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Heart Failure

Heart Failure

Definition

Heart failure is a condition in which the heart has lost the ability to pump enough blood to the body's tissues. With too little blood being delivered, the organs and other tissues do not receive enough oxygen and nutrients to function properly.

Description

According to the American Heart Association, about 4.9 million Americans are living with congestive heart failure. Of these, 2.5 million are males and 2.4 million are females. Ten of every 1,000 people over age 65 have this condition. There are about 400,000 new cases each year.

Heart failure happens when a disease affects the heart's ability to deliver enough blood to the body's tissues. Often, a person with heart failure may have a buildup of fluid in the tissues, called edema. Heart failure with this kind of fluid buildup is called congestive heart failure. Where edema occurs in the body depends on the part of the heart that is affected by heart failure. Heart failure caused by abnormality of the lower left chamber of the heart (left ventricle) means that the left ventricle cannot pump blood out to the body as fast as it returns from the lungs. Because blood cannot get back to the heart, it begins to back up in the blood vessels of the lungs. Some of the fluid in the blood is forced into the breathing space of the lungs, causing pulmonary edema. A person with pulmonary edema has shortness of breath, which may be acute, severe and life threatening. A person with congestive heart failure feels tired because not enough blood circulates to supply the body's tissues with the oxygen and nutrients they need. Abnormalities of the heart structure and rhythm also can be responsible for left ventricular congestive heart failure.

In right-sided heart failure, the lower right chamber of the heart (right ventricle) cannot pump blood to the lungs as fast as it returns from the body through the veins. Blood then engorges the right side of the heart and the veins. Fluid backed up in the veins is forced out into the tissues, causing swelling (edema), usually in the feet and legs. Congestive heart failure of the right ventricle often is caused by abnormalities of the heart valves and lung disorders.

When the heart cannot pump enough blood, it tries to make up for this by becoming larger. By becoming enlarged (hypertrophic) the ventricle can contract more strongly and pump more blood. When this happens, the heart chamber becomes larger and the muscle in the heart wall becomes thicker. The heart also compensates by pumping more often to improve blood output and circulation. The kidneys try to compensate for a failing heart by retaining more salt and water to increase the volume of blood. This extra fluid also can cause edema. Eventually, as the condition worsens over time these measures are not enough to keep the heart pumping enough blood needed by the body. Kidneys often weaken under these circumstances, further aggravating the situation and making therapy more difficult.

For most people, heart failure is a chronic disease with no cure. However, it can be managed and treated with medicines and changes in diet, exercise, and life-style habits. Heart transplantation is considered in some cases.

Causes and symptoms

The most common causes of heart failure are:

  • coronary artery disease and heart attack (which may be "silent")
  • cardiomyopathy
  • high blood pressure (hypertension )
  • heart valve disease
  • congenital heart disease
  • alcoholism and drug abuse

The most common cause of heart failure is coronary artery disease. In coronary artery disease, the arteries supplying blood to the heart become narrowed or blocked. When blood flow to an area of the heart is completely blocked, the person has a heart attack. Some heart attacks go unrecognized. The heart muscle suffers damage when its blood supply is reduced or blocked. If the damage affects the heart's ability to pump blood, heart failure develops.

Cardiomyopathy is a general term for disease of the heart muscle. Cardiomyopathy may be caused by coronary artery disease and various other heart problems. Sometimes the cause of cardiomyopathy cannot be found. In these cases the heart muscle disease is called idiopathic cardiomyopathy. Whatever the cause, cardiomyopathy can weaken the heart, leading to heart failure.

High blood pressure is another common cause of heart failure. High blood pressure makes the heart work harder to pump blood. After a while, the heart cannot keep up and the symptoms of heart failure develop.

Defects of the heart valves, congenital heart diseases, alcoholism, and drug abuse cause damage to the heart that can all lead to heart failure.

A person with heart failure may experience the following:

  • shortness of breath
  • frequent coughing, especially when lying down
  • swollen feet, ankles, and legs
  • abdominal swelling and pain
  • fatigue
  • dizziness or fainting
  • sudden death

A person with left-sided heart failure may have shortness of breath and coughing caused by the fluid buildup in the lungs. Pulmonary edema may cause the person to cough up bubbly phlegm that contains blood. With right-sided heart failure, fluid build-up in the veins and body tissues causes swelling in the feet, legs, and abdomen. When body tissues, such as organs and muscles, do not receive enough oxygen and nutrients they cannot function as well, leading to tiredness and dizziness.

Diagnosis

Diagnosis of heart failure is based on:

  • symptoms
  • medical history
  • physical examination
  • chest x ray
  • electrocardiogram (ECG; also called EKG)
  • other imaging tests
  • cardiac catheterization

A person's symptoms can provide important clues to the presence of heart failure. Shortness of breath while engaging in activities and episodes of shortness of breath that wake a person from sleep are classic symptoms of heart failure. During the physical examination, the physician listens to the heart and lungs with a stethoscope for telltale signs of heart failure. Irregular heart sounds, "gallops," a rapid heart rate, and murmurs of the heart valves may be heard. If there is fluid in the lungs a crackling sound may be heard. Rapid breathing or other changes in breathing may also be present. Patients with heart failure also may have a rapid pulse.

By pressing on the abdomen, the physician can feel if the liver is enlarged. The skin of the fingers and toes may have a bluish tint and feel cool if not enough oxygen is reaching them.

A chest x ray can show if there is fluid in the lungs and if the heart is enlarged. Abnormalities of heart valves and other structures also may be seen on chest x ray.

An electrocardiogram gives information on the heart rhythm and the size of the heart. It can show if the heart chamber is enlarged and if there is damage to the heart muscle from blocked arteries.

Besides chest x ray, other imaging tests may help make a diagnosis. Echocardiography uses sound waves to make images of the heart. These images can show if the heart wall or chambers are enlarged and if there are any abnormalities of the heart valves. An echocardiogram also can be used to find out how much blood the heart is pumping. It determines the amount of blood in the ventricle (ventricular volume) and the amount of blood the ventricle pumps each time it beats (called the ejection fraction). A healthy heart pumps at least one-half the amount of blood in the left ventricle with each heartbeat. Radionuclide ventriculography also measures the ejection fraction by imaging with very low doses of an injected radioactive substance as it travels through the heart.

A new test that measures the level of a particular hormone in the blood was introduced in 2003 and researchers said the test may be useful for testing for heart failure in physicians' offices because it could provide results in 15 minutes.

Cardiac catheterization involves using a small tube (catheter) that is inserted through a blood vessel into the heart. It is used to measure pressure in the heart and the amount of blood pumped by the heart. This test can help find abnormalities of the coronary arteries, heart valves, and heart muscle, and other blood vessels. Combined with echocardiography and other tests, cardiac catheterization can help find the cause of heart failure. It is not always necessary, however.

Treatment

Heart failure usually is treated with lifestyle changes and medicines. Sometimes surgery is needed to correct abnormalities of the heart or heart valves. Heart transplantation is a last resort to be considered in certain cases.

Dietary changes to maintain proper weight and reduce salt intake may be needed. Reducing salt intake helps to lessen swelling in the legs, feet, and abdomen. Appropriate exercise also may be recommended, but it is important that heart failure patients only begin an exercise program with the advice of their doctors. Walking, bicycling, swimming, or low-impact aerobic exercises may be recommended. There are good heart rehabilitation programs at most larger hospitals.

Other lifestyle changes that may reduce the symptoms of heart failure include stopping smoking or other tobacco use, eliminating or reducing alcohol consumption, and not using harmful drugs.

One or more of the following types of medicines may be prescribed for heart failure:

  • diuretics
  • digitalis
  • vasodilators
  • beta blockers
  • angiotensin converting enzyme inhibitors (ACE inhibitors)
  • angiotensin receptor blockers (ARBs)
  • calcium channel blockers

Diuretics help eliminate excess salt and water from the kidneys by making patients urinate more often. This helps reduce the swelling caused by fluid buildup in the tissues. Digitalis helps the heart muscle to have stronger pumping action. Vasodilators, ACE inhibitors, ARBs, and calcium channel blockers lower blood pressure and expand the blood vessels so blood can move more easily through them. This action makes it easier for the heart to pump blood through the vessels. Cholesterol-lowering drugs called statins can help prevent death from heart failure. A 2003 study showed a 62% drop in mortality rate among patients with severe heart failure who took statin therapy.

In 2003, a new noninvasive procedure was being tested for patients with congestive heart failure. Called enhanced external counterpulsation (EECP), it consisted of inflating three sets of pneumatic cuffs attached to the patient's legs. The therapy had positive effects on the blood pressure and reduced frequency of episodes of angina (pain) in a clinical trial by as much as 70%.

Surgery is used to correct certain heart conditions that cause heart failure. Congenital heart defects and abnormal heart valves can be repaired with surgery. Blocked coronary arteries usually can be treated with angioplasty or coronary artery bypass surgery.

With severe heart failure, the heart muscle may become so damaged that available treatments do not help. Patients with this stage of heart failure are said to have end-stage heart failure. Heart transplant usually is considered for patients with end-stage heart failure when all other treatments have stopped working.

Prognosis

Most patients with mild or moderate heart failure can be successfully treated with dietary and exercise programs and the right medications. In fact, in 2003, the American Heart Association said that even those awaiting heart transplants could benefit from exercise. Many people are able to participate in normal daily activities and lead relatively active lives.

Patients with severe heart failure may eventually have to consider heart transplantation. Approximately 50% of patients diagnosed with congestive heart failure live for five years with the condition. Women with heart failure usually live longer than men with heart failure.

Prevention

Heart failure usually is caused by the effects of some type of heart disease. The best way to try to prevent heart failure is to eat a healthy diet and get regular exercise, but many causes of heart failure cannot be prevented. People with risk factors for coronary disease (such as high blood pressure and high cholesterol levels) should work closely with their physician to reduce likelihood of heart attack and heart failure.

KEY TERMS

Angioplasty A technique for treating blocked coronary arteries by inserting a catheter with a tiny balloon at the tip into the artery and inflating it.

Angiotensin-converting enzyme (ACE) inhibitor A drug that relaxes blood vessel walls and lowers blood pressure.

Arrhythmias Abnormal heartbeat.

Atherosclerosis Buildup of a fatty substance called a plaque inside blood vessels.

Calcium channel blocker A drug that relaxes blood vessels and lowers blood pressure.

Cardiac catheterization A diagnostic test for evaluating heart disease; a catheter is inserted into an artery and passed into the heart.

Cardiomyopathy Disease of the heart muscle.

Catheter A thin, hollow tube.

Congenital heart defects Abnormal formation of structures of the heart or of its major blood vessels present at birth.

Congestive heart failure A condition in which the heart cannot pump enough blood to supply the body's tissues with sufficient oxygen and nutrients; back up of blood in vessels and the lungs causes buildup of fluid (congestion) in the tissues.

Coronary arteries Arteries that supply blood to the heart muscle.

Coronary artery bypass Surgical procedure to reroute blood around a blocked coronary artery.

Coronary artery disease Narrowing or blockage of coronary arteries by atherosclerosis.

Digitalis A drug that helps the heart muscle to have stronger pumping action.

Diuretic A type of drug that helps the kidneys eliminate excess salt and water.

Edema Swelling caused by fluid buildup in tissues.

Ejection fraction A measure of the portion of blood that is pumped out of a filled ventricle.

Heart valves Valves that regulate blood flow into and out of the heart chambers.

Hypertension High blood pressure.

Hypertrophic Enlarged.

Idiopathic cardiomyopathy Cardiomyopathy without a known cause.

Pulmonary edema Buildup of fluid in the tissue of the lungs.

Vasodilator Any drug that relaxes blood vessel walls.

Ventricles The two lower chambers of the heart.

Heart failure sometimes can be avoided by identifying and treating any conditions that might lead to heart disease. These include high blood pressure, alcoholism, and coronary artery disease. Regular blood pressure checks and obtaining immediate medical care for symptoms of coronary artery disease, such as chest pain, will help to get these conditions found and treated early, before they can damage the heart muscle.

A 2003 initiative called OPTIMIZE H-F was aimed at preventing severe heart failure and deaths among patients discharge from hospitals. The project created a registry or database of patients with heart failure that could be shared among hospitals. Finally, diagnosing and treating heart failure before the heart becomes severely damaged can improve the prognosis. With proper treatment, many patients may continue to lead active lives for a number of years.

Resources

PERIODICALS

"Even Heart Failure Patients Should Exercise." Clinician Reviews April 2003: 50-52.

Jancin, Bruce. "Noninvasive Procedure Eyed for Heart Failure: Enhanced External Counterpulsation." Family Practice News June 1, 2003: 12.

"New Care Initiative to Improve Outcomes for Heart Failure Patients." Heart Disease Weekly April 20, 2003: 45.

"Rapid Congestive Heart Failure Test a Useful Tool in Physician Offices." Heart Disease Weekly June 15, 2003: 19.

Zoler, Michael N. "Heart Failure Deaths Plunge with Statins." Internal Medicine News April 15, 2003: 35-41.

ORGANIZATIONS

American Heart Association. 7320 Greenville Ave. Dallas, TX 75231. (214) 373-6300. http://www.americanheart.org.

National Heart, Lung and Blood Institute. PO Box 30105, Bethesda, MD 20824-0105. (301) 251-1222. http://www.nhlbi.nih.gov.

Texas Heart Institute. Heart Information Service. PO Box 20345, Houston, TX 77225-0345. http://www.tmc.edu/thi.

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heart failure

heart failure The characteristic symptoms of heart failure are recognizable in writings at least as far back as the twelfth century, when the health problems of Alexius I ( Comnenus), the Byzantine emperor, were documented by his physician. The ‘failure’ is manifest in the heart not providing sufficient output of blood to meet the ‘demands’ of the body. A useful term here is ‘exercise intolerance’. A typical heart failure patient will have become accustomed to an inexorable decline in physical vigour. Activities such as climbing stairs, carrying a heavy load (perhaps a suitcase), even walking, far less running, and other such ‘exercises’ usually considered to be within the normal range become increasingly difficult or impossible. One key associated symptom is breathlessness, another is oedema (the accumulation of fluid in the tissues) for example in the ankles. Both symptoms reflect raised pressure in the veins ultimately caused by the insufficient pumping action of the heart. The seriousness of heart failure is such that, at the time of writing, about half of the patients affected die within five years of the initial diagnosis. Of these fatalities, about half will suffer a major heart attack, the remainder will suffer a steady decline of heart function until pump failure itself proves fatal. Against this gloomy scenario, new discoveries about the underlying causes, the development of new drugs to slow down, halt, and ultimately reverse the harmful aspects, and an increasing awareness of the value of lifestyle and dietary change promise to improve the prospects for the heart failure patient in the twenty-first century — even if too late for the Emperor Alexius.

The most common single cause in modern Western society, accounting for about half of the cases, is a heart attack. By killing one region, the attack leaves heart function compromised. Until the later decades of the twentieth century a very major cause was undiagnosed and untreated high blood pressure — the heart in this instance must work harder and harder to force blood into the arteries where the pressure is too high, and eventually ‘tires’. Although long-term high blood pressure is still a contributor to heart failure, modern drugs have helped to reduce its significance. A range of other causes include the various heart valve malfunctions, certain infections, congenital structural abnormalities, genetically-determined disorders, and drug abuse. There is clear evidence that the factors that increase the likelihood of heart attack also contribute to the severity of the ensuing heart failure. These factors include high blood cholesterol, atheromatous vascular disease, sedentary lifestyle, and smoking. In third-World countries, infections such as the insect-transmitted trypanosomal Chagas' disease are among the main causes of heart failure. Even amongst economically advanced nations there are wide differences in the incidence of heart failure between, say, Japan (very low) and Western Europe and the US (high); nation-specific combinations of dietary and genetic factors are thus the target of much research into underlying causes. There is widespread agreement that taking regular exercise not only strengthens the heart and improves its own circulation (particularly by improving collateral blood supplies) but also that exercise is a very useful part of any rehabilitation regime designed to prevent the development of heart failure after a heart attack.

Heart failure refers to a characteristic pattern of features caused by an abnormality of the heart. It is a complex clinical syndrome resulting from the entanglement of cause and effect, of symptoms and compensatory changes. Several body systems and organs are involved, especially the lungs, kidneys, and blood vessels, their associated hormonal systems, as well as the heart itself. It is increasingly clear that many and varied patterns of disturbance to each of these systems can result in convergence into the full repertoire of malfunctions which together are termed heart failure.

In normal circumstances, the ‘challenge’ to the heart posed by ‘demand’ for increased blood supply is most obvious during exercise, however mild. The physiological challenge is similar when the heart is unable, by virtue of disease, to meet even normal requirements. In either case, homeostatic mechanisms operate which promote the maintenance of two parameters of heart function: blood pressure and blood flow. An example of these compensatory processes is one promoting retention of water and salts by hormonal influences on the kidneys. This will increase blood volume and tend to keep up both blood pressure and cardiac output (the volume pumped). Unfortunately, in heart failure, the compensatory mechanisms prove clearly ineffective; they actually contribute to the symptoms observed (e.g. breathlessness and ankle swelling) and become important factors in the gradual worsening of the condition. The use of diuretic drugs (which stimulate kidney function and reverse fluid retention) is widespread in the treatment of heart failure. The heart itself generally responds to an abnormal workload by increased growth (hypertrophy), but the nature of the growth is abnormal in subtle ways, unlike the hypertrophy associated with general physical fitness which is positively beneficial. It is now known, for example, that a hypertrophied failing heart both contracts and relaxes more slowly, and is more prone to life-threatening electrical abnormalities.

David J. Miller, and Niall G. MacFarlane


See also heart; heart attack.

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heart failure

heart failure n. a condition in which the pumping action of the heart is inadequate due to damaged heart valves, ventricular muscle, or both. This results in back pressure of blood, with congestion of organs. congestive h. f. (congestive cardiac failure, CCF) heart failure involving damage to both left and right ventricles. The patient suffers breathlessness (see also orthopnoea) and fluid accumulates in the lungs, legs, and/or abdominal cavity. There is reduced flow of arterial blood from the heart, which in extreme cases results in peripheral circulatory failure (see cardiogenic shock). Treatment includes diuretics, ACE inhibitors, and beta blockers.

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