Introduction

Heart failure means your heart can't pump enough blood to meet your body's needs. This condition is also known as congestive heart failure (CHF). Many heart conditions can lead to heart failure. Conditions such as coronary artery disease or high blood pressure can affect your heart muscle, leaving it too weak to pump blood efficiently.

Conditions that lead to heart failure are usually irreversible, but in some cases, a readily treatable problem could be the cause. Medications can improve the signs and symptoms of chronic heart failure and lead to improved survival.

Signs and symptoms

Heart failure typically doesn't occur suddenly. It develops slowly, over time. It's usually a chronic, long-term condition. Signs and symptoms of chronic heart failure can include:

• Shortness of breath on exertion
  
  
• Tiredness and weakness
  
  
• Swelling of the legs, ankles and feet
  
  
• Swelling of the abdomen
  
  
• Reduced ability to exercise
  
  
• Persistent cough or wheezing with white or pink blood-tinged phlegm
  
  
• Weight gain from fluid retention
  
  
• Lack of appetite and nausea
  
  
• Irregular or rapid heartbeat

Acute heart failure

Acute heart failure suddenly affects your heart's ability to pump effectively. Signs and symptoms of acute heart failure are similar to those of chronic heart failure, but are more severe and worsen suddenly. Signs and symptoms of acute heart failure may include:

• Sudden breathlessness
  
  
• Rapid or irregular heartbeats
  
  
• Severe shortness of breath and coughing up pink, frothy sputum
  
  
• Chest pain if caused by coronary artery disease

Heart attacks, viruses that attack the heart muscle, severe infections, allergic reactions and blood clots in the lungs may cause acute heart failure. Acute heart failure can trigger rapid, uncoordinated electrical signals (fibrillation), leaving the heart virtually at a standstill. Acute heart failure is an emergency.

Causes

Heart failure often develops after other cardiac conditions have damaged or weakened your heart. Over time, the heart can no longer keep up with even the normal demands placed on it. The failing pump causes blood and fluid to back up throughout your circulatory system — your lungs, feet and ankles — and your kidneys retain excess water. This buildup of fluid is the congestive part of heart failure. Sometimes, your heart becomes weakened without explanation, a condition known as idiopathic dilated cardiomyopathy.

• Coronary artery disease and Heart attack
  Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. Fatty deposits inside the blood vessel wall called atherosclerosis limits oxygen rich blood flow and causes the heart muscle to tire easily and produce heart failure. A heart attack occurs if an unstable plaque ruptures, causing a blood clot to completely block blood flow to an area of the heart muscle. A heart attack results in the death of heart muscle, which can quickly weaken the heart's pumping ability
  
  
• High blood pressure
  In untreated or poorly controlled blood pressure your heart has to work harder than it should to circulate blood throughout your body. Over time, the heart muscle may become thicker to compensate for the extra work it must do. In some cases, the heart will enlarge and eventually the heart muscle may become either too stiff or too weak to effectively pump blood.
  
  
• Valvular heart disease
  There are four valves in your heart that keep blood flowing in the proper direction through the heart. A defective valve forces your heart to work harder to keep blood flowing. Over time, this extra work can weaken your heart and lead to heart failure. Faulty heart valves, however, can be fixed, if detected in time.
  
  
• Cardiomyopathy
  This is a type of heart disease where the muscle of the heart becomes weak. There are many causes like infections, alcohol abuse, and the toxic effect of some drugs used for chemotherapy. In addition, general diseases, such as lupus, or thyroid problems can also damage heart muscle. If a specific cause can't be found, it is referred to as idiopathic dilated cardiomyopathy.
  
  
• Congenital heart defects
  If your heart chambers or valves are malformed at birth, the healthy parts of your heart have to work harder to compensate. Certain genetic defects contribute to the risk of malformation of the heart, which in turn may lead to heart failure.
  
  
• Myocarditis
  Myocarditis is a condition where there is an inflammation of the heart muscle. It's most commonly caused by a virus and can lead to left-sided heart failure.
  
  
• Abnormal heart rhythms
  Abnormal heart rhythms may cause your heart to beat too fast or too slow. Over time, your heart may weaken leading to heart failure. A slow heartbeat may prevent your heart from getting enough blood out to the body and may also lead to heart failure.

Diseases such as diabetes, hyperthyroidism, severe anemia, hypothyroidism, chronic bronchitis/emphysema may also contribute to heart failure.

When to seek medical advice

If you experience any of the signs or symptoms associated with heart failure you must see a doctor at the earliest. Worsening signs and symptoms may require you to attend emergency room where a diagnosis of heart failure is made for the first time.

Diagnosis

A diagnosis of heart failure is made after your doctor has taken a careful medical history and physical examination. After the physical exam, your doctor may do blood tests and a chest X-ray followed by an echocardiogram.

• Blood tests
  Blood tests are done to check your thyroid and kidney function and look for indicators of other diseases that affect the heart.
  
  
• Chest X-ray
  X-ray images helps to visualise your lungs and heart. In heart failure, your heart may appear enlarged and fluid build-up may be visible in your lungs. An X-ray can also diagnose conditions other than heart failure that may explain your signs and symptoms.
  
  
• Echocardiogram
  It is an important test for diagnosing and monitoring various heart conditions. An echocardiogram uses sound waves to produce an image of your heart. This image can help doctors determine how well your heart is pumping by measuring the percentage of blood pumped out. This measurement is called the ejection fraction; normally it is about 60%.
  
  Other imaging tests may be used to measure ejection fraction, including cardiac catheterization, magnetic resonance imaging (MRI) and computerized tomography (CT).
  
  
• Electrocardiogram (ECG)
  This test records the electrical activity of your heart through electrodes attached to your skin. This test helps your doctor diagnose heart attack and heart rhythm problems that may be the cause of heart failure.
  
  
• Coronary Angiogram
  This test helps doctors identify narrowed arteries to your heart (coronary artery disease) that can be a cause of heart failure. The test may include a ventriculogram — a procedure to determine the strength of the left ventricle (the heart's main pumping chamber) and the health of the heart valves.

Classifying heart failure

To determine the best course of treatment, heart failure may be classified as follows:

• New York Heart Association scale
  
  
  • Class I
    The mildest form, you can perform everyday activities without breathlessness.
    
    
  • Class IV
    Is the most severe, and you're short of breath even at rest.

Treatment

Heart failure is a chronic disease needing lifelong treatment. However, with treatment, a failing heart can become stronger and signs and symptoms of heart failure can improve. Doctors sometimes can correct heart failure by treating the underlying cause.

Medications

Several types of drugs have proved useful in the treatment of heart failure. They include:

• Diuretics
  These are often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. The drugs also decrease fluid in your lungs, so you can breathe more easily. Because diuretics make your body lose potassium your doctor may also prescribe potassium supplements. If you're taking a diuretic, your doctor will monitor levels of potassium in your blood through regular blood tests.
  
  
• Angiotensin-converting enzyme (ACE) inhibitors
  These drugs help people with heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens or dilates blood vessels to lower blood pressure, improves blood flow and decrease the workload on the heart.
  
  
• Angiotensin II (A-II) receptor blockers (ARBs)
  These drugs have many of the beneficial effects of ACE inhibitors. They may be an alternative for people who can't tolerate ACE inhibitors.
  
  
• Beta blockers
  This class of drug slows your heart rate and reduces blood pressure. These medicines also reduce the risk of some abnormal heart rhythms. Beta blockers may reduce signs and symptoms of heart failure and improve heart function.
  
  
• Aldosterone antagonists
  These drugs include spironolactone (Aldactone.) They are primarily potassium-sparing diuretics, but they have additional properties that help the heart work better, may reverse scarring of the heart and may help people with severe heart failure live longer.
  
  
• Digoxin (Lanoxin)
  This drug increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms and improves your ability to live with the condition.

You may be hospitalized for a few days if you have a flare up of heart failure symptoms. While in the hospital, you may receive additional medications intravenously. These drugs work quickly to help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen through a mask or small tubes placed in your nose.

Surgery and medical devices

In some cases, doctors recommend surgery to treat the underlying problem that led to heart failure. For example, a damaged heart valve may be repaired or, if necessary, replaced with a new one. Coronary bypass surgery is recommended to treat severely narrowed coronary arteries that are contributing to heart failure.

• Implantable cardioverter-defibrillators (ICDs)
  ICDs are a device implanted under the skin and wired to the inside of the heart. The ICD monitors the heart rhythm. If the heart begins to beat abnormally (Ventricular tachycardia or fibrillation), the ICD shocks it back into normal rhythm.
  
  
• Cardiac Resynchronization Therapy (CRT) or Biventricular Pacing
  A biventricular pacemaker stimulates both of the heart's lower chambers (the left and right ventricles) so that they pump in synchrony and in an efficient, coordinated manner.
  
  
• Heart Transplants
  Have improved the survival and quality of life of people with severe heart failure. However, candidates for transplantation often have to wait for a long time before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment or device therapy and may not need transplant after all.
  
  
• Enhanced External Counter Pulsation (EECP)
  This non-invasive technique has been used as a treatment for angina, and patients with heart failure. Inflatable pressure cuffs are placed on the calves, thighs and buttocks. These cuffs are inflated and deflated in sync with your heartbeat and helps increases blood flow back to the heart.

Lifestyle changes

Lifestyle changes can often help relieve signs and symptoms of heart failure and prevent the disease from worsening.

• Stop smoking
  Smoking damages your blood vessels, reduces the amount of oxygen in your blood may worsen your heart failure.
  
  
• Weight
  Notify your doctor if you have a weight gain of 1.5 kg or more in a day. It may mean that you're retaining fluids and need a change in your treatment plan. Record your weight every morning, and bring the record with you to your doctor's visits.
  
  
• Restrict salt
  Sodium is a component of salt. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet. For people with heart failure the recommended sodium intake is no more than 2,000 milligrams a day.
  
  
• Fats and cholesterol
  Limit your intake of saturated fat, trans fat and cholesterol. Dietary fat and cholesterol is a risk factor for coronary artery disease.
  
  
• Restrict alcohol
  Excessive use of alcohol can directly weaken your heart muscle or increase your risk of abnormal heart rhythms that may worsen existing heart failure. Alcohol may also interact with some medications used to treat heart conditions.
  
  
• Exercise
  Moderate exercise helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. Check with your hospital to see if it offers a cardiac rehabilitation program; if it does, talk to your doctor about enrolling in the program.
  
  
• Reduce stress
  Stress is a risk factor for heart disease. If stressed, your heart beats faster and may worsen the heart failure. Try to relax and find ways to reduce stress in your life.