Heart failure, also called congestive heart failure, is a condition in which the heart cannot pump enough oxygenated blood to meet the needs of the body's other organs. The heart keeps pumping, but not as efficiently as a healthy heart. Usually, the loss in the heart's pumping action is a symptom of an underlying heart problem. Heart failure affects nearly 5 million US adults. It is on the rise with an estimated 400,000 to 700,000 new cases each year.
Heart failure may result from any/all of the following:
- heart valve disease - caused by past rheumatic fever or other infections
- high blood pressure (hypertension)
- infections of the heart valves and/or heart muscle (i.e., endocarditis)
- previous heart attack(s) (myocardial infarction) - scar tissue from previous attacks may interfere with the heart muscle's ability to work normally
- coronary artery disease - narrowed arteries that supply blood to the heart muscle
- cardiomyopathy - or another primary disease of the heart muscle
- congenital heart disease/defects (present at birth)
- cardiac arrhythmias (irregular heartbeats)
- chronic lung disease and pulmonary embolism
- drug-induced heart failure
- excessive sodium intake
- hemorrhage and anemia
Heart failure interferes with the kidney's normal function of eliminating excess sodium and waste from the body. In congestive heart failure, the body retains more fluid - resulting in swelling of the ankles and legs. Fluid also collects in the lungs - resulting in shortness of breath.
The following are the most common symptoms of heart failure. However, each individual may experience symptoms differently. Symptoms may include:
- shortness of breath during rest, exercise, or lying flat
- weight gain
- visible swelling of the legs and ankles (due to a build-up of fluid), and, occasionally, the abdomen
- fatigue and weakness
- loss of appetite and nausea
- persistent cough - often produces mucus or blood-tinged sputum
- reduced urination
The severity of the condition and symptoms depends on how much of the heart's pumping capacity has been lost.
The symptoms of heart failure may resemble other conditions or medical problems. Always consult your physician for a diagnosis.
In addition to a complete medical history and physical examination, diagnostic procedures for heart failure may include any, or a combination of, the following:
- chest x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
- echocardiogram (Also called echo.) - a noninvasive test that uses sound waves to produce a study of 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.
- electrocardiogram (ECG or EKG) - a test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.
- BNP testing - B-type natriuretic peptide (BNP) is a hormone released from the ventricles in response to increased wall tension (stress) that occurs with heart failure. BNP levels rise as wall stress increases. BNP levels are useful in the rapid evaluation of heart failure. The higher the BNP levels, the worse the heart failure.
Specific treatment for heart failure will be determined by your physician based on:
- your age, overall health, and medical history
- extent of the disease
- your tolerance for specific medications, procedures, or therapies
- expectations for the course of the disease
- your opinion or preference
The cause of the heart failure will dictate the treatment protocol established. If the heart failure is caused by a valve disorder, then surgery is usually performed. If the heart failure is caused by a disease, such as anemia, then the disease is treated. And, although there is no cure for heart failure due to a damaged heart muscle, many forms of treatment have proven to be successful.
The goal of treatment is to improve a person's quality of life by making the appropriate lifestyle changes and implementing drug therapy.
Treatment of heart failure may include:
- controlling risk factors
- losing weight (if overweight)
- restricting salt and fat from the diet
- stop smoking
- abstaining from alcohol
- proper rest
- controlling blood sugar if diabetic
- limiting fluids
- medication, such as:
- angiotensin converting enzyme (ACE) inhibitors - to decrease the pressure inside the blood vessels, or angiotensin II receptor blockers if ACE inhibitors are not tolerated
- diuretics - to reduce the amount of fluid in the body
- vasodilators - to dilate the blood vessels and reduce workload on the heart
- digitalis - to increase heart strength and control rhythm problems
- inotropes - increase the pumping action of the heart
- antiarrhythmia medications - keep the rhythm regular and prevent sudden cardiac death
- beta-blockers - reduce the heart's tendency to beat faster by blocking specific receptors on the cells that make up the heart
- aldosterone blockers - block the effects of aldosterone which causes sodium and water retention
- biventricular pacing/cardiac resynchronization therapy - a new type of pacemaker that paces both sides of the heart simultaneously to coordinate contractions and improve pumping ability. Heart failure patients are potential 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
- heart transplantation
- ventricular assist devices (VADs)
A ventricular assist device (VAD) is a mechanical device that is used to take over the pumping function for one or both of the heart’s ventricles. A VAD may be necessary when heart failure progresses to the point that medications and other treatments are no longer effective.
For persons with severe or end-stage heart failure, ventricular assist devices (VADs) may be required to support the heart in order to ensure an adequate cardiac output (amount of blood pumped out by the heart per minute) to meet the body’s needs.
Heart transplantation is an option for some patients with severe heart failure (HF), but during this late stage of HF, over 50 percent of persons on a waiting list for heart transplantation will die before receiving a donor heart. Organ donors are in short supply and do not meet the demand for patients waiting for heart transplant. The wait time for heart transplantation may often exceed 200 days.
Long wait times and decreased availability of donors strengthens the need to seek other methods to support the failing heart. Patients may die waiting for a transplant or important organs such as the liver and kidney may become permanently damaged before a donor heart is available. VADs have shown great promise in maintaining adequate blood circulation in cases of severe HF.
VADs may be used for the following situations:
- bridge to transplant - implantation of a VAD to support the patient with end-stage HF who is waiting for heart transplantation.
- bridge to recovery - implantation of a VAD to support the patient with potentially reversible HF. Once the heart has recovered sufficiently, the VAD may be removed.
- destination therapy - implantation of a VAD to support the patient with end-stage HF who is not a candidate for heart transplantation. A portable VAD may be used in this situation so that the patient may be discharged from the hospital and return home.
Some VADs are designed to support the right heart alone (right ventricular assist device, or RVAD) or both ventricles (biventricular assist device, or BiVAD), but commonly the left ventricle (left ventricular support device, or LVAD) is the primary point of support.
VADs are most commonly implanted during an open heart surgical procedure.
All types of VADs have similar complications postoperatively and during prolonged therapy:
Infection is a serious complication that occurs frequently. Patients in general are vulnerable to postoperative infections such as intravenous (IV) line infections, pneumonia, and urinary tact infections. The patient receiving a VAD is at even greater risk due in part to the patient's weakened state. VAD-related infections may occur at the skin connections of the pump and tubing, in the heart (endocarditis), or in the blood stream (sepsis).
To avoid infections, all cannula (tubing) exit sites must be dressed daily using sterile technique, the exit cannulas must be secured to prevent tension and pulling on the skin, and the skin around all exit sites must be completely healed before extensive activity is allowed.
Bleeding is common in the immediate postoperative period due to cardiopulmonary (heart-lung) bypass time, anticoagulation (prevention of blood clotting with medication), and long surgical procedures. Additionally, liver dysfunction (which may be present preoperatively) and previous heart surgeries increase the patient's risk for bleeding. Blood transfusions may be required for major bleeding, but are avoided if possible.
- right ventricular failure
Right ventricular failure is a concern in patients who have high pressures in the lung circulation before implant. Medications can help support the right ventricle during the initial period of recovery until the pump begins to improve the cardiac output.
- thromboembolism (blood clot)
Thromboembolism (blood clot) may cause strokes. All VADs have a risk of clot formation because blood comes in contact with the surfaces of the pump and cannulas. Almost all VADs require some form of anticoagulation such as Coumadin to reduce the risk of stroke. These medications may put the patient at greater risk for bleeding, however, and should be closely monitored.
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