Facts About
Heart Failure
What is heart failure?
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.
Types of heart failure
The term congestive heart
failure is often used to describe all patients
with heart failure. 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.
How common is heart failure?
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.
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.
What causes heart failure?
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,
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, 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 a
much greater risk of heart failure than those
without. 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.
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.
Also, 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.
What are the symptoms?
A number of symptoms are
associated with heart failure, but none is
specific for the condition. Perhaps the most
common 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. Fatigue 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
-
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.
How do doctors diagnose heart
failure?
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. It can also be used to calculate a
patient's ejection fraction, a measure of the
amount of blood pumped out when the heart
contracts.
Another 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 (caused from an overactive
thyroid gland).
What treatments are available?
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.
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.
Transplant candidates who do not
improve sometimes need mechanical pumps, which
are attached to the heart. Called left
ventricular assist devices (LVAD's), the
machines take over part or virtually all of the
heart's blood-pumping activity. However, current
LVAD's 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.
Common Heart Failure
Medications
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.
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.
Can a person live with heart
failure?
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 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.
What is the outlook for heart
failure?
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
YOUR DOCTOR VISIT
Here are some points you may
want to discuss with your doctor. Don't hesitate
to ask questions to clarify points. 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.
A QUESTION FOR YOUR PHARMACIST
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.
Q & A For Your Doctor Visit
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. 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.
