Heart Failure

Heart failure, also known as congestive heart failure, occurs when your heart muscle fails to pump enough blood to fulfill the needs of your body. It may be caused by conditions such as narrowed heart arteries (coronary artery disease) or high blood pressure. These conditions can cause excessive weakening or stiffening of your heart muscle making it difficult for your heart to pump blood efficiently. Conditions that lead to a heart failure may or may not be reversed but lifestyle modifications such as exercise, limiting salt intake, reducing stress and losing weight can improve quality of life.

Heart transplant has become common today. The heart transplant has become necessary for some people who in spite of having good health, have heart failure due to the minor or major heart problems that puts their lives at risk. The healthy people can replace their weak heart with a possible strong and disease-free heart to live longer.

Heart failure can be prevented by controlling underlying causes such as coronary artery disease, high blood pressure, diabetes, or obesity.

Heart failure can be avoided by a timely heart transplant surgery the moment the heart becomes weak. Heart transplant is possible with a donor’s healthy heart.

The first heart transplant surgery took place in 1967 and it has since been promising for people suffering from heart problems. Heart transplant has changed the way of life for the people suffering from heart diseases. The new advanced techniques have changed the in last four decades completely. Today, more than 2,000 heart transplants are taking place every year. Thousands of people are seeing the benefits of new scientific techniques and enhanced medical technology.

Why are heart transplants performed?

Heart transplants are mainly considered when heart failure is severe and does not respond to any treatment or therapy. If the person is in good health and does not have any other physical problem except for the heart, then heart transplant might be suggested.

Heart transplant can be successful in the following cases:

• Dilated cardiomyopathy
• Severe coronary artery disease with scarred heart tissue from a heart attack
• Birth defects of the heart

Doctors will evaluate the patient and his or her physical condition and the condition of the heart. It is essential to determine the exact cause of the heart failure and the possibilities of successful heart transplant. The patient needs to undergo certain tests and complete medical examination before the doctor decides to suggest a heart transplant. Cardiac surgeons are specialized in studying the heart and also in the person’s ability to handle the change. The doctor generally considers those who are suffering at an advanced stage but are otherwise in good health.

Before a heart transplant

Before you, your family member, and your doctors come to suggest a heart transplant, you should ask yourself the following questions:

• Have you tried all other types of therapies before you decided on a heart transplant?
• Will you able to live without a heart transplant?
• Are you in good health except for heart disease?
• Will you able to live life with regular medical tests, drug treatments, and frequent hospital visits after the heart transplant surgery?

If the answers for the questions is no for any or all the above asked questions, then you should reconsider. Also, if you are already suffering from many other major and complicated diseases, then consider that as well. Even those who are suffering from obesity, infections, and inflammations are not considered at all for a heart transplant.

The process for getting a heart transplant

In order to get a heart transplant, you have to pass rigorous tests. There are several screening tests and medical examinations which you have to undergo. Before the heart surgery there is complete review of your health and it will be considered and studied by the team of of heart doctors, nurses, social workers, and bioethicists who review your medical history and the details of diagnostic test results. The goal by the doctors and other professionals is to make sure that you will lead a better and longer life after the surgery takes place.

Once you are ready for the surgery, then you have to wait for the donor who will donate the heart for you. it is sometimes a long and stressful process which certainly requires patience and complete support from the people around you, including your family and friends. The health care team will support you completely and keep monitoring your health condition and your activities closely. The team of doctors will work hard to keep the functions of the body and the heart in complete control. The hospital staff should know how to contact you when the heart is available for the transplant.

How are donors found for heart transplants?

The heart donors for the transplant are the generally people who have died recently, or those who have suffered from brain death. Brain death is the condition of the body when the brain has lost all senses and does not recover at all. The brain-dead person is likely in a comatose state and will remain unconscious.

Such tragic incidents happen when the person dies suddenly. The donors give permission for organ donation before death and the family members give consent for the organ donation and transplant.

The heart organ to be transplanted should be made available to the best possible match based on blood type, body size, and medical condition of the recipient. There is no bearing for race or gender of the donor. Once specifications of the heart are identified and matched with the recipient, only then can the heart can be successfully transplanted. The surgery takes place and within 2- 4 weeks of the surgery the patient can return to his or her normal activities. But there are many restrictions, so careful and cautious monitoring will be done by medical experts. This helps in resolving any difficulties the patient may face.

Heart failure may present with the following signs and symptoms:

• Short, rapid breath (dyspnea) due to exertion or while lying down
• Tiredness and weakness 
• Swollen legs, ankles and feet (edema)
• Racing heartbeat 
• Decreased exercise capacity 
• Persistent cough or wheezing
• Coughing up white or pink blood-tinged phlegm
• Increased frequency of urination, at night 
• Accumulation of fluid in your abdomen (ascites) 
• Sudden weight gain as a result of fluid retention 
• Decreased appetite 
• Nausea 
• Concentration problems or reduced alertness 
• Severe shortness of breath that occurs suddenly and coughing up pink, foamy phlegm
• Chest pain if heart failure is the result of heart attack

Heart failure can occur all of a sudden (acute) or may progress gradually (chronic).

When to see a doctor

Visit your doctor if you suspect your signs or symptoms are caused by heart failure. Ask for immediate care if you experience:

• Pain in chest 
• Fainting or severe weakness 
• Racing heartbeat along with shortness of breath, chest pain or fainting 
• Severe shortness of breath that occurs suddenly and coughing up pink, foamy phlegm

Similar signs and symptoms may be produced by other serious heart and lung conditions. Therefore, leave it to your doctor or other health care providers who will come to the correct diagnosis. Worsening of existing symptoms or appearance of new signs and symptoms in a person previously diagnosed with heart failure means the existing condition is getting worse or non-responsive to treatment. If you have such a condition, talk to your doctor immediately.

Heart failure is caused by the weakening or stiffening of heart secondary to other conditions. If you have heart failure, your ventricles (pumping chambers of your heart) become so stiff that they cannot accommodate sufficient blood between beats. In other cases, your heart fails to pump blood efficiently as a result of a damage or weakening of your heart, and dilated ventricles.

An ejection fraction provides an important measure of how well your heart is pumping. Ejection fraction can also guide treatment as well as help to classify heart failure. It can be measured by nuclear medicine tests, cardiac catheterization and cardiac MRI. Normal value of ejection fraction is 50% or higher, which means your ventricle pumps out more than half of the filled blood in each beat. But a normal ejection fraction does always rule out a heart failure. This occurs when heart muscle is stiffened due to conditions such as high blood pressure. The term "congestive heart failure" refers to accumulation of excessive blood in various parts of the body such as liver, abdomen, lower extremities and lungs but not all heart failures cause blood build-up. Heart failure can develop in the left side (left ventricle), right side (right ventricle) or both sides of your heart. Heart failure typically involves the left ventricle, your heart’s major pumping chamber. 

Heart failure classification:

• Left-sided heart failure: Characterized by congestion in your lungs and shortness of breath

• Right-sided heart failure: Characterized by congestion and swelling in your abdomen, legs, and feet

• Systolic heart failure: Characterized by limited left ventricular contraction. It indicates problem with pumping

• Diastolic heart failure (also called heart failure with preserved ejection fraction): Characterized by limited left ventricular relaxation. It indicates a filling problem 

Various conditions can weaken or damage your heart leading to heart failure. Some of them are:

• Coronary artery disease and heart attack: Reduced blood flow due to narrowing of arteries in your heart (coronary artery disease) often leads to heart failure. These arteries become narrowed due to fatty deposits in a process called atherosclerosis. When the plaques in such arteries break, blood clots are formed which limit blood supply to your heart causing a heart attack.  

• Elevated blood pressure (hypertension): Increased force on the walls of arteries increases load on your heart. This increased work load on your heart can cause thickening and eventually weakening and stiffening of heart muscle thereby reducing your heart’s pumping ability. 

• Damaged heart valves: Heart valves can be damaged by heart defects, coronary artery disease, or heart infection. Damaged valves make it difficult for your heart to pump efficiently which in the long run can weaken your heart.

• Damaged heart muscle (cardiomyopathy): Heart muscle can be damaged by diseases, infections, chronic alcoholism and cocaine or chemotherapy drugs. Other types of cardiomyopathy, such as dilated cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular noncompaction and restrictive cardiomyopathy can be caused by genetic factors.

• Myocarditis: Inflammation of the heart muscle can cause left-sided heart failure. 

• Congenital heart defects: Structural defects in heart that you are born with may cause heart failure. 

• Irregular heartbeats (arrhythmias): Abnormal rhythms of your heart may cause heart failure. 

• Other diseases: Chronic diseases such as diabetes, HIV, hyperthyroidism, hypothyroidism, or an accumulation of iron (hemochromatosis) or protein (amyloidosis) may also lead to heart failure. 

Your doctor will begin the diagnosis of heart failure by reviewing your medical history, symptoms and risk factors. He or she can conduct a physical examination to look for signs of congestion and fluid retention in abdomen and extremities.

Some tests and procedures for the diagnosis include:

• Blood tests: A sample of blood can be tested to determine if your kidney, liver and thyroid are functioning normally. It can also help to rule out other possible causes and detect a chemical called N-terminal pro-B-type natriuretic peptide (NT-proBNP). 
• Chest X-ray: Chest X-ray can show enlarged heart and accumulation of fluid in your lungs. 
• Electrocardiogram (ECG): It measures electrical impulses from your heart. Any abnormal pattern on the ECG report can indicate irregular heart rhythm and heart damages caused by a heart attack.
• Echocardiogram: It uses sound waves to create a moving image of your heart. Using echocardiogram, your doctor can differentiate systolic heart failure from diastolic heart failure. Information on your heart’s size, shape and pumping ability, defects of valves and evidences of previous heart attacks can also be obtained from echocardiogram. Ejection fraction is often measured during an echocardiogram. 
• Stress test: It measures your heart activities while you walk on a treadmill or pedal a stationary bike. The information from a stress test can help your doctor detect coronary artery disease. 
• Cardiac computerized tomography (CT) scan or magnetic resonance imaging (MRI). 
• Coronary angiogram: A catheter is inserted into arteries in your leg and gently guided to your heart. Then, a liquid dye is passed through the catheters. As the dye moves through the coronary arteries, blockages are detected using X-rays. During the same procedure, your doctor may carry out a ventriculogram which evaluates the left ventricle (main pumping chamber) and the status of heart valves. 
• Myocardial biopsy: A sample of heart muscles can be removed using a flexible biopsy cord that is inserted into your neck or groin. 

Classifying heart failure

Classifying heart failure helps to determine appropriate treatment approach. The systems of classification include:

1. New York Heart Association classification: This symptom-based classification has four categories.

• Class I heart failure: No symptoms are present. 

• Class II heart failure: You experience no difficulty performing daily activities but become tired due to exertion.

• Class III: Performing daily activities causes trouble. 

• Class IV: Most severe, you've shortness of breath even at rest.

2. American College of Cardiology/American Heart Association guidelines: This system classifies heart failure into different stages using letters A to D. It includes people who are at risk of developing heart failure. 

• Stage A: A person exhibits no signs or symptoms of heart failure even though s/he has numerous risk factors for heart failure. 

• Stage B: A person exhibits no signs or symptoms of heart failure even though s/he has heart disease. 

• Stage C: A person is experiencing or has experienced signs or symptoms of heart failure and has heart disease. 

• Stage D: A person has advanced heart failure that requires specialized treatments. 

This classification system focuses on early identification of risk factors and early aggressive treatments to help prevent or delay heart failure. 

People with heart failure need to manage their condition for their entire lives; however, treatments can improve the signs and symptoms of heart failure and prolong life. Sometimes, treating an underlying cause may reverse heart failure such as in heart failure caused by valve defects or abnormal heart rhythm. Treatments include a combination of medications, surgery and devices.

Medications

Medication when used alone or in combination with other medications can treat your condition.

The following medications are commonly used to treat heart failure: 

• Angiotensin-converting enzyme (ACE) inhibitors: Agents such as enalapril, lisinopril or captopril dilate blood vessels thereby lowering blood pressure, facilitating blood flow and reducing stress on the heart.
• Angiotensin II receptor blockers: Drugs such as losartan and valsartan provide an alternative to people who are unable to take ACE inhibitors. 
• Beta blockers: Carvedilol, metoprolol or other such drugs reduce the heart rate and blood pressure and in some cases may help to limit heart damages. 
• Diuretics: Also called water pills, these agents prevent fluid build-up by eliminating more fluid through urine. Furosemide is a common diuretic that decreases fluid build-up in your lungs and facilitates breathing. Taking diuretics can make you deficient in potassium and magnesium. So, you are recommended to have your potassium and magnesium levels checked. You may also need supplements of these minerals. Aldosterone antagonists such as spironolactone are a class of diuretic that may cause dangerous blood levels of potassium. Take care while taking potassium-rich food if you are taking these medications. 
• Inotropes: These injectable medications increase heart’s force of contraction and maintain blood pressure. These are used in severe heart failure. Digoxin (digitalis) in addition to increasing the heart’s pumping ability also slows the heartbeat. It is used in disorders of heart rhythm such as atrial fibrillation and to relieve symptoms in systolic heart failure. 

In addition to these medications, your doctor may also prescribe:

• Nitrates to reduce chest pain
• Cholesterol lowering agents like statins 
• Blood-thinners to help prevent blood clots 
• Supplemental oxygen through a mask if you are hospitalized due to exacerbation of the symptoms. Long term supplemental oxygen is needed in cases of severe heart failure.

Surgery

Surgery can be performed to treat the underlying cause. Some options include:

• Coronary bypass surgery: It is recommended if heart failure is caused by severe blockage in the arteries. The blocked artery is skipped by using blood vessels from your leg, arm or chest.
• Repairing or replacing a defective valve: Faulty heart valves can be corrected or replaced by surgeries called valvuloplasty, annuloplasty or valve replacement. 
• Heart transplant: Heart transplant can be the option of treatment in people with severe heart failure when surgery or medications don't help. The diseased heart may need to be replaced with a healthy donor heart. In people with severe heart failure, heart transplants can dramatically improve the survival and quality of life. 

Medical devices:

• Implantable cardioverter-defibrillators (ICDs): Implantable cardioverter-defibrillator (ICD): An ICD is a heart rhythm monitor that’s implanted near your collarbone. It works as a pacemaker and regulates your heart rhythm to keep it normal. 
• Cardiac resynchronization therapy (CRT), or biventricular pacing: This device discharges impulses to both the ventricles to ensure more efficient pumping action. 
• Heart pumps: These devices may be an option for those who are unable to have a heart transplant. Ventricular assist devices (VADs) are placed into the abdomen or chest and facilitate efficient pumping. 

End-of-life care for people with heart failure

For severe heart failures that do not respond to medications, and for those where a device or having a heart transplant is not possible, hospice care may be considered. Hospice care team consists of professionals who provide emotional, psychological, social, and spiritual support to terminally ill people.

The best way to prevent heart failure is to identify and reduce the risk factors.

Here are some measures to control the risk factors: 

• Quit smoking
• Don’t drink 
• Keep your blood pressure and blood sugar in check
• Exercises and stay active
• Eat a healthy diet 
• Maintain a healthy weight 
• Manage stress

Simple lifestyle changes may be of immense value in relieving the signs and symptoms of heart failure as well as in preventing exacerbation.

Here are some tips to follow:

• Quit smoking
• Monitor weight on a regular basis
• Maintain a diet rich in fruits and vegetables, whole grains, and lean proteins
• Limit fat intake. Restrict saturated fat, trans-fat and cholesterol in your diet
• Limit salt intake
• Maintain a healthy weight
• Get vaccinated for influenza and pneumonia. Consult your doctor before getting vaccinated
• Drink in moderation, if allowed
• Stay physically active. You may perform moderate aerobic exercises
• Consider joining a cardiac rehabilitation progra
• Manage stress and get enough sleep
• Do not take nonprescription medications such as ibuprofen, naproxen, and diet pills as they can worsen heart failure and cause fluid retention 
• Monitor your blood pressure regularly

There are several risks and complications associated with heart failure.

Risks

• High blood pressure
• Coronary artery disease 
• History of a heart attack 
• Diabetes: Some diabetes medications such as rosiglitazone and pioglitazone may boost the risk of heart failure
• Sleep apnea: Temporary cessation of breathing during sleep can cause reduced blood oxygen levels that increases the risk of irregular heartbeats. Both these conditions can weaken heart muscle
• Heart defects present at birth
• Diseases of heart valves 
• Viral infections 
• Excessive alcohol consumption
• Smoking or any form of tobacco use
• Obesity 
• Irregular heartbeats

Complications

• Kidney damage or failure: Heart failure reduces blood flow to your kidneys which over time can progress into kidney failure. Such kidney damage may require dialysis.
• Heart valve problems: Functions of valves may be impaired by enlarged heart.
• Abnormal heart rhythm (arrhythmias) 
• Liver damage: Heart failure can result in damages to the liver when congestion puts too much pressure on the liver. 

Heart failure is a life-threatening condition that may worsen over time even with treatment. In such case, a heart transplantation or ventricular assist device may be needed.