Introduction to the Heart

What does the heart do?

Our heart is essentially two distinct, but
anatomically connected pumps:

1. Right sided - Receives blood from

body and pumps blood into lungs
to gather oxygen
2. Left sided - Receives oxygenated
blood from lungs and sends out to
body

The PULMONARY circulation is

responsible for taking up oxygen and
releasing carbon dioxide. The SYSTEMIC
circulation delivers the oxygenated blood
to our tissues.

It may seem odd that the right and left sides on the diagram appear reversed. This is because all references to
the right or left side of the heart use our outside point of reference (as if they are facing you for inspection).
Problems can arise with either the right or left side of the heart alone, but this will ultimately lead to
complications for the other side of the heart.

The normal adult human heart weights about 11 ounces (0.3 kilograms) and is about the size of a clenched fist.
Click here for anatomical diagrams of the heart.

How does the heart work?

Electrical signals travel through specific cell pathways in the heart that signal and stimulate the heart to begin
pumping. In response to this, the chambers of the heart rhythmically contract to push blood through the
circulation -- first both atria contract, then the ventricles. In the average lifetime, the heart will beat more than
one billion (1,000,000,000) times! The ventricles do the majority of the work pushing the blood through the
body. Blood typically leaves the heart at a speed of about one foot per second (0.3 meters per second) but can
rise to nearly six feet per second with moderate activity! The atrial contraction primarily is done to assist filling
the ventricles with more blood to push out of the heart. People can survive with atria that do not contract
efficiently; however, if the ventricle stops pumping, death occurs within minutes!

As much as it is the heart's job to push the blood to deliver oxygen to all tissues, it also must have its own
supply of oxygen to perform work. It receives this oxygen from the coronary arteries. If this supply is interrupted
for any reason, heart tissue can die causing a heart attack- a possible cause of the onset of heart failure.
Introduction to the Circulatory System
What does the circulatory system do?
Our circulatory system can be thought of as a network of living pipes
that allows our body to transport oxygen as well as nutrients to the
tissues. Chemical wastes produced by our cells enter the blood to
be filtered and eliminated by our body (largely by the kidney and
liver). Our body circulates about 5 liters (5.3 quarts) of blood; at rest,
the heart moves it at a rate of 5 liters per minute. In summary, even
without activity, blood can run the entire circuit of the body in one
minute. During heavy exercise, the whole loop can be completed in
ten seconds.

The main components of the circulation are pictured on the left:

1. Arteries - the red vessels represent arteries. Hemoglobin,

the oxygen carrying chemical in red blood cells, takes on
blood's distinctive red color when it is combined with
oxygen. Arteries carry blood away from the heart and
branch into smaller vessels (first arterioles, then capillaries)
in order to facilitate delivery of its cargo to the organs and
other tissues.
2. Veins - the blue vessels represent veins. This bluish tint is
also due to hemoglobin. After releasing oxygen to living
cells, hemoglobin undergoes a chemical change that gives it
a distinctive reddish-blue tone. Veins also have a series of
one-way valves built into their structure. This is crucial for
proper circulation, as gravity could cause blood to pool
below the heart otherwise!

The body's circulation is a "closed loop". This necessarily means that an irregularity or back-up in one part of
the system will affect blood flow elsewhere in the loop. If the structures in the path seem unfamiliar, click here
for a graphical review.
How does the circulatory system work?
Contractions from the heart eject blood into the lungs and body. The vascular network must be vast in
complexity and length to cover all of this volume. The combined length of all of the tubing would cover nearly
60,000 miles (100,000 kilometers) - more than TWICE around the earth - if plumbed in a straight line! The
vascular system, with the help of neuroendocrine input, can contract and relax different arteries and veins to
guide both the speed and destination of blood flow, depending on the needs of the body. This facilitates
circulation in performing more specialized tasks.

During physical exertion, the vessels going to muscles can dilate to deliver more oxygen to those tissues.
Furthermore, blood also serves as a method to distribute our body heat. By dilating blood vessels at our skin
surface, the body allows conductive heat loss during exercise, while contracting their diameter conserves body
heat when the environment becomes colder.

As mentioned before, the circulatory system is a closed loop. If there are any serious blockages or changes in
vessel resistance along the line, it is like putting a bend or kink in a garden hose - flow through the bend is
slowed and pressure to push through the reduced opening may increase. This resistance to flow is of concern
in heart failure, not only because of the workload it imposes on the heart, but because it hampers delivery of
blood's precious cargoes (food, oxygen, etc.). Placing the heart under such stressful conditions (i.e. increased
heart rate and contraction force with a curtailed oxygen supply) will reduce its ability to compensate for the
needs of the body. For more information on high blood pressure, also known as hypertension, click here.

Introduction to the Lungs

What do the lungs do?
The lungs are two flexible, elastic organs that draw in and collect surrounding air. They are protected by the rib
cage as they are made of very thin tissue that is relatively easy to puncture. Air travels from the mouth and nose
down to the trachea, which splits into two channels called the bronchi (plural for bronchus). After this initial split,
the passages continue to diverge and get smaller until they end in tiny clusters of grape-like air sacs or alveoli
(plural for alveolus). These air sacs contain the region where gas exchange takes place. Capillaries enter
alveoli to uptake the air in the lungs and carry it back to the heart and, eventually, the body tissues. At the same
time that it takes up oxygen the blood releases carbon dioxide it has picked up from the body and releases it.
How do the lungs work?
WE BREATHE BECAUSE OUR TISSUES BREATHE! The lungs basically work as a pair of bellows - as the
chest expands they draw in air (of which oxygen is a component). Upon exhaling the chest uses its elastic
properties to passively "snap back" to its original size.

Oxygen and carbon dioxide can travel between the lungs and bloodstream because the capillaries that
surround the air sacs are permeable to gases. In essence, this means that oxygen and carbon dioxide
molecules are small enough to passively diffuse through the tissues that compose both the blood vessels and
alveoli. This same principal applies to gas exchange between the blood in the capillaries and tissues in the
body. In heart failure conditions, however, if the blood is leaving the lung against a high pressure downstream in
the left atrium, fluid can actually diffuse into the lungs. This condition, known as pulmonary edema, can inhibit
gas exchange and make it very difficult and uncomfortable to breathe.

Introduction to the Neuroendocrine System

What does the neuroendocrine system do?

The heart utilizes electrochemical signals to control the rate at which it contracts. It accomplishes this using
bundles of "pacemaker cells" whose signals maintain an internal rhythm independent of the body. However, at
rest the rhythm it maintains is slightly faster than what is ordinarily required. The neuroendocrine system usually
dampens this rate, but it can elevate it as well using electrical or chemical signals (during exercise or stress).

The neuroendocrine ( neuro-nerve; endocrine-hormone) system is a compilation of inputs from the nervous
system as well as glands throughout the body that secrete chemicals. Both usually work together to account for
transient or even chronic changes in the body. Using nerve signals or hormones, the neuroendocrine system
changes cell activities that alter the diameter of blood vessels, the heart's rate and strength of contraction, and
even the amount of fluid the body retains.

How does the neuroendocrine system work?

This system works as a complex series of checks and balances on the heart and circulatory system in a way
similar to the action of a thermostat. A thermostat detects transient changes in temperature and has a maximum
and minimum temperature range allowed. When the room temperature falls below the minimum, the thermostat
signals to the furnace to turn on and raise the temperature in the room. When the addition of heat causes the
maximum temperature to be reached, the thermostat signals to the furnace to turn off. Much the same way, the
neuroendocrine system monitors certain variables in the body and makes adjustments when variables aren't in
the needed range.

When using the diagram below, think of the brain as a "thermostat" detecting changes, while organs act to
change what the brain dictates. Move the mouse over each symbol to identify it and its role in neuroendocrine
regulation:

This diagram represents a "feedback loop". Just as the brain sends signals to alter activity in the heart, blood
vessels, and adrenaline glands, it must likewise receive input when the condition has been properly changed.
When it receives this input (demonstrated by the animated arrows triggered by the heart and artery), it will halt
its own signaling and allow the system to work more independently.This particular example is a negative
feedback loop, as it reacts to reverse a situation and bring it within a threshold range.

Unfortunately, the changes made by the system are not necessarily beneficial in the long run. Imagine that the
thermostat in the above example is reset to a higher than desirable level. Once the furnace turns on, it will not
receive any input that the room is too hot and will continue to pump heat into the room until the new threshold
temperature is reached. In a similar sense, if the brain doesn't receive a proper "off" signal, it will continue to
raise blood pressure unnecessarily. Going one step further, impaired heart function will lead to ineffective,
sustained signalling activity by the nervous system, which will further create conditions that strain the heart,
driving it towards failure.

The system isn't perfect, but under normal conditions it affords the body a great deal of flexibility. Whether
resting or working, neuroendocrine feedback works in the background to address the changing needs of the
body.
Heart Failure and Your Heart

Once the heart has been injured, the body will attempt to compensate for reduced blood flow. Unfortunately,
many of the countermeasures actually increase strain on the heart and further the development of heart failure.

The heart, after suffering damage or being placed under physical stress by high blood pressure, will begin to
change its own shape. This deforming of the ventricles' shape is known as remodeling or hypertrophy. This
remodeling occurs in two primary patterns - concentric and dilated (as shown below):

Key
h = Thickness c = Concentric
r = Radius n = Normal
d = Dilated

These diagrams represent cross-sections of the left ventricle, the chamber that supplies the body with
oxygenated blood flow. The triangular notches are cut into each ventricle to demonstrate how the wall has
changed in shape and thickness.

For comparative terms, the normal heart essentially looks like a football. When the wall thickens in concentric
circles (lower left), The heart works less effectively and takes on the shape of a large fist. This may be caused
by hypertension, a blocked aortic valve, or underlying genetics. Dilation of the ventricle walls (lower right) gives
the weakened heart a beach-ball shape and an inefficient contraction. This prohibits blood from leaving the
heart as it normally would. This remodeling pattern follows damage from a heart attack, sustained
hypertension, viral infection, or genetic causes.
Heart failure occurs when the heart can't pump blood to the body as quickly as needed. Blood returning to the
heart faster than the heart can eject it congests the system behind it. Decreased blood flow to organs, such as
the kidneys, causes the body to retain more fluid which complicates the problem further. The relationship
between the heart and other organs can be a delicate one - once one is injured, it can send off a cascade of
events that damage other organs and worsens heart failure.

Heart Failure and Your Circulation

Coronary Artery Disease (also known as CAD)
Cause
Coronary Artery Disease is a condition where fatty deposits and cell-proliferation build-up in the arteries
supplying the heart muscle. These plaques form commonly in a condition called atherosclerosis. Genetic
factors or a diet of foods high in cholesterol or saturated fat that result in high blood cholesterol can increase
your risk for this disease. Fatty deposits form silently; no symptoms arise until they are large enough to
significantly restrict blood flow to an area of heart muscle. When this occurs, angina pectoris (chest tightness or
discomfort) usually results. Normally a 70% or greater blockage in the diameter of a coronary artery will cause
symptoms of chest discomfort or pain with exercise.
An abrupt closure of a coronary artery due to a blood clot forming (associated with a fissure of a plaque) can
cause a heart attack (or myocardial infarction).
Cause
Blood pressure refers to the pressure of blood against the walls of arteries and is measured in units of
millimeters of mercury (mmHg), which is a reference to the fluid historically used with blood pressure cuffs.
Blood pressure is always measured by two numbers on this scale. The range of the first number is usually 100-
140 mmHg, which is referred to as systolic (the peak pressure in the arteries after the heart contracts). The
range of the second number is usually 60-90 mmHg and is referred to as diastolic (the minimum pressure
reached in the arteries when the heart relaxes just before the next contraction). The usual cause of
hypertension is not known - the brain's "set-point" for a usual BP increases. Uncommonly, renal artery stenosis
(a blockage of the arteries) going to the kidneys or hormone producing tumors can also be causes. For a more
thorough explanation,

Symptoms
Usually none, but headaches and flushing are sometimes evident.

Diagnosis
Blood pressure cuff (sphygmomanometer), Chest X-ray and echocardiogram (to observe hypertrophy).

Treatment
Hypertension is managed with a combination of hygienic approaches and medication. A low salt diet, exercise,
weight loss when obesity is present, and stress reduction may all help. Most individuals also require medication
to maintain a blood pressure lower than 140/90. If the blood pressure has caused cardiac remodeling (see
diagram) reducing blood pressure can encourage the heart to return to its former shape and function.

Heart Failure and Your Lungs

Shortness of breath with activity is the most common symptom of heart failure. In many cases of heart failure
the left ventricle of the heart, which pumps blood to the body, is rendered unable to properly eject its contents.
As the left ventricle's abilities are diminished, blood tends to pool and back-up behind it in the pulmonary (lung)
circulation. This back-up is under increased pressure, as the right side of the heart is still pumping into this
circulation. The result is fluid leakage into the lungs, a condition called pulmonary edema. Fluid retention in the
body by the kidneys can also be a culprit in developing pulmonary edema. This situation translates into
shortness of breath. The diagram below illustrates just how apparent this problem can develop in some
patients:
Individual genetic and other factors may influence how likely this is to occur at any given pressure backed up
behind the left ventricle. Pulmonary edema can prevent the individual from breathing properly and comfortably.
Furthermore, it can strongly impair one's ability to exercise and lead an active life. A primary way to improve this
is the use of diuretics. Diuretics are a family of drugs that reduce the kidney's ability to retain the body's salt and
water in favor of excreting it in urine. Shedding body salt and water allows for the reduction of symptoms
associated with pulmonary edema as well as reducing the strain of volume overload on the heart.

Heart Failure and Your Neuroendocrine System

Paradoxically, activity of the neuroendocrine (body regulation) system, that normally functions to maintain the
circulation, can actually worsen heart failure if sustained over time. By following the feedback control it is
programmed to, it inadvertently adds strain to the heart. Examine the scenario below where the body is entering
the early stages of heart failure due to blocked heart arteries. Click here to see a quick overview of the
neuroendocrine system, if necessary.
With time, the heart failure becomes worse and worse. High blood volumes and remodeling increase heart size
over time, which further impacts its ability to adequately eject blood. In this way, a system designed to support
our heart has caused it to fail when attempting to compensate for heart injury.

Why would the body do this to itself? Consider that the design of this system has evolved in such a way as to
protect our body not from heart damage, but from exterior threats. For example, if one suffers an injury where
blood is being lost (see example), survival is dependent on maintaining an adequate blood pressure to all vital
organs. If blood is lost, then blood pressure in our arteries will drop accordingly. Fluid retention serves to keep
high blood volumes to buffer the loss due to injury. By constricting our arteries as shown before, the remaining
blood gets mobilized more efficiently to tissues at an adequate pressure. Therefore, possibly the situation
shown in the chart isn't so much an error in design of the neuroendocrine system so much as a misapplication
of a control mechanism initiated by initial heart and circulatory impairment.

Coronary Obstructions and Disease

Blood itself is mostly water. Its characteristic properties and color are more related to the many different types of
cells, salts, and proteins that reside in the fluid. In terms of oxygen delivery, the red blood cells are the most
important. These cells contain an oxygen (O2) trapping molecule called hemoglobin that will uptake oxygen in
the lungs and deliver it to where the circulation leads. All living tissues require oxygen, especially the brain and
heart. Without this O2 delivery, tissues weaken and die. In cases of a heart attack (or myocardial infarction) this
occurs because of an occlusion, or blockage, of a coronary artery feeding the ventricles or main pumping
chambers of the heart.
In this example, a fatty deposit or "plaque" has reduced the diameter that blood can flow through. This occurs in
a condition called atherosclerosis, the thickening and hardening of arterial walls. The plaques are not simply
accumulations of fats - current thinking involves inflamed smooth muscle tissues inside the vessel intermingling
with cholesterol and mineral deposits. Atherosclerosis is the major cause of Coronary Artery Disease (CAD).
In the above example, a partial blockage would likely cause angina, chest pain or pressure caused by
inadequate oxygen delivery to heart tissue. However, as this plaque enhances blood clot (thrombus) formation
(with a partial blockage progressing rapidly to a complete occlusion), a myocardial infarction (heart attack)
becomes more probable.

CAD is responsible for 75% of all deaths from heart disease in the United States! CAD is not simply a
matter of diet though - its occurrence has a strong link to genetics and advancing age. While lifestyle can impact
its onset greatly (e.g. smoking, lack of exercise, stress) other disease states are also responsible (for example,
diabetes and hyper-cholesterolemia). It is largely treated by medical regimens, angioplasty, and bypass
surgery along with changes in lifestyle.

The injuries caused to the heart by a blocked coronary artery vary with the location and severity of the
occlusion. Dead heart tissue will cease to contract properly and will interfere with conduction of signals that
cause the rest of the heart to contract.

Arrythmias such as ventricular fibrillation may be fatal unless promptly converted with electrical paddles. This
area of dead or dying heart tissue is called a myocardial infarction, often causing or referred to as a heart
attack. This may cause severe chest pain or pressure that radiates to the left arm, neck and jaw. Some
individuals with diabetes may experience a heart attack with no awareness of chest pain. Blockages that are
severe, but not completely closed, may also hamper the heart's ability to function as a pump. In either way,
coronary artery disease can ultimately lead to a decrease in the reserve of heart output and start a decline into
heart failure.

Causes of Heart Failure

For heart failure to occur, there must be an unresolved impairment of the heart that compromises its ability to
work as a pump. The source of this can be a cutoff of blood supply, an increase in workload due to high blood
pressure caused by non-functioning valves or a genetic predisposition. Heart failure can be worsened by a poor
diet and lifestyle. Its development follows the scheme below:
Conditions That May Lead To Heart Failure
Coronary Artery Disease (CAD)
This is the most common cause of heart failure in the U.S. today. CAD causing obstruction to the coronary
arteries prevents blood flow and, therefore, oxygen delivery to the heart. CAD is a manifestation of
atherosclerosis, which can affect any artery of the body. Risk factors for CAD also include smoking, high
cholesterol, hypertension, and diabetes.

Hypertension
This is more commonly known as high blood pressure. It is a condition that is treatable and simple to diagnose
with a blood pressure cuff. Although most individuals will not have symptoms, hypertension is detected by a
simple measurement with a blood pressure cuff and stethoscope. It is also a risk factor for CAD, stroke,
peripheral vascular disease, or kidney impairment.

Valvular Heart Disease

A condition that occurs when the valves between the chambers of the heart are faulty, either due to birth defect
or injury.

Cardiomyopathy
A disease of the heart muscle. This can be one of many varieties. It can arise because of genetic causes, a viral
infection, or consumption of toxins (lead, alcohol, etc.). In peripartum cardiomyopathy, women who have
recently given birth can develop heart muscle impairment. In many cases, the condition is called "idiopathic",
which means it has occurred of uncertain origin or cause.

In addition to those causes above, the following factors also can play a role in determining if heart failure will
affect you:

1. family history of heart failure

2. diabetes
3. marked obesity
 4. heavy consumption of alcohol, or drug abuse
5. failure to take medications
6. large salt intake in diet
7. sustained rapid heart rhythms

Many other conditions can actually simulate heart failure symptoms - it is important to seek evaluation from a
medical professional for a definitive diagnosis. Some of these are:

1. lung impairment
2. anemia
3. kidney impairment
4. pericardial disease (rare)

Symptoms and Signs

Swollen Ankles or Legs Shortness of Breath

Swollen ankles or legs, known as peripheral edema,
may be a result of right-sided heart failure since
fluid cannot be pumped to the lungs at an efficient
rate. In right-sided heart failure, fluid backs up in the
veins, leaks out of capillaries and accumulates in
tissues. Also, a decrease in blood flow to the kidneys
can lead to an increase in fluid retention. Diuretics are
often prescribed to get rid of this excess fluid and
reduce the strain on the heart.
Shortness of breath can be caused by
congestion in the lungs. This congestion is
known as pulmonary edema. One sign to
watch out for is whether your shortness of
breath is worse when you lay flat.
Orthopnea is the shortness of breath which
occurs when blood kept in the legs by
gravity returns to the chest when you lay
down.

In the absence of heart failure, peripheral edema may Shortness of breath can also occur at night.
commonly be due to obesity or venous insufficiency Shortness of breath that comes on
with stretched venous valves. suddenly at night is known as paroxysmal
(par-ox-iz-mal) nocturnal dyspnea.

Angina
Angina is chest or arm discomfort due to a blockage of
the coronary arteries. Heart cells typically do not get
enough oxygen when blood flow to the heart muscle is
reduced. Often, angina comes on with exertion and is
relieved by rest. This is because your heart may have
an adequate blood supply when it is not working very
hard but not when under stress. Other common
causes of chest pain unrelated to the heart are chest
muscle, bone or joint disease, and acid in the
esophagus.
Fatigue
Fatigue is often attributed to getting old or
being out of shape. However, if this
condition persists for long periods of time, it
may be the result of heart failure.
Sluggishness may be the result of your
organs not getting enough oxygen. You
may feel as tired after getting up in the
morning as you did when you went to bed.
Let your doctor know if this happens on a
regular basis.

Weight Gain or Loss

Excess fluid in the body may cause an increase in
weight. Similarly, when excess fluid is excreted, your
weight may fall. Weight increases by about two
pounds for each extra quart of fluid. You may notice
that your weight has risen before you notice swelling
of the ankles or extremities. Inform your doctor of
changes of more than five pounds.
Medical Tests and Findings
Chest X-ray
Your doctor can use an x-ray to look at your heart, lungs, and blood vessels. He or she can see if your heart is
enlarged or if there is fluid around your lungs. Pulmonary congestion shows up as cloudy areas on the x-ray. A
chest x-ray requires only a brief exposure to x-rays and is generally considered safe.

Echocardiogram
The echocardiogram is a procedure used to visualize the pumping action of the heart. It is an ultrasound
examination of the heart that can also measure blood flow into and out of the heart.

Electrocardiogram
This test also known as an "ECG" or "EKG", measures the electrical activity of the heart. An electrocardiogram
can check the heart's rhythm, evidence of enlargement, and the presence of a prior or recent heart attack.
Electrical wires with adhesive ends are attached to the skin on your chest, arms, and legs. The electrical activity
of the heart is then recorded on a piece of paper.

Tracer Studies
Radioactive tracers given through a hand or arm IV are another tool used in the diagnosis of heart failure.
Radioactivity is detected as the blood moves through the heart. In this way, doctors can outline the chambers of
the heart, measure the ejection fraction, and assess blood flow to regions of the heart muscle.

Treadmill Test
This test is known as a "stress test" because your heart's activity is being monitored with an electrocardiogram
during exercise. By walking on a treadmill for specific intervals of time at differing intensity levels, your doctor
can see if your symptoms are brought on by exertion and if they correlate with patterns on an
electrocardiogram.

Stress tests can be done using radioactive tracers such as thallium, Sesta MIBI, and Myoview. First, the tracer
is injected into an IV tube in the arm before and during exercise on the treadmill. After exercise, pictures of the
heart can be taken to see where the tracer has been deposited, telling the doctor which areas are getting
enough blood and which are not.

Alternatively, stress testing can be done without exercise. The effects of stress on heart blood flow can be
simulated through the use of an IV drug such as adenosine or persantine that dilates heart blood vessels, or
dobutamine that increases heart rate and function.
Catheterization
Doctors can insert a catheter, or small tube, into a leg (femoral) artery via a needle stick and direct it to a region
of the heart with x-ray guidance. Once in place, the catheter can measure pressures in the heart and direct a
dye used to visualize heart chambers or blood vessels. This visualization technique is called angiography. The
x-rays show areas of narrowing or blockage. Catheters are also used to open blocked heart arteries with
angioplasty and stenting.

Treatment

Heart failure and other cardiac disorders are hot areas of research. With so many new drugs and emergent
technologies becoming available, it is critical that you educate yourself on what is available to you. Building a
basic knowledge of the types of drugs and treatments that are now used as well as how they work will facilitate
your learning process.

Outpatient treatments
Your doctor can prescribe several treatments for heart failure that do not require hospitalization. These
treatments include diuretics, ACE inhibitors, vasodilators, beta-blockers, digitalis, and anticoagulants.

Inpatient treatment
In cases of advanced heart failure, your doctor may choose to keep you in the hospital for close supervision. He
or she may prescribe intravenous (IV) medications since some medications are not active when taken orally.

Compliance
It is important to follow your doctor's instructions carefully. Don't alter the dosage of your medications or
stop any medication suddenly. Keep follow-up appointments and inform your doctor of any new symptoms.

Procedures and Surgeries

Your doctor may suggest surgical treatment for your heart failure. Many of the options available are relatively
non-invasive procedures. When called for, however, there are many more aggressive surgeries that can be
used. Possible options are angioplasty, coronary bypass surgery, valve surgery, or heart transplantation.

Cardiac Medications – Outpatient

Diuretics

Diuretics, also known as water pills, help eliminate excess fluids from the body. They cause the kidneys to
make more urine and increase the body's excretion of sodium, chloride, and potassium. Since the use of most
diuretics can cause potassium levels in the body to be depleted be sure to include foods high in potassium in
your diet.

Diuretics are used to relieve both pulmonary and peripheral edema. In addition, they may be used to treat
hypertension since they dilate blood vessels.

Potential Side effects: dizziness, severe leg cramps, high blood sugar levels, high cholesterol levels

Examples: Furosemide(Lasix, shown below), Bumetanide(Bumex), Hydrochlorthiazide(HCTZ)

ACE Inhibitors

Angiotensin Converting Enzyme (ACE) Inhibitors block the formation of Angiotensin II, a substance that causes
constriction of blood vessels. In this way, ACE inhibitors reduce the strain on the heart. They relax smaller
arteries and lower blood pressure. For this reason they can cause dizziness. Finally, ACE inhibitors can prevent
undesirable increases in heart size.

Potential Side effects: cough, dizziness, worsening of some types of kidney disease

Examples:Lisinopril (Prinivil, shown below), Enalapril (Vasotec), Captopril (Capoten)

Vasodilators

This group of drugs relaxes blood vessels and lowers the resistance against which the heart has to pump. Like
ACE inhibitors or ARBs (Angiotensin Receptor Blockers) they can cause low blood pressure and dizziness.

Potential Side effects: low blood pressure (hypotension), dizziness, abnormally high heart rate (tachycardia),
headache

Examples: Hydralazine, Isosorbide Dinitrate, Nitroglycerin

Beta Blockers

These drugs block the heart cell response to catecholamines (norepinephrine, epinephrine) - compounds that
cause the heart to work harder, increase blood pressure, and increase blood flow to muscles. Catecholamines
are responsible for the "fight or flight" response of the central nervous system. Beta-Blockers may reduce the
energy needs of the heart and when tolerated over a long time may actually reduce heart size and improve the
function of the heart.

Potential Side Effects: decreased ventricular function, slow heart rate, worsening of symptoms due to asthma

Examples: Carvedilol (Coreg, shown below), Metoprolol (Toprol XL)