Lymphedema People Logo



Congestive Heart Failure

Lymphedema and Congestive Heart Failure

There are many medical conditions that can cause edema. These should not be confused with lymphedema. Lymphedema is caused by damage to the lymphatic system.

Warning

If you have any sudden and unexplained edema, it is imperative that you consult your physician and have the specific cause diagnosed and treated. If you have lymphedema, but suddenly also have sudden and unexplained edema (swelling), please do not simply assume it is your lymphedema acting up.  You should also notify your physician "asap"

I have presented articles are various types of edema for information and to help each of us understand the differences.

----------------------

CONGESTIVE HEART FAILURE

Related terms:  Cardiomyopathy, Pulmonary Edema, CHF, Localized edema, Left Sided Heart Failure, Right Sided Heart Failure, Systolic Heart Failure, Diastolic Heart Failure, Pleural Effusions, Acute Pulmonary Edema, Lymphedema, Lymph System, Lymphatics, Electrocardiogram, Echocardiogram, Multiple-gated Acquisition Scan, MUGA, Beta Naturetic Peptide, B-type

Discussion:

This is one of the most common diseases in the United States, affecting an estimated five million people, wih an estimate 500,000 new cases as year. While there is no "cure," there is, however,  treatment not only for the condition but for the complications associated with it.  Heart failure is a condition in which the heart is no longer able to efficiently pump enough blood through the body.  It is a gradually worsening condition that develops usually over a period of time.

It can develop in either side of, or the entire heart.  In left sided heart falure, the heart is not able to pump enough blood through the entire  body, whereas in right sided heart failure, the heart cannot pump blood efficiently or effectively through the lungs.  Left sided heart failure is the more common of the two.

Symptoms:

The most common symptoms of heart failure are shortness of breath or difficulty in breathing, feeling tired and unexplained swelling of the ankles, feet and legs. (edema).

Fluid build up in the lungs may also cause coughing and is generally worse at night when in bed.  You may even experience episodes of waking up feeling as if your are drowning and unable to breath.   This can lead to the life threatening condition known as acute pulmonary edema.

The swelling in the ankles, feet and leg is not to be confused with lymphedema The swelling from lymphedema is caused by malformations, destruction of or damage to the lymph system (lymphatics) and is not related to congestive heart failure.  It is also not a recognized causative factor in congestive heart failure.  Other indications of swelling will include weight gain and more frequent urination as the body attempts to cope with the fluid build up. Edema from congestive heart failure is a result of the heart inability to pump blood and fluids back through the cardiovascular system.  As the fluid "waits" to be pumped back through the heart, it builds up in the leg and begins to "leak" out of the permeable structure of the veins.

Symptoms of chronic heart failure are broken down into four classes, depending on the lmitations the conditions places on your ability to engage in various activities. (1)

Class 1:  No limitations on activities.  Activities do not cause undue fatigue or shortness of breath (Dyspnea)

Class 2:  Slight or mild limits. You are comfortable at rest, but are beginning to experience more  tiredness and shortness of breath when undertaking normal physical activity.

Class 3:  Marked or noticeable limits--comfortable at rest, but less than ordinary physical activity causes tiredness or shortness of breath. 

Class 4:  Severe limits--unable to carry on any physical activity without discomfort. Symptoms are also present at rest. If any physical activity is undertaken, discomfort increases.

Common symptoms include:  

Complications:

Blood and fluid back up in the lungs (pulmonary edema or pleural effusions); buildup of fluids in the feet, ankles and legs (localized edema); tiredness and shortness of breath, mental confusion due to the lack of oxygen rich blood in the brain.

Risk Factors and Precipitating Causes:

There are many risk factors and precipitating causes leading to congestive heart failure.

The most common are life style choices we make and as such, we can reduce our risk by maintaining proper weight, developing a healthy diet, not smoking, limiting alcohol intake, getting enough exercise and limiting caffeine consumption. Of these conditions the most common reason for heart failure  is coronary artery disease (CAD).

Medical conditions that contribute to congestive heart failure include anemia, infections, thyrotoxicosis, endocarditis, arrhythmia, rheumatic fever and other forms of myocarditis, hypertension, heart attacks, pulmonary embolisms, diabetes and congenital heart disease,  emphysema,  overactive thyroid,  severe anemia, underactive thyroid

Physiological Cause:

Risk factors and precipitating causes will over time affect the hearts ability to function properly.  The heart simply begins to "wear" out. The body attempts to compensate by causing the heart to work harder to performs its task. The result of this is that the heart enlarges and pumps faster and less efficiently.  As the heart weakens and less blood flows through the blood vessels, they narrow and constrict causing further damage.  Also, as less blood becomes available, the body will begin to divert the blood supply to organs it deems most important for "survival."  Other areas begin to be deprived of the needed blood flow and this can cause atrophy of muscles.

Eventually, neither the body nor the heart is able to maintain function and the entire system begins to breakdown, leading to failure and death.

Diagnosis:

While a physical exam and patient history can help diagnose congestive heart failure, there are a number of tests that will be administered for an accurate diagnosis.

These tests may include a chest x-ray (helpful in showing pleural edema), an electrocardiogram (shows the hearts electrical activity), echocardiogram which is an ultrasound type (shows the beating of the heart), and a multiple-gated acquisition scan, MUGA (dye test which shows problems with pumping an blood flow).

Blood tests will be done that will show blood counts, sodium and potassium levels, kidney function,  and will reveal the presence of a substance called beta naturetic peptide (B-type).  This is a substance that is produced by a failing heart.

Treatment:

There is no cure for congestive heart failure, but there is treatment for the conditions and for the complications associated with it.  A treatment program will consist of three focal points.  

First is lifestyle changes.  This involves (again) weight control, smoking cessation, limiting of alcohol, low fat and low cholesterol diet, proper exercise and limiting caffeine and salt.

Second, is the appropriate use of medications.  Commonly used medications includes diuretics for the edema. digoxin (digitalis) to improve the pumping ability of the heart, vasodilators which helps enlarge the smaller arteries for improvement in blood flow, beta-blockers which slow down the heart rate.  Other medications may include Nesiritide which is used for congestive heart failure patients in the hospital to help stabalize their condition and anti-arrhythmics which can help control the rythm of the heart

Third is the possible use of surgical therapy.  This may include coronary artery bypass to improve blood flow, angioplasty to clear blockages and may in the most severe cases of congestive heart failure lead to a heart transplant. If there is arrhythemia a pacemaker may be implanted.

------------------------------------------------------------------------------   

LYMPHEDEMA AND CONGESTIVE HEART FAILURE

Lymphedema is a tremendously debilitating condition in and of itself without the added difficulties of congestive heart failure.  Also, diuretics are indicated as a treatment for edema due to heart failure, but is not to be used as a treatment for the swelling caused by lymphedema. In fact, the use of diuretics can make the condition of lymphedema worse.

Diuretics remove only fluids from the body, not the protein rich substances that are a result of lymphedema.  Its this protein rich substance that contributes to tissue fibrosis and acts as a medium for bacterial growth, leading to cellulitis and lymphangitis.

Many lymphedema patients who also have congestive heart failure ask if they should continue taking diuretics.  The answer is a simple and clear yes.  The rule of thumb is that you need to take medications dealing with the most life threatening medical condition you have.  In this case, congestive heart failure is fatal without proper care.  While lymphedema can be fatal due to the complications involved, generally it is not life threatening.

Limiting Risk Factors for congestive heart failure:

It is imperative that lymphedema patients make the necessary life-style changes to avoid adding congestive heart failure to their problems.  

Developing a healthy lifestyle includes:

Weight:  Lymphedema does not cause obesity or morbid obesity.  But, both can cause lymphedema and congestive heart failure.  Its plain and simple - loose that weight!

Diet:  Unhealthy diets rich in fats, sugars, cholesterols complicates lymphedema and helps contribute to congestive heart failure.  Limit (I would even say drastically) your consumption of those types of foods.  Diet is also important in preventing high blood pressure which is another causative factor of congestive heart failure.

Smoking:  While smoking has nothing to do with lymphedema, it is an important contributing factor in congestive heart failure (not to mention cancers and other conditions).

Alcohol:  Excessive use of alcohol complicates lymphedema and is an important contributor to congestive heart failure.  Limit your consumption!!

Exercise:  The human body was not designed to be a couch potato.  Proper and consistent exercise is one key to remaining healthy. Lymph fluid pumps through your body by muscular action.  Exercise will help lymphedema and will help prevent congestive heart failure.

Just because you have lymphedema does not mean you need to quit either life nor activities. Many lymphedema patients complain the pain is one factor that stops them from many activities. Trust me, with severe stage three hereditary lymphedema and with two lymphomas, I know full well the affects of pain on your body, mind and emotions.  But the fact is that you must keep going and must get exercise.

Caffeine:  Caffeine acts as a diuretic which is contraindicated for lymphedema patients.  it also is a stimulant causing the heart to work harder.  Limit your intake.

Salt:  Salt (sodium chloride) contributes to fluid retention (edema and lymphedema), contributes to hypertension and congestive heart failure.  Maintaining a low salt intake is important in the control of both conditions and in maintaining health.

Treatment of Lymphedema with Congestive Heart Failure

You can still have treatment for lymphedema even with CHF.  You will need to work with both the lymphedema therapist and your cardiologist to determine which treatments would be safe for you.  What you shouldn't do is simply ignore the lymphedema.

The gold standard protocol for lymphedema treatment includes manual lymphatic drainage physiotherapy (MLD and/or CDT); compression bandaging, the use of compression garments and stockings,  and exercise.  Your cardiologist should work with your lymphedema therapist to develop a lymphedema treatment and management program specifically designed for you and the stage of your congestive heart failure.

Some or all of these protocols may move too much fluid into the abdominal and/or cardio-pulmonary cavity.  When this happens, it could be dangerous and cause serious complications with the CHF.  Also, if too much fluid is moved into these areas and the lymph system there becomes over whelmed, you actually could cause more permanent damage to the lymph system. This would cause a serious worsening of the lymphedema.  So, work with both the doctor and the therapist for proper and safe treatment/management of both conditions.

Finally, I want to reiterate that it may be absolutely imperative that you take diuretics for the heart failure.  If the doctor prescribes these medicines, you need to cooperate and take them.  Congestive heart failure can be fatal far far quicker then lymphedema.  

-----------------------------------------------------------------

Topic Review - Heart Failure

Osama Gusbi, MD

Albany Medical Review - January 2002

Heart failure is the pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissues and/or doing so using abnormally elevated diastolic volumes.

Heart failure represents a major public health problem in industrialized nations. It appears to be the only common cardiovascular condition that is increasing in prevalence and incidence. In the United States, heart failure is responsible for almost 1 million hospital admissions and 40,000 deaths annually.


Heart failure should be distinguished from (1) conditions in which there is circulatory congestion consequent to abnormal salt and water retention but in which there is no disturbance of cardiac function per se and (2) noncardiac causes of inadequate cardiac output, including shock due to hypovolemia and redistribution of blood volume.

The ventricles respond to a chronically increased hemodynamic burden with progressive hypertrophy. With volume overload, the ventricle is required to deliver an increased cardiac output for prolonged periods, e.g., valvular regurgitation, and it develops eccentric hypertrophy, i.e., cavity dilatation, with an increase in muscle mass such that the ratio between wall thickness and ventricular cavity remains relatively constant. With chronic pressure overload, as in aortic stenosis or untreated hypertension, the ventricle develops concentric hypertrophy, in which the ratio between wall thickness and ventricular cavity size increases.

These descriptors are often useful in a clinical setting, particularly early in the patientís course, but late in the course of chronic heart failure the differences between them become blurred.

Precipitating Causes

Infection.

Anemia.

Thyrotoxicosis.

Pregnancy.

Arrhythmias.

Rheumatic and other forms of myocarditis.

Infective endocarditis.

Physical, dietary, fluid, environmental, and emotional excesses.

Systemic hypertension.

Myocardial infarction. (heart attack)

Pulmonary embolism


Systolic Versus Diastolic Failure

This classification relates to whether the principal abnormality is the inability to contract normally and expel sufficient blood (systolic failure) or to relax and fill normally (diastolic failure). The major clinical manifestations of systolic failure relate to an inadequate cardiac output with weakness, fatigue, reduced exercise tolerance and other symptoms of hypoperfusion, while in diastolic failure they relate principally to an elevation of filling pressures. In many patients, particularly those who have both ventricular hypertrophy and dilatation, abnormalities of contraction and relaxation coexist.

Diastolic heart failure may be caused by increased resistance to ventricular inflow and reduced ventricular diastolic capacity (constrictive pericarditis and restrictive, hypertensive, and hypertrophic cardiomyopathy), impaired ventricular relaxation (acute myocardial ischemia, hypertrophic cardiomyopathy), and myocardial fibrosis and infiltration (dilated, chronic ischemic, and restrictive cardiomyopathy).

High Output Versus Low Output Heart Failure

Low output heart failure occurs secondary to ischemic heart disease, hypertension, dilated cardiomyopathy, and valvular and pericardial disease. High output heart failure occurs in hyperthyroidism, anemia, pregnancy, arteriovenous fistulas, beriberi, and Pagetís disease. In clinical practice, however, low output and high output heart failure cannot always be readily distinguished.

Acute Versus Chronic Heart Failure

The prototype of acute heart failure is the patient who is entirely well but who suddenly develops a large myocardial infarction or rupture of a cardiac valve. Chronic heart failure is typically observed in patients with dilated cardiomyopathy or multivalvular heart disease that develops or progresses slowly. Acute heart failure is usually largely systolic and the sudden reduction in cardiac output often results in systemic hypotension without peripheral edema. In chronic heart failure, arterial pressure tends to be well maintained until very late in the course, but there is often accumulation of peripheral edema.


Right Sided Versus Left Sided Heart Failure

Patients in whom the left ventricle is mechanically overloaded (e.g., aortic stenosis) or weakened (e.g., post myocardial infarction) develop dyspnea and orthopnea as a result of pulmonary congestion, a condition referred to as left sided heart failure. In contrast, when the underlying abnormality affects the right ventricle primarily (e.g., pulmonic stenosis or pulmonary hypertension), symptoms resulting from pulmonary congestion such as orthopnea and paroxysmal nocturnal dyspnea are less common, and edema, congestive hepatomegaly, and systemic venous distention, i.e., clinical manifestations of right sided heart failure, are more prominent. However, when heart failure has existed for months or years, biventricular failure usually results. For example, patients with long standing aortic valve disease or systemic hypertension may have ankle edema, congestive hepatomegaly, and systemic venous distention late in the course of their disease, even though the abnormal hemodynamic burden initially was placed on the left ventricle.


Backward Versus Forward Heart Failure

The concept of backward heart failure contends that in heart failure, one or the other ventricle fails to discharge its contents or fails to fill normally. As a consequence, the pressures in the atrium and venous system behind the failing ventricle rise, and retention of sodium and water occurs as a consequence of the elevation of systemic venous and capillary pressures and the resultant transudation of fluids into the interstitial space. In contrast, the proponents of the forward heart failure hypothesis maintain that the clinical manifestations of heart failure result directly from an inadequate discharge of blood into the arterial system. According to this concept, salt and water retention is a consequence of diminished renal perfusion and excessive proximal tubular sodium reabsorption and of excessive distal tubular reabsorption through activation of the renin-angiotensin-aldosterone system.


Redistribution of Cardiac Output

The redistribution of cardiac output serves as an important compensatory mechanism when cardiac output is reduced. This redistribution is most marked when a patient with heart failure exercises, but as heart failure advances, redistribution occurs even in the basal state. Blood flow is redistributed so that the delivery of oxygen to vital organs, such as the brain and myocardium, is maintained at normal or near-normal levels, while flow to less critical areas, such as the cutaneous and muscular beds and viscera, is reduced. Vasoconstriction mediated by the adrenergic nervous system is largely responsible for this redistribution, which in turn may be responsible for many of the clinical manifestations of heart failure, such as fluid accumulation (reduction of renal flow), low grade fever (redistribution of cutaneous flow), and fatigue (reduction of muscle flow).

CLASSIFICATIONS OF HEART FAILURE

Systolic vs. diastolic - High output vs. low output - Acute vs. chronic - Right sided vs. left sided - Forward vs. backward

Clinical Findings

Tachycardia - Cyanosis of lips and nail beds - Jugular venous distention - Diminished pulse pressure - Third and fourth heart sounds

Pulsus alternans - Pulmonary rales - Cardiac edema - Hydrothorax and ascites - Congestive hepatomegaly

Jaundice - Cardiac cachexia - Cold, pale extremities

CLINICAL MANIFESTATIONS
OF HEART FAILURE


Dyspnea

Orthopnea

Paroxysmal (nocturnal) dyspnea

Cheyne-Stokes respirations (periodic or cyclic respiration)

Fatigue, weakness, and abdominal symptoms

Cerebral symptoms (confusion, headache, insomnia)

ROENTGENOGRAPHIC FINDINGS

In addition to the enlargement of the particular chambers responsible for heart failure, distention of pulmonary veins and redistribution of pulmonary vasculature to the apices is common in patients with heart failure and elevated pulmonary vascular pressures. Also, pleural effusions may be evident and associated with interlobar effusions.

TREATMENT

The treatment of heart failure maybe divided logically into three components: (1) removal of the precipitating cause, (2) correction of the underlying cause, and (3) control of congestive heart failure symptoms. The control of congestive heart failure symptoms, may, in turn, be divided into three categories: (1) reduction of cardiac workload, including both preload and afterload; (2) control of excessive retention of salt and water; and (3) enhancement of myocardial contractility.

While a simple rule for the treatment of all patients with heart failure can not be formulated because of varied etiologies, hemodynamic features, clinical manifestations, and severity of heart failure, insofar as the treatment of chronic congestive heart failure is concerned the administration of an angiotensin-converting enzyme inhibitor has been shown to retard the development of heart failure and should be begun early in patients with cardiac dilatation and/or hypertrophy, even if they are asymptomatic. Then, as symptoms develop, simple measures such as moderate restriction of activity and sodium intake should be encouraged. If these and the use of an ACE inhibitor are insufficient, therapy with a combination of a diuretic, a vasodilator, and usually a digitalis glycoside is then begun. The next step is more rigorous restriction of salt intake and high doses of a loop diuretic, sometimes accompanied by other diuretics. If heart failure persists, hospitalization with rigid salt restriction, bed rest, intravenous vasodilators, and positive inotropic agents follows.

FARMINGHAM CRITERIA FOR DIAGNOSIS OF CONGESTIVE HEART FAILURE

Major Criteria

PND - Neck Vein Distention - Rales - Cardiomegaly - Acute Pulmonary Edema - S3 Gallop - Increased Venous Pressure (>16cm Of H20) - Positive Hepatojugular Reflux

Minor Criteria

Extremity Edema - Night Cough - Dyspnea On Exertion - Hepatomegaly - Pleural Effusion - Vital Capacity Reduced By 1/3 From Normal

Tachycardia (>120bpm)

Major or Minor

Weight loss > 4.5kg over 5 daysí treatment 

In summary, treatment of congestive heart failure includes:

Correction of reversible causes - Dietary restriction (e.g., 2g sodium or 5g salt) - Activity (gradual exercise program)

Diuretic therapy - Thiazide diuretics - Metolazone - Fursemide, Bumetanide, Torsemide - Aldosterone antagonists
(Spironolactone)

Triamterene, Amiloride 

ACE inhibitors

Angiotensin II receptor blockers

Vasodilators - Hydralazine - Nitrates (isosorbide nitrate, sodium nitroprusside) - Digitalis - 

Beta-blockers

Metoprolol - Carvedilol

Sympathomimetic amines

Dopamine - Dobutamine - Amrinone and milrinone

Anticoagulation

Cardiac Transplantation

When patients with heart failure become unresponsive to a combination of therapeutic measures, are in New York Heart Association Class IV (symptomatic at rest), and are deemed unlikely to survive one year, they should be considered for cardiac transplantation. Many centers now have one year survival rates exceeding 80%-90%, and five year survival rates over 70%.

INDICATIONS FOR CARDIAC TRANSPLANTATION

End-stage heart disease that limits prognosis for survival over 2 years or severely limits daily quality of life despite optimal medical and other surgical therapy.

No secondary exclusion criteria.

Suitable psychosocial profile and social support system.

Suitable physiologic/chronological age.

EXCLUSION CRITERIA

Active infectious process - Recent pulmonary infection - Insulin requiring diabetes with evidence of end organ damage

Irreversible pulmonary hypertension - Presence of circulating cytotoxic antibodies - Presence of active peptic ulcer disease

Active or recent malignancy - Presence of severe emphysema or chronic bronchitis - Substance or alcohol abuse

Presence of peripheral or cerebrovascular disease - Other systemic diseases that jeopardize post-transplant rehabilitation

REFERENCES

Braunwald E, Heart Failure, Harrisonís Principles of Internal Medicine, 14th Edition.

Massie BM, Amidon TM, Cardiac Failure, Current Medical Diagnosis and Treatment.

Schrier RW, Abraham WT. Hormones and Hemodynamics in Heart Failure. N Eng J Med 1999; 341:577-585, Aug 19, 1999

Albany Medical Center
43 New Scotland Avenue
Albany, New York 12208
E-mail the AMC Webmaster: Webmaster@mail.amc.edu

http://www.amc.edu/amr/archives/200201/review01.html

-----------------------------

Heart Failure

What Is Heart Failure?

Heart failure is a condition in which the heart canít pump blood the way it should. In some cases, the heart canít fill with enough blood. In other cases, the heart canít send blood to the rest of the body with enough force. Some people have both problems.

ďHeart failureĒ doesnít mean that your heart has stopped or is about to stop working. However, itís a serious condition that requires medical care.

Overview

Heart failure develops over time as the pumping of the heart grows weaker. It can affect the right side of the heart only or both the left and right sides of the heart. Most cases involve both sides of the heart.

Right-side heart failure occurs when the heart canít pump blood to the lungs, where it picks up oxygen. Left-side heart failure occurs when the heart canít pump enough oxygen-rich blood to the rest of the body.

Right-side heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and, rarely, the veins in the neck. Right-side and left-side heart failure also cause shortness of breath and fatigue (tiredness).

The leading causes of heart failure are diseases that damage the heart. These include coronary artery disease (CAD), high blood pressure and diabetes.

Outlook

Heart failure is a very common condition. About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year.

Both children and adults can have heart failure, although the symptoms and treatments differ. This article focuses on heart failure in adults.

Taking steps to prevent CAD can help prevent heart failure. These steps include following a heart healthy diet, not smoking, doing physical activity, and losing weight if youíre overweight or obese. Working with your doctor to control high blood pressure and diabetes also can help prevent heart failure.

People who have heart failure can live longer and more active lives if itís diagnosed early and they follow their treatment plans. For most, treatment includes medicines and lifestyle measures.

Currently, thereís no cure for heart failure. However, researchers are finding and testing new treatments. These treatments offer hope for better ways to delay heart failure and its complications.

Other Names for Heart Failure

Some people have only right-side heart failure. But all people who have left-side heart failure also have right-side heart failure. Treatments for right-side heart failure alone differ from treatments for both right-side and left-side heart failure. Your doctor will plan your treatment based on your type of heart failure and your unique needs.

What Causes Heart Failure?

Conditions that damage the heart muscle or make it work too hard can cause heart failure. Over time, the heart weakens. It isn't able to fill with and/or pump blood as well as it should.

As the heart weakens, certain proteins and other substances may be released into the blood. They have a toxic effect on the heart and blood flow, and they cause heart failure to worsen.

Major Causes

The most common causes of heart failure are coronary artery disease (CAD), high blood pressure, and diabetes. Treating these problems can prevent or improve heart failure.

Coronary Artery Disease

CAD occurs when a fatty material called plaque (plak) builds up in your coronary arteries. These arteries supply oxygen-rich blood to your heart. Plaque narrows the arteries, causing less blood to flow to your heart muscle. This can lead to chest pain, heart attack, and heart damage.

High Blood Pressure

Blood pressure is the force of blood pushing against the walls of the arteries. Blood pressure is ďhighĒ if it stays at or above 140/90 mmHg over a period of time. High blood pressure stiffens blood vessels and makes the heart work harder. Without treatment, the heart may be damaged.

Diabetes

This disease occurs when the level of sugar in the blood is high. The body doesn't make enough insulin or doesn't use its insulin properly. Insulin is a hormone that helps convert food to energy. High sugar levels can damage blood vessels around the heart.

Other Causes

Other diseases and conditions that can lead to heart failure are:

Other factors also can injure the heart muscle and lead to heart failure. These include:

Heart damage from obstructive sleep apnea may cause heart failure to worsen. In obstructive sleep apnea, your breathing stops or gets very shallow while youíre sleeping. This can deprive the heart of oxygen and increase its workload. Treating this sleep problem may improve heart failure.

Who Is At Risk for Heart Failure?

About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year. The number of people who have heart failure is growing. Each year, another 550,000 people are diagnosed for the first time. Heart failure is more common in:

Men have a higher rate of heart failure than women. But in actual numbers, more women have the condition. This is because many more women than men live into their seventies and eighties when itís common.

Children with congenital heart defects also can develop heart failure. Children are born with these defects when the heart, heart valves, and/or blood vessels near the heart donít form correctly. This can weaken the heart muscle and lead to heart failure.

Children donít have the same symptoms or get the same treatment for heart failure as adults. This article focuses on heart failure in adults.

What Are the Signs and Symptoms of Heart Failure?

The most common signs and symptoms of heart failure are:

All of these symptoms are due to the buildup of fluid in your body. When symptoms start, you may feel tired and short of breath after routine physical effortólike climbing stairs.

As the heart grows weaker, symptoms get worse. You may begin to feel tired and short of breath after getting dressed or walking across the room. Some people have shortness of breath while lying flat.

Fluid buildup from heart failure also causes weight gain, frequent urination, and a cough that's worse at night and when you're lying down. This cough may be a sign of a condition called acute pulmonary (PULL-mun-ary) edema (e-DE-ma). This is when too much fluid is in your lungs. This severe condition requires emergency treatment.

How Is Heart Failure Diagnosed?

Your doctor will diagnose heart failure based on your medical and family histories, a physical exam, and tests. Because the symptoms of heart failure also are common in other conditions, your doctor must:

Early diagnosis and treatment can help people with heart failure live longer, more active lives.

Medical and Family Histories

Your doctor will ask whether you or others in your family have or have had a disease or condition that can cause heart failure.

Your doctor also will ask about your symptoms. He or she will want to know which symptoms you've have, when they occur, how long you've had them, and how severe they are. The answers will help show whether and how much your symptoms limit your daily routine.

Physical Exam

During the physical exam, your doctor will:

Diagnostic Tests

No one test shows whether you have heart failure. If you have signs and symptoms of heart failure, your doctor may order an EKG (electrocardiogram), a chest x ray, and a BNP blood test as initial tests.

Initial Tests

EKG. This simple test shows how fast your heart is beating and whether its rhythm is steady or irregular. An EKG may show whether you have had a heart attack or whether the walls in your heart's pumping chambers are thicker than normal. Thicker walls can make it harder for your heart to pump blood.

Chest x ray. A chest x ray takes a picture of your heart and lungs. It can show whether your heart is enlarged, whether you have fluid in your lungs, or whether you have lung disease.

BNP blood test. This new test checks the level of a hormone called BNP, which rises during heart failure.

Followup Tests

Your doctor may refer you to a cardiologist if your initial test results indicate heart failure. A cardiologist is a doctor who specializes in treating people with heart problems.

The cardiologist will likely order one or more other tests to confirm the diagnosis.

Echocardiography. Echocardiography uses sound waves to create a moving picture of your heart. It shows the size and shape of your heart and how well parts of your heart are working. The test also can show where blood flows poorly to the heart, where the heart muscle doesn't contract as it should, and damage to the heart muscle caused by poor blood flow.

Sometimes this test is done both before and after your heart is put through physical stress (see stress testing below). Testing under stress helps show whether there's a lack of blood flow to your heart (a sign of CAD).

Doppler imaging. A Doppler test uses sound waves to measure the speed and direction of blood flow. It's often done with an echocardiogram to give a more complete picture of blood flow to the heart and lungs.

Doppler is often used to find out whether you have right-side heart failure (this is when the heart can't fill with enough blood).

Holter monitor. A Holter monitor is a small box that you carry in a pouch around your neck or clipped to your belt. It's attached to sticky patches called electrodes that are placed on your chest. The device records your heart rhythm for a full 24- or 48-hour period, while you do your normal daily activities.

Nuclear heart scan. A nuclear heart scan  is a test that shows how well blood is passing through your heart and how much blood is reaching your heart muscle.

Your doctor will inject a radioactive substance into your bloodstream, which will make your heart chambers and vessels easy to see. Then, a special camera is used to show where the substance lights up (in healthy heart muscle) and where it doesn't (in damaged heart muscle).

Your doctor may want to do this test while your heart is under physical stress (see stress testing below).

Cardiac catheterization. During cardiac catheterization (KATH-e-ter-i-ZA-shun), a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. This allows your doctor to study the insides of your coronary arteries. Coronary arteries carry oxygen-rich blood to your heart.

During this procedure, your doctor can check the pressure and blood flow in the heart's chambers, collect blood samples, and use x rays to look at the coronary arteries.

Coronary angiography. Coronary angiography (an-jee-OG-ra-fee) is usually done with cardiac catheterization. A dye that can be seen on x ray is injected into the blood through the tip of the catheter. The dye allows your doctor to see the flow of blood to the heart muscle. This test also shows how well your heart is pumping.

Stress test. Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it's at rest. During stress testing  you exercise (or are given medicine if you can't exercise) to make your heart work harder and beat faster. You may walk or run on a treadmill or pedal a bicycle.

Heart tests, such as nuclear heart scanning and echocardiography, are done during stress testing.

Cardiac magnetic resonance imaging (MRI). A cardiac MRI scan shows, in detail, the structures and beating of your heart. An MRI scan can help your doctor see whether parts of your heart are damaged. Doctors also are using MRI in research studies to find early signs of heart failure, even before symptoms appear.

Positron emission tomography (PET). PET scanning shows the level of chemical activity in areas of your heart. This scan can help your doctor see whether enough blood is flowing to these areas. It can show blood flow problems that other types of scans may not pick up.

Thyroid function tests. Thyroid function tests show how well the thyroid is working. They include blood tests, imaging tests, and tests to stimulate the thyroid. These common tests are key in checking for heart failure. Having too much or too little thyroid hormone in the blood can cause heart failure.

How Is Heart Failure Treated?

Early diagnosis and treatment can help people with heart failure live longer, more active lives. How heart failure is treated will depend on your type and stage of heart failure (how severe it is).

The goals of treatment for all stages of heart failure are to:

For people with any stage of heart failure, treatment will include lifestyle measures, medicines, and ongoing care. People who have more severe heart failure also may need medical procedures and surgery.

Lifestyle Measures

You can take simple steps to help yourself feel better and control heart failure. The sooner you start these measures, the better off you're likely to be.

Follow a Healthy Eating Plan

A diet low in salt, fat, saturated fat, trans fat, and cholesterol can help you prevent or control heart failure. Salt can cause extra fluid to build up in your body, making heart failure worse. Fat and saturated fat can increase your blood cholesterol levels. Trans fat raises your LDL ("bad") cholesterol and lowers your HDL ("good") cholesterol. High blood cholesterol can cause heart disease, which in turn can cause heart failure.

A balanced diet with varied nutrients can help your heart work better. Getting enough potassium is key for people with heart failure. Some heart failure medicines deplete the potassium in your body. This can put people with heart failure in danger. Lack of potassium can cause very rapid heart rhythms that lead to sudden death.

Potassium is found in foods like bananas, strawberries, raisins, beets, and greens. Talk to your health care team about getting the correct amount of potassium.

If you have heart failure, you shouldn't drink alcohol. If you have severe heart failure, your doctor may advise you to limit the amount of fluids that you drink.

Examples of healthy eating plans are the National Heart, Lung, and Blood Institute's Therapeutic Lifestyle Changes (TLC) diet and the Dietary Approaches to Stop Hypertension (DASH) eating plan.

The TLC diet is low in saturated fat and cholesterol to help lower blood cholesterol. The DASH eating plan contains less salt/sodium, sweets, added sugars, fats, and red meat than the typical American diet. Fruits, vegetables, fat-free or low-fat diary products, whole grains, fish, poultry, beans, seeds, and nuts are the focus of the plan.

Adopt Healthy Habits

Taking steps to control risk factors for CAD, high blood pressure, and diabetes also will help control heart failure.

Medicines

Your doctor will base your medicine treatment on the type of heart failure you have, how severe it is, and your response to certain medicines. The following are the main medicines for treating heart failure.

Many people with severe heart failure must be treated in the hospital from time to time. In the hospital, you may receive new or special medicines, but you will keep taking your other medicines too. Some people with very severe heart failure are given intravenous (IV) medicines, which are injected into veins in their arms.

Your doctor also will order extra oxygen if you take medicine but still have trouble breathing. The extra oxygen can be given in the hospital and at home.

Ongoing Care

It's important to watch for signs that heart failure is getting worse. Weigh yourself each day. Let your doctor know right away if you have a sudden weight gain or weight loss. Either one can signal a need to adjust your treatment. If your doctor advises you to limit your intake of fluids, carefully watch how much you drink during the day.

It's also important to get medical care for other related conditions. If you have diabetes and/or high blood pressure, work with your health care team to control your condition(s). Have your blood sugar level and blood pressure checked. Your doctor will tell you how often to come in for tests and how often to take measurements at home.

Medical Procedures and Surgery

As heart failure worsens, lifestyle changes and medicines may no longer control heart failure symptoms. You may need a medical procedure or surgery.

If you have heart damage and severe heart failure symptoms, you may need:

People who have heart failure symptoms at rest despite other treatments may need:

Ongoing Research

Researchers continue to learn more about heart failure and how to treat it. As a result, treatments are getting better.

People with heart failure often can be treated in a research study. You get top care from heart failure experts and the chance to help advance heart failure knowledge and care.

You also may want to take part in a heart failure registry, which tracks the course of disease and treatment in large numbers of people. These data help research move forward. You may help yourself and others by taking part. Talk to your health care team to learn more.

How Can Heart Failure Be Prevented?

You can take steps to prevent heart failure. The sooner you start, the better your chances to avoid it or to stay healthier longer.

For People Who Have Healthy Hearts

If you have a healthy heart, you can take action to prevent heart disease, which helps prevent heart failure. To prevent heart disease:

For People Who Are at High Risk for Heart Failure

Even if you're at high risk for heart failure, you can take steps to reduce your risks. People at high risk include those who have  high blood pressure, coronary artery disease, diabetes, or people who are obese.

For People Who Have Heart Damage but No Signs of Heart Failure

If you have heart damage but no signs of heart failure, you can still reduce your risks. In addition to taking the steps above, take all of the medicines your doctor prescribes to reduce your heart's workload.

If you have side effects from a medicine, tell your doctor. You should never stop taking medicine without asking your doctor first.

Living With Heart Failure

Heart failure can't be cured. You will likely have to take medicine and follow a treatment plan for the rest of your life.

Despite treatment, symptoms may get worse over time. You may not be able to do many of the things that you did before you had heart failure. However, if you take all the steps your doctor recommends, you can stay healthier longer.

Researchers also may find new treatments that can help you in the future.

Follow Your Treatment Plan

Treatment can relieve your symptoms and make daily activities easier. It also can reduce the chance that you'll have to go to the hospital. For these reasons, it's vital that you follow your treatment plan.

Take Steps To Prevent Heart Failure From Getting Worse

Certain factors can cause your heart failure to worsen. These include:

These factors can lead to a hospital stay. If you have trouble following your diet, talk to your doctor. Your doctor can help arrange for a dietitian to work with you. Avoid drinking alcohol.

People with heart failure often have other serious conditions that require ongoing treatment. If you do, you're likely taking medicines for them as well as for heart failure. Taking more than one medicine raises the risk of side effects and other problems. Make sure your pharmacist has a complete list of all of the medicines and over-the-counter products that you're taking.

Tell your doctor right away about any problems with your medicines. Also, talk with your doctor before taking any new medicine another doctor prescribes or any new over-the-counter medicines or herbal supplements.

Try to avoid respiratory infections like the flu and pneumonia. Ask your doctor or nurse about getting flu and pneumonia vaccines.

Coping with heart failure and changing your life to decrease symptoms can be hard. You may feel depressed. If so, talk to your doctor. He or she may recommend treatment for depression. This treatment can improve your outlook and help you enjoy life more.

Plan Ahead

Be ready to meet your health needs. Know:

Key Points

National Heart, Lung and Blood Institute

==================

External Links

...............

Congestive Heart Failure

American Heart Association

01/08/04

http://www.heart.org/HEARTORG/Conditions/HeartFailure/Heart-Failure_UCM_002019_SubHomePage.jsp

.................................................

Congestive Heart Failure

Cardiology Channel

http://www.cardiologychannel.com/chf/

.................................................

Congestive Heart Failure and Pulmonary Edema

Author: Shamai Grossman, MD, MS, Director, The Cardiac Emergency Center, Instructor, Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Hospital

http://www.emedicine.com/EMERG/topic108.htm

...............................................

Your Guide to Heart Failure

http://www.webmd.com/heart-disease/guide-heart-failure

...............................................

How Congestive Heart Failure Works

by Carl Bianco, M.D.

http://health.howstuffworks.com/congestive-heart1.htm

............................................... 

Subclinical Thyroid Dysfunction and the Risk of Heart Failure in Older Persons at High Cardiovascular Risk. 

Jan 2012

http://www.ncbi.nlm.nih.gov/pubmed/22238391

...............................................

Mechanical circulatory support for elderly 

heart failure patients. 

Jan. 2012

http://www.ncbi.nlm.nih.gov/pubmed/22237460

...............................................

Trends in death attributed to heart failure over the past two decades in Europe. 

Jan 2012

http://www.ncbi.nlm.nih.gov/pubmed/22237388

...............................................

Functional electrical stimulation for chronic heart failure: A meta-analysis. 

Jan. 2012

http://www.ncbi.nlm.nih.gov/pubmed/22236510

...............................................

Get With The Guidelines Program Participation, Process of Care, and Outcome for Medicare Patients Hospitalized With Heart Failure. 

Jan. 2012

http://circoutcomes.ahajournals.org/content/early/2012/01/10/CIRCOUTCOMES.110.959122.long

=======================================================

ICD-10 

Heart failure
I50 Excludes: complicating:
∑ abortion or ectopic or molar pregnancy ( O00-O07 , O08.8 )
∑ obstetric surgery and procedures ( O75.4 )
due to hypertension ( I11.0 )
∑ with renal disease ( I13.- )
following cardiac surgery or due to presence of cardiac prosthesis ( I97.1 )
neonatal cardiac failure ( P29.0 )
I50.0 Congestive heart failure
Congestive heart disease
Right ventricular failure (secondary to left heart failure)
I50.1 Left ventricular failure
Cardiac asthma
Left heart failure
Oedema of lung
Pulmonary oedema
}
}
with mention of heart disease NOS or heart failure
I50.9 Heart failure, unspecified
Cardiac, heart or myocardial failure NOS

ICD-9

2008 ICD-9-CM Diagnosis 428.0

Congestive heart failure unspecified

  • 1. inadequacy of the heart so that as a pump it fails to maintain the circulation of blood, with the result that congestion and edema develop in the tissues; SEE ALSO forward heart failure, backward heart failure, right ventricular failure, left ventricular failure. SYN cardiac failure, cardiac insufficiency, congestive heart failure, myocardial insufficiency. 2. resulting clinical syndromes including shortness of breath, pitting edema, enlarged tender liver, engorged neck veins, and pulmonary rales in various combinations.
  • A complication of HEART DISEASES. Defective cardiac filling and/or impaired contraction and emptying, resulting in the heart's inability to pump a sufficient amount of blood to meet the needs of the body tissues or to be able to do so only with an elevated filling pressure. (from Braunwald, Heart Disease, 5th ed)
  • Weakness of the heart muscle that leads to a buildup of fluid in body tissues.
  • 428.0 is a specific code that can be used to specify a diagnosis
  • 428.0 contains 34 index entries
  • View the ICD-9-CM Volume 1 428.* hierarchy

428.0 also known as:

  • Congestive heart disease
  • Right heart failure (secondary to left heart failure)

428.0 excludes:

  • fluid overload NOS (276.6)
DiseasesDB 16209
MedlinePlus 000158
eMedicine med/3552 
MeSH D006333

=======================================================

See also:

Edema 

http://www.lymphedemapeople.com/wiki/doku.php?id=edema

Edema and Chronic Venous Insufficiency

http://www.lymphedemapeople.com/thesite/edema_chronic_venous_insufficiency.htm

Edema and Deep Venous Thrombosis

http://www.lymphedemapeople.com/thesite/lymphedema_deep_venous_thrombosis.htm

Edema and Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

http://www.lymphedemapeople.com/thesite/edema_and_reflex_sympathetic_dystrophy.htm

Edema and Venous Pooling

http://www.lymphedemapeople.com/thesite/edema_and_venous_pooling.htm

Angioedema

http://www.lymphedemapeople.com/wiki/doku.php?id=angioedema

Edema of the Neck

http://www.lymphedemapeople.com/thesite/lymphedema_of_the_neck.htm

Edema and Nephrotic Syndrome

http://www.lymphedemapeople.com/thesite/edema_nephrotic_syndrome.htm

Edema of the Face

http://www.lymphedemapeople.com/thesite/edema_of_the_face.htm

Thrombophlebitis

http://www.lymphedemapeople.com/wiki/doku.php?id=thrombophlebitis

Edema and Diabetes

http://www.lymphedemapeople.com/thesite/lymphedema_and_diabetes.htm

===========================

Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe: AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

===========================

For information about Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema\

For Information about Lymphedema Complications

http://www.lymphedemapeople.com/wiki/doku.php?id=complications_of_lymphedema

For Lymphedema Personal Stories

http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=3

For information about How to Treat a Lymphedema Wound

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound

For information about Lymphedema Treatment 

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment

For information about Exercises for Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema

For information on Infections Associated with Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema

For information on Lymphedema in Children

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

===========================

Lymphedema People - Support Groups

-----------------------------------------------

Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com

......................

Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515

Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com

......................

MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscribe@yahoogroups.com

......................

All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com

......................

Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscribe@yahoogroups.com

===========================

Lymphedema People New Wiki Pages

Have you seen our new ďWikiĒ pages yet?  Listed below are just a sample of the more than 140 pages now listed in our Wiki section. We are also working on hundred more.  Come and take a stroll! 

Lymphedema Glossary 

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing 

Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema 

Arm Lymphedema  

http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema 

Leg Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=leg_lymphedema 

Acute Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=acute_lymphedema 

The Lymphedema Diet 

http://www.lymphedemapeople.com/wiki/doku.php?id=the_lymphedema_diet 

Exercises for Lymphedema  

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema 

Diuretics are not for Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=diuretics_are_not_for_lymphedema 

Lymphedema People Online Support Groups 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_people_online_support_groups 

Lipedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=lipedema 

Treatment 

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment 

Lymphedema and Pain Management 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pain_management 

Manual Lymphatic Drainage (MLD) and Complex Decongestive Therapy (CDT)

http://www.lymphedemapeople.com/wiki/doku.php?id=manual_lymphatic_drainage_mld_complex_decongestive_therapy_cdt 

Infections Associated with Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema 

How to Treat a Lymphedema Wound 

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound 

Fungal Infections Associated with Lymphedema 

http://www.lymphedemapeople.com/wiki/doku.php?id=fungal_infections_associated_with_lymphedema 

Lymphedema in Children 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children 

Lymphoscintigraphy 

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphoscintigraphy 

Magnetic Resonance Imaging 

http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging 

Extraperitoneal para-aortic lymph node dissection (EPLND) 

http://www.lymphedemapeople.com/wiki/doku.php?id=extraperitoneal_para-aortic_lymph_node_dissection_eplnd 

Axillary node biopsy 

http://www.lymphedemapeople.com/wiki/doku.php?id=axillary_node_biopsy

Sentinel Node Biopsy 

http://www.lymphedemapeople.com/wiki/doku.php?id=sentinel_node_biopsy

 Small Needle Biopsy - Fine Needle Aspiration 

http://www.lymphedemapeople.com/wiki/doku.php?id=small_needle_biopsy 

Magnetic Resonance Imaging 

http://www.lymphedemapeople.com/wiki/doku.php?id=magnetic_resonance_imaging 

Lymphedema Gene FOXC2

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_foxc2

 Lymphedema Gene VEGFC

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_vegfc

 Lymphedema Gene SOX18

 http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_gene_sox18

 Lymphedema and Pregnancy

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_and_pregnancy

Home page: Lymphedema People

http://www.lymphedemapeople.com

Page Updated: Jan. 13, 2012