HEART FAILURE

HEART FAILURE

 

Definition

Heart failure, also known as congestive heart failure (CHF), means your heart can't pump enough blood to meet your body's needs. Over time, conditions such as coronary artery disease or high blood pressure gradually leave your heart too weak or stiff to fill and pump efficiently.

 

You can't reverse many conditions that lead to heart failure, but heart failure can often be treated with good results. Medications can improve the signs and symptoms of heart failure and lead to improved survival. Lifestyle changes, such as exercising, reducing salt intake, managing stress, treating depression, and especially losing excess weight, also can help prevent fluid buildup and improve your quality of life.

The best way to prevent heart failure is to control risk factors and aggressively manage any underlying conditions such as coronary artery disease, high blood pressure, high cholesterol, diabetes or obesity.

 

Symptoms

Heart failure typically develops slowly and is a chronic, long-term condition, although you may experience a sudden onset of symptoms, known as acute heart failure. The term "congestive heart failure" comes from blood backing up into — or congesting — the liver, abdomen, lower extremities and lungs.

 

Some of the signs and symptoms for chronic and acute heart failure are:

 

Type of heart failure	Signs and symptoms
Chronic heart failure (A long-term condition with signs and symptoms that persist.)	Fatigue and weakness Rapid or irregular heartbeat Shortness of breath (dyspnea) when you exert yourself or when you lie down Reduced ability to exercise Persistent cough or wheezing with white or pink blood-tinged phlegm Swelling (edema) in your legs, ankles and feet Swelling of your abdomen (ascites) Sudden weight gain from fluid retention Lack of appetite and nausea Difficulty concentrating or decreased alertness
Acute heart failure (An emergency situation that occurs when something suddenly affects your heart's ability to function.)	Signs and symptoms similar to those of chronic heart failure but more severe, and start or worsen suddenly Sudden fluid buildup Rapid or irregular heartbeat with palpitations that may cause the heart to stop beating Sudden, severe shortness of breath and coughing up pink, foamy mucus Chest pain if caused by a heart attack

 

In addition to characterizing whether your condition is chronic or acute, your doctor will need to know whether your heart fails to pump, or fills with blood, or a combination of both. Heart failure can involve the left side, right side or both sides of your heart. Typically, heart failure begins with the left side — specifically the left ventricle, your heart's main pumping chamber.

 

Part of your heart affected by heart failure	Description
Left-sided heart failure	Most common form of heart failure. Fluid and blood may back up in your lungs, causing shortness of breath.
Right-sided heart failure	Often occurs with left-sided heart failure. Fluid and blood may back up into your abdomen, legs and feet, causing swelling.
Systolic heart failure	The left ventricle can't contract vigorously, indicating a pumping problem.
Diastolic heart failure (also called heart failure with normal ejection fraction)	The left ventricle can't relax or fill fully, indicating a filling problem.

 

While systolic heart failure was once thought to be more common and less serious, recent studies have shown this to be incorrect. Isolated diastolic heart failure, now also termed "heart failure with normal ejection fraction," is just as common as systolic heart failure and has a similar prognosis. Identifying the type of heart failure, whether systolic, diastolic, or a combination, is important because the drug treatments for each type may

 

Causes

Heart failure often develops after other conditions have damaged or weakened your heart. Over time, the heart can no longer keep up with the normal demands placed on it. The ventricles may become stiff and not fill properly between beats. Also, the heart muscle may weaken, and the ventricles stretch (dilate) to the point that the heart can't pump blood efficiently throughout your body.

 

Any of the following conditions can cause heart failure, which can damage or weaken your heart over time. Some of these can be present without knowing it:

• Coronary artery disease and heart attack. Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. Over time, arteries that supply blood to your heart muscle narrow from a buildup of fatty deposits, a process called atherosclerosis. Blood moves slowly through narrowed arteries, leaving some areas of your heart muscle weak and chronically deprived of oxygen-rich blood. In many cases, the blood flow to the muscle is just enough to keep the muscle alive but not functioning well. A heart attack occurs if plaque formed by the fatty deposits in your arteries ruptures. This causes a blood clot to completely block blood flow to an area of the heart muscle, weakening the heart's pumping ability.

• High blood pressure (hypertension). Blood pressure is the force of blood pumped by your heart through your arteries. If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body. Over time, the heart muscle may become thicker to compensate for the extra work it must perform, enlarging the heart. Eventually, your heart muscle may become either too stiff or too weak to effectively pump blood.

• Faulty heart valves. The four valves of your heart keep blood flowing in the proper direction through the heart. A damaged valve forces your heart to work harder to keep blood flowing as it should. Over time, this extra work can weaken your heart. Faulty heart valves, however, can be fixed if detected in time.

• Damage to the heart muscle (cardiomyopathy). Some of the many causes of heart muscle damage, also called cardiomyopathy, include infections, alcohol abuse, and the toxic effect of drugs such as cocaine or some drugs used for chemotherapy. In addition, whole-body diseases, such as lupus, or thyroid problems also can damage heart muscle. If a specific cause can't be found, it's referred to as idiopathic dilated cardiomyopathy.

• Myocarditis. Myocarditis is an inflammation of the heart muscle. It's most commonly caused by a virus and can lead to left-sided heart failure.

• Heart defects present at birth (congenital heart defects). If your heart and its chambers or valves haven't formed correctly, the healthy parts of your heart have to work harder to compensate. Genetic defects contribute to the risk of certain types of heart disease, which in turn may lead to heart failure.

• Abnormal heart rhythms (heart arrhythmias). Abnormal heart rhythms may cause your heart to beat too fast. This creates extra work for your heart. Over time, your heart may weaken leading to heart failure. A slow heartbeat may prevent your heart from getting enough blood out to the body and may also lead to heart failure.

• Other diseases. Chronic diseases such as diabetes, severe anemia, hyperthyroidism, hypothyroidism, emphysema, lupus, hemochromatosis and amyloidosis also may contribute to heart failure. Causes of acute heart failure include viruses that attack the heart muscle, severe infections, allergic reactions, blood clots in the lungs, the use of certain medications or any illness that affects the whole body.

Risk factors

A single risk factor may be enough to cause heart failure, but a combination of factors increases your risk.

 

Risk factors include:

• High blood pressure. Your heart works harder than it has to if your blood pressure is high.

• Coronary artery disease. Narrowed arteries may limit your heart's supply of oxygen-rich blood, resulting in weakened heart muscle.

• Heart attack. Damage to your heart muscle from a heart attack may mean your heart can no longer pump as well as it should.

• Irregular heartbeats. These abnormal rhythms can create extra work for your heart, weakening the heart muscle.

• Diabetes. Having diabetes increases your risk of high blood pressure and coronary artery disease.

• Some diabetes medications. The diabetes drugs rosiglitazone (Avandia) and pioglitazone (Actos) have been found to increase the risk of heart failure. Don't stop taking these medications on your own, though. If you're taking them, discuss with your doctor whether you need to make any changes.

• Sleep apnea. The inability to breathe properly at night results in low blood oxygen levels and increased risk of abnormal heart rhythms. Both of these problems can weaken the heart.

• Congenital heart defects. Some people who develop heart failure were born with structural heart defects.

• Viruses. A viral infection may have damaged your heart muscle.

• Alcohol use. Alcohol can weaken heart muscle and lead to heart failure.

• Kidney conditions. These can contribute to heart failure because many can lead to high blood pressure and fluid retention.

When to seek medical advice

See your doctor if you experience any of the signs or symptoms associated with heart failure. These include:

• Fatigue and weakness
• Rapid or irregular heartbeat
• Shortness of breath (dyspnea) when you exert yourself or when you lie down
• Reduced ability to exercise
• Persistent cough or wheezing with white or pink blood-tinged phlegm
• Swelling in your abdomen, legs, ankles and feet
• Difficulty concentrating or decreased alertness

 

You may first find out you have heart failure from an emergency room visit after worsening signs and symptoms. Other heart and lung problems can cause signs and symptoms that are similar to heart failure.

 

If you have a diagnosis of heart failure, and if any of the signs or symptoms suddenly become worse or you develop a new sign or symptom, it may mean that existing heart failure is getting worse or not responding to treatment. Contact your doctor promptly.

 

Tests and diagnosis

To diagnose heart failure, your doctor will take a careful medical history and perform a physical examination. Your doctor will also check for the presence of risk factors such as high blood pressure. Using a stethoscope, your doctor can listen to your lungs for signs of congestion. The stethoscope also picks up abnormal heart sounds that may suggest heart failure. After the physical exam, your doctor may do blood tests and a chest X-ray followed by an echocardiogram.

 

• Blood tests. Your doctor may take a sample of your blood to check your kidney and thyroid function and to look for indicators of other diseases that affect the heart. In addition, your doctor may check your blood for specific chemical markers of heart failure, such as a hormone called brain natriuretic peptide (BNP). Although first identified in the brain, BNP is secreted by the heart at high levels when it's injured or overworked.

• Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. In heart failure, your heart may appear enlarged and fluid buildup may be visible in your lungs. Your doctor can also use an X-ray to diagnose conditions other than heart failure that may explain your signs and symptoms.

• Electrocardiogram (ECG). This test records the electrical activity of your heart through electrodes attached to your skin. Impulses are recorded as waves and displayed on a monitor or printed on paper. This test helps your doctor diagnose heart rhythm problems and damage to your heart from a heart attack that may be underlying heart failure.

• Echocardiogram. An important test for diagnosing and monitoring heart failure is the echocardiogram. An echocardiogram also helps distinguish systolic heart failure from diastolic heart failure, in which the heart is stiff and can't fill properly. An echocardiogram uses sound waves to produce a video image of your heart. This image can help doctors determine how well your heart is pumping by measuring the percentage of blood pumped out of your heart's main pumping chamber (the left ventricle) with each heartbeat. This measurement is called the ejection fraction.

• Ejection fraction. Your ejection fraction is measured during an echocardiogram. An ejection fraction is an important measurement of how well your heart is pumping and is used to help classify heart failure and guide treatment. In a healthy heart, the ejection fraction is about 60 percent — meaning 60 percent of the blood that fills the ventricle is pumped out with each beat. Other imaging tests may be used to measure ejection fraction, including cardiac catheterization, multiple gated acquisition (MUGA) scanning of the heart, magnetic resonance imaging (MRI) and computerized tomography (CT).

 

Other tests
In addition to the physical examination, blood tests, chest X-ray and echocardiogram, your doctor may recommend one or more tests to help diagnose heart failure, determine its underlying cause and guide treatment decisions. You may have tests such as:

• Stress test. You may have one of a variety of stress tests either using an exercise bike or treadmill or medications that stress the heart. In some stress tests, pictures are taken of your heart with either nuclear medicine or echocardiographic techniques to try and determine if you have blockages in your heart arteries as a cause for your heart failure. You may also have an oxygen uptake stress test which helps your doctor know how well your body is compensating for your condition.

• Cardiac CT or MRI scan. These tests are now being used with increased frequency for people with heart failure, not only to measure ejection fraction but to check the heart arteries and valves, determine if you have had a heart attack, and look for unusual causes of heart failure.

• Coronary catheterization (angiogram). In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or arm and guided through the aorta into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray. This test helps doctors identify narrowed arteries to your heart (coronary artery disease) that can be a cause of heart failure. The test may include a ventriculogram — a procedure to determine the strength of the left ventricle (the heart's main pumping chamber) and the health of the heart valves.

Classifying heart failure
Results of these tests help doctors determine the cause of your signs and symptoms and develop a program to treat your heart. To determine the best course of treatment, doctors may classify heart failure using two scales:

• New York Heart Association scale. This scale classifies heart failure in categories from one to four. In Class I heart failure, the mildest form, you can perform everyday activities and not feel winded or fatigued. Class IV is the most severe, and you're short of breath even at rest.

• American College of Cardiology scale. This newer classification system uses letters A to D. The system includes a category for people who are at risk of developing heart failure. For example, a person who has several risk factors for heart failure is Stage A, but a person with end-stage heart failure requiring hospice care is Stage D. Doctors use this classification system to identify your risk factors and begin early, more aggressive treatment to help prevent or delay heart failure.

Ask your doctor about your score if you're interested in determining the severity of your heart failure. Your doctor can help you interpret your score and plan your treatment based on your condition.

 

Complications

In systolic heart failure, your heart pumps with less force. To make up for the weak pumping, your ventricle enlarges in an attempt to stretch and contract with more strength, allowing it to pump more blood. This can initially stabilize the situation but, eventually the more the heart dilates, the more inefficient it becomes. The heart muscle may thicken to help increase pumping strength. More muscle means the heart needs more blood, and your coronary arteries may not be able to supply it. Your heart may also beat faster in an attempt to pump more often. In addition, levels of heart-stimulating hormones go up.

 

At first, these means of compensating help a weakened heart pump harder. However, eventually these changes make matters worse by weakening your heart muscle.

If you have heart failure, your outlook depends on the cause and the severity, overall health and other factors such as age. Many people's symptoms and heart function will improve with proper treatment. However, heart failure can be life-threatening. It can lead to sudden death. People with severe heart failure have debilitating symptoms, and some may require heart transplantation or support with an artificial heart device.

 

Treatments and drugs

Heart failure is a chronic disease needing lifelong management. However, with treatment, a failing heart can become stronger and signs and symptoms of heart failure can improve. Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, the treatment of heart failure involves a balance of the right medications, and in some cases, devices that help the heart beat properly.

 

Medications
Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one, two or more of these drugs. Several types of drugs have proved useful in the treatment of heart failure. They include:

• Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people with heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens or dilates blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten). ACE inhibitors also blunt some of the effects of hormones that promote salt and water retention. ACE inhibitors can cause an irritating cough in some people. It may be best to put up with the cough, if you can, to gain the medication's benefits. But be sure to discuss this with your doctor. Switching to another ACE inhibitor or an angiotensin II receptor blocker (ARB) may relieve the problem.

• Angiotensin II (A-II) receptor blockers (ARBs). These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the beneficial effects of ACE inhibitors, but they don't cause a persistent cough. They may be an alternative for people who can't tolerate ACE inhibitors.

• Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves your ability to live with the condition.

• Beta blockers. This class of drug slows your heart rate and reduces blood pressure. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta). These medicines also reduce the risk of some abnormal heart rhythms. Beta blockers may reduce signs and symptoms of heart failure and improve heart function.

• Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Commonly prescribed diuretics for heart failure include bumetanide (Bumex) and furosemide (Lasix). The drugs also decrease fluid in your lungs, so you can breathe more easily. Because diuretics make your body lose potassium and magnesium, your doctor may also prescribe supplements of these minerals. If you're taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.

• Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). They're primarily potassium-sparing diuretics, but they have additional properties that help the heart work better, may reverse scarring of the heart and may help people with severe heart failure live longer. Unlike some other diuretics, spironolactone can raise the level of potassium in your blood to dangerous levels.

A medication called BiDil is a single pill that combines hydralazine and isosorbide dinitrate — both of which dilate and relax the blood vessels. BiDil increases survival when added to standard therapy in black people with advanced heart failure. This is the first drug studied and approved for a specific racial group. Further studies will be necessary to determine if this combination medicine will be helpful for others with heart failure.

 

You'll probably need to take two or more medications to treat heart failure. Your doctor may prescribe other heart medications as well — such as nitrates for chest pain, a statin to lower cholesterol or blood-thinning medications to help prevent blood clots - along with heart failure medications.

 

You may be hospitalized for a few days if you have a flare-up of heart failure symptoms. While in the hospital, you may receive additional medications to help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen through a mask or small tubes placed in your nose. If you have severe heart failure, you may need to use supplemental oxygen long term.

 

Surgery and medical devices
In some cases, doctors recommend surgery to treat the underlying problem that led to heart failure. For example, a damaged heart valve may be repaired or, if necessary, replaced with a new one. Doctors recommend coronary bypass surgery to treat severely narrowed coronary arteries that are contributing to heart failure.

Researchers continue to search for new and better ways to treat heart failure. Some treatments being studied and used in certain people include:

• Implantable cardioverter-defibrillators (ICDs). An ICD is a device implanted under the skin and attached to the heart with small wires. The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, the ICD shocks it back into normal rhythm. Sometimes a biventricular pacemaker is combined with an ICD for people with severe heart failure.

• Cardiac resynchronization therapy (CRT) or biventricular pacing. A biventricular pacemaker sends timed electrical impulses to both of the heart's lower chambers (the left and right ventricles), so that they pump in synchrony and in a more efficient, coordinated manner. As many as half the people with heart failure have abnormalities in their heart's electrical system that cause their already-weak heart muscle to beat in an uncoordinated fashion. This inefficient muscle contraction wastes the heart's limited energy and may cause heart failure to worsen. Sometimes a biventricular pacemaker is combined with an ICD for people at greatest risk of rhythm problems.

• Heart pumps. These mechanical devices, called left ventricular assist devices (LVADs), are implanted into the abdomen and attached to a weakened heart to help it pump. Doctors first used heart pumps to help keep heart transplant candidates alive while they waited for a donor heart. LVADs are now being considered as an alternative to transplantation. Implanted heart pumps can significantly extend and improve the lives of some people with end-stage heart failure who aren't eligible for or able to undergo heart transplantation or are waiting for a new heart.

Some people have such severe heart failure that surgery or medications don't help. They may need to have their diseased heart replaced with a healthy donor heart. Heart transplants have dramatically improved the survival and quality of life of people with severe heart failure. However, candidates for transplantation often have to wait years before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment or device therapy and can be removed from the transplant waiting list.

 

Experimental treatments

• Cardiac wrap surgery. Researchers are studying a technique that wraps a failing heart in a mesh bag, helping to prevent further failure. A surgeon pulls the mesh wrap over the base of the heart and attaches it with stitches. The goal is to prevent a weakened heart from enlarging (dilating) and failing further. Studies are ongoing.

• Ventricular restoration surgery. This surgery is being used experimentally to treat some people with heart failure caused by a heart attack. During the surgery, doctors remove scar tissue in the ventricular muscle caused by a heart attack and reshape the remaining healthy tissue to restore a more normal elliptical left ventricle shape. Reducing the size of and reshaping the left ventricle help restore normal function to the pumping mechanism.

• Enhanced external counterpulsation (EECP). This noninvasive technique has been used as a treatment for heart-related chest pain, and researchers are studying this treatment to see if it's beneficial for people with heart failure. Inflatable pressure cuffs are placed on the calves, thighs and buttocks. These cuffs are inflated and deflated in sync with your heartbeat. The theory is that EECP increases blood flow back to the heart.

Prevention

The key to preventing heart failure is to reduce your risk factors. You can control or eliminate many of the risk factors for heart disease — high blood pressure and coronary artery disease, for example — by making lifestyle changes along with the help of any needed medications.

 

Lifestyle and home remedies

Making lifestyle changes can often help relieve signs and symptoms of heart failure and prevent the disease from worsening. These changes may be among the most important and beneficial you can make:

• Stop smoking. Smoking damages your blood vessels, reduces the amount of oxygen in your blood and makes your heart beat faster. If you smoke, ask your doctor to recommend a program to help you quit. You can't be considered for a heart transplant if you continue to smoke.

• Weigh yourself daily. Do this each morning after you've urinated, but before you've had breakfast. Notify your doctor if you have a weight gain of 3 or more pounds in a day. It may mean that you're retaining fluids and need a change in your treatment plan. Record your weight every morning and bring the record with you to your doctor's visits.

• Restrict sodium. Sodium is a component of salt. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet. For people with heart failure, the recommended sodium intake is no more than 2,000 milligrams a day. Keep in mind that most of this salt is already added to prepared foods, and be careful when using salt substitutes. Some substitutes or "lite" salts contain a mixture of salt and other compounds. To get that familiar salty taste, you may use too much of the substitute and actually not reduce your sodium intake. In addition, many salt substitutes contain potassium chloride. Too much potassium can be harmful if you have kidney problems or if you're taking certain medications for treatment of heart failure. A dietitian can help you outline a healthy, low-salt diet, but it's up to you to stick to it without exception.

• Maintain a healthy weight. If you're overweight, your dietitian will help you work toward your ideal weight.

• Limit fats and cholesterol. In addition to avoiding high-sodium foods, limit your intake of saturated fat, trans fat and cholesterol. A diet high in fat and cholesterol is a risk factor for coronary artery disease, which often underlies or contributes to heart failure.

• Limit alcohol and fluids. Excessive use of alcohol can directly weaken your heart muscle or increase your risk of abnormal heart rhythms that may worsen existing heart failure. Alcohol may also interact with some medications used to treat heart conditions. Your doctor likely will advise you to abstain from alcohol if you have heart failure. If you have severe heart failure, your doctor may also suggest you limit your total intake of fluids.

• Exercise. Exercise was once forbidden for people with heart failure. But, moderate exercise helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. Before you start exercising though, talk to your doctor about an exercise program that's right for you. Your doctor may suggest a walking program. Check with your local hospital to see if it offers a cardiac rehabilitation program; if it does, talk to your doctor about enrolling in the program.

• Reduce stress. When you're anxious or upset, your heart beats faster and you breathe more heavily. This can make heart failure worse, since your heart is already having trouble meeting the body's demands. Find ways to reduce stress in your life. To give your heart a rest, try napping or putting your feet up when possible.

• Sleep easy. If you're having shortness of breath, especially at night, sleep with your head propped up at a 45-degree angle using a pillow or a wedge. If you snore or have had other symptoms of disordered sleep, make sure you get tested for sleep apnea.

Coping and support

Often people with congestive heart failure complain that they wake up tired because lying flat makes it harder to breathe, and their sleep is interrupted because of excess fluid or medications that increase the need to urinate.

 

To improve your sleep at night, prop up your head with pillows and avoid big meals right before bedtime. Also, discuss with your doctor changing the time for taking medications, especially diuretics. Taking diuretics earlier in the day may keep you from having to urinate as often during the night.

 

Although many cases of heart failure can't be reversed, treatment can usually improve symptoms and help you live longer. You and your doctor can work together to help make your life more comfortable. Pay attention to your body and how you feel, and tell your doctor when you're feeling better or feeling worse. This way, your doctor will know what treatment works best for you.

 

Don't be afraid to ask your doctor questions about living with heart failure. These steps can help you work most effectively with your doctor:

 

• Keep track of the medications you take. Make a list and share it with any new doctors treating you. Carry the list with you all the time.

• Keep track of your weight and bring the record to visits with your doctor. An increase in weight can be a sign you're accumulating fluid. Your doctor may instruct you to take extra diuretics if your weight has increased more than a pound or so in a day.

• Keep track of your blood pressure. Consider purchasing a high-quality home blood pressure monitor. Keep track of your blood pressure between doctor appointments and bring the record with you to visits.

• Write down your questions. Before a doctor appointment, prepare a list of any questions or concerns. For example, is it safe for you and your partner to have sex? Most people with heart failure can continue sexual activity once symptoms are under control.

• Ask for clarification. Make sure you understand what your doctor is saying.

Managing heart failure requires an open dialogue between you and your doctor. Be honest about whether you're following recommendations concerning your diet, lifestyle and taking medications. Your doctor often can suggest strategies to help you get and stay on track.