Heart Failure

Article Content

Heart Failure Causes

Symptoms

Complications

Investigations

Treatment

Prophylaxis

Heart failure occurs when the heart muscle does not pump the amount of blood the body needs. Failure does not mean that the heart does not pump blood at all, but that it no longer works as it should.

Because the heart cannot function in normal limits, the cardiovascular system tries to compensate the function by:

  • Retention of water and salt to increase the amount of blood;

  • Increased heart rate (tachycardia);

  • Increasing the size of the heart.

In time the heart gets tired and becomes progressivle less effective. At this time symptoms appear, such as: fatigue and weakness.

Heart Failure Causes

Heart Failure

Heart failure is caused by factors or diseases that affect the pumping ability of the left ventricle (systolic dysfunction) such as:

  • Coronary artery disease or myocardial infarction (the most common cause);

  • Poorly controlled high blood pressure, diabetes or thyroid disease;

  • Cardiomyopathies, alcoholic cardiomyopathy, infection or inflammation of the heart muscle (myocarditis);

  • Use of cocaine or other illegal drugs;

  • Diseases of the sac around the heart (pericardial disease);

  • Congenital heart disease;

  • Valvular disease or valvular rupture;

  • Heart diseases that cause too high, too low or irregular (arrhythmia) heart rate;

  • Age: with aging the heart muscle becomes stiff, preventing the heart to fill with blood.

When the left ventricle cannot fill normally, the condition is called: diastolic heart failure. This can be caused by hypertension, coronary artery disease or valvular disease. Certain factors may cause sudden worsening of the heart failure and sometimes life-threatening pathology such as lung edema or cardiogenic shock.

Heart Failure Symptoms

In the early stages of heart failure there may not be any symptoms. Difficult breathing at effort with the appearance of fatigue, occurs when the heart is weakened and does not pump enough blood to provide nutrients and oxygen needed for the body. The body’s effort to counteract the heart failure leads to symptoms which can become severe.

Classic symptoms of heart failure

Dyspnea at effort. Features:

  • Patient is panting;

  • tiredness when walking;

  • The need for frequent stops while walking;

  • Chest tightness;

  • Short breathing;

  • Short breathing while the patient is lying (orthopnea);

  • Short breathing during sleep (paroxysmal nocturnal dyspnea).

Gain in weight due to the fluid accumulation in the body.

Leg swelling (edema). Features:

  • Leg swelling worsens at the end of the day or after the patient has spent a lot of time standing;

  • Pain;

  • Shoes can become too small.

Fatigue or inability to make any effort. Features:

  • Increased fatigue;

  • Inability to make effort as in the past;

  • Fatigue.

Abdomen enlargement. Features:

  • Pain;

  • Soft abdomen.

Decreased appetite and muscle weakness.

Frequent urination, nocturia.

Cough. Features:

  • Dry cough, nagging;

  • Is accentuated if the patient is lying.

Classification of the heart failure

Class I – physical activity is not limited and does not cause severe fatigue, palpitations, shortness of breath, chest pain.

Class II – slightly limited physical activity, the patient can rest comfortably, but normal activities lead to the appearance of fatigue, palpitations, shortness of breath, chest pain.

Class III – limited physical activity, the patient can rest comfortably, but there is fatigue, palpitations, breathing difficulties and chest pain at the slightest effort.

Class IV – any physical activity causes discomfort; symptoms are present at rest; the least effort aggravates the symptomatology.

A newer classification of heart failure is based on the disease evolution.

Heart failure stages

Stage A – high risk for heart failure but without structural cardiac abnormalities. It includes people with hypertension, coronary artery disease, diabetes, alcohol and drug abuse, history of rheumatic fever or a family history of cardiomyopathy.

Stage B – structural cardiac abnormalities are present but without symptoms. It includes people with structural abnormalities of the left ventricle, valvular disease or myocardial infarction.

Stage C – heart failure symptoms in the past or present and structural abnormalities. It includes people with shortness of breath or tiredness caused by systolic ventricular dysfunction or those who currently have no symptoms but are treated for symptoms appeared earlier.

Stage D – in the end-stage of the disease it is required a special treatment. It includes people who have frequent hospitalizations for heart failure or may be discharged safely; those who are hospitalized awaiting a transplant, are at home and receiving continuous intravenous medication to mitigate the symptoms that are with assisted ventilation or those who are in institutionalized health centers for heart failure management.

Heart Failure Complications

Cardiac chronic failure can cause complications such as:

  • Irregular heart rhythm;

  • Strokes;

  • Myocardial infarctions;

  • Blood clots in the leg vessels (deep vein thrombosis);

  • Blood clots in the lung (pulmonary embolism);

  • Anemia;

  • Impaired consciousness;

  • Mitral insufficiency.

Heart Failure Investigations

Heart failure is a complex medical condition. There are several types of heart failure and various causes. For this reason it will be conducted a series of investigations for the diagnosis and assessment of the disease severity. In some cases, the cause of heart failure can be easily found (as in valvular diseases) or easily to treat (like thyroid disease), but these are exceptions.

Patients with symptoms of heart failure will need to perform the following investigations:

  • Medical history and clinical examination;

  • Laboratory investigations;

  • Electrocardiogram (EKG);

  • Chest radiography

  • Cardiac ultrasound.

Echocardiography is the easiest and the best test for diagnosing heart failure and its type, systolic or diastolic. It can also determine the disease and guide the treatment.

Dosage of brain natriuretic peptide (BNP) is a new investigation that can be used in the diagnosis of heart failure. Are measured the levels of brain natriuretic peptide which are elevated in heart failure.

These following investigations are used to identify ischemic areas and to assess the left ventricular function:

  • cardiac perfusion scan (isotopic methods): This test may show a poor cardiac perfusion;

  • Ventriculography with radionuclides (assessment of ventricular volumes): This test is used when echocardiography results are unsatisfactory (an obese person or big breasts or severe pulmonary disease); is less sensitive in assessing valvular heart disease or cardiac ischemia;

  • Cardiac catheterization is used to discover stenotic coronary arteries (narrowed) or obstructed and for pressures measurement within the heart. It is also useful in diagnosing the causes that produce specific symptoms or aggravates heart failure.

The patient will be monitored regularly by the doctor or physician. These periods may be lower or higher depending on the severity and course of the disease. Investigations help your doctor determine the type of failure and the degree of its severity.

Precocious diagnosis

Brain natriuretic peptide helps early detection of heart failure and of symptoms which aggravate the causes of the disease. Identifying individuals at high risk before the disease can be highlighted on echocardiography, it is important to monitor patients for the treatment of aggravating factors (such as hypertension or hypercholesterolemia) and for starting the treatment (ACE inhibitors, for example).

Heart failure Treatment – general things

Treatment depends on the cause of heart failure, the type of the disease, severity of symptoms and how well the body manages to compensate it.

Treatment of heart failure caused by deficiency of ventricular filling (diastolic failure type) is different from the one produced by a deficiency of pump (systolic type). Identifying the type of failure guides the treatment. Sometimes heart failure can be cured when the causative factor is corrected, such as a valve replacement surgery or treatment of hyperthyroidism. If heart failure develops soon after a heart attack it can sometimes be successfully treated by coronary bypass or angioplasty, or cardiac rehabilitation medicine.

Initial treatment

The treatments goals for heart failure in early stages are to ameliorate symptoms and prevent further damages to the heart. Usually, it is initially administered a diuretic to lower the blood pressure and avoid liquid accumulation in tissues. Later, it may be prescribed one or more medications, including an inhibitor of angiotensin converting enzyme, which reduces ventricular filling pressure, lowers blood pressure and prevents fluid retention. Another drug used is a beta blocker that prevents further worsening of the heart failure and, in some cases, improves heart function and vital prognosis. However, some patients cannot use this drug because of its side effects.

Recommendations regarding the lifestyle of the patients with heart failure include:

  • Monitoring the liquids consumed;

  • Reducing salt ingestion;

  • Carry out an exercise program under the supervision of a physician;

  • Normalization of weight for obese patients;

  • Quitting smoking because it increases the risk of heart disease;

  • Avoiding alcohol;

  • Effective control of blood pressure: physical exertion dosing, avoiding alcohol and avoiding stress will keep your blood pressure normal.

The doctor must treat the cause of heart failure. It is therefore possible to administer an additional medication for coronary heart disease, hypertension, diabetes, or irregular heart rhythms (arrhythmia).

Maintenance treatment

Although some causes of heart failure are reversible, in most cases this condition cannot be cured, so the treatment is for lifetime. Maintenance treatment is focused on slowing the disease progression, preventing complications and to reduce hospitalization, improve symptoms and prolonging the lifetime. Angiotensin converting enzyme inhibitor is the cornerstone of the treatment. They relieve the symptomatology and prolonge life. In case of edema, the most appropriate medicine is a diuretic such as furosemide. In medium to severe heart failure, you need a different type of diuretic; spironolactone – prevents worsening of the disease and relieves symptoms.

Digoxin improves the heart function, decreases the number of required hospitalizations. If symptoms are not controlled with described medications, it may also be administered angiotensin II receptor blockers, nitrates or hydralazine. To relieve symptoms there are necessary lifestyle changes. Exercise and an active life, in general, are very important for patients with heart failure. The doctor will indicate an exercise program, activity that is part of cardiac rehabilitation. Worsening heart failure may occur in situations such as high intake of salt, treatment failure, and emergence of diseases such as pneumonia or flu. Pneumococcal and influenza immunization, reducing sodium intake, compliance to the treatment reduce the risk of worsening.

Patients with heart failure will have to monitor their body weight. For example, if patient suddenly increases in weight 0.91 to 1.36 kg will be given an additional diuretic that day.

Bicameral pacemaker can be a solution for patients with heart failure and heart’s electrical system problems. Doctors call this cardiac resynchronization therapy. Recent studies show that the bicameral pacemaker improves the heart function, exercise capacity and quality of life.

Implantable cardioverter defibrillator is another promising device addressed to patients with heart failure. Studies show that implantable cardioverter defibrillator significantly reduces the risk of death in individuals with moderate to severe heart failure.

The association of the bicameral pacemaker and implantable defibrillator in a single device significantly reduces the rate of hospitalization and death in people with heart failure.

It may be recommended oxygen therapy to reduce dyspnea and increase exercise capacity of the patient.

Patients should continue the treatment for related diseases (hypertension, diabetes, coronary artery disease) or for aggravating factors of heart failure (fever, arrhythmia, anemia or infection).

Patients with heart failure should be monitored periodically to assess the effectiveness of treatment and to make any changes in therapy to prevent worsening of the disease and complications.

Treatment if the condition gets worse

Sometimes when standard treatment does not work it can be considered other treatment such as cardiac transplantation or left ventricular assist devices (mechanical pump implanted in the chest), methods which, however, will benefit a small number of patients.

Palliative care

With disease worsening, the patient should take into account some options such as palliative care. These are services addressed for patients with illnesses that cannot be cured and that usually evolve into aggravation. Palliative treatment is aimed to improve the quality of life, physically, mentally and spiritually. Usually two types of treatment are associated. Palliative care can help manage symptoms and side effects of medication.

Death

Thousands of people die each year due to heart failure despite the efforts of doctors and modern medicine. Although the condition may progress rapidly from mild to severe, many patients (and their families) are not prepared to make decisions regarding imminent death. Patients should be directed to take a decision in accordance with their wishes, the acceptance or not of life support measures, the type of care desired or refusal of certain treatments.

Medical treatment

Drugs do not cure heart failure, but relieve the symptoms. The goal of treatment is to relieve and control symptoms, improve cardiac function and quality of life, to slow disease progression and reduce complications, hospitalizations and premature death.

Medicines are used to treat heart failure and associated problems:

  • Accumulation of fluid, water retention (edema);

  • Decreased heart pumping force;

  • Compensatory effects of the body;

  • Associated diseases that can lead to heart failure: coronary artery disease, hypertension, diabetes;

  • Prevention of complications, such as stroke.

It is also very important to respect the medical treatment to prevent worsening of the disease or acute heart failure.

Heart Failure Prophylaxis

The best way to prevent heart failure is to make lifestyle changes and follow an effective treatment for diseases such as hypertension or diabetes, which may increase the risk of this disease. Myocardial infarction and coronary heart disease caused by narrowing and hardening of coronary arteries (atherosclerosis) lead to heart failure over time.

To prevent atherosclerosis you should follow a few tips:

  • Avoid smoking: Smoking increases the risk of heart disease;

  • Lower cholesterol levels by diet, exercise;

  • Control blood pressure: people with hypertension are at increased risk of developing heart disease; studies show that lowering blood pressure in these individuals, to normal, reduces by half the risk of developind heart failure; exercise, limit alcohol ingestion and stress management, maintain the normal limits of blood pressure;

  • Regular program of exercise: exercises help controlling your weight, blood pressure and reduce stress;

  • Control diabetes through a diet, by treatment compliance;


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