Heart failure

Overview

Heart failure, also known as congestive heart failure, occurs when an individual’s heart loses its capacity to pump blood sufficiently. As a result, the blood is retained in the heart chambers, which leads to unwanted fluid buildup in the lungs. Hence, the patient might experience shortness of breath.

While heart failure is a sudden manifestation in the body, the symptoms appear early. This is because congestive heart failure happens due to other problems that might lead to narrowed arteries, high blood pressure, or weak heart muscles. The heart cannot pump blood sufficiently in all of the above-mentioned issues.

Due to a lack of proper blood flow, other organ functions are impacted significantly. In simple terms, the heart muscles become stiff, reducing the blood flow to other organs. This phenomenon can occur in the left or right side of the heart, and the condition could be acute or chronic.

Even though the condition can be improved with proper treatment and timely intervention, it is essential to observe the symptoms to live a healthy and longer life. Additionally, there is a need to bring lifestyle changes that include weight loss, a nutritious diet, regular exercise, and reduced sodium content in food.

The primary approach to prevent heart failure is to work on the root cause and eliminate the conditions that lead to congestion in the heart. Ultimately, this approach includes better managing pre-existing conditions like high blood pressure, diabetes, and obesity.

Symptoms:

If you have heart failure, your heart cannot pump enough blood to meet your body's needs.
Symptoms may develop gradually. Sometimes, heart failure symptoms appear unexpectedly. Heart failure symptoms might include:
 

• Shortness of breath during exercise or while lying down.

• Fatigue and weakness.

• Swelling in the legs, ankles, and feet.

• A fast or irregular heartbeat.

• Reduced exercise capacity.

• Wheezing.

• A persistent cough that produces white or pink mucus with blood spots.

• Swelling of the abdomen.

• Fluid buildup leads to rapid weight gain.

• Nausea and a loss of appetite.

• Concentration problems or a decrease in alertness.

• Chest pain if a heart attack causes heart failure.

Causes:

Heart failure is when the heart cannot pump enough blood to meet the body's needs. There are many possible causes of heart failure, such as:

- Coronary artery disease (CAD), which is the narrowing or blockage of the arteries that supply blood to the heart muscle.
- Heart attack, which is the sudden interruption of blood flow to the heart muscle, causing permanent damage.
- Cardiomyopathy, which is the weakening or stiffening of the heart muscle due to infection, alcohol or drug abuse, or other factors.
- High blood pressure, which makes the heart work harder and can damage the heart over time.
- Heart valve problems, which can affect the flow of blood through the heart chambers.
- Congenital heart defects, which are heart problems that are present at birth.
- Diabetes, kidney disease, thyroid disease, and other conditions that can affect heart function or increase the risk of heart failure.

Heart failure can be classified by the side of the affected heart (left or right) or by the type of dysfunction (systolic or diastolic). Heart failure can also be acute or chronic, depending on how quickly the symptoms develop and how long they last. Heart failure is a serious condition that requires medical attention and treatment. Some treatments may include medications, lifestyle changes, surgery, or devices to help the heart pump better.

Risk factors:

Some of the risk factors of heart failure are:

- Smoking
- Being obese or overweight
- Alcohol or drug abuse
- Certain types of radiation and chemotherapy
- Coronary artery disease (CAD), which is the narrowing or blockage of the arteries that supply blood to the heart muscle
- Heart attack, which is the sudden interruption of blood flow to the heart muscle, causing permanent damage
- Cardiomyopathy, which is the weakening or stiffening of the heart muscle due to infection, alcohol or drug abuse, or other factors
- High blood pressure, which makes the heart work harder and can damage the heart over time
- Heart valve problems, which can affect the flow of blood through the heart chambers
- Congenital heart defects, which are heart problems that are present at birth
- Diabetes, kidney disease, thyroid disease, and other conditions that can affect heart function or increase the risk of heart failure
- Ethnicity – Common among African Americans

You can reduce your risk of heart failure by adopting a healthy lifestyle, such as quitting smoking, losing weight, exercising regularly, eating a balanced diet, limiting alcohol and salt intake, managing stress, and controlling your blood pressure and blood sugar levels. You should also see your doctor regularly and follow their advice on treating underlying conditions that may cause or worsen heart failure.

Complications: 

Below are some of the risk factors of heart failure that might aggravate the condition:

• Chronic hypertension or diabetes in patients 

• Sleep apnea might increase the risk of arrhythmias

• Pre-existing valve disease, which might further weaken the heart valves and surrounding muscles 

• Hyperthyroidism or hypothyroidism directly affects the heart rate and leads to shortness of breath in patients 

• Anaemia is another significant risk factor that might intensify heart failure symptoms 

• Coronary artery disease is a significant risk factor contributing to heart failures 

• Certain behavioural traits or lifestyle habits like smoking, alcohol consumption, overeating, and lethargy can also increase the risk of heart failure

In addition to worsening the symptoms, untreated heart failure can further lead to congestion and death of the patient. It might lead to severe fluid buildup in the liver and lungs, potentially life-threatening.
Furthermore, the complications also include kidney dysfunction, thromboembolism, stroke, and atrial fibrillation.

Prevention:

A heart-healthy lifestyle can lower your risk of developing heart failure:

• Treat known heart conditions like high blood pressure (hypertension)

• Stop smoking

• Avoid using illicit drugs, which can harm your heart muscle

• Avoid excessive alcohol consumption

• To maintain good health, exercise regularly and consume omega-3 fatty acid-rich, low-sodium foods

• Maintain a healthy weight—obesity puts a strain on your heart's ability to pump effectively

• Some cases of congestive heart failure may not be avoidable. For example, suppose your heart failure is caused by heart valve disease as a result of natural ageing processes.

When to Consult a Doctor?

Several symptoms associated with heart failure begin when the problem is at an early stage. However, many people might also suffer from sudden or acute heart failure. Hence, when an individual notices unexplained symptoms related to heart problems, the correct time to consult a doctor is.

The common symptoms include shortness of breath, rapid or irregular heartbeat, bloating, sudden weight gain, constant fatigue, difficulty in concentrating, persistent pain or heaviness in the chest, and inability to exercise.

However, below are some significant signs that must motivate a person to consult with a cardiologist

• Chest pain: Chest pain could be minor or severe depending on the hardness and stiffening of the heart muscles. An individual must see a doctor immediately if he/she has no congenital heart defect or a history of heart problems. In addition, chest pain could be a warning sign for any individual if he/she has been diagnosed with high blood pressure or cholesterol.

• Severe weakness: The heart's inability to pump blood adequately impacts the blood flow in several organs. This collectively weakens the body system, and an individual can often feel dizzy. Thus, if a person has unexplained weakness or fatigue even after consuming a healthy diet, it might be a sign to see a doctor immediately.

• Irregular heartbeat: Several people experience irregularities in their heartbeat or arrhythmia. However, it is not long-lasting unless he/she has a significant heart problem. Hence, if an arrhythmia is persistent without any previous heart condition, an individual must take the necessary tests to diagnose the condition.

• Other abnormalities in the blood test:  When a blood test shows high levels of bad cholesterol and triglycerides, it is essential to visit the doctor. Another prominent symptom could include coughing alongside shortness of breath. The sputum during coughing could consist of white or pink foamy mucus.

Diagnosis:

The doctor needs to look at the patient’s medical history to find out the early signs of heart failure. Below are some of the diagnostic methods used by an expert to diagnose the condition:

• Physical examination

This is an essential diagnostic procedure that looks after the physical signs of heart failure in other body parts. This involves observing swelling in the foot and ankle, keeping track of high blood pressure, and looking at an individual's BMI. In addition, the doctor might also listen to the activity in the lungs, which might indicate fluid buildup and heart murmur. In some cases, the doctor might also look at the veins in the neck, and check for fluid buildup in the abdomen or legs.

• Echocardiogram

An ECG is one of the most effective and standard methods to identify heart problems. The sound waves and rhythm of the heart are captured in this method to look for irregularities. This test helps in evaluating the damage to a heart. An ECG also helps determine the underlying causes based on the squeezing and relaxing function of the heart.

• MRI

Magnetic resonance imaging is an appropriate technique to produce images of the heart without radiation. Similarly, a nuclear scan uses radioactive material to make a clear image of the heart chambers during the scan.

• Blood test

The blood test detects the rise in B-type natriuretic peptide. An increase in this hormone indicates heart failure and requires an immediate action plan from experts.

• Coronary angiogram

This type of test in which the doctor inserts a catheter into the blood vessels through the arms or groin. The catheter is guided toward the heart and assesses the amount of blood flowing through the heart. This determines the blood volume and detects inefficiencies in the heart.

Treatment:

Heart conditions that lead to heart failure are chronic and require lifelong treatment to prevent congestion in the heart. However, timely treatment can improve the quality of life significantly.

Below are some treatment options to prevent heart failure:

Medications

There are different classes of drugs used to treat heart failure, depending on the type and severity of the condition. Some of the common classes and examples are:

- Angiotensin-converting enzyme (ACE) inhibitors: These drugs lower blood pressure and reduce the workload of the heart by widening blood vessels. They also prevent the progression of heart failure and reduce the risk of death. Examples include captopril, enalapril, lisinopril, and ramipril.

- Angiotensin II receptor blockers (ARBs): These drugs have similar effects as ACE inhibitors, but they block the action of angiotensin II, a hormone that narrows blood vessels and increases blood pressure. They are used as an alternative for patients who cannot tolerate ACE inhibitors. Examples include candesartan, losartan, and valsartan.

- Angiotensin receptor/neprilysin inhibitors (ARNIs): These drugs are a combination of an ARB and a neprilysin inhibitor, which prevents the breakdown of natriuretic peptides. These natural substances help lower blood pressure and reduce fluid retention. They are used instead of ACE inhibitors or ARBs for patients with reduced ejection fraction, as they have been shown to improve survival and reduce hospitalizations. The only approved ARNI is sacubitril/valsartan.

- Beta-blockers: These drugs lower heart rate and blood pressure, and reduce the stress on the heart. They also prevent the harmful effects of adrenaline and other hormones that can worsen heart failure. They are used in combination with ACE inhibitors, ARBs, or ARNIs for patients with reduced ejection fraction. Examples include carvedilol, metoprolol, and bisoprolol.

- Diuretics: These drugs help the body get rid of excess fluid and salt, which can cause swelling, shortness of breath, and weight gain in heart failure patients. They also lower blood pressure and reduce the workload of the heart. They are used for symptom relief and to prevent fluid overload. Examples include furosemide, bumetanide, and spironolactone.

- Aldosterone antagonists: These drugs are a type of diuretic that block the action of aldosterone, a hormone that causes salt and water retention and damages the heart and blood vessels. They are used in addition to ACE inhibitors, ARBs, or ARNIs and beta-blockers for patients with reduced ejection fraction, as they have been shown to improve survival and reduce hospitalizations. Examples include spironolactone and eplerenone.

- Sodium-glucose cotransporter-2 inhibitors (SGLT2): These drugs lower blood sugar levels by preventing the kidneys from reabsorbing glucose and increasing its excretion in the urine. They also benefit the heart and kidneys by lowering blood pressure, reducing fluid retention, and preventing kidney damage. They are used in addition to standard care for patients with reduced ejection fraction, with or without diabetes, as they have been shown to reduce mortality and hospitalizations. Examples include dapagliflozin and empagliflozin.

- Sinus node inhibitors: These drugs lower heart rate by acting on the sinus node, the heart's natural pacemaker. They are used for patients with reduced ejection fraction who have a high resting heart rate despite optimal doses of beta-blockers, as they have been shown to improve survival and reduce hospitalizations. The only approved sinus node inhibitor is ivabradine.

- Digoxin: This drug increases the strength and efficiency of heart contractions and lowers heart rate. It is used for symptom relief and to prevent hospitalizations for patients with reduced ejection fraction, especially those who have atrial fibrillation, a type of irregular heartbeat. It does not improve survival and may have serious side effects, such as irregular heartbeat, nausea, and vision problems.

These are some of the main classes of drugs used to treat heart failure, but there may be others depending on the individual patient's condition and response to therapy. It is important to follow the doctor's instructions and take the medications as prescribed, as they can help improve heart failure patients' quality and length of life.

Surgical Procedure

• Coronary bypass surgery

This procedure is used for people suffering from severe blockage in arteries. In this surgery, a healthy blood vessel is taken from the leg, arm, or chest and grafted below or above the blocked arteries. This improves the blood flow of the heart.

• Heart valve repair or replacement

If the heart muscles are damaged, causing irregularities in the contraction and relaxation, there is a requirement for heart valve repair or replacement. This involves repairing the valve flaps for better movement and tightening the supporting muscles.

• Cardiac resynchronisation therapy

As the name suggests, it involves biventricular pacing so that both chambers function in sync with each other. A biventricular pacemaker sends electrical signals regularly to ensure the contractions are coordinated.

• Heart transplant

This is performed in severe cases when surgical procedures and medications are no more effective. It requires a large team of highly experienced doctors to complete the procedure successfully.

Palliative Care

Palliative care is a specialised medical care that alleviates the symptoms and enhances the quality of life in terminally ill patients. The sole aim of this therapy is to reduce the pain and side effects of the condition.

Additional Information

Heart failure is divided into multiple classes and stages. Below is a brief explanation of the classification of heart failure. 
Different classes of heart failure are mentioned below:

• Class I: No visible symptoms of heart failure

• Class II: The individual can complete day-to-day activities typically, but exertion causes shortness of breath

• Class III: Difficulty in completing regular tasks and activities 

• Class IV: Shortness of breath even when the individual rests or makes a minor movement. This is one of the most severe forms of heart failure.

Below are the different stages of heart failure in an individual:

• Stage A: Individual has multiple risk factors, but there are no early signs of heart failure

• Stage B: No signs of heart failure despite having heart disease 

• Stage C: A major or minor heart disease accompanied by heart failure symptoms 

• Stage D: Advanced symptoms of heart failure which demand immediate treatment