Heart Failure

Heart failure, often referred to as congestive heart failure, is a condition where the heart muscle doesn't pump blood to the rest of the body as well as it should. Blood often moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart can't pump enough oxygen-rich blood and nutrients to meet the body's needs.

Heart failure can develop because of medical conditions that either damage your heart or make it harder for it to work properly, such as coronary artery disease, high blood pressure, faulty heart valves, an irregular heartbeat, damage to the heart muscle (cardiomyopathy), inflammation, and congenital heart disease. Lifestyle factors, such as obesity, a high-fat diet, and a sedentary lifestyle, can also increase the risk of developing heart failure.

Symptoms of heart failure include shortness of breath, fatigue, swollen legs, and rapid heartbeat. The treatment typically involves a combination of medications, lifestyle changes, and possibly surgery to manage the symptoms and prevent the condition from worsening.

There are 4 main types of heart failure, including:

• Left-sided heart failure: This type of heart failure affects your lower left heart chamber, which is called the left ventricle. In this type fluid may back up in your lungs, causing shortness of breath.

• Right-sided heart failure: This type of heart failure affects your lower right heart chamber, which is called the right ventricle. In this type, fluid may back up into your stomach, legs, and feet, and cause swelling.

• Heart failure with reduced ejection fraction (HFrEF): This type is also known as systolic heart failure. It is a type of left-sided heart failure and occurs because your left ventricle cannot squeeze as strongly as it should so your heart cannot pump enough blood to your body.
• Heart failure with preserved ejection fraction (HFpEF): This type is also known as diastolic heart failure. It is also a type of left-sided heart failure and occurs because your left ventricle cannot relax or fill fully which means your heart has a problem filling with blood.

Heart failure is caused by heart conditions that damage the heart muscle or increase your heart's workload. Some of the common causes and risk factors for heart failure include:

• Coronary Artery Disease (CAD): This is the most common cause of heart failure. The arteries that supply blood to your heart become narrowed due to plaque buildup, reducing blood flow and leading to heart damage.
• High Blood Pressure (Hypertension): When blood pressure is high, your heart has to work harder to circulate blood throughout the body, which can weaken the heart over time and lead to heart failure.

• Heart Attack (Myocardial Infarction): A heart attack occurs when a coronary artery is blocked suddenly, which stops the flow of blood to a part of the heart muscle. This can damage your heart muscle and affect its ability to pump blood properly.

• Cardiomyopathy: This term refers to diseases of the heart muscle. Some forms of cardiomyopathy are genetic, while others happen because of infection, alcohol abuse, or because of drugs such as chemotherapy or antidepressants.
• Faulty Heart Valves: When heart valves don't open or close properly, your heart must work harder to pump blood. This can be caused by infections, congenital heart defects, or other diseases.
• Arrhythmias: Abnormal heart rhythms can cause your heart to beat too fast, causing it to work harder. Over time, this can lead to heart failure.
• Infections: A previous infection, such as myocarditis, rheumatic fever, or endocarditis can lead to heart failure.
• Chronic Diseases: Conditions such as diabetes, severe anemia, hyperthyroidism, hypothyroidism, pulmonary hypertension (high pressure in the lungs), emphysema, or lupus can cause or worsen heart failure.
• Lifestyle Factors: Obesity, a diet high in fats and cholesterol, and not exercising regularly can increase your risk of developing conditions that lead to heart failure.

The symptoms of heart failure will vary depending on the type of heart failure (systolic or diastolic), the severity of the condition, and which side of the heart is affected. Symptoms can develop quickly (acute heart failure) or gradually over weeks or months (chronic heart failure). Common symptoms of heart failure include:

• Shortness of Breath (Dyspnea): You may experience trouble breathing during activity or while resting, especially when lying flat in bed. Shortness of breath can also occur at night, waking you up from sleep.
• Persistent Cough or Wheezing: A cough that produces white or pink blood-tinged mucus can be a symptom of heart failure.
• Edema (Swelling): Swelling in your feet, ankles, legs, or stomach is common because the heart is not pumping effectively, leading to fluid buildup.
• Tiredness, Fatigue: Feeling tired all the time and having difficulty with everyday activities, such as shopping, climbing stairs, carrying groceries, or walking, can be a sign of heart failure.
• Lack of Appetite, Nausea: A feeling of being full or sick to your stomach can occur when fluid builds up around your liver and intestines.
• Impaired Thinking or Confusion: Reduced blood flow to your brain can cause confusion or impaired thinking.
• Increased Heart Rate: The heart may try to compensate for its lack of pumping capacity by beating faster.
• Weight Gain or Loss: Rapid weight gain may be a sign of fluid build-up. Reduced blood flow to your stomach can make it harder for you to absorb nutrients from your food, which can lead to weight loss.

Diagnosing heart failure typically involves a combination of medical history, physical examination, and specific tests, including:

• Medical History and Physical Exam:

  • Medical History: Your doctor will ask about symptoms, family history of heart disease, and personal risk factors such as high blood pressure, coronary artery disease, diabetes, and lifestyle habits.

  • Physical Exam: Your doctor will look for signs of heart failure, such as fluid buildup (edema), abnormal heart sounds, and signs of other conditions.

• Blood Tests:

  • Tests may be done to check levels of certain substances in your blood, such as natriuretic peptides (BNP and NT-proBNP) which are released by the heart and increase in heart failure. Blood tests can also check kidney, liver, and thyroid function, which can be affected by heart failure.

• Chest X-ray:

  • This procedure can show the size of your heart and whether there is fluid build-up around the heart and lungs, which are indicators of heart failure.

• Electrocardiogram (ECG or EKG):

  • This test records the electrical activity of your heart and can show abnormal rhythms, which can be signs of heart damage.

• Echocardiogram:

  • This is a key diagnostic tool for heart failure. An echocardiogram uses ultrasound waves to produce a detailed image of your heart's structure and function. It can measure your heart's pumping action (ejection fraction) and see any abnormalities in the heart muscle and valves.

• Stress Test:

  • This test involves exercising on a treadmill or stationary bike while your heart’s activity is monitored. It helps determine how well your heart handles physical activity.

• Cardiac MRI or CT Scan:

  • These imaging tests provide detailed images of your heart and can be used to see how well your heart is working.

• Cardiac Catheterization:

  • In this procedure, a catheter is inserted into a heart blood vessel to measure pressure within the heart and look for blockages in the coronary arteries.

The combination of these tests allows your healthcare provider to confirm the diagnosis of heart failure, identify any underlying cause, and determine the severity, which is important to determine the appropriate treatment.

Treating heart failure involves a combination of lifestyle changes, medications, and sometimes procedures or surgeries. The goal of treatment is to manage symptoms, slow disease progression, and improve your quality of life. Some common treatment options include:

• Diet and Nutrition: You may be advised to follow a low-salt diet to help reduce fluid retention. Managing fluid intake might also be necessary.

• Exercise: Regular physical activity is encouraged to improve heart health, as tolerated, and should be discussed with a healthcare provider.

• Weight Management: Reaching and maintaining a healthy weight can reduce the burden on your heart.
• Smoking Cessation and Limiting Alcohol Intake: Smoking and excessive alcohol use can worsen heart failure, so quitting smoking and limiting alcohol are important.

Several types of medications are used to treat heart failure, including:

• ACE Inhibitors and ARBs: These medications help relax blood vessels and reduce blood pressure to help improve blood flow.
• Angiotensin receptor-neprilysin inhibitor (ARNI): Entresto (sacubitril/valsartan) uses two blood pressure medications to treat heart failure. It helps get rid of extra fluid in your body and it also relaxes your blood vessels to improve blood flow.
• Beta-Blockers: Beta-blockers reduce your heart rate and blood pressure which will decrease the heart's workload. They also help keep your heart rhythm regular.
• Diuretics: These are used to reduce the amount of fluid in your body to ease symptoms like swelling and breathing difficulty.
• Aldosterone Blockers: These medications block the effects of the hormone aldosterone, encouraging your body to release sodium and water. They also help prevent scarring in your heart.
• Digoxin: It increases the force of your heart's contractions, helping it pump more effectively.
• SGLT2 Inhibitors: Originally used for diabetes, these have been found beneficial in reducing the risk of worsening heart failure and hospitalization.
• Vasodilators: These open your blood vessels so your heart does not have to work as hard to pump blood.

Depending on the severity and type of heart failure, your healthcare provider may recommend one of the following:

• Implantable Cardioverter Defibrillators (ICDs): This device helps prevent sudden death from arrhythmias by detecting and correcting abnormal heart rhythms.
• Cardiac Resynchronization Therapy (CRT): A special pacemaker is implanted to make the ventricles contract at the same time. This helps the lower heart chambers pump and relax together.
• Ventricular Assist Devices (VADs): These help pump blood from the lower chambers of your heart to the rest of the body.
• Coronary Artery Bypass: This surgery reroutes the blood supply around a blocked section of the artery. The new pathway improves blood flow to your heart muscle.
• Heart Transplant: This is typically considered when your heart failure is life-threatening and other treatments have failed.

Regular follow-up appointments are important to monitor the progression of your disease, adjust treatments, and manage symptoms.

Treatment plans typically involve a team of healthcare professionals, including cardiologists, primary care providers, and possibly heart failure specialists.

Sources:

• What is Heart Failure? American Heart Association. Accessed Apr. 25, 2024.

• Heart failure. National Heart, Lung, and Blood Institute. Accessed Apr. 25, 2024.
• Heart failure (HF). Merck Manual Professional Version. Accessed Apr. 25, 2024.
• Heidenreich PA, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022; doi:10.1161/CIR.0000000000001063.