Heart Failure

With heart failure, not enough oxygen-rich blood leaves the heart with each beat. There are 2 types of heart failure. Both affect the ventricles’ ability to pump blood. You may have 1 or both types.

The heart muscle becomes weak and enlarged. It can’t pump enough oxygen-rich blood forward to the rest of the body when the ventricles contract. The measurement of how much blood your heart pushes out when it beats is called ejection fraction. In systolic heart failure, the ejection fraction is lower than normal. This can cause blood to back up into the lungs and cause shortness of breath and eventually ankle swelling (edema).  This is also called heart failure with reduced ejection fraction, or HFrEF.

The heart muscle becomes stiff. It doesn’t relax normally between contractions, which keeps the ventricles from filling with blood. Ejection fraction is often in the normal range. This can still lead to the backup of blood into the body and affect the organs such as the liver. This is also called heart failure with preserved ejection fraction or HFpEF.

When you have heart failure, you need to pay close attention to your body and how you feel, every single day. That way, if a problem occurs, you can get help before it becomes too severe. You'll need to watch for changes in your symptoms. As long as symptoms stay about the same from one day to the next, your heart failure is stable. But if symptoms start to get worse, it's time to take action.

Signs and symptoms of worsening heart failure include:

• Rapid weight gain
• Shortness of breath
• Swelling (edema)
• Fatigue

When the heart doesn't pump enough blood, hormones (body chemicals) are sent to increase the amount of work the heart does. Some hormones make the heart grow larger. Others tell the heart to pump faster. As a result, the heart may pump more blood at first, but it can't keep up with the ongoing demands. So, the heart muscle becomes even more weak. Over time, even less blood is pumped through the heart. This leads to problems throughout the body as organs began to feel the effects of a long-term lack of oxygen. Eventually, if untreated, this can cause problems with your lungs, liver, kidneys, and loss of elasticity in the skin, and skin changes in the lower legs. A weak heart itself can eventually cause a severe decline in health and possible death if left untreated.

Heart failure may result from:

• Heart valve disease caused by past rheumatic fever or other infections
• High blood pressure (hypertension)
• Active infections of the heart valves or heart muscle (for example, endocarditis or myocarditis)
• Previous heart attack(s) (myocardial infarction)
• Coronary artery disease
• Cardiomyopathy or another primary disease of the heart muscle
• Congenital heart disease or defects (present at birth)
• Cardiac arrhythmias (irregular heartbeats)
• Chronic lung disease and pulmonary embolism
• Certain medicines
• Excessive sodium (salt) intake
• Anemia and excessive blood loss
• Complications of diabetes
• Alcohol abuse
• Certain viral infections

These are the most common symptoms of heart failure:

• Shortness of breath during rest, exercise, or while lying flat
• Weight gain
• Visible swelling of the legs and ankles (due to a buildup of fluid), and, occasionally, swelling of the abdomen
• Fatigue and weakness
• Loss of appetite, nausea, and abdominal pain
• Persistent cough that can cause blood-tinged sputum

The severity of the condition and symptoms depends on how much of the heart's pumping capacity has been compromised.

The symptoms of heart failure may look like other conditions or medical problems. Always talk to your healthcare provider for a diagnosis.

Your doctor will do a complete medical history and physical exam. Other tests may include:

• Chest X-ray. This test uses electromagnetic energy beams to make images of internal tissues, bones, and organs onto film. This test shows the size and shape of your heart. Fluid in the lungs will also show up on X-ray.
• Echocardiogram (also called echo). This noninvasive test uses sound waves to evaluate the motion of the heart's chambers and valves. The echo sound waves create an image on the monitor as an ultrasound transducer is passed over the heart. This shows how well the heart pumps. It also shows the thickness of the heart walls, and if the heart is enlarged. It is one of the most useful tests because it shows a great deal of information about the heart's function and helps guide treatment decisions.
• Electrocardiogram (ECG). This test records the electrical activity of the heart, shows abnormal rhythms (arrhythmias), and can sometimes detect heart muscle damage.
• BNP testing. B-type natriuretic peptide (BNP) is a hormone released from the ventricles that occurs with heart failure. BNP levels are useful in the rapid evaluation of heart failure. In general, the higher the BNP levels, the worse the heart failure. BNP is measured from a blood sample.

The cause of the heart failure will guide the treatment plan. If the heart failure is caused by a valve disorder, then surgery may be done to fix the valve. If the heart failure is caused by a disease, such as anemia, then the underlying disease will be treated. Although there is no cure for heart failure due to damaged heart muscle, many forms of treatment have been used to treat symptoms very effectively.

Treatment of heart failure may include the following.

Controlling risk factors

These include:

• Quitting smoking
• Losing weight (if overweight) and increasing moderate exercise
• Restrict salt and fat from the diet
• Avoiding alcohol
• Proper rest
• Controlling blood sugar if diabetic
• Controlling blood pressure
• Limiting fluids

Medicine

Medicines include:

• Angiotensin converting enzyme (ACE) inhibitors. This medicine decreases the pressure inside the blood vessels and reduces the resistance against which the heart pumps. These also help remodel the heart, which can promote better pumping ability.
• Angiotensin receptor blockers (ARB). This is an alternative medicine to reduce workload on the heart if you can't tolerate ACE inhibitors. Some people develop a cough and need to discontinue ACE inhibitors. It helps to relax blood vessels, reduce stress on the heart, and helps your body get rid of salt and fluid.
• Angiotensin receptor-neprilysin inhibitors (ARNIs). This new medicine combines an ARB and a neprilysin inhibitor. It helps relax blood vessels, reduce stress on the heart, and helps your body get rid of salt and fluid.
• Sinus node I-f channel blocker. This is a newer medicine that may be used to reduce heart rate, which puts less stress on the heart.
• Diuretics. These reduce the amount of fluid in the body and are among the most important medicines in helping control fluid buildup in the body.
• Vasodilators. These widen (dilate) the blood vessels and reduce workload on the heart.
• Digitalis. This medicine helps the heart beat stronger with a more regular rhythm.
• Antiarrhythmics. These medicines help maintain normal heart rhythm and help prevent sudden cardiac death.
• Beta-blockers. These reduce the heart's tendency to beat faster and reduce workload by blocking specific receptors on heart cells. They can also promote better pumping over time.
• Aldosterone blockers. This medicine blocks the effects of the hormone aldosterone which causes sodium and water retention.
• Statins. These medicines lower the amount of bad cholesterol in your blood. While not used to treat heart failure, your doctor may prescribe a statin if you have high cholesterol or have had a past heart attack and are at risk for heart failure.

Other treatments

• Biventricular pacing/cardiac resynchronization therapy. A type of pacemaker that paces both pumping chambers of the heart at the same time to coordinate contractions and to improve the heart's function. Some people with heart failure are candidates for this therapy.
• Implantable cardioverter defibrillator. A device similar to a pacemaker that senses when the heart is beating too fast and delivers an electrical shock to convert the fast rhythm to a normal rhythm. This can be a life saving device.
• Heart transplant. This is replacing the diseased heart with a healthy one from a donor.
• Ventricular assist devices (VADs). These are mechanical devices used to take over the pumping function for one or both of the heart's ventricles, or pumping chambers. A VAD may be needed when heart failure progresses to the point that medicines and other treatments no longer help.

Heart failure is a chronic health problem. It’s a gradual weakening of the heart. It’s when your heart can no longer pump the amount of blood your body needs to work properly. Heart failure can affect the right, left, or both ventricles of your heart.

If the right ventricle of your heart is failing, your heart may have trouble filling up with enough blood. If the left ventricle is weak, your heart may not empty completely when it pushes blood out to the rest of your body. In either case, a ventricular assist device (VAD) can support one or both of your ventricles. It can help your heart pump blood throughout your body.

Heart failure happens over time. In its early stages, your heart may be weaker. But it may not be weak enough to cause any symptoms. As the condition worsens, or advances, though, you may start to suffer from tiredness (fatigue) and shortness of breath. These symptoms may occur only while exercising or doing activities such as climbing stairs.

Lifestyle changes and medicine can often help ease the symptoms of heart failure. You may feel better for a time. But your heart will continue to weaken. Eventually you may develop advanced heart failure. That’s when you have symptoms even at rest. Treatments such as medicine may also no longer work.

In advanced heart failure, daily activities like dressing may become hard to do. You may feel extreme fatigue. You may also have swelling in your legs, ankles, feet, and belly (abdomen). Swelling happens because fluid builds up in your body.

Other symptoms of advanced heart failure include:

• Trouble breathing while sleeping
• Chest congestion
• Weight gain from fluid buildup
• Weight loss from a lack of appetite
• Chest pain
• Lightheadedness
• Heart palpitations or flutters
• Abnormal heart rhythms (arrhythmias)
• Depression

Advanced heart failure can be cured only with a heart transplant. But you may have to wait some time for a donor heart. Or you may not be able to have a heart transplant because of your age or other health problems, such as kidney disease. In these cases, a VAD can help you feel better and be more active. It may extend your life.

A VAD can ease your symptoms while you are waiting for a transplant. This is called a bridge to transplantation. If you can’t have a transplant, you may use a VAD as long-term treatment for your heart failure. This is called destination therapy.

Before you can have a VAD implanted, your healthcare provider will talk with you about the benefits and risks. He or she will have to determine whether a VAD is right for you. You will need some tests to check on your heart and overall health. You also need to be healthy enough to have the surgery.

Living with a VAD can be challenging. It requires a lot of follow-up care. You will need periodic checkups and tests. You will also have to make some lifestyle changes. A care team will help you make the transition to living with a VAD.