Heart Failure Definition Heart failure is a condition in which the heart has lost the ability to pump enough blood to the body's tissues. With too little blood being delivered, the organs and other tissues do not receive enough oxygen and nutrients to function properly. Description According to the American Heart Association, about 4.9 million Americans are living with congestive heart failure. Of these, 2.5 million are males and 2.4 million are females. Ten of every 1,000 people over age 65 have this condition. There are about 400,000 new cases each year. Heart failure happens when a disease affects the heart's ability to deliver enough blood to the body's tissues. Often, a person with heart failure may have a buildup of fluid in the tissues, called edema. Heart failure with this kind of fluid buildup is called congestive heart failure. Where edema occurs in the body depends on the part of the heart that is affected by heart failure. Heart failure caused by abnormality of the lower left chamber of the heart (left ventricle) means that the left ventricle cannot pump blood out to the body as fast as it returns from the lungs. Because blood cannot get back to the heart, it begins to back up in the blood vessels of the lungs. Some of the fluid in the blood is forced into the breathing space of the lungs, causing pulmonary edema. A person with pulmonary edema has shortness of breath, which may be acute, severe and life threatening. A person with congestive heart failure feels tired because not enough blood circulates to supply the body's tissues with the oxygen and nutrients they need. Abnormalities of the heart structure and rhythm also can be responsible for left ventricular congestive heart failure. In right-sided heart failure, the lower right chamber of the heart (right ventricle) cannot pump blood to the lungs as fast as it returns from the body through the veins. Blood then engorges the right side of the heart and the veins. Fluid backed up in the veins is forced out into the tissues, causing swelling (edema), usually in the feet and legs. Congestive heart failure of the right ventricle often is caused by abnormalities of the heart valves and lung disorders. When the heart cannot pump enough blood, it tries to make up for this by becoming larger. By becoming enlarged (hypertrophic) the ventricle can contract more strongly and pump more blood. When this happens, the heart chamber becomes larger and the muscle in the heart wall becomes thicker. The heart also compensates by pumping more often to improve blood output and circulation. The kidneys try to compensate for a failing heart by retaining more salt and water to increase the volume of blood. This extra fluid also can cause edema. Eventually, as the condition worsens over time these measures are not enough to keep the heart pumping enough blood needed by the body. Kidneys often weaken under these circumstances, further aggravating the situation and making therapy more difficult. For most people, heart failure is a chronic disease with no cure. However, it can be managed and treated with medicines and changes in diet, exercise, and life-style habits. Heart transplantation is considered in some cases. Causes and symptoms The most common causes of heart failure are: • coronary artery disease and heart attack (which may be "silent") • cardiomyopathy • high blood pressure (hypertension) • heart valve disease • congenital heart disease • alcoholism and drug abuse The most common cause of heart failure is coronary artery disease. In coronary artery disease, the arteries supplying blood to the heart become narrowed or blocked. When blood flow to an area of the heart is completely blocked, the person has a heart attack. Some heart attacks go unrecognized. The heart muscle suffers damage when its blood supply is reduced or blocked. If the damage affects the heart's ability to pump blood, heart failure develops. Cardiomyopathy is a general term for disease of the heart muscle. Cardiomyopathy may be caused by coronary artery disease and various other heart problems. Sometimes the cause of cardiomyopathy cannot be found. In these cases the heart muscle disease is called idiopathic cardiomyopathy. Whatever the cause, cardiomyopathy can weaken the heart, leading to heart failure. High blood pressure is another common cause of heart failure. High blood pressure makes the heart work harder to pump blood. After a while, the heart cannot keep up and the symptoms of heart failure develop. Defects of the heart valves, congenital heart diseases, alcoholism, and drug abuse cause damage to the heart that can all lead to heart failure. A person with heart failure may experience the following: • shortness of breath • frequent coughing, especially when lying down • swollen feet, ankles, and legs • abdominal swelling and pain • fatigue • dizziness or fainting • sudden death A person with left-sided heart failure may have shortness of breath and coughing caused by the fluid buildup in the lungs. Pulmonary edema may cause the person to cough up bubbly phlegm that contains blood. With right-sided heart failure, fluid build-up in the veins and body tissues causes swelling in the feet, legs, and abdomen. When body tissues, such as organs and muscles, do not receive enough oxygen and nutrients they cannot function as well, leading to tiredness and dizziness. Diagnosis Diagnosis of heart failure is based on: • symptoms • medical history • physical examination • chest x ray • electrocardiogram (ECG; also called EKG) • other imaging tests • cardiac catheterization A person's symptoms can provide important clues to the presence of heart failure. Shortness of breath while engaging in activities and episodes of shortness of breath that wake a person from sleep are classic symptoms of heart failure. During the physical examination, the physician listens to the heart and lungs with a stethoscope for telltale signs of heart failure. Irregular heart sounds, "gallops," a rapid heart rate, and murmurs of the heart valves may be heard. If there is fluid in the lungs a crackling sound may be heard. Rapid breathing or other changes in breathing may also be present. Patients with heart failure also may have a rapid pulse. By pressing on the abdomen, the physician can feel if the liver is enlarged. The skin of the fingers and toes may have a bluish tint and feel cool if not enough oxygen is reaching them. A chest x ray can show if there is fluid in the lungs and if the heart is enlarged. Abnormalities of heart valves and other structures also may be seen on chest x ray. An electrocardiogram gives information on the heart rhythm and the size of the heart. It can show if the heart chamber is enlarged and if there is damage to the heart muscle from blocked arteries. Besides chest x ray, other imaging tests may help make a diagnosis. Echocardiography uses sound waves to make images of the heart. These images can show if the heart wall or chambers are enlarged and if there are any abnormalities of the heart valves. An echocardiogram also can be used to find out how much blood the heart is pumping. It determines the amount of blood in the ventricle (ventricular volume) and the amount of blood the ventricle pumps each time it beats (called the ejection fraction). A healthy heart pumps at least one-half the amount of blood in the left ventricle with each heartbeat. Radionuclide ventriculography also measures the ejection fraction by imaging with very low doses of an injected radioactive substance as it travels through the heart. A new test that measures the level of a particular hormone in the blood was introduced in 2003 and researchers said the test may be useful for testing for heart failure in physicians' offices because it could provide results in 15 minutes. Cardiac catheterization involves using a small tube (catheter) that is inserted through a blood vessel into the heart. It is used to measure pressure in the heart and the amount of blood pumped by the heart. This test can help find abnormalities of the coronary arteries, heart valves, and heart muscle, and other blood vessels. Combined with echocardiography and other tests, cardiac catheterization can help find the cause of heart failure. It is not always necessary, however. Treatment Heart failure usually is treated with lifestyle changes and medicines. Sometimes surgery is needed to correct abnormalities of the heart or heart valves. Heart transplantation is a last resort to be considered in certain cases. Dietary changes to maintain proper weight and reduce salt intake may be needed. Reducing salt intake helps to lessen swelling in the legs, feet, and abdomen. Appropriate exercise also may be recommended, but it is important that heart failure patients only begin an exercise program with the advice of their doctors. Walking, bicycling, swimming, or low-impact aerobic exercises may be recommended. There are good heart rehabilitation programs at most larger hospitals. Other lifestyle changes that may reduce the symptoms of heart failure include stopping smoking or other tobacco use, eliminating or reducing alcohol consumption, and not using harmful drugs. One or more of the following types of medicines may be prescribed for heart failure: • diuretics • digitalis • vasodilators • beta blockers • angiotensin converting enzyme inhibitors (ACE inhibitors) • angiotensin receptor blockers (ARBs) • calcium channel blockers Diuretics help eliminate excess salt and water from the kidneys by making patients urinate more often. This helps reduce the swelling caused by fluid buildup in the tissues. Digitalis helps the heart muscle to have stronger pumping action. Vasodilators, ACE inhibitors, ARBs, and calcium channel blockers lower blood pressure and expand the blood vessels so blood can move more easily through them. This action makes it easier for the heart to pump blood through the vessels. Cholesterol-lowering drugs called statins can help prevent death from heart failure. A 2003 study showed a 62% drop in mortality rate among patients with severe heart failure who took statin therapy. In 2003, a new noninvasive procedure was being tested for patients with congestive heart failure. Called enhanced external counterpulsation (EECP), it consisted of inflating three sets of pneumatic cuffs attached to the patient's legs. The therapy had positive effects on the blood pressure and reduced frequency of episodes of angina (pain) in a clinical trial by as much as 70%. Surgery is used to correct certain heart conditions that cause heart failure. Congenital heart defects and abnormal heart valves can be repaired with surgery. Blocked coronary arteries usually can be treated with angioplasty or coronary artery bypass surgery. With severe heart failure, the heart muscle may become so damaged that available treatments do not help. Patients with this stage of heart failure are said to have end- stage heart failure. Heart transplant usually is considered for patients with end-stage heart failure when all other treatments have stopped working. Prognosis Most patients with mild or moderate heart failure can be successfully treated with dietary and exercise programs and the right medications. In fact, in 2003, the American Heart Association said that even those awaiting heart transplants could benefit from exercise. Many people are able to participate in normal daily activities and lead relatively active lives. Patients with severe heart failure may eventually have to consider heart transplantation. Approximately 50% of patients diagnosed with congestive heart failure live for five years with the condition. Women with heart failure usually live longer than men with heart failure. Prevention Heart failure usually is caused by the effects of some type of heart disease. The best way to try to prevent heart failure is to eat a healthy diet and get regular exercise, but many causes of heart failure cannot be prevented. People with risk factors for coronary disease (such as high blood pressure and high cholesterol levels) should work closely with their physician to reduce likelihood of heart attack and heart failure . heart valves, congenital heart diseases, alcoholism, and drug abuse cause damage to the heart that can all lead to heart failure. A person with heart failure. Women with heart failure usually live longer than men with heart failure. Prevention Heart failure usually is caused by the effects of some type of heart disease.