Treatment for congestive heart failure (CHF) varies and involves reducing symptoms, treating the underlying cause of the condition when possible, and using medications to prevent further deterioration of heart function.
Lifestyle changes can help reduce symptoms such as fatigue, shortness of breath, and edema (swelling). These modifications may include dietary changes (such as a restricted salt intake of less than 2,000 mg daily), abstaining from alcohol, stopping smoking, and exercising regularly (under the supervision of a doctor).
A combination of medications is used to treat CHF. Depending on the symptoms, individuals with CHF may take one, two, or more of these drugs. Several types of medications have proved useful in the treatment of heart failure including: angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBS), beta-blockers, digoxin, diuretics, and aldosterone antagonists.
Angiotensin-converting enzyme (ACE) inhibitors: Angiotensin-converting enzyme (ACE) inhibitors are a medication that dilates or widens blood vessels to lower blood pressure, improve blood flow, and decrease the workload on the heart. ACE inhibitors include enalapril (Vasotec®), lisinopril (Prinivil®, Zestril®), and captopril (Capoten®).
Side effects of ACE inhibitors include chronic, nonproductive cough (occurs in about 10% of patients), dizziness or weakness (caused by low blood pressure), increased potassium levels, skin rashes, and sudden swelling of the lips, face, and cheeks (if this occurs, the patient must seek medical attention immediately).
Angiotensin II (A-II) receptor blockers (ARBs): Angiotensin receptor blockers, or ARBS, have many of the beneficial effects of ACE inhibitors, but they do not cause a persistent cough. They may be an alternative for individuals who cannot tolerate ACE inhibitors. ARBs include losartan (Cozaar®) and valsartan (Diovan®).
Digoxin (Lanoxin®): Digoxin (Lanoxin®) increases the strength of the heart muscle contractions. Digoxin also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves the individual's ability to live with the CHF. Side effects are rare, but may include blurred vision, cardiac problems (such as arrhythmias or heart block), diarrhea, headaches, loss of appetite, hypotension (low blood pressure), and nausea and vomiting.
Beta blockers: Beta blockers are a class of drugs that slows the heart rate and reduces blood pressure. Beta blockers include carvedilol (Coreg®), metoprolol (Lopressor®), and propranolol (Inderal®). 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. Beta-blockers are started at low doses that are gradually increased over a period of several months. During the first several weeks of treatment, some patients experience worsening symptoms due to a decrease in oxygen circulation in the body. Other side effects include low blood pressure, difficulty breathing, sexual dysfunction, nausea, and weakness with exertion.
Diuretics: Diuretics, or water pills, make individuals urinate more frequently and keep fluid from collecting in the body. Commonly prescribed diuretics for heart failure include hydrochlorothiazide (Diuril®) and furosemide (Lasix®). Diuretics also decrease fluid in the lungs, helping individuals breathe more easily. Side effects include frequent urination and low potassium blood levels. Because of this, blood tests are performed periodically and a potassium supplement is prescribed if blood levels are low. Individuals may be asked to eat more fruits high in potassium, such as bananas and oranges, while on diuretic therapy.
Aldosterone antagonists: Aldosterone antagonists are primarily potassium-sparing diuretics, but they have additional properties that help the heart work better, may reverse scarring of the heart, and may help individuals with severe heart failure live longer. Aldosterone antagonists include spironolactone (Aldactone®) and eplerenone (Inspra®). Unlike other diuretics, spironolactone can raise the level of potassium in the blood to dangerous levels. Healthcare professionals recommend eliminating high-potassium foods, such as bananas, lentils, nuts, peaches, potatoes, salmon, tomatoes, and watermelon while taking aldosterone antagonists.
Others: 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 African American individuals 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. Side effects may include blurred vision, dry mout, irregular heart beat, blood in the urine or stools, numbness or tingling in the arms or legs, and fainting.
Doctors often prescribe other heart medications, such as HMG-CoA reductase inhibitors (statin) drugs, for cholesterol reduction. Statin drugs include atorvastatin (Lipitor®) or lovastatin (Mevacor®). They may cause liver problems or muscle pain. Anti-arrhythmic drugs may also be prescribed to control irregular heart beats, including diltiazem (Cardizem®, Cardizem CR®) and verapamil (Calan®, Calan SR®).
Individuals may be hospitalized for a few days if complications arise as a result of CHF symptoms. While in the hospital, individuals may receive additional medications such as intravenous (IV, or into the veins) dobutamine (Dobutrex®), milrinone, (Primacor®), and nitroglycerin. These drugs work quickly to help the heart pump better and relieve symptoms. Individuals may also receive supplemental oxygen through a mask or small tubes placed in the nose. If severe heart failure is present, the individual may need to use supplemental oxygen long term.
Individuals hospitalized with severe CHF may be given an intravenous drug called nesiritide (Natrecor®). Nesiritide is a synthetic version of a naturally occurring hormone in the body called brain natriuretic peptide (BNP). BNP is secreted in high levels by the heart in response to a failing heart. However, it is not clear if nesiritide is better than other intravenous medications for severe heart failure. Studies are ongoing to evaluate the safety and effectiveness of nesiritide in heart failure.
Aquapheresis: In some cases, heart failure persists or worsens in spite of treatment. An ultrafiltration process called aquapheresis, which uses a mechanical system called the Aquadex FlexFlow™, may be used to remove excess fluids and salt in CHF individuals who do not respond to lifestyle modifications and medication. In this treatment, blood is withdrawn using catheters (small tubes) inserted into veins in the arm, leg, or neck. The blood is then passed through a filter that removes excess fluid and is returned to the body. Studies have reported that ultrafiltration can remove more fluid at a faster rate than medication. The length of each treatment depends on the rate at which fluid can be removed from the body and the amount that must be removed.
Angioplasty: CHF caused by reduced blood flow in the heart as a result of blockages (plaques) in one or more coronary arteries may be treated using coronary angioplasty. In this procedure, a hollow tube (catheter) is inserted through an artery (usually the femoral artery in the groin), into the coronary artery, and to the blockage. A small balloon is then inserted through the catheter and is inflated to open the blocked artery. There is a slight risk for damage to the artery during angioplasty, but heart failure symptoms usually improve following the procedure. Stenting is used along with balloon angioplasty. Stenting involves placing a mesh-like metal device into an artery at a site narrowed by plaque. The stent is mounted on a balloon-tipped catheter, threaded through an artery, and positioned at the blockage. The balloon is then inflated, opening the stent. Then, the catheter and deflated balloon are removed, leaving the stent in place. The opened stent keeps the vessel open and stops the artery from collapsing. Re-closure may occur with both balloon angioplasty and stenting. Doctors will prescribe blood thinning medications to help keep the arteries open, including aspirin, warfarin (Coumadin®), and clopidogrel (Plavix®).
Coronary artery bypass graft surgery (CABG): A coronary artery bypass surgery (CABG) may be recommended if the individual has severe coronary artery disease in addition to CHF. This may improve the blood supply to the heart. Coronary artery bypass graft (CABG) surgery uses blood vessel grafts, which usually come from the patient's own arteries and veins located in the chest, leg, or arm. The graft goes around the clogged artery to create new pathways for oxygen-rich blood to flow to the heart. Some problems associated with CABG include a heart attack (occurs in 5% of patients), stroke (occurs in 5%, with the risk greatest in those over 70 years old), blood clots, death (occurs in 1 - 2% of individuals), and wound infection (occurs in 1 - 4%). Infection is most often associated with obesity, diabetes, or having had a previous CABG. In about 30% of patients, post-pericardiotomy syndrome can occur anywhere from a few days to six months after surgery. The symptoms of this syndrome are fever and chest pain. Symptoms can be treated with medications, including antibiotics (for infection), nitroglycerin, and anti-inflammatory drugs. The incision in the chest or the graft site (if the graft was from the leg or arm) can be itchy, sore, numb, or bruised. Some individuals report memory loss, loss of mental clarity, or "fuzzy thinking" following a CABG.
Implantable cardiac defibrillator: An implantable cardiac defibrillator (ICD) may be used to treat severe heart failure. An ICD is a small electronic device that is surgically implanted under the skin in the chest to monitor heart rhythm. When an abnormal rhythm is detected, the defibrillator delivers an electrical "shock" to the heart to restore normal heart rhythm.
Intra-aortic balloon pump: An intra-aortic balloon pump (IABP) is a device that is inserted through an artery in the groin (femoral artery) and then placed within the main artery (aorta). An IABP is an inflatable balloon that expands and deflates in coordination with each heartbeat. It can be left in place for days to weeks, and decreases the strain on the heart and increases blood flow throughout the body.
Valve replacement surgery: Individuals with heart failure caused by an abnormal heart valve may require valve repair or valve replacement surgery. These are open-heart procedures in which an abnormal valve is repaired or replaced with a porcine valve (from pig tissue), a mechanical valve (made of synthetic material), or a homograft valve (from a human donor). Complications include bleeding, blood clots, infection, kidney failure, stroke, heart attack, and death. A homograft valve is preferred, as these valves are not associated with a significant risk for blood clot formation and, thus, do not require blood thinner therapy. Most individuals remain in the hospital for a week after surgery and recovery takes approximately three to four weeks, after which most patients can resume leisure activities and many return to work. Approximately 60% of individuals who have valve replacement have a ten-year post-surgery survival rate.
Left ventricular assist device: A left ventricular assist device (LVAD) is a mechanical pump that is surgically implanted in the upper abdomen to bypass the left ventricle and pump blood throughout the body. This device may be used in patients with end-stage heart failure who are awaiting heart transplantation. Long-term use of the device in patients with severe heart failure is being explored and defined.
Pacemaker: If individuals with CHF experience arrhythmias that will not respond to medication therapy, the arrhythmias may be corrected with a pacemaker. A pacemaker is a small, battery-powered device that is usually implanted near the collarbone. Pacemakers can be surgically placed into the chest (a permanent pacemaker) through a small incision, or they can be worn outside the body (a temporary pacemaker) and attached to the heart through a wire that is threaded through a neck vein. Temporary pacemakers are used only while an individual is in the hospital.
The surgery needed to implant a permanent pacemaker is considered a minor surgical procedure. The procedure may take one to two hours to complete. The area where the pacemaker will be inserted will be numbed with an injection of an anesthetic such as lidocaine (Xylocaine®). The individual should not feel any pain during the procedure, and should inform the doctor or staff if they are having pain so that more anesthetic medication may be given. One or more electrode-tipped wires run from the pacemaker through the blood vessels to the inner heart. If the heart rate is too slow or if it stops, the pacemaker sends out electrical impulses that stimulate the heart to beat at a steady, proper rate. The more advanced pacemakers can monitor and pace either the atria or ventricles (or both) in proper sequence to maximize the amount of blood being pumped from the heart. The pacemaker's batteries may need to be changed every five to ten years. It is recommended by the American Heart Association to limit exposure to devices that may interfere with pulse generators such as cellular phones, CB radios, electric blankets, and microwaves.
It is normal for the surgical wound to be somewhat painful and swollen for a few days after the procedure. This can usually be controlled with medications, such as ultram (Tramadol®) or ibuprofen (Motrin®). The wound may also appear mildly red for a few days; however, if the area of redness enlarges, a doctor should be notified due to the potential for a serious infection. If there are no other problems, most individuals who have a permanent pacemaker surgically implanted can go home the next day. They can usually return to normal activities within six weeks. For several weeks after having a pacemaker implanted, the individual may be asked not to lift more than five pounds or raise the affected arm over their shoulder.
Heart transplant: In some cases, despite the use of optimal therapies as described above, the individual's condition continues to deteriorate due to progressive CHF. In selected individuals, heart transplantation is a viable treatment option. Candidates for a heart transplant are generally under age 70, do not smoke, and do not have severe or irreversible diseases affecting the other organs. Additionally, a transplant is done only when it is clear that the individual's prognosis on continued medical treatment is poor. Transplant patients require close medical follow-up while taking necessary drugs that suppress the immune system and because of the risk of rejection of the transplanted heart. They must even be monitored for possible development of coronary artery disease in the transplanted heart.
Although there are thousands of patients on waiting lists for a heart transplant at any given time, the number of operations performed each year is limited by the number of available donor organs. For these reasons, heart transplantation is a realistic option in only a small subset of the large numbers of patients with congestive heart failure.
Strong scientific evidence
Hawthorn: Hawthorn (Crataegus sp.), a flowering shrub of the rose family has an extensive history of use in cardiovascular disease dating back to the 1st Century. Increased blood flow to the heart and heart performance has been observed in animals when given hawthorn supplements. One randomized, human clinical trial indicates that hawthorn may be effective in decreasing frequency or severity of anginal symptoms. Hawthorn has not been tested in the setting of concomitant drugs such as beta-blockers or ACE-inhibitors, which are often the standard-of-care. At this time, there is insufficient evidence to recommend for or against hawthorn's use in coronary artery disease or angina. Hawthorn supplements should not be used if pregnant or breastfeeding, unless otherwise directed by a doctor.
Good scientific evidence
Berberine: Berberine is a bitter-tasting, yellow, plant alkaloid with a long history of medicinal use in Chinese and Ayurvedic medicine. Berberine is present in the roots, rhizomes, and stem bark of various plants including Hydrastis canadensis (goldenseal), Coptis chinensis (coptis or goldenthread), Berberis aquifolium (Oregon grape), Berberis vulgaris (barberry), and Berberis aristata (tree turmeric). Preliminary clinical research suggests that berberine, in addition to a standard prescription drug regimen for chronic congestive heart failure (CHF), may improve quality of life, heart function, and mortality. Further research is necessary. Berberine has been reported to cause nausea, vomiting, hypertension (high blood pressure), respiratory failure, and paresthesias (abnormal sensations such as numbness or tingling). Berberine is used with caution in individuals with diabetes.
Coleus: Coleus species have been used in the Asian traditional medicine for several indications. Since the 1970s, research was predominantly concentrated on forskolin, a root extract of Coleus forskohlii. A small number of studies suggest that forskolin may improve cardiovascular function in patients with cardiomyopathy. However, these trials are small and of poor quality. Larger studies are needed.
Creatine: Creatine is naturally synthesized in the human body from amino acids primarily in the kidney and liver, and transported in the blood for use by muscles. Cardiac creatine levels are reported as depressed in chronic heart failure. Several studies report that creatine supplementation is associated with improved heart muscle strength, body weight, and endurance in patients with heart failure. However, it is not clear what dose may be safe or effective. Supplementation is also reported to increase creatine in skeletal muscle in these patients, helping to increase strength and endurance. Well-designed studies comparing creatine with drugs used to treat heart failure are needed.
Selenium: Selenium is a trace metal that has been reported to have antioxidant properties. Keshan disease is cardiomyopathy (heart disease) restricted to areas of China in people having an extremely low selenium status. Prophylactic administration of sodium selenite has been shown to significantly decrease the incidence of this disorder.
Unclear or conflicting scientific evidence
Arginine: Arginine or L-arginine is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. There is initial evidence from several studies that arginine when taken orally or by injection improves exercise tolerance and blood flow in arteries of the heart. Benefits have been reported in some patients with coronary artery disease and angina. Studies of arginine in patients with chronic heart failure have shown mixed results. Some studies report improved exercise tolerance. Additional studies are needed to confirm these findings before a firm conclusion can be drawn. L-arginine is generally considered safe in recommended dosages.
Astragalus: Astragalus (Astragalus membranaceus) is used in combination with other herbs in Chinese medicine to treat various heart diseases. There are several human case reports of reduced symptoms and improved heart function and diuretic ("water pill") effects, although these are not well described. High quality human research is needed. Astragalus is used with caution in individuals with blood sugar regulation problems and those taking drugs to suppress immunity.
Ayurveda: Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. Preliminary evidence suggests that sodium nimbidinate, made from the traditional Ayurvedic herb Nimba/Neem/Arishta (Azadirachta indica), may be an effective diuretic in patients with congestive heart failure. More studies are needed to confirm this effect.
Coenzyme Q10 (CoQ10: CoQ10 is produced by the human body and is necessary for the basic functioning of cells. The evidence for CoQ10 in the treatment of heart failure is controversial and remains unclear. Different levels of disease severity have been studied (New York Heart Association classes I through IV). Better research is needed in this area, studying effects on quality of life, hospitalization, and death rates. There is also conflicting evidence from research on the use of CoQ10 in patients with dilated or hypertrophic cardiomyopathy. CoQ10 is generally safe in recommended dosages, but further studies are needed.
Ginseng: A clinical study on the effect of Panax ginseng on congestive heart failure did not show a clear benefit of combining digoxin with ginseng. The relatively small study size and the use of a drug instead of a standardized extract limit the value of the evidence. Ginseng may also lower blood pressure. Caution is used when taking ginseng supplements, as adverse effects including drug interactions are possible. Ginseng supplements are not used if pregnant or breastfeeding unless otherwise directed by a doctor.
L-carnitine: L-carnitine, carnitine, or acetyl-L-carnitine, is an amino acid found in the body. Although preliminary results are promising, there is insufficient available clinical evidence for the use of L-carnitine in congestive heart failure.
Oleander: Extracts of Thevetia peruviana (also known as Thevetia neriifolia) and Nerium oleander have been observed to possess cardiac glycoside properties since the mid 1900s. Human clinical studies began in the 1930s, but have largely been abandoned due to the significant gastrointestinal toxicity of thevetin and peruvoside preparations. These glycosides have been staples of congestive heart failure therapy in China and Russia for decades, but data supporting use are scant, and no high-quality comparative studies to other better-tolerated cardiac glycoside preparations appear to exist. Notably, cardiac glycosides have not been shown to improve mortality in patients with congestive heart failure, although well-tolerated and widely used drugs such as digoxin have been demonstrated to alleviate symptoms and reduce frequency of hospitalization. Oral oleander ingestion cannot be recommended, particularly in its unprocessed "natural form" as an herbal remedy. The therapeutic to toxic window appears to be extremely narrow.
Passionflower: An extract containing passionflower and hawthorn has been studied in people with congestive heart failure for the treatment of shortness of breath and difficulty exercising. Individuals using this combination of herbs have experienced improvements in these symptoms. However, any positive effects may have resulted from hawthorn, which is more commonly used for congestive heart failure. High quality human research of passion flower alone and compared to prescription drugs used for this condition is needed. Passionflower extracts may cause drowsiness in sensitive individuals. Care is recommended when driving an automobile or operating heavy machinery while taking passionflower.
Taurine: Taurine is a nonessential amino acid-like compound, taurine is found in high abundance in the tissues of many animals, especially sea animals, and in much lower concentrations in plants, fungi, and some bacteria. Preliminary study suggests that taurine may be beneficial as an adjunct to traditional medications for symptoms of congestive heart failure. Taurine appears to be safe in recommended dosages.
Thiamin: Thiamin (also spelled "thiamine") is a water-soluble B-complex vitamin, previously known as vitamin B1 or aneurine. Thiamin was isolated and characterized in the 1920s, and thus was one of the first organic compounds to be recognized as a vitamin. Chronic severe thiamin deficiency can cause heart failure (wet beriberi), a condition that merits thiamin supplementation. It is not clear that thiamin supplementation is beneficial in patients with heart failure due to other causes.
Thymus extract: The thymus is a lobular gland located under the breastbone near the thyroid gland. It reaches its maximum size during early childhood and plays a large role in immune function. Preliminary evidence suggests that thymus extract may increase left ventricular function, exercise tolerance, and survival. Additional study is needed in this area. It is important to use high quality thymus gland supplements.
Fair negative scientific evidence
Guided imagery: Therapeutic guided imagery may be used to help individuals relax and focus on images associated with personal issues they are confronting. Preliminary human research reports no benefits of guided imagery in congestive heart failure.
Traditional or theoretical uses which lack sufficient evidence
Integrative therapies traditionally used in CHF, but that lack sufficient scientific evidence include: acupuncture, aloe (Aloe vera), buchu (Agathosma betulina), dandelion (Taraxacum officinale), danshen (Salvia miltiorrhiza), dong quai (Angelica sinensis), ginkgo (Ginkgo biloba), horse chestnut (Aesculus hippocastanum), horsetail (Equisetum arvense), omega-3 fatty acids, fish oil, alpha-linolenic acid, scotch broom (Cytisus scoparius), tai chi, valerian (Valeriana officinalis), and vitamin E.
Smoking cessation: Smoking damages blood vessels, reduces the amount of oxygen in the blood, and makes the heart beat faster. If an individual smokes, a doctor can help recommend a program to help them quit. Individuals are not considered for a heart transplant if smoking is continued.
Weight control: It is recommended that individuals weigh themselves each morning after urination, but before breakfast. Notify a doctor if there is a weight gain of three or more pounds in a day. Weight gain may indicate fluid build-up.
Being overweight contributes to other risk factors for stroke, such as high blood pressure, cardiovascular disease, and diabetes. Weight loss of as little as ten pounds may lower blood pressure and improve cholesterol levels.
Exercise can lower blood pressure, increase the level of high density lipoprotein (HDL cholesterol or good cholesterol), and improve the overall health of blood vessels and heart. It also helps control weight, control diabetes, and reduce stress. Cardiac rehabilitation programs exist for individuals recovering from heart surgery. Cardiac rehabilitation is a medically supervised program to help heart patients recover quickly and improve their overall physical, mental, and social functioning. The goal is to stabilize, slow, or even reverse the progression of cardiovascular disease, thereby reducing the risk of heart disease, another cardiac event, or death. Cardiac rehabilitation programs include: counseling so the individual can understand and manage the disease process; an exercise program; counseling on nutrition; helping the patient modify risk factors such as high blood pressure, smoking, high blood cholesterol, physical inactivity, obesity, and diabetes; providing vocational guidance to enable the patient to return to work; information on physical limitations; lending emotional support; and counseling on appropriate use of prescribed medications. A doctor can help initiate an exercise program and cardiac rehabilitation tailored to the individual with congestive heart failure (CHF).
Salt restriction: Too much sodium (from salt) contributes to water retention, which makes the heart work harder. Excess sodium may causes shortness of breath and swollen legs, ankles, and feet. For individuals with heart failure the recommended sodium intake is no more than 2,000 mg daily. Some substitutes or "lite" salts contain a mixture of salt and other compounds. To get that familiar salty taste, individuals may use too much of the substitute and actually not reduce sodium intake. In addition, many salt substitutes contain potassium chloride. Too much potassium can be harmful. A dietitian can help outline a healthy, low-salt diet.
Stress management: Stress can cause an increase in blood pressure along with increasing the blood's tendency to clot. Managing stress can be vital to keeping a heart healthy.
Diet modification: Eating healthy foods is important. A heart-healthy diet should include five or more daily servings of fruits and vegetables, foods rich in soluble fiber (such as oatmeal and beans), foods rich in calcium (dairy products, spinach), soy products (such as tempeh, miso, tofu, and soy milk), and foods rich in omega-3 fatty acids, including cold-water fish, such as salmon, mackerel, and tuna. Pregnant women and women who plan to become pregnant in the next several years should limit their weekly intake of cold-water fish because of the potential for mercury contamination. Limiting red meats and high fat foods (such as doughnuts, cookies, and chips) is recommended by healthcare professionals.
Alcohol: Excessive use of alcohol may weaken the heart muscle or increase the risk of abnormal heart rhythms, further worsening existing heart failure. Alcohol may also interact with some medications used to treat heart conditions. One glass of red wine daily may be beneficial for heart health.
Swelling: Leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. Leg elevation alone may be sufficient therapy for patients with mild venous insufficiency, but is usually not adequate for more severe cases. In addition, it may not be practical for those who work to elevate their legs several times per day.
Leg edema (swelling) can also be prevented and treated with the use of compression stockings. Many types are available, including knee-high, thigh-high, and pantyhose. Knee-high stockings are sufficient for most individuals; thigh-high stockings are less desirable because they tend to provide too much pressure behind the knees, reducing blood flow in the veins, and causing discomfort. The stockings should be put on as early as possible in the morning when edema is minimal. Healthcare professionals can help with choosing the right compression stocking for each individual.
Sleep: It is recommended that individuals with CHF who have shortness of breath sleep with their head propped up at a 45 degree angle using a pillow or a wedge.