Heart Views

: 2019  |  Volume : 20  |  Issue : 3  |  Page : 129--132

Congestive heart failure: A history

Rachel Hajar 
 Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar

Correspondence Address:
Dr. Rachel Hajar
Sr. Consultant Cardiologist, Director of HH Publications and Executive Coordinator for Research; Director of Noninvasive Cardiology (1981-2014), Heart Hospital, Hamad Medical Corporation, Doha

How to cite this article:
Hajar R. Congestive heart failure: A history.Heart Views 2019;20:129-132

How to cite this URL:
Hajar R. Congestive heart failure: A history. Heart Views [serial online] 2019 [cited 2022 Aug 9 ];20:129-132
Available from: https://www.heartviews.org/text.asp?2019/20/3/129/267850

Full Text

“The very essence of cardiovascular practice is the early detection of heart failure.”

– Sir Thomas Lewis, 1933.


Heart failure (HF) is a major public health problem, affecting 26 million people worldwide.[1] Many articles have been published addressing various aspects of the burden of HF in the general population. Cardiac societies – most notably the Heart Failure Association arm of the European Society of Cardiology (ESC) and American Heart Association – are addressing issues related to this epidemic. They have published consensus statements regarding this important topic.

HF is the end stage of all diseases of the heart and is a major cause of morbidity and mortality.[2] Over the years, cardiologists and cardiac societies have published their own definition of HF. The task force of the ESC has published guidelines on the diagnosis of HF, which require the presence of symptoms and objective evidence of cardiac dysfunction and also reversibility of symptoms on appropriate treatment. Echocardiography is recommended as the most practicable way of assessing cardiac function.

The Framingham Heart Study, which was established in 1948, has been the most important longitudinal source of data on the epidemiology of HF. One of the seminal papers describing the epidemiology of congestive HF (CHF) arose out of Framingham. In 1971, McKee et al.[3] published a paper where they described the criteria for diagnosing HF. The criteria have continued to be used to this day in clinical and epidemiologic studies. The paper also stated that hypertension is an important precursor for HF and that those patients who develop CHF have a poor prognosis.

 Summary of Our Current Knowledge About the Epidemiology, Etiology, and Prognosis of Heart Failure

The overall prevalence of clinically identified HF is estimated to be 3–20 cases/1000 population but rises to >100 cases/1000 population in those aged ≥65 years. The overall annual incidence of clinically overt HF in middle-aged men and women is approximately 0.1%–0.2%. For each additional decade of life, there is an approximate doubling of this rate and the incidence of HF in those aged >85 years is approximately 2%–3%.[4]

One of the most controversial issues pertaining to HF is the presence or absence of left ventricular dysfunction by echocardiography. Some people have overt clinical signs of HF with preserved left ventricular systolic function. Many of the earlier studies on HF contained only clinical criteria.[4]

In all industrialized countries, especially among older individuals, hospital admission rates are increasing. The annual cost of HF to insurers is estimated to be between $8000 and $12,000/person/year.[5]

HF is associated with a 60% mortality rate within 5 years of diagnosis.[4]

Investigators have found that death in patients with HF is inversely related to the wealth of the country they live in.[6] Death rates in India and Africa were found to be three to four times higher than those documented in Western countries.[6]

The most common causes of HF are coronary artery disease, chronic hypertension, and valvular disease. There are of course other causes of HF as it is the end stage of heart disease. There has been an evolution in the etiology of HF, with coronary artery disease becoming increasingly prevalent as the cause, whereas the contribution of hypertension and valvular disease declined dramatically from 1950 to 1987 according to the analysis of the Framingham Heart Study.[1] [Figure 1][7] depicts the change in causal factors for HF in the Framingham Heart Study during the period of 1950–1987.{Figure 1}

 Early Discoveries That Promoted Our Understanding of Heart Failure

Although descriptions of HF were known from ancient civilizations such as the Egyptian, Greek, Indian, and Chinese, there was no understanding of the pathophysiology until the discovery of pulmonary system and pulmonary circulation by the Arab physician Ibn al-Nafis[8] in the 13th century and then the elaboration on systemic circulation by the English physician William Harvey in the 17th century. It is important to mention Ibn al-Nafis'contribution to circulation because most Western authors were probably unaware of his great contribution until recently, and hence, they usually begin their discussion of the history of circulation with Harvey.

Ibn al-Nafis' most famous medical discovery is the pulmonary circulation of the blood. He described the blood movement from the right to the left side of the heart via the lungs. He corrected the mistakes Galen had made when describing the role of the heart and blood.[9] Ibn al-Nafis had an insight into what would become a larger theory of the capillary circulation. He stated that “there must be small communications or pores (manafidh in Arabic) between the pulmonary artery and vein,” a prediction that preceded the discovery of the capillary system by Malpighi by more than 400 years.[10]

Harvey, based on his experiments and also on [Ib Al-Nafis' experiments], made his revolutionary conclusion that blood circulates continuously from right to left and from left to right through the lungs by the pumping or propelling action of the cardiac muscle, thus making the heart the center of the cardiovascular system. He described completely and in detail, the systemic circulation. He showed that arteries and veins form a complete circuit, which starts at the heart and leads back to the heart.

Röntgen's discovery of X-rays and Einthoven's development of electrocardiography in the 1890s led to improvements in the investigation of HF. The advent of echocardiography, cardiac catheterization, and nuclear medicine has since improved the diagnosis and study of patients with HF.

In the 18th century, specifically in 1785, William Withering [11] publishes his observations on the Foxglove. He reported on the indication and toxicity of digitalis, a cardiac glycoside which increases the power of contraction of the heart. For centuries, drugs that increase the power of contraction (cardiac glycosides) of the failing heart have been used for the treatment of HF or what is termed “dropsy.” Cardiac glycosides were isolated for digitalis. Since its standardization, digitalis was a mainstay in our armamentarium of HF for 200 years.[11],[12]

Because cardiac glycosides were isolated from digitalis, it has led to biochemical and pharmacological studies, which in turn led to scientific advances, making us understand cardiac muscle contractility and the role of Na and K pump as the cellular receptor for the inotropic action of digitalis.[11],[12]

 How People Viewed Illness in the Past

Some historians claim that the Babylonian civilization that started in ancient Iraq is older than the Egyptian civilization, but when we think of ancient medicine, we think of Egypt and Greece. Ancient people experienced the same wide array of diseases that people of the present day are exposed to. However, unlike us, they attributed diseases mainly to supernatural causes. It has been said that if one had to be ill in ancient times, the best place to be would probably have been Egypt.[13]

Ancient people believed that the common reasons for diseases were sin, evil spirits, and angry ghosts, or the will of the gods to teach someone an important lesson.[2]

It is undisputable that the medicine of ancient Egypt is the oldest documented and highly advanced for its time. Although their understanding of physiology was limited, Egyptian physicians seem to have been quite successful in treating their patients and were highly regarded by other cultures.[14] However, physicians, pharaohs, and commoners alike believed that “magic is effective together with medicine; medicine is effective together with magic.”[14] Like other ancient cultures, their medicine was often mixed with magical incantations and their pharmacopeia contained unconvincing ingredients for certain diseases.

Egyptian medical thought was unchanged for millennia which influenced later traditions, including the Greeks. The Egyptians believed that the heart gives rise to vessels that lead to different parts of the body, and that its motion can be felt at different peripheral sites; they recognized that pulse is an important diagnostic sign, linked to cardiac activity.[14] It is an important insight in cardiovascular physiology.

 Oldest Case of Heart Failure

In 2015, archeologists announced that the oldest case of HF is found in a 3500-year-old ancient mummy in Egypt. The archeologists believe that the mummy was very well preserved; hence, they were able to study it. The mummy consisted only of a head and canopic jars (internal organs in jars). His name was Nebiri, “Chief of Stables.” Nebiri was a middle-aged (about 40–60 years) man when he died. He was affected by severe periodontal disease with massive abscesses as revealed by computed tomography scan and three-dimensional skull reconstruction. However, most interesting was the histology of Nebiri's lungs: (1) they found “heart failure” cells and (2) fluid accumulation in the air sacs – pulmonary edema. Histochemical staining ruled out tuberculosis, granulomas, and acid-fast bacilli. The researchers concluded that Nebiri probably would have died from acute decompensation of chronic left-sided HF due to chronic hypertension.[15]

 How Ancient Physicians Treated Heart Failure

Ancient civilizations may have disappeared already but they left behind traditions that we in the modern world still practice. The belief that health and sickness is an unceasing fight between the good and the evil is one of them. When a previously normal patient falls ill, that patient often asks, Why me? Whatever have I done wrong to deserve this?

Many of the sources of our knowledge of ancient medical practices come from ancient Egypt, and these observations were disseminated throughout the ancient world at the time.

Nebiri would have probably been treated with a combination of magical incantations and pharaonic medical prescriptions of the time. The ingredients of the prescriptions of the ancient Egyptians were derived from plants and trees and their fruits. Other drugs were made up of mineral substances. Eggs, liver, hair, milk, animal horns and fat, honey, and wax were also used in drug preparation. These prescriptions were administered as ointments, infusions, pills, gargles, snuffs, poultices, suppositories, and enemas.

 The Modern Treatment of Heart Failure

HF cannot be cured, but early diagnosis and treatment can help people who have HF live longer and live more active lives. Progress in our understanding of the pathogenesis of HF has led to new treatments, and this has led to reducing HF-related mortality. Angiotensin-converting enzyme (ACE) inhibitors are essential. The CONSENSUS-1 study (1987) unequivocally showed a survival benefit of ACE inhibition in HF.[4]

Since William Withering's report on the Foxglove in 1785, digitalis (which is a cardiac glycoside) has remained, until recently, a mainstay in the treatment of HF. With the introduction of potent diuretics and other agents, there has been a de-emphasis on the role of digitalis despite its therapeutic value.[16]

Diuresis is an important aspect in alleviating the symptoms of HF. Blood-letting and leeches were used for centuries. In the 19th and early 20th centuries, HF associated with fluid retention was treated with Southey's tubes, which were inserted into edematous peripheries, allowing some drainage of fluid.[2] The advent of diuretics prevented fluid buildup, easing the swelling in the legs and congestion in the lungs. The loop diuretic furosemide, in particular, prevents accumulation of fluid in the lungs.

The goals of treatment of HF include treating the conditions underlying its causes such as coronary heart disease, high blood pressure or diabetes, or valvular heart disease. Other options include heart-healthy lifestyle changes, medications, devices and surgical procedures, and ongoing care.

Although there have been many strides in our comprehension of HF which have led to new treatments (beyond the scope of this article) that improve survival, hospitalizations for HF remain very frequent and readmissions continue to increase.

Notwithstanding our sophistication, we have not found a cure for HF.

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Conflicts of interest

There are no conflicts of interest.


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