Heart Failure

What Is Heart Failure?

Heart failure is a condition where the heart is unable to efficiently pump enough blood that is required by the body to carry on it is normal functioning.

Alternate names

• Congestive Heart Failure (CHF)
• Congestive Cardiac Failure (CCF)

Is this condition a medical emergency?

While congestive heart failure develops over a while, it is a medical emergency when the symptoms suddenly worsen. It is advisable to seek immediate medical attention.

Types of this condition

Congestive heart failure may be categorized in several ways as follows:

• Based on the side of the heart that is involved -

1. Left-sided heart failure: The left side of the heart receives oxygen-rich blood. Failure of the left side of the heart causes blood to back up into the lungs and deprivation of oxygen-rich blood to the rest of the body.
2. Right-sided heart failure: The right side of the heart receives the de-oxygenated blood from the body and sends it to the lungs. Failure of the right side of the heart causes fluid to back up into the abdomen, legs, and feet.
3. Biventricular heart failure: Both sides of the heart are involved. Usually, the involvement of one side leads to the eventual involvement of both sides.

• Based on whether it is a filling defect or a pumping defect -

1. Systolic Heart Failure: The left ventricle is unable to contract sufficiently indicating a pumping defect.
2. Diastolic Failure: The left ventricle is unable to relax and fill properly, indicating a filling problem.

• Based on ejection fraction - which is the proportion of blood pumped out in a single contraction, with the normal ejection fraction being 50 -75%.

1. Heart Failure with reduced ejection fraction (HFrEF): When the proportion of blood pumped out is less than 40% (Also termed Systolic failure).
2. Heart failure with preserved ejection fraction (HFpEF): The ejection fraction is normal because even though the left ventricle contracts normally, it fails to relax completely and fill properly. (Also known as diastolic failure).

Causes

Congestive heart failure results when the muscle of the heart fails to either properly contract or relax to allow for either proper pumping or filling respectively, resulting in an insufficient supply of blood to meet the demands of the body. Conditions that cause the heart muscle to either become too stiff and hard or too weak and thin can result in heart failure. The various causes of congestive heart failure may include:

• Coronary Artery Disease (CAD)
• Heart Attack or Myocardial Infarction
• Heart Valve disease
• Diabetes
• High blood pressure
• Thyroid disease - Hyperthyroidism, Hypothyroidism
• HIV infection
• Cardiomyopathy (damaged heart muscle)
• Congenital heart defects (developmental defects of the heart )
• Abnormal heart rhythms or arrhythmias
• Hemochromatosis
• Amyloidosis
• Alcohol and recreational drugs like cocaine
• Pregnancy
• Severe anemia
• Kidney disease
• Sepsis
• Chronic Lung disease
• Allergic reactions
• Pulmonary Embolism
• Neuromuscular disease
• Bone disease
• Some cancers

Risk factors

The risk factors for congestive heart failure include:

• Coronary artery disease
• Diabetes and some diabetes medications ( rosiglitazone, pioglitazone)
• High blood pressure
• Heart rhythm disorders
• Obesity
• Prescription drugs used for a variety of medical conditions
• Sleep apnea
• Valvular heart disease
• Alcohol abuse
• Smoking and tobacco use

Triggering factors

Some of the factors that can trigger congestive heart failure are:

• Improper alteration of dosage of medications being given for heart disease.
• Uncontrolled hypertension
• Systemic illness or infections such as sepsis
• Extensive confinement to bed rest
• Intensive physical activity and fatigue
• Emotional stress
• Excessive intake of water and salt

Symptoms & signs

The symptoms and signs of congestive heart failure may include:

• Shortness of breath at rest or on physical exertion
• Swelling in the ankles, feet, or legs
• Tiredness and weakness
• Fast or irregular heart rate
• Persistent cough and wheezing with frothy or pink phlegm
• Increased frequency of urination at night
• Swelling of the abdomen
• Rapid weight gain
• Nausea
• Loss of appetite
• Enlargement of veins in the neck
• Exercise intolerance
• Blue extremities
• Chest pain
• Drowsiness

Investigations

The investigations that are done for congestive heart failure may include:

• Laboratory tests-
  • Complete blood picture
  • Serum electrolytes
  • Thyroid function tests
  • Liver function tests
  • Renal function tests
  • Serum Natriuretic peptide: B type Natriuretic peptide (BNP) or N-terminal proBNP
  • Genetic testing: For cardiomyopathy
• Arterial and venous blood gases
• Electrocardiography
• Chest X-ray
• Echocardiography-
  • 2D and Doppler: To determine the diastolic function
  • Transesophageal: For individuals who are very obese or on mechanical ventilation
• CT scan: To assess chamber size, cardiac function, wall motion, valve abnormalities, and pericardial disease
• MRI: To assess chamber size, cardiac function, wall motion, valve abnormalities, and pericardial disease
• Nuclear Imaging-
  • MUGA scan (Multi gated acquisition) for assessing left and right ventricle function, wall motion, and ejection fraction
  • Myocardial perfusion imaging.
• Catheterization and Angiography - To identify the presence of obstructed coronary vessels
• Cardiopulmonary Stress Testing

Diagnosis

A diagnosis of congestive heart failure is established based on medical history, clinical evaluation, and results of the investigations. Besides the Framingham system is used to establish the diagnosis of heart failure when 2 major criteria or 1 major criterion and 2 minor criteria are present. Minor criteria are acceptable only if no other condition is causing them. The criteria are:

• Major criteria
  • Enlarged heart on chest x-ray
  • Third heart sound
  • Acute pulmonary edema
  • Waking up from sleep gasping for breath
  • Crackles on lung auscultation
  • Jugular vein distension
  • Central venous pressure more than 16 cm H2O
  • Weight loss of more than 5 Kg in 5 days after starting treatment
  • Positive abdominojugular test
• Minor Criteria
  • Heart rate more than 120 beats per minute
  • Coughing at night
  • Difficulty breathing with physical activity
  • Pleural effusion
  • Liver enlargement
  • Ankle swelling
  • A decrease in the vital capacity

Course & stages

Staging of heart failure is done based as follows:

• According to the New York Heart Association guidelines -
  • Class I: No limitation of physical activity
  • Class II: Slight limitation of physical activity; comfortable at rest, but ordinary physical activity leads to fatigue, breathlessness, palpitation, and chest pain
  • Class III: Marked limitation of physical activity, comfortable at rest, but less than ordinary physical activity leads to fatigue, breathlessness, palpitation, and chest pain
  • Class IV: Unable to carry out any physical activity without discomfort, and symptoms are present even at rest
• According to the American College of Cardiology and American Heart Association -
  • Level A: At high risk of heart failure but without structural heart disease or symptoms and signs of heart failure
  • Level B: Structural heart disease present but no symptoms and signs of heart failure
  • Level C: Structural heart disease with present or past symptoms of fatigue, breathlessness, palpitations, and chest pain
  • Level D: Significant symptoms at rest despite maximum medical therapy

Treatment options

The management of congestive heart failure is primarily aimed at stabilizing the individual, establishing the diagnosis, causes, and precipitating factors, providing symptomatic relief, and treating the identified underlying cause.  Management may include medical, surgical, or a combination of both to reverse heart failure and prevent future complications. Treatment of the underlying causes usually reverses congestive heart failure and improves the quality of life.

A. Medical management

Medical management of congestive heart failure may include the following medications are:

• Diuretics: To manage the fluid levels in the body
• Angiotensin-Converting Enzyme (ACE) inhibitors: To widen the blood vessels and reduce the load on the left ventricle
• Angiotensin II receptor blockers: To widen the blood vessels and reduce the load on the left ventricle, useful in individuals who cannot tolerate ACE inhibitors
• Beta-Blockers: To slow heart rate, control blood pressure, improve heart function
• Inotropes: To improve heart muscle function, administered intravenously
• Digoxin: To slow the heart rate and increase the strength of the heart muscle contraction
• Antibiotics: If widespread sepsis or infection is present

B. Interventional including surgery and indications for surgery

Surgical intervention or interventional procedures may be required in some cases of congestive heart failure either for the management of heart failure itself or for the underlying cause. The following procedures may be done:

• Implantable cardioverter defibrillators (ICDs): Are placed under the skin to monitor the heart rate, and to deliver a small shock to get the heart back into a normal rhythm.
• Ventricular assist devices (VADs): It is a mechanical pump that helps to pump blood from the lower chambers of the heart. It may be used as an interim measure while waiting for a heart transplant.
• Cardiac Resynchronization Therapy (CRT) or Bi Ventricular Pacing: It is a kind of pacemaker that sends electrical signals to both lower chambers of the heart, to help in regulated contraction and efficient pumping of blood. They are usually used in combination with an ICD.
• Valve repair or replacement: Faulty Heart valves may need to be either repaired or replaced to improve the functioning of the heart. Most valve repairs or replacements are done via minimally invasive surgery.
• Coronary Bypass Surgery: May be required if the cause of heart failure is due to severely obstructed coronary arteries.
• Heart Transplant: Individuals with severe heart failure may require the replacement of the diseased heart with a healthy donor heart.

C. Role of diet/exercise/lifestyle changes/preventive measures

Individuals who have or who are undergoing treatment will need to adopt healthy lifestyle practices to recover and heal from heart failure. Some of these measures that also help in the prevention of congestive heart failure include:

• Cessation of smoking
• Eating a healthy diet that is low fat, and low sodium, with vegetables, fruits, lean proteins, and whole grains
• Maintaining an ideal body weight
• Regular exercise in moderation
• Moderation of alcohol and fluid consumption
• Decreasing and avoiding mental and emotional stress
• Getting enough rest
• Keeping high blood pressure and diabetes under control

Complications

The complications may include:

• Kidney disease and failure
• Liver disease and failure
• Heart rhythm abnormalities
• Heart valve disease and abnormalities

Prognosis

The prognosis depends on multiple factors, and in general, the 5-year survival rate for individuals who have been hospitalized for heart failure is about 50%. Heart failure impacts the quality of life as it affects both the physical and mental health of an individual. Individuals who have a low risk of death during hospitalization or immediate future complications are those with:

• Systolic blood pressure between 90 -115 mm Hg,
• Blood urea nitrogen levels less than 43 mg/dl,
• Respiratory rate less than 30 breaths per minute,
• Serum sodium levels over 135 mmol/L,
• No new ST-T wave changes on an ECG

When to contact the doctor or hospital/How to identify the emergency or complications?

It is advisable to seek medical advice on noticing the following symptoms:

• Chest pain
• Breathlessness and discomfort progressively increasing with lesser activity or at rest.
• Severe weakness or fainting
• Persistent cough with wheezing, and pink or frothy sputum
• Irregular heartbeat with shortness of breath, and chest pain

Indications for hospitalization if required

Hospitalization may be required depending on the severity of the condition, and would also be required for investigations, and interventional and surgical management.

Suggested clinical specialist/Departments to consult for this condition

It would be attended by the Emergency Department and the Department of Cardiology.