Heart failure defined
		Heart failure - diagnosis and treatment

1. Heart failure affects 5 million Americans, with 550,000 new cases diagnosed each year.



2. When the heart loses efficiency in pumping oxygen-rich blood, the muscles simply don’t have enough "fuel" and patients find it harder to do their usual daily activities.



3. Symptoms may vary from patient to patient, but people with heart failure may commonly experience fatigue, weakness, shortness of breath, swelling, or coughing.



4. Heart failure can be mild, with little effect on one’s daily activities. Or it can be severe, making even the simplest tasks difficult.

Heart failure is an alarming term, conjuring up images of a heart that simply stops working. In reality, heart failure means that the heart is losing its pumping efficiency and can’t circulate enough blood to meet the body’s demands for oxygen and nutrients. Although the problem is serious and requires medical attention, people with heart failure may be able to live with the condition for years.

Heart failure affects 5 million Americans, with 550,000 new cases diagnosed each year, according to the American Heart Association.¹ Heart failure can happen at any age, but it’s more common among older people, as well as among African Americans. Ironically, better treatment has enabled more people to survive heart attacks, but these growing numbers of survivors have heart damage that can leave them vulnerable to heart failure.

Typically, heart failure results from an underlying heart problem, for example, damage and scarring of heart muscle after a heart attack. But it can also result from other conditions that weaken the heart, such as longstanding high blood pressure, clogged arteries, diabetes, severe lung disease, heart valve disorders, irregular heartbeats, infections of the heart, or heart defects present at birth. Having only one of these risk factors may increase the chance of heart failure; having a combination of factors may raise the risk even more.

Whatever the underlying cause, a failing heart cannot keep up with its workload. At first, the heart tries to make up for the difference. It gets larger, develops more muscle mass, and pumps faster. Eventually, though, it can no longer keep up with these changes and begins to lose pumping efficiency. Heart failure tends to develop slowly. In fact, some people fail to notice any symptoms until after the problem has progressed for years.

Heart failure can be mild, with little bearing on one’s daily activities. Or it can be severe, making even the simplest tasks – such as walking or carrying groceries – difficult. Regardless, any kind of heart failure requires a doctor’s regular care and a patient’s willingness to follow treatment closely.

Heart failure usually affects both sides of the heart, but may be more severe on one side, leading doctors to talk about left-sided or right-sided heart failure.² When the left side of the heart loses the ability to pump blood efficiently, fluid can leak into the lungs and cause shortness of breath. Coughing and production of frothy or blood-tinged mucus may occur. At first, this problem may only occur during physical exertion, but as heart failure progresses, it can happen even during rest. Breathlessness can also strike at night as a person lies flat in bed and fluid moves into the lungs. She or he may wake up struggling for breath and find that sitting up restores freer breathing as fluid drains to the bottom of the lungs. To avoid these nighttime episodes, some people may sleep propped up on several pillows.

Right-sided heart failure tends to cause a buildup of blood flowing into the right side of the heart. Blood backs up in the veins and fluid leaks out of the circulatory system into the surrounding tissues. This leads to symptoms such as swelling in the legs, ankles, feet, abdomen and liver. The neck veins also may become pronounced. Some patients may also lose their appetite or feel nauseated or bloated. People with right-sided disease may also have lung congestion.

Symptoms may vary from patient to patient, but people with either left- or right-sided failure commonly experience fatigue, weakness, and faintness. When the heart loses efficiency in pumping oxygen-rich blood, the muscles simply don’t have enough "fuel" and patients find it harder to perform work. Patients with heart failure may also gain weight rapidly from the excessive fluid buildup.

Heart failure - diagnosis and treatment

Often, a doctor can diagnose heart failure by recognizing symptoms during a physical exam, for instance, swollen ankles and feet, fatigue, shortness of breath, a weak pulse rate, or other signs. He or she can also use a stethoscope to listen for lung congestion or abnormal heart sounds that may point to heart failure. A patient’s medical history is important, too, for identifying risk factors such as high blood pressure or a history of heart problems.

A doctor may order a chest X-ray to look for an enlarged heart or fluid in the lungs. Other tests may include an electrocardiogram (EKG) to check the electrical activity of the heart; echocardiography, in which ultrasound waves creates images of the heart; or radionuclide imaging, a nuclear medicine test that shows how much blood the heart can pump per beat.

Treatment for heart failure varies, depending on the cause. Some cases can be cured. For example, heart failure caused by an anatomical problem, such as a narrowed or leaking heart valve, may be corrected with surgery. However, most patients cannot be cured and must learn to live with a chronic condition. Fortunately, though, treatment and lifestyle changes can help ease symptoms, boost quality of life, and perhaps prolong life as well. See Angina – Living Longer, Living Better for more information about quality of life.

Most patients with heart failure will need medication, often more than one drug. Here are some common types:³

• Angiotensin-converting enzyme (ACE) inhibitors reduce the heart’s workload by causing blood vessels to widen. (It’s easier for the heart to pump blood through wider vessels than narrowed ones.) They are the main group of drugs for treating heart failure. Not only do ACE inhibitors reduce symptoms, but they also prolong life. A similar class of drug known as Angiotensin II receptor blockers (or ARBs) may sometimes be used in place of ACE inhibitors. These drugs may also help prolong the lives of many people with heart failure.



• Beta-blockers slow the heart rate and prevent a substance in the nervous system called epinephrine from over-stimulating the heart. Symptoms may worsen at first if the starting dose is too high or is increased too quickly, but over the long term beta-blockers can help improve heart function in many patients.



• Other vasodilators, or drugs to help keep the blood vessels open wide for better blood flow, may be prescribed if a patient doesn’t respond to or can’t tolerate ACE inhibitors. Examples include hydralazine and nitroglycerin, which is especially helpful for patients with angina and heart failure.



• Digoxin is a drug that increases the force of each heartbeat and can slow rapid heart rates.



• Diuretics ("water pills") reduce the amount of fluid in the bloodstream by helping the kidneys clear the body of excess of salt and water, reducing swelling and lowering blood pressure.



• Anticoagulants ("blood thinners") help prevent blood clots from forming. Because people with heart failure have sluggish blood flow, they may be more prone to blood clots in the heart or leg veins.

People with severe heart failure that worsens despite maximal drug therapy may need a heart transplant, but they must be aware that the wait for a suitable heart can be long. Patients can also look into experimental surgeries offered at some research centers, for example, pumping devices inserted into the body to prolong life while a person awaits a heart transplant.

While it’s crucial to be under a doctor’s care, patients must also take care of themselves. They should talk to their doctor about how much exercise they can do to stay fit, and they can also work on losing any extra pounds. You can learn more in Exercise for Heart Health and Nutrition Matters. In addition, it is wise to quit smoking and limit caffeine and alcohol intake. Following a low-sodium diet will help prevent fluid build-up and swelling. In fact, it’s a good idea to weigh oneself daily – usually in the morning after urinating but before eating breakfast – because an increase of more than 2 lbs. a day offers an early warning sign of fluid build-up. As with any worsening of symptoms, be sure to check in with your doctor.

To prevent heart failure, people who remain healthy should make the same lifestyle changes that help ward off heart disease. That means controlling risk factors that are major culprits in harming the heart: high blood pressure, high cholesterol, diabetes, obesity and smoking.

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Sources

1. Heart Disease and Stroke Statistics - 2004 Update. Dallas, Tex.: American Heart Association; 2003. http://www.americanheart.org/downloadable/heart/
1079736729696HDSStats2004UpdateREV3-19-04.pdf. Accessed on June 16, 2004.

2. Types of Heart Disease. Mayo Clinic Heart Book, 2^nd ed., Ed. B.J. Gersh. New York: William Morrow-HarperCollins Publishers, 2000, p. 46.

3. "Heart Failure." Merck Manual of Medical Information, 2^nd ed. Ed. M.H. Beers. West Point, Pennsylvania: Merck & Co. Inc., 2003, pp. 156-157.