Heart Failure

What is Heart Failure?

Heart failure is a condition that results when the heart (particularly the left ventricle) can not pump or fill with enough blood. Therefore, the heart must work harder to deliver oxygen rich blood to the body.

Heart ‘failure’ does not mean the heart has completely stopped or failed.

There are several types of heart failure. As the heart’s pumping action is weakened, blood may back up in and accumulate fluid in parts of the body; this is termed as congestive heart failure. Diminished pumping of the ventricles due to muscle weakening is termed as systolic dysfunction. After each ventricle contracts (systole) the ventricles need to relax (diastole) and fill with blood. Due to stiffening of the heart muscle, the ventricles are unable to completely relax, preventing the complete filling of blood in the ventricle; this is termed as diastolic dysfunction. The conditions may only affect one side of the heart; either the right or left side termed as right heart failure or left heart failure, although both sides are commonly involved

Animation of a Normal Bloodflow

Animation of a Heart Failure Systolic

What are the causes of heart failure?

Heart failure is caused by a disease or condition that damages the heart.

Some of the most common causes include:

  • Congenital heart disease- defects present from birth
  • Hypertension (high blood pressure) – long standing or chronic hypertension forces the heart to work harder to pump blood. This constant stress increases the workload of the heart, causing it to enlarge.
  • Coronary artery disease- narrowing of the blood vessels supplying the heart muscle deprives the heart of oxygen. This can lead to a heart attack which causes permanent damage to the heart and impairs the hearts function.
  • Valvular Disease – aging, infection, previous heart attacks, or high blood pressure can damage the heart valves. Valvular disease may present as a narrowed or stenosed valve, limiting blood flow through the valve. A leaky or insufficient valve causes a backward flow or regurgitation. Valvular insufficiency and regurgitation may both be present.
  • Cardiomyopathy – damage to the heart muscle leading to an enlarged, thick, and rigid heart.
  • Other causes- chronic alcohol abuse, thyroid disorders, viral infections, and arrhythmias (irregular heart rhythm).

What are the symptoms of heart failure?

Heart failure is characterized by specific symptoms and usually starts off slowly. Symptoms first start off during exertion then progress to symptoms at rest. Symptoms may also occur suddenly after a heart attack.

Common symptoms include:

  • Easy fatigability
  • Weakness, lightheadedness, or dizziness
  • Shortness of breath or difficulty in breathing
  • Fast or irregular heart rate
  • Swelling (edema) of lower legs, feet, or abdomen (ascites)

What are the complications?

The most common complications of heart failure include:

  • Cardiomyopathy- a weakened and enlarged heart muscle
  • Arrhythmias- irregular heart rhythms that can lead to blood clot formation
  • Heart attack
  • Stroke
  • Death

What is ejection fraction?

Ejection fraction (EF) is the amount of blood pumped out of the ventricles during each contraction.

This is measured to diagnose heart failure and the degree of heart failure.

A normal ejection fraction is 55- 70%. This will be decreased in a heart failure patient.

How is it diagnosed?

Heart failure is diagnosed based on your medical history, physical examination, and certain tests

  1. Patient History

A significant history of previous heart attack, high blood pressure, diabetes, or alcohol can be used as clues.

Symptoms of heart failure may be told due to excess fluid accumulation such as shortness of breath, swelling, abdominal pain or distension.

Symptoms can also be due to decreased cardiac output including easy fatigability and weakness.

2. Physical Examination

You will be examined for signs of heart failure including:

  • Rapid or irregular heart rate
  • Rapid or difficulty in breathing
  • Weight gain
  • Leg swelling
  • Distended neck veins
  • Swelling in abdomen (ascites)
  • Sounds (crepitations) may be heard over the lungs

3. Tests

A series of test may be performed to determine how well your heart is functioning and the cause of heart failure.

These tests include:

  • Blood tests- B-type natriuretic peptide (BNP) is typically elevated from heart failure and can aid in the diagnosis. This is routinely followed for the response to treatment of congestive heart failure.

– Sodium and potassium levels will also be assessed.

  • Electrocardiogram (EKG) – a noninvasive test performed in our clinic which determines the electrical activity of your heart. This is test is used to detect conditions associated with an abnormal heart rhythm or previous heart attack that may cause heart failure.
  • Chest X-ray- shows the size and shape of the heart. Also reveals the presence of fluid in the lungs. This is performed in our office.
  • Echocardiogram (ECHO) – a noninvasive test performed in our office to determine the size and function of the heart’s chambers and structure and function of the heart valves.
  • Stress test- determines how well the heart works during exercise.
  • CT or MRI- is sometimes used to visualize the coronary arteries.
  • Cardiac catheterization– a simple invasive procedure that helps measure the hearts function and visualize the arteries of the heart under x-ray guidance by the use of injecting a dye.

How is it treated?

Heart failure can be controlled and treated, but rarely completely goes away.

Treatment involves diet and lifestyle modification, medications, procedures, and sometimes surgery for advanced cases.

Diet and Lifestyle Modification

  • Salt and water restriction- manage the amount of salt in your diet. Eat less than 2000 mg (2 grams) of sodium per day. Read food labels to keep track of how much sodium you eat. Canned food, frozen, and processed foods are high in sodium. Make sure to check the amount of sodium in each serving. Do not add salt to food when you are cooking, instead season food with lemon, pepper, garlic, or onion. Reducing salt intake improves high blood pressure that may be the cause of heart failure or may lead to worsening of heart failure.

– Water intake should be limited. Patients with severe heart failure should drink less than 2 liters of fluid per day, including all fluids. Only drink when you are thirsty and measure drinks in a cup before you drink them. Suck on lemon wedges to quench thirst and suck on hard candy to keep your mouth moist.

  • Weigh yourself everyday- if there is weight gain of more than 2 pounds in one day or weight increases by 4 pounds in one week, see your physician. Weight gain is a sign that you may be retaining more fluid than you should be.
  • Control weight- maintain a healthy weight with a BMI less than 25. Extra weight makes the heart work harder. By reducing your weight you can reduce the strain on your heart.
  • Do not smoke- smoking increases the risk of heart attack which can worsen heart failure.
  • Limit alcohol- limit alcohol to one serving per day if you choose to drink.
  • Exercise- ask your physician which exercise routine is best for you. Exercise for at least 30 minutes a day 5 days a week. This can improve symptoms of shortness of breath and fatigue.

Medications

Most heart failure patients benefit from the use of one or more medications. Medications are used to improve symptoms and prolong survival.

The most common heart failure medications include:

  • Diuretics- these are sometimes referred to as ‘water pills’ that is used for patients with leg swelling or fluid in the lungs. This helps excrete excess water and has been demonstrated to impact a long term survival.
  • ACE inhibitors or ARBs- dilate blood vessels and lower blood pressure making it easier for the heart to pump, which is especially useful in those with heart muscle weakness. ACE inhibitors sometimes cause dry cough, therefore ARBs may be preferred.
  • Beta blockers- this lowers the heart rate and decreases blood pressure.
  • Digoxin- this helps the heart muscle to contract with more strength, allowing more blood to be pumped with each beat.
  • Anticoagulants- patients with heart failure and with an irregular heart rhythm are at risk for developing a blood clot.To prevent this, aspirin or warfarin (Coumadin) may be started.

Procedures

  • Heart rhythm treatment- for patients with a life-threatening abnormal heart rhythm, a device may be recommended to you. An implantable cardioverter-defibrillator (ICD) is an implantable device that detects abnormal rhythms and shocks the heart to return it to a normal rhythm.

– Cardiac resynchronization therapy (CRT) is a treatment used in patients with an abnormal electrical conduction in the heart whose ventricles contract out of sync. This is a special type of pacemaker used to treat the problem and keep the contraction of the heart in sync.

  • Artery and valvular treatment- procedures used to improve blood flow to help the heart pump better and improve symptoms. This can be done with cardiac catheterization with angioplasty or stenting. Bypass surgery allows blood to flow around a clogged artery.

– Valvular disease may require valve repair or replacement

Heart transplantation can be helpful in patients with severe heart failure or those who do not respond to other treatments.Treatment in advanced heart failure

You may be recommended a left ventricular assist device (LVAD) instead of transplantation or during the waiting period for transplantation. This is an implantable device used as a temporary mode of support to improve blood flow.

What is the prognosis?

The prognosis of a patient depends on:

  • The nature of the underlying disease
  • The response to medications
  • The degree of involvement of other organ systems
  • The degree of symptoms and impairment

The prognosis of heart failure is associated with the patient’s grade of functioning. Heart failure is graded on a scale of I to IV

  • Class I- patients with no symptoms or limitation of physical activity
  • Class II- patients with symptoms and slight limitation of physical activity
  • Class III- patients with symptoms on ordinary activity and limitation of physical activity
  • Class IV- patients symptoms at rest

Heart failure is often a progressive condition that may lead to the development and worsening of clinical illness. Some people may be at risk of deadly heart rhythms.

Heart failure can be controlled by following a healthy lifestyle, being compliant with medications and other treatments as well as treating the cause of heart failure (i.e. high blood pressure).

Heart failure may get worse due to:

  • Angina (chest pain)
  • High salt intake
  • Heart attacks
  • Infections
  • Improper medication usage

How to live with heart failure

Some guidelines to help manage your condition include:

  • See your physician regularly and follow instructions closely.
  • Never stop taking medication without consulting your physician. Do not skip doses when you feel better or can not afford medication. Talk to your doctor about other treatment options.
  • Try to eat foods without added salt
  • Monitor blood pressure, pulse, and weight regularly
  • Do not smoke
  • Ask your doctor about receiving a flu shot. This can be important in preventing the effects of disease.
  • Look for signs of worsening of heart failure like worsened shortness of breath or cough, worsening of leg swelling, weight gain of 2 pounds in one day, or fast or irregular heartbeat.