Heart Failure

Heart Failure

The term “heart failure” can be frightening. It does not mean that the heart has “failed” or stopped working. It means that the heart does not pump as well as it should.

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Heart failure, sometimes known as congestive heart failure, occurs when your heart muscle doesn't pump blood as well as it should. Certain conditions, such as narrowed arteries in your heart (coronary artery disease) or high blood pressure, gradually leave your heart too weak or stiff to fill and pump efficiently.

In heart failure, the main pumping chambers of your heart (the ventricles) may become stiff and not fill properly between beats. In some cases of heart failure, your heart muscle may become damaged and weakened, and the ventricles stretch (dilate) to the point that the heart can't pump blood efficiently throughout your body. Over time, the heart can no longer keep up with the normal demands placed on it to pump blood to the rest of your body.

An ejection fraction is an important measurement of how well your heart is pumping and is used to help classify heart failure and guide treatment. In a healthy heart, the ejection fraction is 50 percent or higher — meaning that more than half of the blood that fills the ventricle is pumped out with each beat. But heart failure can occur even with a normal ejection fraction. This happens if the heart muscle becomes stiff from conditions such as high blood pressure.

The term "congestive heart failure" comes from blood backing up into — or congesting — the liver, abdomen, lower extremities and lungs. However, not all heart failure is congestive. You might have shortness of breath or weakness due to heart failure and not have any fluid building up.

Heart failure can involve the left side (left ventricle), right side (right ventricle) or both sides of your heart. Generally, heart failure begins with the left side, specifically the left ventricle — your heart's main pumping chamber.

How did I get heart failure?

Heart failure can be caused by many medical conditions that damage the heart muscle, including the following:

  • Coronary artery disease

  • Heart attack or myocardial infarction

  • Cardiomyopathy

  • Heart defects present at birth (congenital heart disease)

  • Diabetes

  • High blood pressure

  • Arrhythmias

  • Kidney disease

  • Obesity

  • Tobacco or illicit drug use

  • Certain medications, such as those used to fight cancer (chemotherapy)

How is heart failure diagnosed?

In order to make a diagnosis, your doctor will look at your symptoms and review your medical history, as well as perform a physical examination and perform some diagnostic tests.  Symptoms that you may experience include the following:

  • Shortness of breath

  • Fatigue or weakness

  • Swelling in your legs, ankles or feet

  • Rapid or irregular heart beat

  • Reduced ability to exercise

  • Persistent cough or wheezing with white or pink blood tinged phlegm

  • Increased need to urinate at night

  • Swelling of your abdomen

  • Sudden weight gain from fluid retention

  • Lack of appetite and nausea

  • Difficulty concentrating or decreased alertness

  • Sudden, severe shortness of breath and coughing up pink foamy mucus

  • Chest pain

Testing will be performed to determine how bad your heart failure is and what the causes may be.  These may include the following:

  • Blood tests, such as cholesterol levels, hemoglobin to look for high cholesterol levels or anemia

  • NT-proB-type Natriuretic Peptide (BNP) blood test- BNP is a hormone released into the blood by the lower chambers of the heart in people with heart failure and the level changes based on the severity of the disease.

  • Cardiac catheterization: a long, thin tube called a catheter is inserted into an artery in your arm or leg. The doctor uses a special X-ray machine to guide the catheter to your heart. There are two types of cardiac catheterization — left and right. If you have a left heart catheterization, your doctor may inject dye to record videos of your heart valves, coronary arteries and heart chambers (atria and ventricles). A right heart catheterization does not use dye; it lets your doctor know how well your heart is pumping blood and checks your ejection fraction.

  • Chest x-ray- shows the size of your heart as well as will show presence of any fluid build up around your heart and lungs.

  • Echocardiogram-this is an ultrasound to see how well your heart can pump and relax, as well as can check the heart valves, measure your heart and check blood flow

  • Ejection fraction- is a measurement of the blood pumped out of your heart with each beat and can be checked either by echocardiogram, MUGA scan, nuclear stress test, MRI or cardiac catheterization

  • Electrocardiogram- this test records the electrical activity of the heart by using electrodes which are connected with wires to a monitor.

  • MUGA scan- the test shows your doctor how well the lower chambers of your heart (ventricles) are pumping blood.  A small amount of dye is injected into a vein and a special camera is used to create a video of your heart as it beats.

  • Stress test- this test shows how your heart reacts to stress, which is induced with either exercise or with a medication that will create the same effect on your heart.

What are my treatment options for heart failure?

Heart failure is a chronic disease that requires lifelong management. With treatment, signs and symptoms of heart failure can improve and the heart sometimes becomes stronger.  Treatment may help you live longer and reduce your chance of sudden death.  Treatment depends on the type of heart failure you have and in part, what may have caused it.  It includes the following singly or in combination, as well as in addition to other drugs your doctor may prescribe such as nitrates for chest pain, statins to lower cholesterol or blood thinners to reduce the risk of blood clots.

Medications are usually given in combination and may include the following:

  • ACE inhibitors- a type of vasodilator that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload of the heart.

  • ARBs- the same benefits as ACE inhibitors and may be an alternative for people who cannot tolerate them.

  • Beta Blockers-slows the heart rate, reduces blood pressure and may limit or reverse some damage to the heart.

  • Diuretics- often called “water pills” they make you urinate more frequently and keep fluid from collecting in your body.

  • Aldosterone antagonists- another form of diuretic that spares potassium and has additional properties that are known to help people with systolic heart failure live longer.

  • Inotropes- these are iv medications used in patients with severe heart failure to improve heart pumping function and maintain blood pressure.

  • Digoxin- this durg increases the strength of the heart muscle contractions and slows the heart rate, decreasing the workload of the heart.

Surgery or medical devices may be recommended by your physician if they feel that it will effectively treat the underlying problem that led to heart failure.

  • Coronary bypass surgery. If severely blocked arteries are contributing to your heart failure, your doctor may recommend coronary artery bypass surgery. In this procedure, blood vessels from your leg, arm or chest bypass a blocked artery in your heart to allow blood to flow through your heart more freely.

  • Heart valve repair or replacement. If a faulty heart valve causes your heart failure, your doctor may recommend repairing or replacing the valve. The surgeon can modify the original valve (valvuloplasty) to eliminate backward blood flow. Surgeons can also repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly. Sometimes repairing the valve includes tightening or replacing the ring around the valve (annuloplasty).

  • Valve replacement is done when valve repair isn't possible. In valve replacement surgery, the damaged valve is replaced by an artificial (prosthetic) valve.

Certain types of heart valve repair or replacement can now be done without open heart surgery, using either minimally invasive surgery or cardiac catheterization techniques.

  • Implantable cardioverter-defibrillators (ICDs). An ICD is a device similar to a pacemaker. It's implanted under the skin in your chest with wires leading through your veins and into your heart. The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm. An ICD can also function as a pacemaker and speed your heart up if it is going too slow

  • Cardiac resynchronization therapy (CRT), or biventricular pacing. A biventricular pacemaker sends timed electrical impulses to both of the heart's lower chambers (the left and right ventricles) so that they pump in a more efficient, coordinated manner. Many people with heart failure have problems with their heart's electrical system that cause their already-weak heart muscle to beat in an uncoordinated fashion. This inefficient muscle contraction may cause heart failure to worsen. Often a biventricular pacemaker is combined with an ICD for people with heart failure.

  • Heart pumps. These mechanical devices, such as ventricular assist devices (VADs), are implanted into the abdomen or chest and attached to a weakened heart to help it pump blood to the rest of your body. VADs are most often used in the heart's left ventricle, but they can also be used in the right ventricle or in both ventricles. Doctors first used heart pumps to help keep heart transplant candidates alive while they waited for a donor heart. VADs are now sometimes used as an alternative to transplantation. Implanted heart pumps can significantly extend and improve the lives of some people with severe heart failure who aren't eligible for or able to undergo heart transplantation or are waiting for a new heart.

  • Heart transplant. Some people have such severe heart failure that surgery or medications don't help. They may need to have their diseased heart replaced with a healthy donor heart. Heart transplants can dramatically improve the survival and quality of life of some people with severe heart failure. However, candidates for transplantation often have to wait a long time before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment or device therapy and can be removed from the transplant waiting list.

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