CHRONIC HEART FAILURE

BACKGROUD

Heart failure is a condition caused by the heart failing to pump enough blood around the body at the right pressure. It usually occurs because the heart muscle has become too weak or stiff to work properly. If you have heart failure, it does not mean your heart is about to stop working. It means your heart needs some support to do its job, usually in the form of medicines. Heart failure can be aggravated by conditions like high blood pressure and arterial blockages, which weaken the heart and inhibit it from functioning properly.  ​

DISEASE OCCURRENCE IN POPULATION

Heart failure (HF) is a major public health problem, with a prevalence of more than 5.8 million in the United States and more than 23 million worldwide.

In Pakistan around 14.75-22.87 % people are affected with this chronic cardiac illness.

RISK FACTORS:

HIGH BLOOD PRESSURE: Your heart works harder than it has to if your blood pressure is high.

CORONARY ARTERY DISEASE: Narrowed arteries may limit your heart's supply of oxygen-rich blood, resulting in weakened heart muscle.

HEART ATTACK: Damage to your heart muscle from a heart attack may mean your heart can no longer pump as well as it should.

DIABETES: Having diabetes increases your risk of high blood pressure and coronary artery disease.

CERTAIN MEDICATIONS: Some medications may lead to heart failure or heart problems. Medications that may increase the risk of heart problems include nonsteroidal anti-inflammatory drugs (NSAIDs); certain anesthesia medications; some antiarrhythmic medications; certain medications used to treat high blood pressure, cancer, blood conditions, neurological conditions, psychiatric conditions, lung conditions, urological conditions, inflammatory conditions and infections; and other prescription and over-the-counter medications.

Don't stop taking any medications on your own. If you have questions about medications you're taking, discuss with your doctor whether he or she recommends any changes.

SLEEP APNEA: The inability to breathe properly while you sleep at night results in low blood oxygen levels and increased risk of abnormal heart rhythms. Both of these problems can weaken the heart.

CONGENITAL HEART DEFECTS: Some people who develop heart failure were born with structural heart defects.

VALVULAR HEART DISEASE: People with valvular heart disease have a higher risk of heart failure.

VIRUSES: A viral infection may have damaged your heart muscle.

ALCOHOL USE: Drinking too much alcohol can weaken heart muscle and lead to heart failure.

TOBACCO USE: Using tobacco can increase your risk of heart failure.

OBESITY: People who are obese have a higher risk of developing heart failure.

IRREGULAR HEARTBEATS: These abnormal rhythms, especially if they are very frequent and fast, can weaken the heart muscle and cause heart failure.

SIGNS AND SYMPTOMS:

Symptoms which can be attributed to heart failure can have many other causes, only some of which are serious. Symptoms of heart failure may be misdiagnosed as another less serious condition.

Common symptoms may include:

• Shortness of breath (dyspnea) when you exert yourself or when you lie down
• Fatigue and weakness
• Swelling (edema) in your legs, ankles and feet
• Rapid or irregular heartbeat
• 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 (ascites)
• 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 if your heart failure is caused by a heart attack

DIAGNOSTIC TEST: To diagnose heart failure, your doctor will take a careful medical history, review your symptoms and perform a physical examination. Your doctor will also check for the presence of risk factors, such as high blood pressure, coronary artery disease or diabetes.

Using a stethoscope, your doctor can listen to your lungs for signs of congestion. The stethoscope also picks up abnormal heart sounds that may suggest heart failure. The doctor may examine the veins in your neck and check for fluid buildup in your abdomen and legs.

After the physical exam, your doctor may also order some of these tests:

BLOOD TESTS: This will be necessary to determine that keys organs like your liver and kidneys are working as they should. This will also help to look for any other heart related diseases that may be affecting your health.

CHEST X-RAY: X-ray images help your doctor see the condition of your lungs and heart. In heart failure, your heart may appear enlarged and fluid buildup may be visible in your lungs.

ELECTROCARDIOGRAM (ECG): This test records the electrical activity of your heart through electrodes attached to your skin. This test helps your doctor diagnose heart rhythm problems and damage to your heart from a heart attack that may be underlying heart failure.

ECHOCARDIOGRAM: This test helps to determine whether you have systolic heart failure (heart pumps the blood slower than usual) or a diastolic heart failure (heart fills with blood inadequately, at high pressure). Through an echocardiogram, your doctor can also see the shape and size of your heart and its performance.

STRESS TEST: During a stress test, you might be asked to run or walk on a treadmill while you have an ECG or other heart tests. Physical activity makes the heart pump harder and increases the heart's need for blood. This test helps doctors see if the heart is getting enough blood when it is under stress. If you cannot walk or run, you might instead get a medicine to stress your heart.

CARDIAC CT (COMPUTERIZED TOMOGRAPHY) AND MRI (MAGNETIC RESONANCE IMAGING) SCAN:  This is done to acquire images of your chest and heart to diagnose heart structural and functional abnormalities.

CORONARY ANGIOGRAM: This test identifies blockages in arteries which are critical in providing blood to the heart.

MYOCARDIAL BIOPSY: This test may be performed to diagnose certain types of heart muscle diseases that cause heart failure

TREATMENT OPTIONS: Heart failure is a chronic disease needing lifelong management. However, 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 dying suddenly.

MEDICATIONS: Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one or more medications, including:

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS: ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril lisinopril and captopril.

ANGIOTENSIN II RECEPTOR BLOCKERS: These drugs, which include losartan and valsartan, have many of the same benefits as ACE inhibitors. They may be an alternative for people who can't tolerate ACE inhibitors.

BETA-BLOCKER: A beta blocker slows the heart down and can lower blood pressure. It can help reduce the amount of work the heart has to do.

Some examples of beta blockers include carvedilol , metoprolol , and bisoprolol.

DIURETIC: When you have heart failure, your body holds onto extra fluid. A diuretic helps the body get rid of extra salt and fluid. It is sometimes called a "water pill." It can reduce heart failure symptoms or keep them from getting worse. For example, a diuretic can help pull fluid out of the lungs, which makes breathing easier. Some examples of diuretics include furosemide, torsemide and bumetanide.

MINERALOCORTICOID RECEPTOR ANTAGONIST: A mineralocorticoid receptor antagonist is a type of diuretic. It helps the body get rid of extra salt and fluid. But it also helps the body hold onto potassium. That's important because other diuretics sometimes make the body lose too much potassium, which the body needs to work normally. Some examples of mineralocorticoid receptor antagonists include spironolactone and eplerenone

NITRATE WITH HYDRALAZINE: A nitrate and hydralazine work together to relax and expand blood vessels. This makes it easier for the heart to pump blood throughout the body. This combination of medicines is sometimes used in people who cannot take an ACE inhibitor.

DIGOXIN: Digoxin helps the heart pump with more force. This can help reduce some of the symptoms of heart failure.

SURGERY AND MEDICAL DEVICES: In some cases, doctors recommend surgery to treat the underlying problem that led to heart failure. Some treatments being studied and used in certain people include:

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).

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.

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.

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.

PRECAUTIONS:

• Not to smoke. Also avoid secondhand smoke.
• Eat heart-healthy foods. Eat fruits, vegetables, fish, lean meats, and whole grains. Choose foods that are low in saturated fat and avoid trans-fat. Limit sodium, alcohol, and sugar.
• Get regular exercise. Try to do activities that raise your heart rate. Aim for at least 2½ hours of moderate exercise a week.
• Stay at a healthy weight. Lose weight if you need to.
  Manage other health problems that can raise your risk of heart disease and heart failure. These include high blood pressure, high cholesterol, and diabetes. You can use heart-healthy lifestyle changes along with medicines to manage these conditions.
• Consider getting vaccinations If you have heart failure, you may want to get influenza and pneumonia vaccinations. Ask your doctor about these vaccinations.

REFERENCES:

• Lloyd-Jones D, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. 2010;121:e46–e215.
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• Yamani M, Massie BM. Congestive heart failure: insights from epidemiology, implications for treatment. Mayo Clin Proc 68 (1993), pp. 1214-1218.
• Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:1810.
• McMurray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33:1787.
• Cohn JN, Ziesche S, Smith R, et al. Effect of the calcium antagonist felodipine as supplementary vasodilator therapy in patients with chronic heart failure treated with enalapril: VHeFT III. Vasodilator Heart Failure Trial (VHeFT) Study Group. Circulation 1997; 96:856.