and metolazone) and vasodilators (e.g ACE inhibitors, angiotensin II receptor blockers). Medications used to reduce systemic vascular resistance are mostly comprised of the same vasodilators mentioned above. The most important medications used to provide ionotropic and chronotropic support is digoxin. Digoxin increases the force of myocardial contraction (positively ionotropic) but decreases the heart rate (negatively chronotropic). Beta-adrenergic blockers (e.g. metoprolol, carvedilo) are also sometimes used, as are sympathomimetics such as norepinepherine, dopamine and dobutamine. Antidysrhythmics are also used to control the rhythm of the heart, particularly in diastolic heart failure, such as amiodarone and flecainide. (Mattu 2005; Berkow 1992; Zevitz et al 2005)

Holistic treatment

CHF is a condition in which probably many herbalists would decline to treat, given the severity of the condition and the number of medications that the patient is likely to be on, fearing potential drug interactions. It is interesting to note however that the key drug used to treat CHF (i.e. digoxin) is in fact of herbal origin, a glycoside derived from Foxglove (Digitalis pupurea). Medicine attributes the inclusion of this drug in its materia medica to William Withering in 1785. According to Withering, he learned of the use of Digitalis from a Shropshire woman who used it in combination with a variety of herbs to treat cardiac “dropsy.” Withering isolated Digitalis and began to experiment with it, noting its delayed effects and cumulative toxicity, including vomiting, diarrhea, bradycardia, seizures, sweating and a transient loss of consciousness (syncope). Although it would be interesting to observe the effects of the original polyherbal formulation, the natural variance of cardioactive glycosides in the various Digitalis spp. as well as its cumulative, toxic effects, makes Digitalis a difficult herb to prescribe with a great deal of confidence. In Herbal Medicine Rudolf Weiss suggest that a tincture of Grecian Foxglove (Digitalis lanata) can be used to good effect in small doses in maintenance therapy for CHF, 5-10 gtt in water, twice daily, using the smallest dose possible. Another important botanical that can be used to good effect in CHF is Lily of the Valley (Convallaria majalis), which also contains cardioactive glycosides. Convallaria is given specifically in bradycardia, particularly in senile hearts which are easily overcome by activity but “perform reasonably well at rest” (Weiss 1988, 146). The primary advantage over Digitalis is that the cardioactive glycosides (i.e. convallatoxin and the cardenolides) have a rapid onset of action and are non-cumulative. Weiss also states that Convallaria is “effective in mild to medium-severe forms of heart failure, but cannot replace Digitalis when decompensation is severe.” Beyond its cardioactive glycosides Convallaria contains several flavonoids that contribute to the restorative effect that it has upon the heart. Dose of the tincture of the fresh (1:2) or dried rhizome (1:5) is 5-20 gtt, bid-tid. Needless to say perhaps, but neither Digitalis nor Convallaria should be used concurrent with digoxin therapy, although Convallaria may be carefully used to wean the patient off of digoxin.

Beyond the use of Digitalis and Convallaria, a number of other botanicals can be of great benefit to control the rate and rhythm of the heart, including:

• Night Blooming Cactus (Selenicereus grandiflorus) is described as having a digitalis-like effect, and in small doses is an excellent heart tonic, increasing the force while and regulating the rhythm of ventricular contraction. Dose of the fresh plant tincture (1:2) is 10-20 gtt bid-tid.
  
• Hawthorn (Crataegus spp.) and Arjuna (Terminalia arjuna) are rich in flavonoids and are well-known trophorestorative agents, particularly indicated in senile hearts, helping to strengthen the heart beat while regulating its rhythm. The dose for either Crataegus flower tincture or tincture of Terminalia arjuna is 1-5 mL bid-tid. (fresh plant 1:2; dry plant 1:3). Both plants can also be taken as a powder (2-3 g bid-tid.) or as an aqueous extract (100-150 mL bid-tid.).
  
• Scotch Broom (Cytisus scoparius) is a cholagogue and diuretic that is used in extrasystole, arrhythmia and tachycardia. Dose of the tincture is 15-40 gtt bid-tid. (fresh plant 1:2, dry plant 1:5).
  
• Motherwort (Leonorus cardiaca) is an important antispasmodic herb that is particularly useful in tachycardia associated with anxiety and nervousness. Dose of the tincture is 1-4 mL bid-tid (fresh plant 1:2, dry plant 1:3), or it may be taken as an infusion, 100-150 mL bid-tid.
  

Other important botanicals include Valerain (Valeriana officinalis), Lime flowers (Tilia cordata), and Skullcap (Scutellaria lateriflora). Any botanical that has a cardioactive activity may interact with drug therapy, and thus extreme caution is warranted.

Botanicals that have a particular benefit in reducing hypertensive states include Mistletoe (Viscum album), Coleus (Coleus forskohli), Garlic (Allium sativum), Cramp Bark (Viburnum opulus) and Lime flowers (Tilia cordata). Also called for in CHF are diuretics to relieve pulmonary and venous congestion, such as Parsley (Petroselinum crispum), Buchu (Barosma betulina), and Pipsissewa (Chimaphila umbellata), and expectorants such as Pleurisy Root (Asclepius tuberosa), Mullein (Verbascum thapsus) and Elecampane (Inula helenium).

In some cases where the patient does not want alternatives to drug treatment, in particularly severe cases, or where it is difficult to work with the attending physician, it may be impossible to employ any of the above remedies as alternatives. Beyond these specific herbs however, the basic treatment for CHF will be essentially the same as it is for atherosclerosis in the vast majority of cases.