Heart failure

 

Heart failure can occur at any age. But the occurrence increases with advancing age. Heart failure is most common in older adults. In India, patients with heart failure are younger.

 

 

Males – at younger age

No sex predilection – at older age

Heart failure presents a decade earlier in our population, mainly affecting <65 years of age group with preponderance of males being twice than that of females

 

 

Global: Heart failure (HF) is a global pandemic and is increasing in prevalence. At least 26 million people worldwide are estimated to be affected.[1]

 

India: India is projected to have heart failure patients with about 1% prevalence in adult population[2] and an annual incidence of 4,91,600–1.8 million. 

 

 

Heart failure is caused by diseases that damage the heart. This damage could be a result of conditions like coronary artery disease, heart attack, diabetes, high blood pressure (hypertension), etc.

 

• Coronary artery disease:  The build-up of plaque (fatty deposits) in the arteries that supply blood to your heart muscle causes them to get narrowed. As a result of this, less oxygen and nutrient reach the heart muscle. Your heart will need to work harder in order to pump blood throughout your body.

• Heart attack (myocardial infarction): Reduced or blocked blood flow to the heart muscle causes heart attack. A part of the heart's muscle tissue dies. The damaged heart does not contract efficiently. Your heart's ability to pump blood weakens. It has to pump harder to compensate. This puts workload on your heart more than it can handle. Over several months or years, this can lead to heart failure.

• Cardiomyopathy: (heart muscle disease): Diseases of the heart muscle may lead to left ventricle dysfunction and heart failure. Thyroid disease; certain cytotoxic cancer drugs, toxic agents like ephedra, anabolic steroids, cobalt, chloroquine, etc.; thiamine deficiency due to chronic alcoholism, anorexia nervosa, AIDS, etc.; inflammation of the heart muscle (myocarditis), etc. damage the heart muscles and change the structure of your heart making it harder for your heart to pump blood to the rest of your body. In some women, during the last trimester of pregnancy or up to five months after childbirth the heart chambers enlarge and the muscle weakens and causes heart failure (peripartum cardiomyopathy).

• Valvular Heart Disease (Disease of heart valves): Rheumatic fever may permanently damage the heart valves leading to heart failure. 

• Hypertension(High blood pressure): Uncontrolled hypertension can take a toll on your heart and lead to heart failure. When the blood pressure is high, your heart has to pump harder than normal to maintain blood circulation. Eventually, the chambers of your heart get larger and weaker.

• Atrial fibrillation: Atrial fibrillation (AF) refers to the irregular and rapid beating of the heart. It is both a cause and consequence of heart failure.[3] The heart beats so fast that it is unable to properly fill up with blood to pump out to the rest of the body. The condition is associated with a three-fold increased risk of incident heart failure. The link can be other way around too. The structural and nerve-hormone changes in heart failure make the development and progression of atrial fibrillation much more likely.[4]

• Untreated congenital heart defects: At birth, the heart and its chambers may not be formed correctly. As a result, the blood flow in the heart may be blocked or may have abnormal pathways or connections. The oxygen-rich blood from your lungs mixes with oxygen-deficient blood from your body. Your body tissues do not get sufficient oxygen to sustain. The heart then compensates by working harder to supply oxygen to the rest of the body.

• Lung disease like COPD secondary to high biomass fuel use

• Excessive alcohol consumption

• Diabetes

 

There can be several factors which can lead to heart failure. Some of these risk factors are:

 

Non-modifiable factors:

• Advancing age: Some factors increase your risk of heart failure. By the time you get older, diseases you may have been suffering from for many years like coronary artery disease, diabetes, hypertension, etc. would have damaged your heart and lead to heart failure.

• Gender:  Women are at a higher risk of heart failure if they have hypertension, while men are greatly impacted if they have coronary artery disease. 

• Race/ethnicity: Race/ethnicity can be a risk factor for heart failure. Heart failure strikes young in black-skinned people, particularly men, and people of Hispanic (Spanish) origin.[5] 

• Genetic Predisposition: Growing numbers of Indians are being afflicted and genetic predisposition is one of the reasons. Indians have high levels of lipoprotein (a), a type of cholesterol, which is reported to accentuate the risk associated with other risk factors of heart failure.[6] 

• Heart disease: You are at a higher risk of heart dysfunction and heart failure if you suffer from coronary artery disease and have had any sudden incidents, such as a heart attack, that may cause damage to your heart muscle.

• Diabetes Mellitus:  Diabetes increases your risk of heart failure through several biochemical and molecular changes. It causes changes in the size, shape, structure and functions of the lower left chamber of your heart (left ventricular remodeling) and increases the stiffening of the blood vessels (vascular stiffness). Diabetes is also associated with other clinical risk factors of heart failure like higher circulating levels of triglycerides, lower HDL cholesterol concentrations, obesity, etc.

• Sleep apnea: Sleep apnea (interruption in breathing during sleep) is an important risk factor for heart failure. In sleep apnea, the cycles of intermittent interruption of airflow (apnea), reduced oxygen in the blood (hypoxia), CO2 retention (hypercapnia), large reductions in chest cavity pressure, and transient awakening from sleep (arousal) can cause surges in blood pressure and heart rate. These factors also encourage restriction of blood supply to heart muscle, death of heart muscle cells, alteration in the heart size, mass and shape, irregular heartbeat and eventually, accelerated disease progression in HF.[7] 

• Obesity: The risk of heart failure increases with increased body-mass index.[8] If you are extremely obese, you are at double the risk of heart failure as your heart has to work comparatively harder. Increased body-mass index may also cause sleep apnea, a risk factor for heart failure.

• Lifestyle factors: Unhealthy behaviors like smoking tobacco, eating high-fat diet, physical inactivity, heavy alcohol consumption etc. are important risk factors for heart failure.

 

The symptoms may start suddenly or progress gradually over weeks or months. Most of the heart failure symptoms are due to impaired function of the left ventricle. The signs and symptoms of heart failure may also result from disorders of the heart sac (pericardium), heart muscle (myocardium), lining of the chambers of the heart (endocardium), heart valves, the large blood vessels or from certain metabolic disorders. Indians with heart failure have a much higher morbidity (sickness) and fatality rates as compared to their western counterparts.

 

The most common symptoms of heart failure are breathlessness, fatigue and swelling in legs, feet, and ankles. 

• Breathlessness/dyspnea, initially on exertion: Inefficient pumping of blood causes extra fluid to build up in your body. Sometimes, fluid may accumulate in your lungs too. When the heart is not able to pump efficiently, blood leaks back to the veins of your lungs causing increased pressure in them. Fluid is pushed into the lung air spaces which reduces movement of oxygen through your lungs. These factors cause difficulty while breathing, most commonly during activity. Your breathing may be rapid and shallow (tachypnea). However, shortness of breath may progressively occur at rest or while sleeping as well. The fluid build-up in lungs can also make you cough and wake up at night. The persistent cough may be accompanied by white or blood-tinged mucus as well.

• Fatigue: You may feel very tired most of the time. Exercising can be exhausting. 

• Edema of legs: Right-side heart failure may cause swelling in the feet, ankles, legs, liver and abdomen due to fluid buildup. 

• Loss of appetite: Too much fluid in your stomach can leave you with a bloated tummy and you may not feel hungry.

• Increased heart rate: Your heart rate is increased (tachycardia) as the heart tends to beat faster in order to compensate for the decline in pumping action. Your doctor may be able to hear abnormal lung sounds or vibrations (pulmonary rales) using a stethoscope. This happens during exhalation because of rapid opening and closing small airways collapsed by fluid or because of lack of air circulation. Severe heart failure causes blood to back up in the large vein that carries blood from the lower parts of the body to the heart (inferior vena cava). This congestion increases the pressure in the inferior vena cava and liver veins. The liver becomes congested and enlarged (congestive hepatomegaly). 

• Dizziness: Low blood pressure can cause dizziness and fainting. Being chronically sick can make you feel depressed.

 

Symptoms in children: Heart failure in infants causes breathing trouble, poor feeding and poor growth. Older children may become tired quickly.

 

• Tachycardia (increased heart rate)
• Tachypnea (rapid and shallow breathing)
• Rales (abnormal lung sound)
• Pleural effusion (excess fluid around the lung)
• Elevated jugular venous pressure
• Peripheral edema (swelling in limbs due to accumulation of fluid)
• Hepatomegaly (enlarged liver)

 

There is no cure for heart failure. The damaged heart cannot heal. Hence, your heart will need some support to work better. You can manage the symptoms and improve the quality and length of your life.

Treatment of heart failure usually involves taking medications.

A medical device may be recommended to help your heart work better.

A heart transplant or other surgery may be needed in some cases of heart failure.

 

1. Angiotensin-converting enzyme inhibitors - Captopril, Enalapril, Lisinopril, Perindopril, Ramipril
2. Angiotensin receptor blockers [ARBs] - Losartan, Valsartan
3. Angiotensin-Receptor Neprilysin Inhibitors (ARNIs) - Sacubitril/valsartan
4. β Blockers - Bisoprolol, Carvedilol, Metoprolol succinate extended release
5. Diuretics – Bumetanide, Furosemide, Torsemide, Chlorothiazide, Chlorthalidone, Indapamide
6. Mineralocorticoid receptor antagonists MRAs - Aldactone, eplerenone
7. Digoxin
8. Vasodilators – Hydralazine, isosorbide dinitrate
9. Inotropic agents including Levosimendan
10. Ivabradine
11. Anticoagulants

 

Specific recommendations 

• If you have known ischemic heart disease, antiplatelet agents like aspirin should be continued.
• Anticoagulants (blood thinners) may be prescribed if you have heart failure with atrial fibrillation.
• Anticoagulants may be prescribed after a large tissue death of the heart muscle (myocardial infarction). It may also be prescribed if you have blood clot in the heart (intracardiac thrombus) or if you have had previous blockage of an artery by a blood clot (systemic embolism).
• Iron deficiency should be diagnosed and treated. If you have iron deficiency, iron supplements should be initiated.

 

1. Implantable cardioverter defibrillator (ICD)

 

ICDs are used if the lower chambers of your heart (ventricles) beat too fast, too slow, or irregularly. These devices help reset your heart rhythm. These implantable devices use small, electrical shocks to convert abnormally fast heart rate (tachycardia) to a normal rhythm and help pacing of your heart.

 

2. Cardiac resynchronization therapy (CRT)

 

Cardiac resynchronization therapy (CRT) or biventricular pacing involves insertion of a pacemaker, usually just below the collarbone into the lower chambers of the heart. Pacemakers are small, battery-operated devices that are implanted under your skin with a small wire connected to the heart. The wires monitor your heart rate and help coordinate the function of the lower chambers. When they detect irregularities in your heart rate they emit tiny electric pulses to correct them.

 

CRT may be recommended if you have heart failure and have developed irregular heart rhythm (arrhythmia). They electrically activate the lower chambers of your heart in a coordinated manner and help maintain a normal heart rate. There are two types of CRT devices — cardiac resynchronization therapy pacemaker (CRT-P) and cardiac resynchronization therapy defibrillator (CRT-D).

   

3. Left ventricular assist device (LVAD)

 

An LVAD is a mechanical pump that is surgically implanted to the heart. The device is connected to a control unit and battery pack worn outside the body. An LVAD is given to patients suffering from advanced HF when there is an irreversible damage to the heart muscle and heart function continues to worsen even after drug therapy. Long-term LVAD support can ‘rest’ the failing heart and help in reversing the changes in the size, shape, structure and functions of the heart caused by heart failure (reverse remodeling of heart muscle).[10]

 

4. Extracorporeal membrane oxygenator (ECMO)

 

It is used there is sudden worsening (acute exacerbation) of chronic heart failure. It is also a valuable assistant in caring for infants and children with heart failure. The device uses a pump to circulate blood through an artificial lung back into your bloodstream. It provides prolonged blood circulation and respiratory support allowing your heart and lungs to rest.

 

5. Radiofrequency catheter ablation

 

If you have heart failure caused by a heartbeat that’s too fast (HF with AF) a procedure called radiofrequency catheter ablation may be recommended at times to correct your heart’s abnormal rhythm. The procedure involves applying short bursts of radio waves to the area of heart muscle with faulty electrical pathway. The percentage of blood the left ventricle pumps out with each contraction (left ventricular ejection fraction) improves after ablation.

 

 

Surgery may be advised only when you have specific underlying causes. Some of the surgeries that may be performed to treat heart failure are:

 

 

1. Valvular surgery

 

If valvular heart disease (VHD) is the cause or the aggravating factor of your heart failure, surgery may be considered. Your heart failure and other medical conditions, if any, should be optimally managed prior to surgery.

 

2. Revascularization

 

Restoration of blood supply to the heart is considered if you have coronary artery disease and angina. It is achieved through two means — coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).

 

3. Heart Transplantation

 

You may need a heart transplant if you have refractory end-stage heart failure i.e. your heart muscle function continues to deteriorate despite treatment.

 

Indications to cardiac transplantation in adults[11]

• End stage heart failure—for example, ischaemic heart disease and dilated cardiomyopathy
• Rarely, restrictive cardiomyopathy and peripartum cardiomyopathy
• Congenital heart disease (often combined heart-lung transplantation required)

  

You may not be a suitable candidate for heart transplant if you are too old, or have high BMI, pulmonary hypertension, HIV, recent malignancy, poor function of the kidneys (renal insufficiency) or liver failure. In such cases ventricular assist device may be considered.

Management 

 

Management of heart failure will depend on its severity and the underlying conditions. When heart failure is diagnosed an attempt should be made to establish its cause. Timely intervention greatly improves the prospects of the condition. Heart failure can be best managed through medications, regular checkups, keeping a watch on your diet and making certain lifestyle changes.

 

Take your medicines as prescribed. Don’t miss your appointment with your doctor for regular checkups. 

 

• Limit salt intake: Salt causes retention of fluid in the body. So make sure to cut down on your salt consumption. Limit salt intake to  2-3 gm/day. In severe cases, limit salt intake to 500 mg/day. Watch out for the hidden salts in packaged food too. 

• Limit fat consumption: Replace unhealthy fats with the healthier ones. Avoid foods containing trans fats like salty snacks, cookies, deep fried eatables, frozen foods, etc. Limit intake of caffeine and soft drinks.

• Eat more fruits and vegetables.

 

• Restrict your fluid intake to 1.5 L/day.
• Keep a watch on your weight. Weigh yourself daily at same time each day. See your doctor immediately if you gain weight >2kg/week.
• Limit alcohol intake.
• Be physically active:  Be physically active. Do not follow a sedentary lifestyle. Talk to your doctor about the kind of exercise you need to do.
• Quit smoking: Kick the butt. The chemicals in tobacco can damage the function of your heart and blood vessels. Cut down on alcohol.
• Reduce your weight if you are obese.
• Avoid over the counter painkillers like NSAIDs
• Naturoceutical products like ephedrine, hawthorne, chinese herbs, etc. are contraindicated

 

Prevention of diseases that damage the heart is the best way to keep heart failure at bay. If you suffer from any of the conditions that cause heart failure, then prompt treatment and optimal management of the condition is important. Recognizing and avoiding or controlling all the factors that may lead to or contribute to heart failure can help prevent the development of the condition. Eat healthy, maintain a healthy weight, avoid agents that are toxic to heart, quit tobacco use and limit your alcohol intake. Keep yourself physically active.

 

For patients at risk of developing heart failure, screening for natriuretic peptide biomarker and early intervention may prevent the condition.

 

We understand that carrying burden of a chronic condition like heart failure is quite distressing at times. But knowing what you need to know can not only relieve symptoms but also help you achieve better results of the medicines. The need of the hour is to reinforce your determination to combat this serious condition. Just have a quick look over on this checklist: 

 

• Am I avoiding high-salt foods that may worsen swelling in my organs due to fluid retention? 
• Am I regularly monitoring my important health parameters, like heart rate?
• Am I keeping a check on my diabetes and glycemic control?
• Am I overweight, not only a concern with my esthetics but also to affect my heart health? 
• Do I follow a strict exercise regimen of at least 30 minutes 5 days a week?
• Do I take all my medications on time as and when prescribed by my doctor? 
• Am I loyal to my doctor not to hide any persisting symptoms?
• Am I skipping any follow-up with my doctor?

 

Hope you scored well. If not, you really need to improve and reappear for the test!         

  

Fact box

• Heart failure does not actually mean that your heart has stopped working
• You can slow down the progression of your heart failure with prompt treatment and good management
• Not all cases of heart failure are congestive (fluid buildup)
• Around 50% of people who develop heart failure die within 5 years of diagnosis