Heart Failure.

Heart Failure

Definition Heart failure (HF) can be defined as a clinical syndrome that is based on abnormal structure or function of the heart and clinical symptoms and signs of heart failure such as dyspnea, fatigue and fluid retention. Chronic heart failure (CHF) is a common condition that is responsible for a large number of death and considerable morbidity and cost.

Description HF can occur in people of any age, even in young children (especially those born with a heart defect). But, it is much more common among older people, because older people are more likely to have disorders that damage the heart muscle and because age-related changes in the heart tend to make the heart pump less efficiently. HF develops in about 1 of 100 people. The disorder is likely to become more common because people are living longer and because, in some countries, certain risk factors for heart disease (such as smoking, high blood pressure, and a high-fat diet) are affecting more people.Abdominal obesity

Description HF does not mean that the heart has stopped, as some people mistakenly believe; it means that the heart cannot keep up with the work required of it (its workload). But this definition is remarkably simplified. Heart failure is extremely complex, and no simple definition can encompass its many causes, aspects, forms, and consequences.

The function of the heart is to pump blood.
Description The function of the heart is to pump blood. Pumping has two aspects: -to move a fluid into something (the heart pumps blood into the arteries) -to move a fluid out of something (the heart moves blood out of the veins, as a sump pump moves water out of a basement). HF develops when the pumping action of the heart is inadequate. As a result, blood flow to body tissues is reduced and blood returning to the heart accumulates, causing congestion in the veins. That is why HF is also known as congestive heart failure.

Description Accumulation of blood coming into the left side of the heart (from the lungs causes congestion in the lungs, impairing lung function and making breathing difficult. Accumulation of blood coming into the right side of the heart (from the rest of the body) causes congestion in other parts of the body, including fluid accumulation (edema) in the legs and enlargement of organs such as the liver. HF usually affects both the right and left sides of the heart to some degree. But, one side may be affected more than the other. In such cases, HF may be described as right-sided heart failure or left-sided heart failure.

HF: Pumping and Filling Problems
Normally, the heart stretches as it fills with blood (during diastole), then contracts to pump out the blood (during systole).

HF due to systolic dysfunction usually develops because the heart cannot contract normally. It may fill with blood, but it cannot pump out as much of the blood it contains because the muscle is weaker. As a result, the amount of blood pumped to the body and to the lungs is reduced, and the heart, particularly the left ventricle, usually enlarges.

HF due to diastolic dysfunction develops because the heart's walls stiffen and may thicken so that the heart cannot fill normally with blood. Consequently, blood backs up in the left atrium and lung (pulmonary) blood vessels and causes congestion. Nonetheless, the heart may be able to pump out a normal percentage of the blood it receives.

Pathogeny In HF, the heart cannot pump enough blood to meet the body's need for oxygen and nutrients, which are supplied by the blood. As a result, arm and leg muscles may tire more quickly, and the kidneys may not function normally. Blood pressure in the arteries normally enables the kidneys to filter fluid and waste products from the blood into the urine. When the heart cannot pump adequately, blood pressure falls and the kidneys malfunction: The kidneys cannot remove excess fluid from the blood. As a result, the amount of fluid in the bloodstream increases, and the workload of the failing heart increases, creating a vicious circle. Thus, HF becomes even worse.

Pathogeny HF has two main forms:
Systolic dysfunction (which is more common) In systolic dysfunction, the heart contracts less forcefully and cannot pump out as much of the blood that is returned to it as it normally does. As a result, more blood remains in the lower chambers of the heart (ventricles). Blood then accumulates in the veins. Diastolic dysfunction In diastolic dysfunction, the heart is stiff and does not relax normally after contracting. Even though it may be able to pump a normal amount of blood out of the ventricles, the stiff heart does not allow as much blood to enter its chambers from the veins. As in systolic dysfunction, the blood returning to the heart then accumulates in the veins. Often, both forms of heart failure occur together.

Causes Any disorder that directly affects the heart can lead to HF, as can some disorders that indirectly affect the heart. Some disorders cause HF quickly; others do so only after many years. Some disorders cause systolic dysfunction, impairing the heart's ability to pump out blood, and others cause diastolic dysfunction, impairing the heart's ability to fill with blood. Some disorders, such as high blood pressure and heart valve disorders, can cause both types of dysfunction.

COMMON CAUSES OF HEART FAILURE
Coronary artery disease Hypertensive cardiovascular disease Diabetes mellitus plus hypertension Valvular heart disease Dilated cardiomyopathy Infiltrative cardiomyopathy Myocardial hypertrophy

Systolic Dysfunction Disorders that cause systolic dysfunction may impair the entire heart or one area of the heart. As a result, the heart does not contract normally. Coronary artery disease is a common cause of systolic dysfunction. It can impair large areas of heart muscle because it reduces the flow of oxygen-rich blood to the heart muscle, which needs oxygen for normal contraction. Blockage of a coronary artery can cause a heart attack, which destroys an area of heart muscle. As a result, that area can no longer contract normally.

Systolic Dysfunction Heart valve disorders - narrowing (stenosis) of a valve, which hinders blood flow through the heart, or leakage of blood backward (regurgitation) through a valve—can cause heart failure. Both stenosis and regurgitation of a valve can severely stress the heart, so that over time, the heart enlarges and cannot pump adequately. An abnormal connection (septal defects between the heart chambers can allow blood to recirculate within the heart, increasing the workload of the heart, and thus can cause heart failure.

Systolic Dysfunction Myocarditis (inflammation of heart muscle) caused by a bacterial, viral, or other infection can damage all or part of the heart muscle, impairing its pumping ability. Disorders that affect the heart's electrical conduction system, producing changes in heart rhythms, (especially if heartbeats are fast or irregular), can cause HF. When the heart beats abnormally, it cannot pump blood adequately.

Systolic Dysfunction Some lung disorders, such as pulmonary hypertension, may alter or damage blood vessels in the lungs. As a result, the heart has to work harder to pump blood into the arteries that supply the lungs (pulmonary arteries). Pulmonary hypertension may lead to cor pulmonale. In this disorder, the right ventricle, which pumps blood to the lungs, becomes enlarged, eventually resulting in right-sided heart failure.

Systolic Dysfunction Sudden, usually complete blockage of a pulmonary artery by several small blood clots or one very large clot (pulmonary embolism) also makes pumping blood into the pulmonary arteries difficult. A very large clot can be immediately life threatening. The increased effort required to pump blood into the blocked pulmonary arteries can cause the right side of the heart to enlarge and may cause the walls of the right ventricle to thicken, resulting in right-sided heart failure.

Systolic Dysfunction Disorders that indirectly affect the heart's pumping ability include a deficiency of red blood cells or hemoglobin (anemia), an overactive thyroid gland (hyperthyroidism), an under active thyroid gland (hypothyroidism), and kidney failure. Red blood cells contain hemoglobin, which enables them to carry oxygen from the lungs and deliver it to body tissues. Anemia reduces the amount of oxygen the blood carries, so that the heart must work harder to provide the same amount of oxygen to tissues. (Anemia has many causes, including chronic bleeding due to a stomach ulcer).

Systolic Dysfunction An overactive thyroid gland over stimulates the heart, so that it pumps too rapidly and does not empty normally during each heartbeat. When the thyroid gland is under active, levels of thyroid hormones are low. As a result, all muscles, including the heart, become weak because muscles depend on thyroid hormones to function normally. Kidney failure strains the heart because the kidneys cannot remove excess fluid from the bloodstream, so the heart has to pump more blood. Eventually, the heart cannot keep up, and heart failure develops.

Diastolic Dysfunction
Inadequately treated high blood pressure is the most common cause of diastolic dysfunction. High blood pressure stresses the heart because the heart must pump blood more forcefully than normal to force blood into the arteries against the higher pressure. Eventually, the heart's walls thicken (hypertrophy), then stiffen. The stiff heart does not fill quickly or adequately, so that with each contraction, the heart pumps less blood than it normally does.

As people age, the heart's walls also tend to stiffen. The combination of high blood pressure, which is common among older people and age-related stiffening, makes HFparticularly common among older people. In constrictive pericarditis, the sac that envelops the heart (pericardium) stiffens, preventing even a healthy heart from pumping and filling normally.

HF may result from disorders that cause the heart's walls to stiffen, such as infiltrations and infections. In amyloidosis, amyloid, an unusual protein not normally present in the body, infiltrates many tissues in the body. If amyloid infiltrates the heart's walls, they stiffen, and HF results. In tropical countries, infiltration by certain parasites into heart muscle can cause HF, even in young people. Some heart valve disorders, such as aortic valve stenosis, hinder blood flow out of the heart. As a result, the heart muscle has to work harder and thickens, and diastolic dysfunction develops initially. Eventually, systolic dysfunction also develops.

Compensatory Mechanisms
The body has several mechanisms to compensate for HF. The body's first response to stress, including that due to HF, is to release the fight-or-flight hormones, epinephrine (adrenaline) and norepinephrine (noradrenaline). These hormones may be released immediately after a heart attack damages the heart. Epinephrine and norepinephrine cause the heart to pump faster and more forcefully. They help the heart increase the amount of blood pumped out (cardiac output), sometimes to a normal amount, and thus help compensate partially and temporarily for the heart's impaired pumping ability.

People who do not have heart disease usually benefit from release of these hormones when more work is temporarily required of the heart. But for people who have chronic HF, this response results in increased demands on an already damaged heart. Over time, the increased demands lead to further deterioration of heart function.

Another of the body's main compensatory mechanisms for HF is to decrease the amount of salt and water excreted by the kidneys. Retaining salt and water instead of excreting it into urine increases the volume of blood in the bloodstream and helps maintain blood pressure. The larger volume of blood also stretches the heart muscle, enlarging the heart chambers, particularly the ventricles, which pump blood out of the heart. The more the heart muscle is stretched, the more forcefully it contracts. At first, this mechanism improves heart function, but after a point, stretching no longer helps but instead weakens the heart's contractions (as when a rubber band is overstretched). Consequently, HF worsens.

Another important compensatory mechanism is enlargement of the muscular walls of the ventricles (ventricular hypertrophy). When the heart must work harder, the heart's walls enlarge and thicken, as biceps muscles enlarge after months of weight training. At first, the thickened heart walls can contract more forcefully. But the thickened heart walls eventually become stiff, worsening diastolic dysfunction. Eventually, the contractions become weaker, causing systolic dysfunction.

Symptoms Symptoms of HF may begin suddenly, especially if the cause is a heart attack. But, in most people, symptoms develop over days to months. The disorder may stabilize for periods of time but often progresses slowly and insidiously. People with HF feel: tired and weak when performing physical activities, because their muscles are not receiving enough blood. In older people, HF sometimes causes vague symptoms such as sleepiness, confusion, and disorientation, as well as weakness and fatigue.

Right-sided heart failure Symptoms
The main symptoms of right-sided heart failure are fluid accumulation and swelling (edema) in the feet, ankles, legs, liver, and abdomen. Where the fluid accumulates depends on the amount of excess fluid and the effects of gravity. If a person is standing, fluid accumulates in the legs and feet. If a person is lying down, fluid usually accumulates in the lower back. If the amount of fluid is large, fluid also accumulates in the abdomen. Fluid accumulation in the liver or stomach can cause nausea and loss of appetite. Eventually, food is not absorbed well, resulting in loss of weight and muscle.This condition is called cardiac cachexia.

Left-sided heart failure Symptoms
Left-sided HF leads to fluid accumulation in the lungs, which causes shortness of breath. At first, shortness of breath occurs only during exertion, but as HF progresses, it occurs with less and less exertion and eventually occurs even at rest. People with severe left-sided HF may be short of breath when lying down (a condition called orthopnea, because gravity causes more fluid to move into the lungs. Such people often wake up, gasping for breath or wheezing (a condition called paroxysmal nocturnal dyspnea). Sitting up causes some of the fluid to drain to the bottom of the lungs, making breathing easier. Eventually, left-sided HF causes right-sided HF.

Left-sided heart failure Symptoms
A sudden accumulation of a large amount of fluid in the lungs (acute pulmonary edema) causes extreme difficulty breathing, rapid breathing, bluish skin, and feelings of restlessness, anxiety, and suffocation. Some people have severe spasms of the airways (bronchospasms) and wheezing; this condition is called cardiac asthma, which resembles asthma but has a different cause. Acute pulmonary edema is a life-threatening emergency.

SIGNS OF HF ON PHYSICAL EXAMINATION
Left HF and pulmonary venous congestion: Pulmonary rales Decreased breath sounds Dullness to percussion Third heart sound Displaced apical impulse

Right HF and systemic venous congestion: Peripheral edema Elevated jugular venous pressure, prominent v wave and steep y descent Hepatojugular reflux Hepatomegaly Ascites Right-sided third heart sound Left parasternal heave

Low cardiac output Tachycardia Pulsus alternans Decreased pulse pressure Hypotension

Diagnosis Doctors usually suspect HF on the basis of symptoms alone.
The diagnosis is supported by the results of a physical examination, including a weak, often rapid pulse, reduced blood pressure, abnormal heart sounds fluid accumulation in the lungs (both heard through a stethoscope), an enlarged heart, swollen neck veins, an enlarged liver, swelling in the abdomen or legs.

Diagnosis Electrocardiogram: Q waves ST-T wave abnormalities
Left ventricular hypertrophy Right ventricular hypertrophy Low voltage (infiltrative cardiomyopathy, pericardial effusion, hypothyroidism) Intraventricular conduction disturbances Tachyarrhythmias

Diagnosis A chest x-ray can show an enlarged heart and fluid accumulation in the lungs.

Diagnosis Echocardiography, which uses sound waves to produce an image of the heart, is one of the best procedures for evaluating heart function, including the pumping ability of the heart and the functioning of heart valves. It can show whether the heart walls are thickened, whether the valves are functioning normally, whether contractions are normal, whether any area of the heart is contracting abnormally.

Diagnosis Echocardiography may help determine
whether heart failure is due to systolic or diastolic dysfunction by enabling doctors to estimate the thickness of the heart walls the ejection fraction. The ejection fraction, an important measure of heart function, is the percentage of blood pumped out by the heart with each beat. A normal left ventricle ejects about 60% of the blood in it. If the ejection fraction is low, systolic dysfunction is likely. If it is normal or high, diastolic dysfunction is likely.

Diagnosis Other procedures, such as radionuclide imaging and cardiac catheterization with angiography, may be performed to identify the cause of heart failure. Rarely, a biopsy is needed, usually when doctors suspect infiltration of the heart (as occurs in amyloidosis) or myocarditis due to a bacterial, viral, or other infection. BNP blood test. This new test checks the level of a hormone called BNP (B-type natriuretic peptide) that rises in HF.

Classification of HF (NYHA)
Class 1: No limits-ordinary physical activity does not cause undue tiredness or shortness of breath. Class 2: Slight or mild limits-comfortable at rest, but ordinary physical activity results in tiredness or shortness of breath. Class 3: Marked or noticeable limits-comfortable at rest, but less than ordinary physical activity causes tiredness or shortness of breath. Class 4: Severe limits-unable to carry on any physical activity without discomfort. Symptoms are also present at rest. If any physical activity is undertaken, discomfort increases.

The treatment for HF The goals of treatment are to:
Treat the underlying cause of HF Improve symptoms and quality of life Stop HF from getting worse. Prolong life span

The treatment for HF Lifestyle changes Medications
The treatment for HF includes: Lifestyle changes Medications Specialized care for those in the most advanced stage.

The treatment for HF Lifestyle Changes
Follow a diet low in salt. Salt can cause extra fluid to build up in your body making your heart failure worse. Limit the amount of fluids that you drink. Weigh yourself every day and let your doctor know right away if you have a sudden weight gain. This could mean you have extra fluid building up in your body. Exercise as directed to help build up your fitness level and ability to be more active. Lose weight if you are overweight Quit smoking if you smoke Limit the amount of alcohol that you drink.

The treatment for HF Medications The main medicines are:
Diuretics (water or fluid pills) to help reduce fluid buildup in your lungs and swelling in your feet and ankles. ACE inhibitors to lower blood pressure and reduce the strain on your heart. These medications also may reduce the risk of a future heart attack. Beta blockers to slow your heart rate and lower your blood pressure to decrease the workload on your heart. Digoxin to make the heart beat stronger and pump more blood.

Some Drugs Used to Treat HF
Type Drug Comments Angiotensin-converting enzyme (ACE) inhibitors Captopril Enalapril Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril ACE inhibitors cause blood vessels to widen (dilate), thus decreasing the amount of work the heart has to do; they may also have direct beneficial effects on the heart. These drugs are the mainstay of heart failure treatment. They reduce symptoms and the need for hospitalization, and they prolong life.

Type Drug Comments Angiotensin II receptor blocers Candesartan Eprosartan Irbesartan Losartan Telmisartan Valsartan Angiotensin II receptor blocers have effects similar to those ACE. Inhibitors may be tolerated better. But, their effects are still being evaluated in people with HF. They may be used with ACE inhibitors or used alone in people who cannot take an ACE inhibitors.

Type Drug Comments Beta-blockers Bisoprolol Carvedilol Metoprolo Beta-blockers drugs slow the heart rate and block excessive stimulation of the heart. They are appropriate for some people with heart failure. These drugs are usually used with ACE inhibitors and provide an added benefit. They may temporarily worsen symptoms but result in long-term improvement in heart function

Type Drug Comments Other vasodilators Hydralazine Isosorbide dinitrate Nitroglycerin Vasodilators cause blood vessels to dilate. These vasodilators are usually given to people who cannot take an ACE inhibitor or angiotensin II receptor blocker. NitroglycerinSOME TRADE NAMES NITRO-BID NITROL is particularly useful in people who have heart failure and angina.

Type Drug Comments Cardiac glycosides Digitoxin Digoxin Cardiac glycosides increase the force of each heartbeat and slow a heart rate that is too fast.

Type Drug Comments Loop diuretics Bumetanide Ethacrynic acid Furosemide These diuretics help the kidneys eliminate salt and water, thus decreasing the volume of fluid in the bloodstream. Potassium-sparing diuretics Amiloride Spironolactone Triamterene Because these diuretics prevent potassium loss, they may be given in addition to thiazide or loop diuretics, which cause potassium to be lost. Spironolactone (ALDACTONE) is particularly useful in the treatment of severe heart failure.

Type Drug Comments Thiazide and thiazide-like diuretics Chlorthalidone Hydrochlorothiazide Indapamide Metolazone The effects of these diuretics are similar to but milder than those of loop diuretics. The two types of diuretics are particularly effective when used together.

Type Drug Comments Anticoagulants Heparin Warfarin Anticoagulants may be given to prevent clots from forming in the heart chambers. Opioids Morphine Morphine (MS CONTIN,ORAMORPH) is given to relieve the anxiety that usually accompanies acute pulmonary edema, which is a medical emergency.

Positive inotropic drugs (drugs that make muscle contract more forcefully) Dobutamine Dopamine Milrinone For people who have severe symptoms, these drugs may be given intravenously to stimulate heart contractions and help keep blood circulating.

Treatment of Acute HF If acute pulmonary edema develops:
HF that develops or worsens quickly requires emergency treatment in a hospital. If acute pulmonary edema develops: oxygen is given through a face mask. diuretics given intravenously nitroglycerin given intravenously or under the tongue can produce rapid, dramatic improvement. Morphine relieves the anxiety that usually accompanies acute pulmonary edema. It also decreases the rate of breathing, slows the heart rate, dilates blood vessels, and thereby reduces the amount of work the heart has to do. If these measures do not adequately improve breathing, a tube may be inserted into the person's airway so that a mechanical ventilator can assist breathing.

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Heart Failure.

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