What is Heart Failure?

Heart failure is a major health problem in the United States, affecting about 4.6 million Americans. About 550,000 new cases of heart failure occur each year. It is the leading cause of hospitalization in people older than 65.

If you have heart failure, you will enjoy better health and quality of life if you take care of yourself and keep yourself in balance. It is important to learn about heart failure, how to keep in good balance, and when to call the doctor.

Heart failure means the heart does not pump as well as it should, often due to a heart disease such as cardiomyopathy or cardiovascular disease. The "poor pump" is unable to keep up with the body’s constant need for oxygen and nutrients. In response:

• The walls of the heart stretch to hold more blood.
• The heart muscle walls thicken to pump more strongly.
• The kidneys cause the body to retain fluid and sodium. This increases the amount of blood circulating through the heart and blood vessels.
• Your body tries to compensate by releasing hormones that make the heart work harder. Over time, these compensatory mechanisms fail and symptoms of heart failure begin to appear. Like an over-stretched rubber band, the heart's ability to stretch and shrink back decreases. The heart muscle becomes over-stretched and is unable to pump blood effectively.
• Blood backs up into the arms, legs, ankles, feet, liver, lungs or other organs; the body becomes congested. This is called congestive heart failure.
• Heart failure is a progressive process, even if no new damage occurs to the heart.

Normal Heart	Dialated Cardiomyopathy

Words Related to Heart Failure

Ejection fraction (EF): a measurement of the amount of blood pumped out of the left ventricle with each heartbeat. In a normal person, the ejection fraction equals about 50 percent or more. If someone has systolic heart failure, the ejection fraction will equal about 20 to 40 percent, or even less.

Ventricular remodeling: the changes that occur to the heart’s pumping chamber (ventricle) when someone has heart failure. The inside of the left ventricle gets bigger, the walls become thicker and the heart changes shape (becoming more round rather than pear-shaped). These changes worsen the heart’s ability to pump blood, stress the heart and may cause the mitral valve to leak.

Systolic heart failure (systolic dysfunction): occurs when the heart muscle does not contract with enough force, so there is not enough oxygen-rich blood pumped throughout the body. An ejection fraction less than 40 percent indicates systolic heart failure.

Diastolic heart failure (diastolic dysfunction): occurs when the heart contracts normally (a normal ejection fraction) but the ventricle does not relax or fill properly, so less blood enters the heart.
 

What Causes Heart Failure?

Heart failure is most often caused by Coronary artery disease (myocardial infarction or heart attack). Coronary artery disease causes decreased blood flow to the heart muscle. If the arteries become blocked, the heart becomes starved for oxygen and nutrients (ischemia). In a short time, damage to the heart muscle (a heart attack) occurs. The damaged area can not pump normally, causing heart failure.

Other causes include damage to the heart muscle from:

• Infection
• Alcohol or drug abuse
• Pregnancy
• No apparent cause

Conditions that overwork the heart:

• High blood pressure (hypertension)
• Valve disease 
• Thyroid disease
• Kidney disease
• Diabetes mellitus
• Heart defect

What are the Symptoms of Heart Failure?

Symptoms of heart failure are related to the changes that occur to your heart and body.

Shortness of breath: Occurs with exercise or rest or when lying flat in bed. Fluid backs up in the lungs, causing shortness of breath and, often, a hacking cough.

Dizziness: Less blood to the brain causes dizziness. 

Tiredness (fatigue) and weakness: Less blood to the major organs and muscles causes fatigue.

Rapid or irregular heartbeats: The heart beats faster to pump en ough blood to the body. This causes a fast or irregular heartbeat.

Swelling in ankles, legs and abdomen and weight gain: Less blood to your kidneys causes the kidneys to retain fluid and water, resulting in edema (swelling) and water weight gain.

Other symptoms: nausea, palpitations, chest pain, waking suddenly at night unable to breathe, changes in sleep pattern.

Your doctor will ask you about your symptoms (what they feel like, how severe they are, what causes them and how long they last). Your symptoms may not be related to how weak your heart is. You may have many symptoms and your heart function may be mildly weakened. Or you may have a more severely damaged heart but have no symptoms.

How is Heart Failure Diagnosed?

When diagnosing heart failure, your doctor first looks at three areas:

Medical history: Your doctor will ask you many questions about your symptoms and medical history and will need to know:

• If you have any other health conditions such as diabetes, kidney disease, angina, high blood pressure, or other heart problems
• If you smoke
• If you drink alcohol and how much you drink
• Your current medications

Physical exam: Your doctor will listen to your heart and give you a complete physical exam, looking for signs of heart failure and any other illnesses that may have caused your heart to weaken.

Tests: Certain tests that can help your doctor determine the extent of heart failure and may be recommended

• Blood tests — to evaluate kidney and thyroid function as well as to check cholesterol levels and presence of anemia. Anemia is a blood disorder that occurs when there is not enough hemoglobin (the substance in red blood cells that enables the blood to transport oxygen through the body) in a person's blood.
  • B-type Natriuretic Peptide (BNP) blood test - BNP is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable. The BNP level in a person with heart failure - even someone whose condition is stable - is higher than in a person with normal heart function.
• Chest X-ray — shows the size of your heart and whether there is fluid build-up around the heart and lungs.
• Echocardiogram (or echo)  — a graphic outline of the heart's movement. During an echo, a wand is placed on the surface of your chest. This wand sends ultrasound waves that provide pictures of the heart's valves and chambers so the pumping action of the heart can be studied. Echo is often combined with an ultrasound to find changes in the blood flow across the heart's valves and the pressure within the heart's chambers.
• Electrocardiogram (EKG or ECG) - records the electrical impulses traveling through the heart. During the test, small, flat, sticky patches called electrodes are placed on your chest. The electrodes are attached to an electrocardiograph monitor (EKG) that charts your heart's electrical activity on graph paper.
• Ejection fraction (EF) — test that determines how well your heart pumps with each beat. This test measures how much blood is pumped out of the heart with each beat, and how much blood pumps through the heart with each beat.
  • A normal EF is generally greater than 50 percent, which means that over half of the blood volume is pumped out of the heart with each beat.
  • An EF of less than 40 percent usually confirms a diagnosis of systolic heart failure.
  • An EF greater than 40 percent means that your heart failure is due to another cause, such as a valve disorder or diastolic dysfunction. Please note, however, that people with diastolic dysfunction can have a normal EF.

Systolic dysfunction 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 dysfunction occurs when the heart contracts normally, but the ventricle doesn't relax properly so less blood can enter the heart. Your doctor can discuss which condition is present in your heart.

What is Cardiomyopathy?

Cardiomyopathy is a disease of the heart muscle that decreases heart's ability to pump blood. About 36,000 people in the United States are hospitalized each year with cardiomyopathy. This condition is a major cause of heart failure. Cardiomyopathy can be classified as primary or secondary and ischemic or nonischemic.

• Primary cardiomyopathy occurs in the absence of other cardiac conditions.
• Secondary cardiomyopathy is caused by a known medical condition (such as hypertension, valve disease, congenital heart disease, or coronary artery disease).
• Ischemic cardiomyopathy is caused by coronary artery disease and heart attacks. Lack of blood damages the heart muscle, causes damage to it, resulting in cardiomyopathy.
• Nonischemic cardiomyopathy includes the four types of heart muscle disease listed below. These forms of cardiomyopathy are not related to coronary artery disease (poor coronary artery blood supply). There are four types of nonischemic cardiomyopathy:
  •  Dilated Cardiomyopathy
  • Hypertrophic Cardiomyopathy
  • Restrictive Cardiomyopathy
  • Arrhythmogenic Right Ventricular Dysplasia (ARVD)

How is Heart Failure Treated?

Medical treatment

The goal of the medical treatment of heart failure include the following:

• Decrease the likelihood of disease progression, thereby decreasing the risk of death and the need for hospitalization
• Lessen symptoms
• Improve quality of life

How to Decrease the Likelihood of Disease Progression

• Keep your blood pressure low. In heart failure, the release of hormones cause the blood vessels to constrict or tighten. The heart must work hard to pump blood through the constricted vessels. It is important to keep your blood pressure as low as possible, so that your heart can pump effectively without extra stress.
• Schedule regular visits with your doctor or nurse.
• Monitor symptoms.
• Check for changes in your fluid status (daily weights and checking for swelling).
• Schedule regular follow-up visits with your special team of doctors and nurses. If you have questions, write them down and bring them to your appointment. Call your doctor if you have urgent questions.

What to Bring to Your Doctor Visit:

• Medication list
• Daily weights
• List of symptoms - what they are, when they occur, how long they last, and what relieves them
• Test and lab results
• Records from all doctor or emergency room visits
• Questions 

Notify all your doctors about your heart failure, medications and any restrictions. Check with your heart failure doctor about any new medications prescribed by another doctor. Keep good records and bring them with you to each doctor visit.

How to Decrease Risk of Further Heart Damage

• Stop smoking.
• Reach and maintain your healthy weight.
• Control high blood pressure, high blood cholesterol and diabetes.
• Exercise regularly.
• Do not drink alcohol.
• Have surgery or other procedures to treat your heart failure or what may have caused it.

How to Lessen Symptoms

• Maintain fluid balance
• Decrease sodium (salt) in your diet.
• Sodium is found naturally in many foods we eat. It is also added for flavoring (known as salt!) or to preserve food (make it last longer). If you follow a low-sodium diet, you should have less fluid retention, less swelling and breathe easier.
• Weigh yourself daily.
• Weigh yourself each morning, in similar clothing, after urinating, but before eating, and on the same scale. Record your weight in a diary or calendar. If you gain two pounds in one day or five pounds in one week, call your doctor. Your doctor may want to adjust your medications.
• Learn what your "dry" or "ideal" weight is.
• This is your weight without extra water (fluid). Your goal is to keep your weight within four pounds of your dry weight.

Your doctor may also ask you to:

• Drink or eat less fluids
• Keep a record of the amount of fluids you drink or eat and your urine output. Remember, the more fluid you carry in your blood vessels, the harder the heart must work to pump excess fluid through the body. A 2000 mg sodium diet and limiting fluid intake to less than 2 liters per day will help decrease the workload of your heart and prevent symptoms from recurring.

Monitor your symptoms. Call your doctor if:

• New symptoms occur
• Your symptoms worsen

Do NOT wait for your symptoms to become so severe that you need to seek emergency treatment. See "When to Call the Doctor about Your Heart Failure Symptoms".

Take your medications as prescribed.

Medications are used to improve your heart’s ability to pump blood, decrease stress on your heart, decrease the progression of heart failure (ventricular remodeling) and prevent fluid retention. Many heart failure medications are used to decrease the release of harmful hormones. These drugs will cause your blood vessels to dilate or relax (thereby lowering your blood pressure).

Common medications for heart failure
• ACE-inhibitors
• Beta-blockers
• Digoxin
• Diuretics
• Anticoagulants (blood thinners), if needed

Other medications are used to treat any associated problems, such as controlling abnormal heart rhythms, hypertension and high cholesterol.

Medications you should avoid if you have heart failure
• Non-steroidal anti-inflammatory drugs
• Most antiarrhythmic agents
• Most calcium antagonists
• Some nutritional supplements and growth hormone therapies
• Antacids that contain sodium (salt)
• Decongestants (they make your heart work harder)

If you are taking any of these medications, discuss this with your doctor.

How to Improve Your Quality of Life

• Eat a healthy diet.
• Eat less than 2,000 milligrams (2 grams) of sodium each day. 
• Eat foods high in fiber and potassium. 
• Reach and maintain a healthy weight (you may need to take in fewer calories per day).
• Limit foods high in fat, cholesterol, and sugar.
• Manage your fluids.
• Weigh yourself daily.
• Keep your weight within four pounds (two pounds lower or higher) than your dry weight.
• Limit fluid intake to 2 liters or less per day.
• Be creative in managing your thirst.
• Exercise regularly.
• A regular cardiovascular exercise program, prescribed by your doctor, will help improve symptoms, strength, and your sense of well-being. It may also decrease heart failure progression.
• Avoid heavy exercise or activities.Activities, such as pushing or pulling heavy objects, shoveling, or strenuous occupations may worsen heart failure and its symptoms.
• Prevent respiratory infections
• Ask your doctor about flu and pneumonia vaccines.
• Take your medications as prescribed. Do not stop taking them without first contacting your doctor.
• Get emotional or psychological support – if you need it.

Heart failure can be difficult for your whole family. If you have questions, ask your doctor or nurse. If you need emotional support, social workers, psychologists, clergy and heart failure support groups are a phone call away. Ask your doctor or nurse for more information.

Heart Failure and Arrhythmia Prevention Program

You may benefit from a heart failure disease management program. As part of this program, you will have frequent contact with medical professionals through office visits, telephone calls, or home monitoring. This program should help alleviate symptoms, prevent symptoms from recurring, prevent serious arrhythmias (abnormal heart rhythms), and decrease the need for emergency care or hospitalization.

This program places emphasis on increasing your knowledge of heart failure and helping you self-manage your condition. Ask your doctor for a referral to the Heart Failure and Arrhythmia Prevention Program or call for an appointment today at 216-778-BEAT.