Heart failure

Epidemiology

Do you know how many people die from heart-related problems including heart failure? That’s right, it is a big concern to society, in particular for people over 65 years who are at much greater risk.  Heart failure has a prevalence of over 5.8 million people in the USA and over 23 million people across the world. Moreover every year more than 550 000  new cases are being diagnosed. It is recognized as an epidemic, and it is associated with a higher risk of sudden death (mortality), increased morbidity, and healthcare expenses. If you are diagnosed with this condition don’t go desperate, because if you change your lifestyle, take your medicines regularly, and take some supplements you can have a normal, fulfilling life.

heart failure

Pathophysiology

So what does heart failure stand for? It does not mean that the heart is utterly failing so it’s going to stop working suddenly. It means that the heart is at a special structural or functional condition so it can’t work properly. Moreover, it can’t provide enough oxygen and nutrients to peripheral tissues failing to pump enough blood or the atrial filling is being decreased. So the heart which is already in a problem must work even harder to accomplish the body requirements, and that causes the symptoms, minor or the very serious ones which can be life-threatening.

The organism can’t excrete all of the metabolism products which makes the stagnation of body fluids in the lungs and other body parts. There are many types of heart failures, but the main distinction is between the acute and the chronic one. While the chronic heart failure develops (CHF) throughout the time, eventually becoming more and more difficult, the acute heart failure (AHF) is extreme from the start, and it’s accompanied with much higher mortality. AHF often happens after a heart attack, because the body can’t compensate for the sudden loss of a heart function. In CHF, adapting mechanisms of the body help the heart at first, but over the time they’re doing more and more damage.

The heart is trying to recompense the lack of tissue demands via increased heart contractions, increased heart pace, and through maintaining the blood in circulation. This leads to overstretching the muscle fibers, decreasing the amount of cardiac input, increasing the residual blood in ventricles and their overflow during the diastole. While the myocardium is being over-strained trying to push the blood in the bloodstream to maintain the normal circulation, it engages the compensatory hypertrophy. Due to the weakness of heart muscle fibers a decompensation occurs developing the process of dystrophy and weakening it which leaves the myocardium in lack of a blood supply itself. In this stage, the neurohumoral mechanisms are being involved activating the sympathetic-adrenal and renin-angiotensin system which causes vasoconstriction in the periphery.

The most common causes of heart failure are:

High blood pressure (hypertension). If you have hypertension your heart is forced to work with a greater load which can lead to decreased strength in blood pumping and heart muscle cell deformation mentioned above.

Coronary heart disease (CHD). This disease causes the constriction of the vessels that supply the heart and thus are reducing the flow when the myocytes require oxygen which lowers their performance, especially in physical exertion when the oxygen demand is even higher. CHD can lead to irreversible heart muscle damage via heart attack which can replace the healthy muscle tissue with the connective tissue.

Problems with heart valves which include heart valve morphological changes; heart valve stenosis – when the lumen of the valve narrows and prevents the blood to flow through it, increasing the pressure; and the heart valve failure – when the valve completely closes, causing the blood to revert its direction.

Cardiomyopathy. The heart muscle is structurally changed. It may thicken or lose its ability to expand, so its function weakens.

Lung diseases. In lung diseases, the concentration of oxygen in the blood is lower which intensifies the heart strain making it work harder, and that may lead to a right-sided heart failure manifested by edema in ankles or abdomen.

Kidney diseases. Kidneys are trying to compensate heart failure by saving the sodium in the blood which leads to fluid accumulation in the body. When the kidneys are performing low they make hormones which maintain the flow through them so they are continuing to save the sodium, making the accumulation of fluids in the body even more.

heart failure symptoms

Symptoms

Shortness of breath

It is caused by the stagnation of blood inside the lungs which then interfere with gas exchange. At the earlier stadiums, this is felt occasionally when a person is physically engaged, while in later stages it happens even in a relaxed position. If the shortness of breath occurs in nighttime while someone is asleep, they should elevate the upper body with some pillows.

Coughing and wheezing

These symptoms come from the same problem like shortness of breath, due to blood congestion inside the lungs, but they could actually be the symptoms of bronchitis or asthma.

Tachycardia

A compensating mechanism for sustaining blood circulation. Sometimes the heartbeats are irregular and are felt like palpitations.

Dizziness

If the brain blood flow is inadequate or the blood pressure is, low dizziness might occur. Likewise, an irregular heartbeat or a sudden drop in arterial pressure after standing up can lead to dizziness (postural hypotension).

Fatigue

You can feel very tired even after doing some minor activities and that worsens over time. This happens because muscles and other organs are not gaining the nutrition and oxygen they need. The problems with concentration and memory may develop over time.

Swelling in ankles

Swelling of the ankles occurs due to fluid accumulation, and it can spread to the rest of the leg and on the abdomen after. This can be reduced by raising legs when lying down; by introducing less fluids in your organism and by using diuretics. The fluids from edema may return to bloodstream overnight and cause the onset of night urination.

Thirst and dry mouth

Those are common symptoms of heart failure. They may be induced by drugs taken to treat heart failure or from heart failure itself.

Sudden changes in weight

Sudden changes in weight may be found due to fluid stagnation. It is recommended to measure your weight every day and to report to your doctor if you notice them.

Heart failure classification

Heart failure is classified by NYHA scale of 4 stages based on symptom seriousness, and it involves symptoms and physical activity. This classification is mostly used in clinical work.

Stage I:  The patient has no physical activity restrictions. Physical activity usually doesn’t lead to fatigue, shortness of breath or palpitations.

Stage II: Some physical activity restriction exists. The patient is feeling well while in a relaxed position, but usual physical activities are causing fatigue, shortness of breath or palpitations.

Stage III: The patient has significant physical ability restriction. When in a relaxed state no problems are being observed, but small trivial activities are causing the manifestation of symptoms.

Stage IV: The slightest physical activity is making trouble to the patient / Heart failure symptoms are present even in a relaxed state and they’re becoming more intense after a trivial physical activity.

Diagnosis

To declare a heart failure diagnose a doctor has to consider:
  • Full detailed medical history (personal and family medical history). By patient’s description of symptoms and by manifested signs of illness the doctor can suspect that the heart failure is presented. The drugs that patient is taking are needed to be acknowledged because many of them can lead to heart failure.
  • Standard physical tests.
  • Electrocardiogram (ECG). Abnormal ECG waves are a usual sign of arrhythmia or left ventricle hypertrophy, but sometimes the electrical waves are normal.
  • Echocardiogram. An echocardiogram can provide the information for blood pumping ability, structural or functional changes.
  • Chest X-ray. With X-ray imaging, a doctor can say if there is a heart enlargement or fluid stagnation in the lungs.
  • Blood tests. Full blood count, electrolytes, urea, creatinine, and most importantly B-type natriuretic peptide.
  • Stress test. The heart is examined while the body is in exertion. The exertion is inducted by taking a drug or by walking / running on a treadmill.
  • Differential tests which exclude heart failure from other lung/kidney diseases.

Treatment

The goal of heart failure treatment is to reduce the symptoms and signs of illness, as well as to reduce the number of hospital visits.

Non-pharmacological methods

Physical activity

There is no need to overwhelm yourself with physical activity at the beginning. After the diagnose you should avoid any strain, but after some time you can start slowly with some minor exercises or simply by walking more often. After a while, you can see how your heart and body are reacting to a new activity, and then you can increase your training a little bit. By increased physical activity your heart will not heal itself of course, but your other body muscles will generally have more ability to work so some of the symptoms should reduce.

Diet

The most important thing here is to remember that the more salt means more body fluids, so you should definitely lower your salt input. Bigger sized meals are to be avoided because they put an additional burden to an already weakened heart. Generally, obesity put an additional strain to your circulation, so losing weight, in this case, is highly recommended, and it will make you feel better in general. Avoid those nasty fatty meals, and have some fruits and vegetables. Don’t eat so much red meat, and take some fish.

Smoking

Tobacco smoking is bad for your health and that is a fact. Nicotine from cigarettes is acting as a vasoconstriction agent, making your blood vessels to narrow, and so on forcing your weakened heart to put even more effort for blood pumping. Carbon monoxide (CO) in your blood is taking a place from oxygen, so less of the oxygen can make it to peripheral tissues and their requirements are not being filled. Remember, it’s never too late to stop smoking!

Alcohol

Ingesting too much alcohol over time may induct the alcohol-related cardiomyopathy. In that case, all alcoholic drinks should be excluded from your diet. If your condition is not in a later stage you may drink one glass of beer or wine per day.

Vaccination

It is important for patients with heart failure to be vaccinated against the flu because respiratory infections may worsen your heart state. Vaccination should be done annually, just before the flu season.

Pharmacological measures

ACE inhibitors / AT1 antagonists

They have a main role in the treatment and prevention of heart failure in all of the condition stages. The effects of these drugs are manifested in circulation on a local renin angiotensin aldosterone system. They reduce the shortness of breath and improve physical tolerance. These drugs are cutting down the chance of a sudden death significantly.

Diuretics

Diuretics cause an increased ejection of sodium and water. They manage the shortness of breath and edema. Diuretics do not lower the mortality, but they’re good for reducing the symptoms.

Beta blockers

They’re always used. At first in a lower dose, but over the time an adjustment is needed. With these drugs, the mortality is reduced notably (65%) because they regulate the arrhythmia. β blockers must be used on the dry heart when all of the excess fluids are eliminated because they lower the inotropic value (the force of heart muscle contraction).

Digoxin

Digoxin works as an inotropic agent, so it induces the contractility and it slows down the heartbeat pace. This drug does not lower the mortality, but it lowers the number of hospital visits, regulates the symptoms, and improves the quality of life. It is used in very low doses, and its concentration in blood should be monitored.