| FACTS
ABOUT HEART FAILURE
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 Glossary
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.
Is there only one
type of heart failure?
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.
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. 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.
What causes heart
failure? 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.
What are the symptoms?
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
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. 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).
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.
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.
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 (Vasotec, Capoten, Zestril,
Monopril) - 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. Digoxin (Lanoxin) -
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 (Lasix, Bumex, Demadex, Zaroxolyn)
- 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 (Nitrodur)
- 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. Beta Blockers
(Coreg, Toprol) - These drugs improve the efficiency with which
the heart beats and reduce the bad effects which the failing heart
has upon the kidney.
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
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 product
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.
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; o 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
Developing new therapies, especially those based
on early signs of heart failure. Making
The Most Of Your Doctor Visit
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.
1. Briefly describe your symptoms, even those
you feel may not be important. You may want to keep a list so you
will remember them.
2. Tell the doctor all of the medications
you take--including over-the-counter drugs--and any problems you
may be having with them.
3. 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.
4. Find out what side effects are possible
from any drug the doctor prescribes for you.
5. 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 Dr. Stratienko's office
to get the information you need.
GLOSSARY
Angiotensin converting enzyme (ACE) inhibitor–A
drug used to decrease pressure inside blood vessels.
Arrhythmia--An irregular heartbeat.
Cardiomyoplasty--A surgical procedure
that involves detaching one end of a back muscle and attaching it
to the heart. An electric stimulator causes the muscle to contract
to pump blood from the heart.
Congestive heart failure--A heart
disease condition that involves loss of pumping ability by the heart,
generally accompanied by fluid accumulation in body tissues, especially
the lungs.
Diastolic heart failure--Inability
of the heart to relax properly and fill with blood as a result of
stiffening of the heart muscle.
Dyspnea--Shortness of breath.
Echocardiography--Recording sound
waves bounced off the heart to produce images of the heart.
Edema--Abnormal fluid accumulation
in body tissues.
Electrocardiogram (EKG or ECG)--Measurement
of electrical activity associated with heartbeats.
Heart failure--Loss of blood-pumping
ability by the heart.
Left ventricular assist device--A
mechanical device used to increase the heart's pumping ability.
Pulmonary congestion (or edema)--Fluid
accumulation in the lungs.
Sudden cardiac death--Cardiac arrest
caused by an irregular heartbeat.
Systolic heart failure--Inability
of the heart to contract with enough force to pump adequate amounts
of blood through the body.
Valves--Flap-like structures that
control the direction of blood flow through the heart.
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