HEART FAILURE
Table of Contents
What is heart failure?
Is there only one type of heart failure?
How common is heart failure?
What causes heart failure?
What are the symptoms?
How do doctors diagnose heart failure?
What treatments are available?
Common heart failure medications
Can a person live with heart failure?
What is the outlook for heart failure?
Making the most of your doctor visit
A question for your pharmacist
Glossary
Readying a q & a for your doctor visit
Heart failure occurs when the heart loses its ability
to pump enough blood through the body. Usually, the loss in pumping action
is a symptom of an underlying heart problem, such as coronary artery disease.
The term heart failure suggests
a sudden and complete stop of heart activity. But, actually, the heart
does not suddenly stop. Rather, heart failure usually develops slowly, often over
years, as the heart gradually loses its pumping ability and works less
efficiently. Some people may not become aware of their condition until
symptoms appear years after their heart began its decline.
How serious the condition
is depends on how much pumping capacity the heart has lost. Nearly everyone
loses some pumping capacity as he or she ages. But the loss is significantly
more in heart failure and often results from a heart attack or other
disease that damages the heart.
The severity of the condition
determines the impact it has on a person's life. At one end of the spectrum,
the mild form of heart failure may have little effect on a person's
life; at the other end, severe heart failure can interfere with even
simple activities and prove fatal. Between those extremes, treatment
often helps people lead full lives.
But all forms of heart failure,
even the mildest, are a serious health problem, which must be treated.
To improve their chance of living longer, patients must take care of
themselves, see their physician regularly, and closely follow treatments.
The term congestive heart failure is often used to describe
all patients with heart failure. In reality, congestion (the buildup of
fluid) is just one feature of the condition and does not occur in all
patients. There are two main categories of heart failure although within
each category, symptoms and effects may differ from patient to patient.
The two categories are:
- Systolic heart failure--This occurs when the
heart's ability to contract decreases. The heart cannot pump with
enough force to push a sufficient amount of blood into the circulation.
Blood coming into the heart from the lungs may back up and cause fluid
to leak into the lungs, a condition known as pulmonary congestion.
- Diastolic heart failure--This occurs when the
heart has a problem relaxing. The heart cannot properly fill with
blood because the muscle has become stiff, losing its ability to relax.
This form may lead to fluid accumulation, especially in the feet,
ankles, and legs. Some patients may have lung congestion.
Between 2 to 3 million Americans
have heart failure, and 400,000 new cases are diagnosed each year. The
condition is slightly more common among men than women and is twice as
common among African Americans as whites.
Heart failure causes 39,000
deaths a year and is a contributing factor in another 225,000 deaths.
The death rate attributed to heart failure rose by 64 percent from 1970
to 1990, while the death rate from coronary heart disease dropped by
49 percent during the same period. Heart failure mortality is about
twice as high for African Americans as whites for all age groups.
In a sense, heart failure's
growing presence as a health problem reflects the Nation's changing
population: More people are living longer. People age 65 and older represent
the fastest growing segment of the population, and the risk of heart
failure increases with age. The condition affects 1 percent of people
age 50, but about 5 percent of people age 75.
As stated, the heart loses some
of its blood-pumping ability as a natural consequence of aging. However,
a number of other factors can lead to a potentially life-threatening loss
of pumping activity.
As a symptom of underlying
heart disease, heart failure is closely associated with the major risk
factors for coronary heart disease: smoking, high cholesterol levels,
hypertension (persistent high blood pressure), diabetes and abnormal
blood sugar levels, and obesity. A person can change or eliminate those
risk factors and thus lower their risk of developing or aggravating
their heart disease and heart failure.
Among prominent risk factors,
hypertension (high blood pressure) and diabetes are particularly important.
Uncontrolled high blood pressure increases the risk of heart failure
by 200 percent, compared with those who do not have hypertension. Moreover,
the degree of risk appears directly related to the severity of the high
blood pressure.
Persons with diabetes have
about a two- to eightfold greater risk of heart failure than those without
diabetes. Women with diabetes have a greater risk of heart failure than
men with diabetes. Part of the risk comes from diabetes' association
with other heart failure risk factors, such as high blood pressure,
obesity, and high cholesterol levels. However, the disease process in
diabetes also damages the heart muscle.
The presence of coronary
disease is among the greatest risks for heart failure. Muscle damage
and scarring caused by a heart attack greatly increase the risk of heart
failure. Cardiac arrhythmias, or irregular heartbeats, also raise
heart failure risk. Any disorder that causes abnormal swelling or thickening
of the heart sets the stage for heart failure.
In some people, heart failure
arises from problems with heart valves, the flap-like structures that help regulate
blood flow through the heart. Infections in the heart are another source
of increased risk for heart failure.
A single risk factor may
be sufficient to cause heart failure, but a combination of factors dramatically
increases the risk. Advanced age adds to the potential impact of any
heart failure risk.
Finally, genetic abnormalities
contribute to the risk for certain types of heart disease, which in
turn may lead to heart failure. However, in most instances, a specific
genetic link to heart failure has not been identified.
A number of symptoms are associated
with heart failure, but none is specific for the condition. Perhaps the
best known symptom is shortness of breath ("dyspnea"). In heart failure, this may result
from excess fluid in the lungs. The breathing difficulties may occur at
rest or during exercise. In some cases, congestion may be severe enough
to prevent or interrupt sleep.
Fatigue or easy tiring is
another common symptom. As the heart's pumping capacity decreases, muscles
and other tissues receive less oxygen and nutrition, which are carried
in the blood. Without proper "fuel," the body cannot perform as much
work, which translates into fatigue.
Fluid accumulation, or edema,
may cause swelling of the feet, ankles, legs, and occasionally, the
abdomen. Excess fluid retained by the body may result in weight gain,
which sometimes occurs fairly quickly.
Persistent coughing is another
common sign, especially coughing that regularly produces mucus or pink,
blood-tinged sputum. Some people develop raspy breathing or wheezing.
Because heart failure usually
develops slowly, the symptoms may not appear until the condition has
progressed over years. The heart hides the underlying problem by making
adjustments that delay--but do not prevent--the eventual loss in pumping
capacity. The heart adjusts, or compensates, in three ways to cope with
and hide the effects of heart failure:
- Enlargement ("dilatation"),
which allows more blood into the heart;
- Thickening of muscle fibers
("hypertrophy") to strengthen the heart muscle, which allows the heart
to contract more forcefully and pump more blood; and
- More frequent contraction,
which increases circulation.
By making these adjustments,
or compensating, the heart can temporarily make up for losses in pumping
ability, sometimes for years. However, compensation has its limits. Eventually,
the heart cannot offset the lost ability to pump blood, and the signs
of heart failure appear.
In many cases, physicians diagnose
heart failure during a physical examination. Readily
identifiable signs are shortness of breath, fatigue, and swollen ankles
and feet. The physician also will check for the presence of risk factors,
such as hypertension, obesity, and a history of heart problems. Using
a stethoscope, the physician can listen to a patient breathe and identify
the sounds of lung congestion. The stethoscope also picks up the abnormal
heart sounds indicative of heart failure.
If neither the symptoms nor
the patient's history point to a clear-cut diagnosis, the physician
may recommend any of a variety of laboratory tests, including, initially,
an electrocardiogram, which uses recording devices
placed on the chest to evaluate the electrical activity of a patient's
heartbeat.
Echocardiography is another means of evaluating heart
function from outside the body. Sound waves bounced off the heart are
recorded and translated into images. The pictures can reveal abnormal
heart size, shape, and movement. Echocardiography also can be used to calculate a patient's
ejection fraction, a measure of the amount of blood pumped out when
the heart contracts.
Another possible test is
the chest x ray, which also determines the heart's size and shape, as
well as the presence of congestion in the lungs.
Tests help rule out other
possible causes of symptoms. The symptoms of heart failure can result
when the heart is made to work too hard, instead of from damaged muscle.
Conditions that overload the heart occur rarely and include severe anemia
and thyrotoxicosis (a disease resulting from an overactive thyroid gland).
Heart failure caused by an excessive
workload is curable by treating the primary disease, such as anemia or
thyrotoxicosis. Also curable are forms caused by anatomical problems,
such as a heart valve defect. These defects can be surgically corrected.
However, for the common forms
of heart failure--those due to damaged heart muscle--no known cure exists.
But treatment for these forms may be quite successful. The treatment
seeks to improve patients' quality of life and length of survival through
lifestyle change and drug therapy.
Patients can minimize the
effects of heart failure by controlling the risk factors for heart disease.
Obvious steps include quitting smoking, losing weight if necessary,
abstaining from alcohol, and making dietary changes to reduce the amount
of salt and fat consumed. Regular, modest exercise is also helpful for
many patients, though the amount and intensity should be carefully monitored
by a physician.
But, even with lifestyle
changes, most heart failure patients must take medication. Many patients
receive two or more drugs.
Several types of drugs have
proven useful in the treatment of heart failure:
- Diuretics help reduce
the amount of fluid in the body and are useful for patients with fluid
retention and hypertension.
- Digitalis increases the
force of the heart's contractions, helping to improve circulation.
- Results of recent studies
have placed more emphasis on the use of drugs known as angiotensin converting enzyme (ACE) inhibitors. Several
large studies have indicated that ACE inhibitors improve survival among heart failure
patients and may slow, or perhaps even prevent, the loss of heart
pumping activity.
Originally developed as a treatment
for hypertension, ACE inhibitors help heart failure patients by, among
other things, decreasing the pressure inside blood vessels. As a result,
the heart does not have to work as hard to pump blood through the vessels.
Patients who cannot take
ACE inhibitors may get a nitrate and/or a drug called hydralazine, each
of which helps relax tension in blood vessels to improve blood flow.
Sometimes, heart failure
is life-threatening. Usually, this happens when drug therapy and lifestyle
changes fail to control its symptoms. In such cases, a heart transplant
may be the only treatment option. However, candidates for transplantation
often have to wait months or even years before a suitable donor heart
is found. Recent studies indicate that some transplant candidates improve
during this waiting period through drug treatment and other therapy,
and can be removed from the transplant list.
Transplant candidates who
do not improve sometimes need mechanical pumps, which are attached to
the heart. Called left ventricular assist devices (LVADs), the machines take over part or virtually all
of the heart's blood-pumping activity. However, current LVADs are not permanent solutions for heart failure
but are considered bridges to transplantation.
An experimental surgical
procedure for severe heart failure is available at a few U.S. medical
centers. The procedure, called cardiomyoplasty, involves detaching one end of a
muscle in the back, wrapping it around the heart, and then suturing
the muscle to the heart. An implanted electric stimulator causes the
back muscle to contract, pumping blood from the heart.
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Listed below are some
of the medications prescribed for heart failure. Not all medications
are suitable for all patients, and more than one drug may be needed.
Also, the list provides
the full range of possible side effects for these drugs. Not all
patients will develop these side effects. If you suspect that
you are having a side effect, alert your physician.
- ACE
Inhibitors.
These prevent the production of a chemical that causes blood
vessels to narrow. As a result, blood pressure drops and the
heart does not have to work as hard to pump blood.
- Side effects
may include coughing, skin rashes, fluid retention, excess
potassium in the bloodstream, kidney problems, and an altered
or lost sense of taste.
- Digitalis.
Increases the force of the heart's contractions. It also slows
certain fast heart rhythms. As a result, the heart beats less
frequently but more effectively, and more blood is pumped into
the arteries.
- Side effects
may include nausea, vomiting, loss of appetite, diarrhea,
confusion, and new heartbeat irregularities.
- Diuretics.
These decrease the body's retention of salt and so of water.
Diuretics are commonly prescribed to reduce high blood pressure.
Diuretics come in many types, with different periods of effectiveness.
- Side effects
may include loss of too much potassium, weakness, muscle
cramps, joint pains, and impotence.
- Hydralazine.
This drug widens blood vessels, easing blood flow.
- Side effects
may include headaches, rapid heartbeat, and joint pain.
- Nitrates.
These drugs are used mostly for chest pain, but may also help
diminish heart failure symptoms. They relax smooth muscle and
widen blood vessels. They act to lower primarily systolic blood
pressure.
- Side effects
may include headaches.
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Heart failure is one of the
most serious symptoms of heart disease. About two-thirds of all patients
die within 5 years of diagnosis. However, some live beyond 5 years, even
into old age. The outlook for an individual patient depends on the patient's
age, severity of heart failure, overall health, and a number of other
factors.
As heart failure progresses,
the effects can become quite severe, and patients often lose the ability
to perform even modest physical activity. Eventually, the heart's reduced
pumping capacity may interfere with routine functions, and patients
may become unable to care for themselves. The loss in functional ability
can occur quickly if the heart is further weakened by heart attacks
or the worsening of other conditions that affect heart failure, such
as diabetes and coronary heart disease.
Heart failure patients also
have an increased risk of sudden death, or cardiac arrest, caused by an irregular
heartbeat.
To improve the chances of
surviving with heart failure, patients must take care of themselves.
Patients must:
- See their physician regularly;
- Closely follow all of
their physician's instructions;
- Take any medication according
to instructions; and
- Immediately inform their
physician of any significant change in their condition, such as an
intensified shortness of breath or swollen feet.
Patients with heart failure
also should:
- Control their weight;
- Watch what they eat;
- Not smoke cigarettes or
use other tobacco products; and
- Abstain from or strictly
limit alcohol consumption.
Even with the best care, heart
failure can worsen, but patients who don't take care of themselves are
almost writing themselves a prescription for poor health.
The best defense against
heart failure is the prevention of heart disease. Almost all of the
major coronary risk factors can be controlled or eliminated: smoking,
high cholesterol, high blood pressure, diabetes, and obesity.
Within the past decade, knowledge
of heart failure has improved dramatically but, clearly, much more remains
to be learned. The National Heart, Lung, and Blood Institute (NHLBI) supports
numerous research projects aimed at building on what is already known
about heart failure and at uncovering new knowledge about its process,
diagnosis, and treatment. NHLBI research priorities for heart failure
include:
- Learning more about basic
cellular changes that lead to heart failure;
- Developing tests to detect
the earliest signs of heart failure;
- Identifying factors that
cause heart failure to worsen;
- Determining how heart
failure can be reversed once it starts;
- Understanding better the
heart's ability to compensate for lost pumping ability; and
- Developing new therapies,
especially those based on early signs of heart failure.
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Here are some points you
may want to discuss with your doctor. Don't hesitate to ask questions
to clarify points. Also, ask your doctor to rephrase a reply you
cannot understand. You may want to take a family member or friend
to the appointment with you to help you better understand and remember
what's said.
- Briefly describe
your symptoms, even those you feel may not be important. You
may want to keep a list so you will remember them.
- Tell the doctor
all of the medications you take--including over-the-counter
drugs--and any problems you may be having with them.
- Be sure you understand
all of the doctor's instructions--especially for medications.
Know what drug to take when, how often, and in what amount.
- Find out what side
effects are possible from any drug the doctor prescribes for
you.
- Ask the meaning
of any medical term you don't understand.
- If, after your appointment,
you still have questions or are uncertain about your treatment,
call the doctor's office to get the information you need.
Your pharmacist is a good
resource for information about medications. Ask if any drug you're
taking interacts badly with certain foods or with other drugs, including
nonprescription ones. Your pharmacist also can help you understand
product package inserts and label instructions.
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Going to the doctor can be a
nervous time. It may be hard to remember everything you want to ask and
everything you hear.
It helps to prepare a list
of important questions. Use the spaces below to list questions you want
answered. Then take this fact sheet with you to your appointment so
you can record the answers.
Before you leave the doctor's
office, be sure you understand your condition and its treatment, including
any medications.
Your Question:
1. _______________________________________________________
__________________________________________________________
Answer:
__________________________________________________________ __________________________________________________________
Your Question:
2. _______________________________________________________
__________________________________________________________
Answer:
__________________________________________________________ __________________________________________________________
Your Question:
3. _______________________________________________________
__________________________________________________________
Answer:
__________________________________________________________ __________________________________________________________
Your Question:
4. _______________________________________________________
__________________________________________________________
Answer:
__________________________________________________________ __________________________________________________________
Your Question:
5. _______________________________________________________
__________________________________________________________
Answer:
__________________________________________________________ __________________________________________________________
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 95-923
Reprinted May 1997 |
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