Congestive Heart Failure > General

What Does My Heart Do?

Your heart is a hollow organ in the center of your chest. Although you may feel your heart beat when you place your hand over it, your heart is not right under your skin. Instead, your heart is behind your breastbone, inside your ribcage, and between your lungs.

Your heart is part of the circulatory system (see Figure 1), which also includes your blood vessels and lungs.

The main job of your heart is to pump blood. It pumps blood from the heart to the lungs to “pick up” oxygen. The oxygenated blood returns to the heart.

Your heart is divided into four sections, called chambers. Each chamber is like a separate room, with doors that let blood in and out.

• The two upper chambers are called atria (one upper chamber is called an atrium). The atria are where blood flows in.
• The two lower chambers are called ventricles. The ventricles are where blood is pumped out.

Your heart also pumps blood out into a complex system of tubes called blood vessels that carry blood, which is full of oxygen and nutrients, to every part of your body. At each tissue or organ in your body, blood makes an exchange—it "drops off" oxygen and nutrients and "picks up" waste products. After the exchange, blood returns to your heart.

Figure 1. The Circulatory System

• The red circulatory system indicates the flow of oxygenated blood coming from the lung, flowing into the left atrium of the heart, and pumped out to the body by the left ventricle.
• The blue circulatory system indicates the flow of blood low in oxygen coming from the body, returning to the right atrium of the heart and pumped out to the lungs by the right ventricle.

What Will Influence How Well My Heart Work?

As you grow older, the heart gradually loses some of its ability to pump well. Your heart has to work harder when you are ill, to help the body heal. When your heart is damaged (as in a heart attack), some of the heart muscle actually dies and no longer useful as part of the pump.

Your heart is affected by many factors:
When your activity increases or there is stress in your life, your heart responds by working harder. Feelings (such as worry, fear, anger, and grief) can increase the heart’s workload. Daily living choices also affect how well the heart works: what you eat, lifestyle decisions, climate and weather, and every medication you take (even non-prescription ones).

What Is Congestive Heart Failure?

Congestive heart failure (CHF) is an illness in which the pumping action of the heart becomes less and less powerful. Despite its misleading name, in heart failure the heart doesn't suddenly stop working. Instead, heart failure develops slowly as the heart muscle gradually weakens. The "failure" refers to the heart's inability to pump enough blood.

When this happens, blood and fluid do not move efficiently through the circulatory system, and starts to "back up." Eventually, parts of your body (lungs, abdomen, and lower limbs) hold blood and fluid that your heart isn't circulating very well. This is called "becoming congested," and is why this condition is called "congestive heart failure".

The result is people with CHF often do not tolerate exercise very well and feel fatigued or short of breath with ordinary activity.

Heart failure can involve the heart's left side, right side or both sides, though CHF much more affects the left heart.

• Left-sided heart failure:
  When the left side of the heart starts to fail, fluid collects in the lungs. This extra fluid in the lungs ("congestion") makes it more difficult for the airways to expand as you inhale. Breathing becomes more difficult, and you may feel short of breath. Fluid pressure can continue to back up causing swelling of the extremities.
• Right-sided heart failure:
  When the right side of the heart starts to fail, fluid collects in other body tissues (without affecting the lungs too much) especially the lower parts of the body such as the ankles, feet, and legs. Puffy swelling is a sign of right heart failure.

How Common Is Congestive Heart Failure? How Does The Treatment Cost?

• In the United States, about 4.7 million Americans suffer from CHF. Each year about 550,000 new cases are diagnosed.
• CHF is one of the most common and serious illnesses in patients older than 65 years in the United States. It affects 1% of people aged 50 years and about 5% of those aged 75 years or older.
• The condition is twice as common among African Americans as whites.
• The rate of death from heart failure is about 10% after 1 year. About half of those with CHF die within 5 years after their diagnosis.
• CHF is probably the most common reason for admission to hospital. Approximately 30 to 40 percent of patients with CHF are readmitted within six months of hospitalization. Studies have concluded that readmissions for CHF could be prevented in at least 40 percent of cases.
• The cost of treating heart failure in the US is estimated to be $21 billion annually. Hospitalization alone costs $15.8 billion.
• About 20% of hospitalization patients who are 65 or older have CHF. It is possible to control the condition. If not successfully controlled, CHF can cause serious disability and death.

Can It Be Cured?

Heart failure can't be cured, but its symptoms can be managed successfully. In most cases, heart failure can be managed by taking medications and making healthy changes in habits such as diet and exercise. These changes are often the key to leading a full, enjoyable life.

What Are The Common Signs of Congestive Heart Failure?

• You may have sudden weight gain, despite loss of appetite.
• Swelling in legs, ankles, feet, or abdomen.
• You may feel extremely tired and short of breath when doing things that are normally easy, such as walking.
• You may have breathing difficulty when lying flat in bed or may wake up with a choking feeling. You may need to sleep with your head raised up on several pillows.
• You may have persistent cough that is usually more bothersome at night.
• Less frequent urination during the day
• Irregular heartbeats, feeling of heart pounding
• Chest pain, pressure or chest discomfort
• Loss of appetite
• Dizziness or lightheadedness, inability to concentrate

There are four stages of congestive heart failure -- New York Heart Association (NYHA) Classification

When Do I Need to Call My Doctor?

You should contact your physician if you experience:

• Weight gain of more than two pounds in one day, or five or more pounds in one week
• Increased swelling of your ankles, hands, feet, legs or abdomen
• Increased shortness of breath on exertion, at night or when lying flat
• Increased fatigue
• Need to sleep with more pillows at night
• Marked loss of your appetite
• Nausea or being unable to eat and/or take medications
• Persistent dry cough
• Coughing up pink or blood-tinged mucus
• Unexplained cough, or a "hacking" night cough
• Decreased urination during the day, but more frequent need to urine at night
• Lightheadedness, dizziness or mental confusion

What Causes Congestive Heart Failure?

• Coronary artery disease – This causes the blood vessels of the heart to become narrow and clogged, which results in receded blood supply to the heart. The first sign of this disease is chest pain called angina.
• Heart attack – after a heart attack, a section of the heart may no longer work. This causes the heart to pump less, which in turn may lead to congestive heart failure.
• Hypertension (uncontrolled high blood pressure) – This increases the workload of heart overtime.
• Valve disease – Heart valves do not open or close properly, causing the heart to work harder. Over time the heart chambers lose their ability to pump blood well.
• Weakened heart muscle (Cardiomyopathy) – This causes your heart muscle to either become enlarged and weakened or thickened and stiff. It may result from infection, alcohol or drug abuse, or unknown causes.
• Congenital heart defects (you are born with this) – Several conditions that may be present from birth could eventually result in heart failure later in life.
• Diabetes, smoking or alcoholism also can lead to congestive heart failure.

How Is Congestive Heart Failure Diagnosed?

To diagnose congestive heart failure, the doctor must take a health history. He or she will ask questions such as:

• What do you feel and when did these signs start?
• What other health problems do you have and how are they being treated?
• Have any family members had heart problems? What type of problems?

Other questions your doctor will ask include:

• What is your daily life like (eating, working, sleeping)?
• What are your health habits (exercise, diet, smoking, alcohol, illegal drugs)?

It is important to be very honest when answering this kind of questions.

The doctor will also do a physical exam and tests to make an exact diagnosis.

• Physical exam: Your doctor will exam you, focusing on the organ systems associated with the heart, the lungs, and the extremities. With a stethoscope, a doctor can listen to your chest for the crackling sounds of fluid in the lungs, the distinct sound of faulty valves (heart murmur), or the presence of a very quick heartbeat. By tapping on your chest, doctors can find out if fluid has build up in your chest.
• Chest x-ray: This is very helpful in identifying the build-up fluid in the lungs. Also, the heart usually enlarges when you develop congestive heart failure, and this is visible on the x-ray.
• A heart tracing, called an Electrocardiography (ECG or EKG): This painless test can determine the rhythm of the heart. The ECG gives clues as to the underlying cause of heart failure. For this test, which takes just a few minutes, you lie on a table with electrodes fastened to the skin of your chest, arms, and legs.
• A heart-imaging test, called an Echocardiography: This test produces a video that shows the beating of the heart and is helpful for determining how well the heart is pumping.
• Blood tests may also be performed.

How Is CHF Treated?

The treatment for heart failure depends on several factors, such as the cause of it, the severity of it, and the health condition of the patient.

• Medication and changes in lifestyle:
  For most patients, however, heart failure cannot be cured; only managed through medication and changes in lifestyle.

• Surgery:
  Once in a while, heart failure is due to specific abnormalities in the heart valves or the heart itself. Surgery to replace a valve or close a hole between the heart chambers might be able to cure heart failure. For patients with heart failure that is a result of blocked coronary arteries, opening or bypassing the arteries may provide enough relief to the heart. Sometimes a pacemaker will be placed surgically. It can improve the effectiveness of the heart as a pump.

• Heart transplant:
  When congestive heart failure is extremely severe, a heart transplant may be a last resort for patients who can handle such surgery.

What Medications Are Used For CHF And What Do They Do?

Common medications for CHF belong to five groups (or families) of drugs:

1. Aldosterone antagonists
• Help reduce the stress to the heart and also have a weak diuretic effect
2. Angiotensin converting enzyme (ACE) inhibitors
• Help reduce the stress on your heart and may prevent your symptoms from becoming worse
3. Beta blockers
   • Help decrease the heart’s need for blood and oxygen by reducing its workload
   • Help the heart to beat more regularly
4. Digoxin (Lanoxin®)
• Help increases the strength of the pumping action of your heart
5. Diuretics (water pills)
   • Help reduce the amount of fluid in your body
   • Prevent or reduce swelling, shortness of breath and bloating associated with CHF
   • Help the heart by lessening the amount of fluid it must pump around. The kidneys get rid of this extra fluid, meaning that more urine is produced and urination occurs more often.
   • Some (but not all) of these drugs can affect your body’s normal amount of sodium and potassium. As a result, you may need to take a potassium supplement depending on which diuretic you use.

Each of these groups may encompass several different drugs. You may need one or more drugs from each group. It is important to understand how they work together and what they can do for you.

You may suffer from other conditions beside your congestive heart failure, including angina, high blood pressure, and irregular heart rhythm. Other medications that are used to treat these conditions include

• Calcium channel blockers
• Antiarrhythmics
• Antihypertensives
• Anticoagulants

You should tell your doctor about any medication you are currently taking, including over-the counter medicines. This way, your doctor can ensure that the best combination of medication is prescribed to treat the heart failure.

Your doctor will explain the possible side effects of the prescribed medication. Your doctor should be notified if any side effects are noticed.

See CHF: Medications in this website for more information. 

What Should I Do To Manage Congestive Heart Failure?

Reduce fluid and salt intake , and maintain a healthy weight.

Fluid balance, salt restriction, and daily weight are the most important concepts that can make your life much easier. Eat a healthy, balanced diet that is rich in fiber and low in cholesterol and fat.

How to reduce salt intake?

• Food that is high in salt (sodium) can cause extra fluid to build up in your body and makes the heart work harder. By reducing the amount of salt that you eat, you can reduce swelling and fluid buildup in the body. Food that does not seem “salty” can have hidden salt (sodium).
• Cut down the salt intake to 1,500 mg – 2,000 mg (about 2/3 of a teaspoon) per day.
• To do this, limit your use of table salt to 1/4 tsp (1mL) when cooking and at the table AND eliminate or cut back on:

• High-sodium processed foods, beverages or condiments
• Fast foods
• Salad dressings
• Smoked, salted and kosher meats
• Canned food (not including fruits)
• Pickled vegetables
• Salted snack foods
• Luncheon meats
• Soy sauce
• This will require careful reading of labels on all the food you buy and careful choices when you eat out. When possible, replace “regular” products with a “low- sodium” version.
• Remember these important guides to reduce your intake of salts:
• Get rid of the salt shaker.
• Choose fresh and fresh-frozen foods.
• Avoid processed foods including convenience and fast foods.
• Prepare foods from scratch more often using herbs or spices to increase the flavor.
• Read nutrition labels on food packages.

How to avoid excessive fluid intake?

• The recommend intake of fluid is 1500 cc (1 ½ quarts) per day. This is about 6 cups (a cup = 240 CC). This includes all types of fluids that you drink, at meals and between meals. Some examples are:
• Water, juice, milk, beverages, soups, Jell-O, pudding, popsicles, gelatin, and ice cream
• At least half your fluid intake should be water. If your blood sodium is at a very low level, you may have to drastically reduce your fluid intake to let your body balance out your blood sodium level. Talk to your doctor if you are experiencing this.

See CHF: Nutrition in this website for more information.

How to monitor my weight?

• Weigh yourself first thing every morning after using the bathroom and before eating breakfast.
• Always use the same scale.
• Wear the same amount of clothing.
• Look for sudden change in weight gain (higher or lower).
• Be aware of reduced volume of urine.
• Contact your physician if you gain weight by 2 pounds (or 1 kilogram) over night or by 3-5 pounds in two days or by 5 pounds in one week.

For more information regarding weight management, see CHF: Weight Management in this website.

What if my appetite changes?

You may find there are some changes in your appetite. Nausea or lack of appetite can be a side effect of heart medications. It can also be a sign of increasing heart failure. It’s hard work for the heart to digest large meals. Try eating smaller portions more frequently, and have a rest period after eating.

Why high-fiber food is good for me?

• You may not be as physically active as you would like to be, due to your level of heart failure. Also, you may have to restrict the amount of fluid you drink. Some of your medications (such as the diuretics or fluid pills), reduce the amount of fluid in your body. These factors can lead to constipation which causes a strain on your heart. You can avoid constipation by increasing the fiber in your diet.
• Fiber is found in whole grain cereals, breads, legumes, fruits, and fresh vegetables. Add these to your daily diet.

For more information, please see CHF: Nutrition in this website.

Why should I avoid food that is high in fat and cholesterol?

Food that is high in fat and cholesterol can damage the inside of blood vessels. This makes it much harder for the heart to pump blood through them.

For guide with a balanced diet with low fat and cholesterol, see CHF: Nutrition in this website.

How to plan and prepare my food?

How you plan and prepare your food is just as important as what you choose to prepare:

• Steam, broil or bake instead of frying foods.
• Substitute soft, non-hydrogenated margarine for butter.
• Plan your grocery shopping so you have the needed ingredients at home.
• Read labels or get someone to check the contents for you.
• Watch for any items with the words ‘salt’ or ‘sodium’ listed on the label.

Take medication as prescribed .

Medications help control both the underlying cause(s) of heart failure and the symptoms.

• It is very important that you take your medications as prescribed:
• the right medication
• at the right time
• even when you feel well
• Do not make changes on your own. Always discuss your situation with your physician.
• Learn the names, dose, frequency, the purpose, and main side effects for each of your medications.
• Be sure to provide a complete list of your medications to all healthcare professionals you work with.
• Check with your pharmacist, nurse, or physician when buying any over-the-counter medications to see if they affect your heart medications.
• Plan ahead to be sure you have enough medications on hand, especially when going on a trip or over holidays when stores are closed.
• Be consistent in taking your medications at the same time each day. It will help you remember to take them, and to get the best effect from them.
• If you need an extra reminder to take your medication, consider using a medication chart to record what pills you’ve taken and when, or invest in a day-by-day pill box. Check with your pharmacist to ensure your drugs are stable in these containers.

Exercise on a regular basis.

Exercise (physical activity) helps strengthen your heart so it works more efficiently. Activity helps blood flow to all parts of the body. It gives you a feeling of well-being and adds to your quality of life.

It’s very important to discuss your physical activity program with your nurse or family doctor before starting. Every person with congestive heart failure has unique needs and limits. Your exercise program has to be designed with your specific needs and limits in mind.

The keys to your level of exercise are:

• Beginning with your ability as it is now.
• Being active regularly. Daily exercise is best. Walking is an excellent exercise. It can be done outdoors or indoors (even in gyms or shopping malls) at your own pace. Cycling on a regular bike or exercise bike is another good choice.
• Increasing your activity a small amount each day.
• Being careful not to overdo it. Feeling tired the following day usually means you over-exerted.
• Stopping any exercise if you feel pain, become fatigued, or become short of breath.

See CHF: Exercise in this website for more information.

Check your blood pressure regularly.

If it is high, keep it under control by avoiding foods that are high in salt and taking prescribed medication.

Check your cholesterol and blood sugar levels.

If either is high, get it under control with a healthy diet and possibly medication.

Quit smoking.

Smoking increases the heart’s workload. It reduces blood flow to the heart muscle itself and robs it of needed oxygen and nutrients. Smoking also narrows the vessels that carry the blood, making the heart pump against increased pressure. Smoking harms the heart extensively. The best action you can take to manage CHF is to stop smoking.

Avoid or limit alcohol.

Excessive alcohol may cause CHF. Reduce your use of alcohol to no more than one drink per day. This is equal to a glass of wine (5 oz./150 mL/12% alcohol), beer (12 oz./350 mL/5% alcohol), or one mixed drink (1 1/2 oz./50 mL/40% alcohol). In some types of heart failure, alcohol must be totally avoided; your physician can tell you if this applies to you.

• You need to discuss drinking alcohol with your doctor because:
• Alcohol may change how your medication works.
• Alcohol can affect other medical conditions you may have.
• Alcohol reduces the strength of the heart’s contraction.
• Alcohol may cause or worsen irregular heart rhythm.

See CHF: Alcohol and Smoking in this website for more information.

Rest frequently and save your energy during the day and get enough sleep at night.

Rest and sleep are very important. After any period of activity, it is important to allow the heart to rest and catch up with the body’s demands. Also, by resting you allow the heart to mobilize fluid faster and get it out of your system.

Resting does not have to be sleeping. It can be a quiet time of listening to music, relaxing or reading.

• Find your position of comfort.
• Sitting with your feet and legs elevated slightly.
  • Helps blood to return back to the heart
• Lie down or lie with your head and shoulders raised slightly.
  • Helps you breathe more easily
• It is recommended that you lie down in the middle of the day for 30-45 minutes just to rest your heart.
• Long rest periods are not recommended if you suffer from central sleep apnea.

Energy conservation helps your heart, by saving up energy for activities you plan to do in the next day or the next week. If you have a big job to do, or a long day away from home planned, do only one part of the task at a time. Allow yourself rest periods between parts.

What are good ways to save my energy?

Some examples include:

• Use assistive devices to minimize exertion such as a walker or shower chair.
• Schedule many activities for a day that you enjoy.
• Schedule events ahead of the time and write it in a planner
• Get extra rest the day before a celebration.
• Break up your self-care activities (shaving, bathing, preparing breakfast, etc.) with rest periods between them.
• Divide shopping needs into several, short trips rather than one long trip.
• Get help from family and friends.

What are good ways to boost my energy?

• Refrain from regular exercise.
• Share your feelings and concerns with friends and caregivers.
• Engage in activities that you enjoy but pace yourself.

Manage stress in your life.

When stress is excessive, sudden, or lasts for too long, it makes your heart work harder than usual. This extra workload may cause your symptoms to worsen.

Early management of stress can prevent a hospital admission and its disruption to your daily life. Some signs of stress that you may notice include:

• changes in breathing
• tenseness in the face, neck, shoulders
• increased heart rate
• stomach upsets
• anxiety
• restlessness
• mental confusion

You may decide to seek help from a counselor, a spiritual advisor, or a close friend to help you with mental and emotional stress. It is also very important to maintain friendships and social contacts.

Avoid high altitude.

High altitude will make breathing more difficult because of the lower level of oxygen in the atmosphere.

Avoid extreme weather.

When the weather is extremely hot and humid or extremely cold, your body may not be able to adjust to these conditions.

• Listen to the weather forecasts.
• Avoid exercise and prolonged activities during this time.
• Space your usual activities between periods of rest.
• Avoid outdoor activity until the weather returns to normal.
• Be especially cautious about drinking too much fluid during hot weather to avoid overloading your heart.

Communicate better.

To communicate better, record your health conditions and show them to your physician because dealing with CHF is a joint effort!

It is also important to communicate with your peers who have similar conditions (CHF), because:

• You can exchange information to better manage your health.
• You can prevent depression.
• You can be helpful to them because you can share your experience or vice versa.

How to Prevent Further Complications for CHF?

• You have to regularly monitor your health by yourself and take a proactive attitude to maintain health.
• You have to educate yourself about CHF and healthy behaviors.
• Encourage yourself to commit to healthy behaviors by communicating with health professionals and your peers who have similar conditions (CHF).

Why Is It Important For Me To Have Knowledge Regarding CHF?

It is important to have knowledge regarding CHF, because you understand the relationship between your health behaviors and consequences. Also, you can assess your health and can have strategies to maintain your health. In addition, you can prepare for the situations you should be aware of, and having the knowledge is the first step for proactive self-management of your health.

QUIZ

1. CHF means that: (choose one)

1. Your heart is about to stop working.
2. Your heart’s pumping power is weaker than it should be.
3. You are about to have a heart attack.

Answer: b.

2. Many different health problems may cause CHF, including: (choose all that apply)

1. A heart attack or receded blood supply to the heart
2. Excessive alcohol
3. Weakened heart muscle (Cardiomyopathy)

Answer: All of the above.

3. You should manage CHF by: (choose all that apply)

1. Taking medications regularly
2. Regular exercise as prescribed by your doctor
3. Reducing salt intake

Answer: All of the above.

4. You should contact your physician if you experience: (choose all that apply)

1. Increased shortness of breath
2. Increased swelling of your ankles, hands and feet
3. Marked loss of your appetite
4. Persistent dry cough
5. Mental confusion

Answer: All of the above.

5. What are good ways to save your energy? (choose all that apply)

1. Use devices to minimize exertion such as a walker or shower chair.
2. Schedule many activities for a day that you enjoy.
3. Schedule events ahead of the time and write it in a planner

Answer: All of the above.

6. What are good ways to boost your energy? (choose all that apply)

1. Refrain from regular exercise.
2. Share your feelings and concerns with friends and caregivers.
3. Engage in activities that you enjoy but pace yourself.

Answer: All of the above.

7. Which demographic statements are correct? (Choose all that apply)

1. CHF is twice as common among African Americans as whites
2. The cost of treating heart failure in the US is estimated to be $21 billion annually
3. About 4.7 million Americans suffer from heart failure

Answer: All of the above.

8. Which are ways to prevent further complications for CHF? (Choose all that apply)

1. To regularly monitor your health by yourself and take a proactive attitude to maintain health.
2. To educate yourself about CHF and healthy behaviors.
3. To encourage yourself to commit to healthy behaviors by communicating with health professionals and peer group.

Answer: All of the above.

9. What are the benefits of communicating with your peers who have similar conditions (CHF)? (Choose all that apply)

1. You can exchange information to better manage your health.
2. You can prevent depression.
3. You can be helpful to them because you can share your experience or vice versa.

Answer: All of the above.

10. Why it is important to have knowledge regarding CHF? (Choose all that apply)

1. Because you understand the relationship between your health behaviors and consequences.
2. Because you can assess your health and can have strategies to maintain your health.
3. Because you can prepare for the situations you should be aware of.
4. Because having the knowledge is the first step for proactive self-management of your health.

Answer: All of the above.

11. What is the best method to deal with CHF? (Choose only one)

1. To follow your physician’s recommendations because he/she knows your health best.
2. To revise your physician’s recommendations to suit better your needs because you know your health best.
3. To communicate better, record your health conditions and show them to your physician because dealing with CHF is a joint effort.

Answer: c.

Sources

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• eMedicine Consumer Health. (2004). Congestive heart failure. Retrieved December 15, 2004, from http://www.emedicinehealth.com/articles/10929-1.asp
• Guidant Corporation. (2004). Heart and blood vessels basics. Retrieved December 15, 2004, from http://www.guidant.com/condition/heart/heart_intro.shtml
• Heart and Stroke Foundation. (2002). Managing congestive heart failure. Retrieved December 15, 2004, from http://ww1.heartandstroke.ca/images/English/Managing_CHF.pdf
• Hoyt, R. E., Capt, M. C., Bowling, L. S. (2001). Reducing readmission for congestive heart failure. American Academy of Family Physicians, April 15, 2001. Retrieved September 26, 2004, from http://www.aafp.org/afp/20010415/1593.html
• Jackson Health System. (2004). Congestive heart failure handbook. Retrieved December 15, 2004, from http://um-jmh.org/body.cfm?id=1438
• National Heart, Lung, and Blood Institute (2004). Heart and vascular diseases: Heart failure. Retrieved December 15, 2004, from http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_WhatIs.html
• National Institute of Health, National Library of Medicine. (2004). Congestive heart failure. Retrieved December 15, 2004, from http://www.nlm.nih.gov/medlineplus/tutorials/congestiveheartfailure/ct129102.pdf
• Texas Heart Institute. (2004). Congestive heart failure. Retrieved December 15, 2004, from http://www.tmc.edu/thi/chf.html
• VA Healthcare Network Upstate New York. (2002). Guidelines for living with congestive heart failure. Retrieved December 15, 2004, from http://www1.va.gov/visns/visn02/network/pubs/CongestiveHeartFailureguidelines.pdf

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