Understanding Heart Failure
What is
heart failure?
Heart failure means that the heart's
pumping power is weaker than normal. Heart failure does not mean that your
heart has stopped working.
With
heart failure, blood moves through the heart and body at a slower rate, and
pressure in the heart increases. Therefore, the heart cannot pump enough
oxygen and nutrients to meet the body's needs. The chambers of the heart
respond by stretching to hold more blood to pump through the body. This helps
to keep the blood moving for a short while, but then the heart muscle walls
weaken and are not able to pump as strongly. The kidneys often respond by
causing the body to retain fluid (water) and sodium.
If
fluid builds up in the arms, legs, ankles, feet, lungs or other organs, the
body becomes congested, and congestive heart failure is the term used to
describe the condition.
What are
the symptoms of heart failure?
 The signs and symptoms of heart failure may be mild to severe, depending on how weak your heart is. The congestive heart failure symptoms are related to the changes that occur in your heart and body, including:
- Congested lungs
(caused by fluid backing up in the lungs) -- cause shortness of breath
with exercise or difficulty breathing at rest or when laying flat at
night. Also cause dry, hacking cough or wheezing.
- Less blood to your
kidneys causes fluid and water retention, resulting in swollen ankles,
legs and abdomen (called edema) and weight gain. Symptoms may also
include an increased need to urinate during the night.
- Less blood to your
major organs and muscles causes fatigue (tiredness) and weakness when
exercising. Less blood to the brain also causes dizziness or confusion.
- A feeling of fullness
(bloating) in your stomach. A loss of appetite or nausea may also occur.
- Heart beating faster
to pump enough blood to the body causes rapid or irregular heartbeats.
If you have heart failure or congestive heart failure, you may have one or all of these symptoms of heart failure. Sometimes, people with heart failure do not have any symptoms.
What are
systolic and diastolic heart failure?
Systolic cardiac (heart) dysfunction (or
systolic heart failure) occurs when the heart muscle doesn't contract with
enough force, so there is not enough oxygen-rich blood to be pumped
throughout the body.
Diastolic
cardiac dysfunction (or diastolic heart failure) occurs when the heart
contracts normally, but the ventricle doesn't relax properly so less blood
can enter the heart.
A test
called the ejection fraction (EF) is used measure how well your heart pumps
with each beat to determine if systolic or diastolic dysfunction are present.
Your doctor can discuss which condition is present in your heart.
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How the
Heart Works
 A healthy heart beats about 60 to 80 times per
minute to pump blood throughout the body. The right and left sides of
the heart work together. Blood that is low in oxygen first enters the
right upper chamber (right atrium) of the heart. The blood flows from
the right atrium to the lower chamber (right ventricle) through the open
tricuspid valve. Blood passes through a valve before leaving each
chamber of the heart. There are four valves in your heart; valves
make sure blood flows in only one direction through your heart. The
blood then travels through the pulmonary artery to the lungs where oxygen
is added.
Oxygen-rich blood then returns to the left
side of the heart. The blood flows from the left upper chamber (left
atrium) to the lower chamber (left ventricle) through the open mitral
valve.
From the left ventricle, the blood is pumped
into a network of arteries (blood vessels) which carry the blood throughout
the body.
With heart failure, the heart's pumping power
is weaker than normal, causing less blood to move through the heart and to
the body. Less blood flow throughout the body causes certain
symptoms, as described above.
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What
causes heart failure?
Heart failure is caused by many
conditions that damage the heart muscle, including:
- Coronary artery
disease (also called coronary atherosclerosis) -- a disease of the
arteries that supply blood and oxygen to the heart. Coronary artery
disease occurs when the normal lining of the arteries breaks down, the
walls of the arteries thicken and deposits of fat and plaque block the
flow of blood through the arteries.
The arteries that supply blood to the heart become severely narrowed and
the heart can no longer respond to increased activity. Extra strain on
the heart may result in chest pain (angina pectoris) and other symptoms
of heart disease.
- Heart attack --
occurs when a coronary artery becomes suddenly blocked, stopping the
flow of blood to the heart muscle and damaging it. All or part of the
heart muscle becomes cut off from its supply of oxygen. A heart attack
can damage the heart muscle, resulting in a scarred area which does not
function.
- Cardiomyopathy --
damage to the heart muscle from causes other than artery or blood flow
problems. Causes include infections, alcohol or drug abuse.
Heart
failure is also caused by conditions that overwork the heart muscle,
including:
- High blood pressure
(hypertension) -- Blood pressure is the force of blood pushing against
blood vessel walls. High blood pressure means the pressure in the
arteries is above the normal range.
- Valve disease -- a
heart valve that is not working properly and is either leaking or
blocking the normal flow of blood.
- Heart defects present
at birth
- Diabetes Mellitus
- Chronic kidney disease
In
addition, heart failure often occurs when several diseases or conditions are
present at once.
Stages of heart failure
In 2001, the American Heart Association and American
College of Cardiology developed the “Stages of Heart Failure”. This
terminology will help you to understand that heart failure is often a progressive
condition and can worsen over time. It will allow you to see what “stage” or
level of heart failure you are in (you cannot go backward in stage…only
forward). It will also help you to understand why a new drug therapy was
added to your regime and may assist you in understanding the need for
lifestyle changes (low sodium or salt diet, weight monitoring, etc) and other
treatments.
These stages are different than the New York Heart
Association (NYHA) clinical classifications of heart failure that rank
patients as class I-II-III-IV according to the degree of symptomatic or
functional limits.
You should ask your healthcare provider what stage of
heart failure you are in and check the table below to see if your therapy
matches what the American Heart Association and American College of
Cardiology recommend. The following table is a basic plan of care that
may or may not apply to you, based on the cause of your heart failure and
your special needs. Ask your doctor to explain therapies that are listed if
you do not understand why you are or are not receiving them. Refer to other
parts of this handbook to learn more about specific medication, diet, and
other lifestyle recommendations.
Stage
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Definition of
Stage
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Usual Therapies
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Stage A
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Those at high risk for developing heart failure.
Includes people with:
-
Hypertension
- Diabetes mellitus
-
Coronary artery disease (including heart attack)
-
History of cardiotoxic drug therapy
-
History of alcohol abuse
-
History of rheumatic fever
-
Family history of cardiomyopathy.
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-
Exercise regularly
- Quit smoking
-
Treat hypertension
- Treat lipid disorders
- Discourage alcohol or illicit drug use
-
If previous heart attack or current diabetes
mellitus or hypertension ® angiotensin converting
enzyme inhibitor (ACE-I)
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Stage B
|
Those diagnosed with “systolic” heart failure but have never had symptoms of heart
failure (usually by finding an ejection fraction of less than 40% on
echocardiogram).
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-
Care measures in Stage A +
- All patients should be on ACE-I
-
Beta-blockers should be added
- Surgical consultation for coronary artery
revascularization and valve repair/replacement (as appropriate)
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Stage C
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Patients with known
heart failure with current or
prior symptoms.
Symptoms include:
-
Shortness of breath
- Fatigue
-
Reduced exercise intolerance.
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In this group, care measures from Stage A apply, ACE-I
and beta-blockers should be used +
-
Diuretics (water pills)
-
Digoxin
-
Dietary sodium (salt) restriction
- Weight monitoring
- Fluid restriction (as appropriate)
-
Withdrawal of drugs that worsen the condition
-
Spironolactone when symptoms remain severe with
other therapies
|
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Stage D
|
Presence of advanced symptoms, after assuring optimized medical care
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All therapies under Stages A, B and C + evaluation for:
-
Cardiac transplantation
-
Ventricular assist devices
- Surgical options
-
Research therapies
-
Continuous intravenous inotropic infusions
-
End-of-life care
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How is
heart failure treated?
Together, you and your doctor will
discuss your treatment options. Your doctor will determine which of these
treatment methods is right for you. Heart failure is treated by:
- Appropriately
diagnosing and analyzing the problem
- Taking medications as
prescribed by your doctor. Heart failure medications may include ACE
inhibitors, diuretics, inotropic agents, vasodilators, potassium, beta
blockers and other medications.
- Making dietary
changes, including: decreasing the total amount of sodium you consume to
2,000 milligrams (mg) or 2 grams (g) or less per day; eating foods high
in fiber and potassium; limiting total daily calories to lose weight if
necessary; and limiting foods that contain refined sugar, saturated fats
and cholesterol.
- Making lifestyle
changes, including: monitoring your weight by weighing yourself at the
same time each day and recording your weight; increasing your activity
level (as recommended by your provider); resting more often; planning
your activities; losing weight if you are overweight; not smoking or
chewing tobacco; avoiding or reducing alcohol.
- Having surgery, if
needed. Heart failure surgeries include the left ventricular assist
device, coronary bypass grafting, mitral valve repair, ventricular
surgeries and sometimes heart transplantation.
- Seeing your doctor
regularly -- during follow-up visits, your doctor will make sure you are
staying healthy and that your heart failure is not getting any worse.
Your doctor will ask to review your weight record and list of
medications. Your doctor will tell you how often you need to see him or her.
Heart failure treatment is a team effort
Heart failure management is a team effort, and you are the key player on the
team. Your heart doctor will prescribe your medications and manage other
medical problems. Other team members, including nurses, dietitians,
pharmacists, exercise specialists and social workers, will help you achieve
success. But it is up to YOU to take your medications, make dietary changes,
live a healthy lifestyle, keep your follow-up appointments, and be an active
member of the team.
What is
the outlook?
With the right care, heart failure will
not stop you from doing the things you enjoy. Your prognosis or outlook for
the future will depend on how well your heart muscle is functioning, your
symptoms, and how well you respond to and follow your treatment plan.
Everyone
with a long-term illness, such as heart failure, should discuss their desires
for extended medical care with their doctor and family. An "advanced
directive" or "living will" is one way to let everyone know
your wishes. A living will expresses your desires about the use of medical
treatments to prolong your life. This document is prepared while you are
fully competent in case you are unable to make these decisions at a later
time.
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