Heart Failure

Heart failure is quite different from a heart attack. Heart failure is not a disease by itself but a constellation of various signs and symptoms caused by a wide variety of disorders that includes valvular, heart muscle, pericardial (covering layer of heart) and other non-cardiac (unrelated to heart) diseases. The onset and severity of the symptoms of heart failure depends on the nature of the underlying cardiac disease and the rate at which this develops.

Heart failure is a problem on the rise as –

• Ageing population is on the increase.
• There are better diagnostic facilities and increased awareness of the public.
• More cardiac patients are able to survive & live longer with their diseases.
• Heart failure is the most common diagnosis in hospital patients aged 65 years and older.

How severe and life threatening is heart failure?

The presentation of heart failure may be sudden (acute) or over a period of time (chronic). Heart failure can occur with normal pumping capacity of heart but where there is still a failure to relax normally (diastolic heat failure where ejection fraction or pumping capacity is near normal). It can also occur due to poor pumping capacity of the heat (systolic heat failure). It becomes an emergency when the patient presents with acute heart failure and when it occurs in the background of angina or heart attacks or with severe high blood pressure.

What are the symptoms of heart failure?

Most of the symptoms and signs of heart failure are due to congestion and fluid collection in the lungs, legs, abdomen etc and the inability of the heart to pump efficiently to meet the demands of the organs and tissues in the body. There is a mismatch between demand and supply. There could be breathlessness, which could be an exaggerated uncomfortable awareness of breathing.

The description of this sensation is various:

• Air does not go all the way down
• shortness of breath
• Heavy breathing
• Tightness in chest
• Choking
• Air hunger

This may come on during exertion in early stages of the disease but may occur at rest when the disease is advanced. There could be breathlessness occurring in lying posture that is relieved on sitting up. Patients state that they have to sleep on three or more pillows to feel comfortable at night. And then there could be what we call in technical parlance as Paroxymal Nocturnal Dyspnoea (PND) which usually starts 2 -4 hours after onset of sleep. Patients develop cough and sweating with breathlessness, which is relieved by getting out of bed. Fatigue and impaired effort capacity are other prominent symptoms of heart failure. Patients may also report abdominal fullness, leg swinging, nausea and loss of appetite.

How does heart failure get diagnosed?

The physician diagnoses heart failure based on the symptoms that the patients present with and the signs he observes while he examines the patient. The patient may have prominent neck veins, leg swelling, may appear breathless, have increased heart rate and respiratory rate, cold clammy hands and feet, enlargement of liver, wheezing etc.

Once the clinical suspicion of heart failure is entertained, certain tests are carried out to ascertain the presence and cause of heart failure. In a new patient with suspected heart failure a blood test is done to assess BHP (Brain Natriuretic Peptide); if it is raised more than 100 pg/ml, there is a strong possibility of heart failure. ECG and Chest X ray are routinely done and an echo cardiogram reveals the functioning of the heart. A nuclear scan of the heart called MUGA scan accurately assesses the pumping efficacy of the heart. An evaluation for precipitating factors is also done, with specific tests to rule out reversible causes such as metabolic or hormonal disturbances and infection.

What are the modalities of treating heart failure?

The treatment consists in removing the underlying cause, removing the precipitating factors and containing the disease. General measures include rest, administration of O2, sedation, salt and fluid restriction. Drugs that

• decrease the fluid overload (diuretics)
• decrease the filling pressures within the heart (nitroglycerine)
• decrease the stress on the heart (vasodilators)
• improve or strengthen heart muscle performance (Digoxin & inotropes)
• improve or prevent adverse changes in the heart (ACE inhibitors and AT II blockers)
• improve survival and decrease need for hospitalization and prevent sudden death (B blockers)
• prevent dysrhythmia (antiarrhythmic agents)
• prevent blood clotting (antiplatelets, anticoagulants) are the mainstay of drug treatment of heart failure. Drugs to treat Hypertension, Diabetes and Coronary artery disease are also given as and when required.

Surgical treatment includes treatment for ischemia (Coronary Artery Bypass Graft surgery), valvular disease surgery to restore heart size and geometry and ventricular assist devices. Heart Transplantation is the last option.

Can pacemakers help in this condition?

The loss of synchronized contraction of the left and right ventricle of the heart in a patient with heart failure can be rectified by implanting a pacemaker (Triple chamber pacemaker) which improves the overall pumping efficacy of the heart by making the right and left sides of the heart contract in a synchronized manner. This cardiac resynchronization therapy (CRT) gives symptom relief, improves survival as well as decreases the number of hospitalizations in a patient with heart failure. Heart failure management is complex. It needs a multidisciplinary approach, which includes patient education, dietary advice, review by cardiologist, medication dose adjustment and home visits to ultimately deliver cost effective treatment to reduce morbidity and recurrent hospitalization.