INTRODUCTION

Heart Failure (HF) - a condition in which a weakened heart can’t pump enough blood throughout the body. This leads to reduced quality of life, frequent hospitalization and high mortality. Although Heart Failure, like other heart ailments, has been acquiring epidemic proportions in India in the recent past, it has not received adequate public attention.

Heart Failure usually can’t be cured, but thanks to advances in technology and drug discovery, it can be effectively managed and patients’ quality of life is improved. Coupled with appropriate lifestyle changes, the inexorable progression of the disease can even be arrested. Hence the importance of early diagnosis and treatment.

WHAT IS HEART FAILURE?

Heart Failure does not mean that heart has stopped working or is about to stop working. Heart Failure is a condition in which the heart becomes so weak that it has trouble pumping a normal amount of blood carrying enough oxygen and nutrients to meet the body's needs. While the word ‘failure’ sounds alarming as it implies that the heart has suddenly stopped working, the medical term actually describes a chronic syndrome that typically develops slowly.

By itself, Heart Failure is not a disease. Heart Failure develops either as a result of damage to the heart muscle (caused by coronary artery disease, infection or toxic exposure to chemicals such as alcohol and drugs) or when too much strain is placed on the heart because of years of untreated high blood pressure or an abnormal heart valve.

SIGNS AND SYMPTOMS

In the early stages, Heart Failure may not have any symptoms. In the later stages, the patient may have severe symptoms because the weakened heart is unable to pump enough oxygen-rich blood with each contraction to satisfy the body.

The most common symptoms are -

1.	Difficulty in Breathing - Fluid back up into and around the lungs can cause shortness of breath with exercise or difficulty in breathing at rest. Some people with Heart Failure must prop themselves up with extra pillows to breathe more easily.
2.	Chronic Cough - The build-up of fluid in the lungs causes the lungs to work harder. Patients may have a persistent cough or wheezing (a whistling sound in the lungs, or labored breathing).
3.	Edema - Less blood to the kidneys causes fluid and water retention, resulting in swollen ankles, legs and abdomen and weight gain. Symptoms may cause an increased need to urinate during the night.
4.	Loss of Appetite - Bloating in the abdomen may result in loss of appetite or nausea. Patients have the feeling of being “full,” even when they have not eaten for a long time. Their abdomen may become swollen or distended.
5.	Fatigue - Less blood to major organs and muscles makes one feel tired and weak. Patients find even walking difficult.
6.	Rapid or Iirregular Heartbeats - The heart may speed up to compensate for its failing ability to pump blood normally. Patients may feel palpitations, or a heartbeat that seems irregular or out of rhythm. Patients often experience a pounding sensation in the chest.
7.	Mental Confusion or Impaired Thinking - Abnormal levels of certain substances in the blood, such as sodium, or reduced blood flow to the brain can cause memory loss, dizziness or confusion.
8.	Increase in Body Weight - Also due to accumulation of fluid.
9.	Extreme Fatigue and Weakness - Due to inadequate supply of oxygen and nutrients to tissues.
10.	Cyanosis (blue color of skin), low blood pressure (hypotension), cold sweating and gradual loss of consciousness are late features of CHF

WHAT CAUSES HEART FAILURE?

Heart Failure is caused by many conditions that damage the heart muscle, including -

1.	Coronary Artery Disease - Coronary artery disease (CAD), a disease of the arteries that supply blood and oxygen to the heart, causes decreased blood flow to the heart muscle. If the arteries become blocked, the heart becomes starved of oxygen and nutrients.
2.	Heart Attack - A heart attack may occur when a coronary artery becomes suddenly blocked, stopping the flow of blood to the heart muscle and damaging it. The damaged heart muscle does not function properly.
3.	Cardiomyopathy - Damage to the heart muscle may be caused by infections or alcohol or drug abuse, pregnancy or no apparent cause.
4.	Strain on the Heart - Conditions including high blood pressure (hypertension), valve disease, thyroid disease, kidney disease, diabetes or heart defects present at birth can all cause Heart Failure.
5.	High Blood Pressure (Hypertension) - Increases the workload on heart muscle.
6.	Diseases of Valves of Heart - Improper functioning of heart valves leads to increased work load and stress on heart muscle.
7.	Diseases of Muscle of Heart - The muscle of heart is diseased and not functioning properly. It is also known as cardiomyopathy.
8.	Birth Defects of Heart - Abnormal development of heart leads to variety of structural defects, which are present since birth. Also known as congenital heart disease.

TYPES OF HEART FAILURE

Heart Failure may be of two types - left-sided Heart Failure and right-sided Heart Failure.

Left-sided Heart Failure occurs when the left ventricle cannot adequately pump oxygen-rich blood from the heart to the rest of the body. The main symptoms include shortness of breath, fatigue and coughing. There may also be lung congestion (with both blood and fluid).

Right-sided Heart Failure occurs when the right ventricle is not pumping adequately, which tends to cause fluid build-up in the veins and swelling in the legs and ankles. Right-sided Heart Failure usually occurs as a direct result of left-sided Heart Failure. It can also be caused by severe lung disease.

Heart Failure is also defined in terms of the cardiac cycle. Systolic Heart Failure means that the heart is unable to pump adequate amounts of blood during its contraction. Lung congestion and swelling (edema) of the lower extremities are typical symptoms of systolic Heart Failure. Coronary artery disease, high blood pressure and heart valve disease cause systolic Heart Failure.

Diastolic Heart Failure refers to the heart’s inability to relax between contractions and allow enough blood to enter the ventricles. Symptoms may be identical to those of systolic Heart Failure. Diastolic Heart Failure is often a precursor to systolic Heart Failure. Coronary artery disease, high blood pressure and cardiomyopathy cause diastolic Heart Failure.

DIAGNOSIS

A physician diagnoses Heart Failure after listening to the patient’s medical history, performing a physical examination and subjecting him to certain tests. The physician may refer the patient to a cardiologist, a specialist in the diagnosis and treatment of heart diseases, if the patient is suspected to be suffering from Heart Failure.

There is no single test that can diagnose Heart Failure. The patient may have to go some of the following tests -

1.	EKG (Electrocardiogram) - This test is used to measure the heart’s electrical activity. It may show if the patient has had a heart attack or if there is thickening of the walls in the heart’s pumping chambers (ventricles) or if the heart rhythms are abnormal.
2.	Chest X-ray - A chest X-ray shows if the heart is enlarged or if there is fluid in the lungs, or any lung disease.
3.	BNP Blood Test - This test checks the level of a hormone called BNP (B-type natriuretic peptide) that rises in Heart Failure.
4.	Thyroid Function Tests - These tests reveal whether an overactive or an under-active thyroid is responsible for Heart Failure.
5.	Echocardiogram - Echocardiogram enables the doctor to evaluate the size, thickness and pumping action of the heart, as well as evaluate how well the heart valves are functioning. A stress echocardiogram may also be useful in assessing how well the heart is functioning at rest and during exercise.
6.	Holter Monitor (Ambulatory Electrocardiography, EKG) Test - This test provides a continuous recording of heart rhythm during normal activity.
7.	Nuclear Heart Scan - This test provides moving pictures of the blood passing through the heart's chambers and arteries and reveals if the heart muscle has been damaged or has a blocked artery.
8.	Cardiac Catheterization - A thin, flexible tube is passed through an artery in the groin or in the arm to reach the coronary arteries. This enables the doctor to find out if there is any blockage in the arteries.
9.	Coronary Angiography - This test, usually performed along with cardiac catheterization, helps the doctor see the flow of blood to the heart muscle.
10.	Ejection Fraction (EF) Test - This test measures how well the heart pumps with each beat to determine whether it is a systolic dysfunction or Heart Failure with preserved left ventrical function.
11.	Magnetic Resonance Imaging (MRI) - MRI shows detailed images of the structures and beating of the heart, enabling the doctor to assess if parts of the heart are weak or damaged.
12.	Positron Emission Tomography (PET) Scanning - PET scanning shows the level of chemical activity in different areas of the heart. This helps the doctor determine if enough blood is flowing to the heart. A PET scan can show decreased blood flow caused by disease or damaged muscles that may not be detected by other scanning methods.
13.	Radionuclide Heart Scan.

TREATMENT

Treatment for Heart Failures aims at -

1.	Slowing its progression (thereby decreasing the risk of death and the need for hospitalization)
2.	Reducing symptoms (water retention, shortness of breath, etc.)
3.	Addressing heart rhythm disturbances.
4.	Improving the quality of life.

Heart Failure is a chronic and progressive condition that can be managed but rarely cured. Many people's symptoms and heart function will improve with proper treatment. In some cases, doctors correct Heart Failure by treating the underlying cause.

Treatments, or a combination of treatments, are selected based on the type, cause and severity of Heart Failure and the overall health and other factors such as age of the patient. Treatment may include -

1.	Lifestyle changes.
2.	Medications for Heart Failure and underlying causes, such as coronary artery disease, heart valve disease, high blood pressure and arrhythmias.
3.	Surgical procedures including heart transplantation in extreme cases.

LIFESTYLE CHANGES

If the Heart Failure has been diagnosed as mild, lifestyle changes along with medication will be effective in slowing its progression. A patient should observe the following do’s and don’ts -

1.	Eat a Healthy Diet - Eat foods high in fiber and limit foods high in fat, cholesterol and sugar. Reduce total daily intake of calories to lose weight if necessary. Stop smoking or chewing tobacco and drinking alcohol.
2.	Exercise Regularly - A regular cardiovascular exercise program, prescribed by the doctor, will help improve symptoms and strength and makes the patient feel better. It may also decrease Heart Failure progression. Avoid activities like pushing or pulling heavy objects, which worsen Heart Failure.
3.	Keep Blood Pressure Low - In Heart Failure, the release of hormones causes the blood vessels to constrict or tighten. The heart must work hard to pump blood through constricted vessels. Keep the blood pressure low so that the heart can pump effectively without extra stress. Prevent respiratory flu and pneumonia infections by undergoing vaccination.
4.	Monitor Symptoms - Check for changes in the fluid status by weighing and checking for swelling.
5.	Maintain Ffluid Balance - The more fluid one carries in one’s blood vessels, the harder the heart must work to pump excess fluid through the body. Limiting fluid intake to less than 2 liters per day will help decrease the workload on the heart and prevent symptoms from recurring.
6.	Limit Salt Intake - Follow a low-sodium diet to ensure that there is less fluid retention and less swelling and breathing is easier. Limit consumption of sodium to less than 2,000 milligrams (2 grams) each day.
7.	Take Medications as Prescribed - Medications improve the heart's ability to pump blood, decrease stress on the heart, prevent fluid retention and the progression of Heart Failure. The medications also decrease the release of harmful hormones, and dilate blood vessels and thereby lower blood pressure.
8.	See the Doctor Regularly - During follow-up visits, the doctor will find out whether Heart Failure is getting worse.
9.	Bed Rest - It is recommended for those with severe CHF. To reduce lung congestion the patient’s upper body should be elevated.
10.	Stress Reduction - Various stress reduction techniques such as meditation; relaxation response methods have a direct effect of reducing stress hormone levels.
11.	Others lifestyle changes that may reduce the symptoms of heart failure include stopping smoking or other tobacco use, eliminating or reducing alcohol consumption, and not using harmful drugs.

MEDICATIONS

Doctors usually treat Heart Failure with a combination of medications depending on the symptoms. Several types of drugs have proved useful in the treatment. The main medicines are -

1.	Angiotensin-Converting Enzyme (ACE) Inhibitors - These drugs help people with Heart Failure live longer and feel better. ACE inhibitors widen or dilate blood vessels and lower blood pressure, improve blood flow and decrease the workload on the heart. ACE inhibitors also blunt some of the effects of hormones that promote salt and water retention. ACE inhibitors can cause an irritating cough in some people.
2.	Angiotensin II (A-II) Receptor Blockers (ARBs) - These drugs have many of the beneficial effects of ACE inhibitors, but they don't cause a persistent cough. They may be an alternative for people who can't tolerate ACE inhibitors.
3.	Digoxin (Lanoxin) - This drug, also referred to as digitalis, increases the strength of the heart muscle contractions and slows the heartbeat.
4.	Beta Blockers - These drugs slow the heart rate, and reduce blood pressure and abnormal heart rhythms.
5.	Diuretics (Water Tablets) - Diuretics promote more urination and keep fluid from collecting in the body. As they decrease fluid in the lungs, the patient can breathe more easily. Because diuretics make the body lose potassium and magnesium, the doctor may prescribe supplements of these minerals.
6.	Aldosterone Antagonists - These potassium-sparing diuretics help the heart work better and reverse scarring of the heart.
7.	BiDil - This drug combines hydralazine and isosorbide dinitrate — both of which dilate and relax the blood vessels.
8.	Cardiac Glycosides (eg. Digoxin) - They strengthen and slow the heartbeat and are usually only taken in addition to other medication.
9.	Other Medications - Nitrates for chest pain (They relax and dilate the blood vessels and lower blood pressure, decreasing the workload on heart muscle) , a statin to lower cholesterol or blood-thinning medications to help prevent blood clots may be given with Heart Failure medications.

SURGICAL TREATMENT

Surgery is aimed at stopping further damage to the heart and improving its function. Procedures include -

1.	Heart Pumps - These mechanical devices, called left ventricular assist devices (LVADs), are implanted into the abdomen and attached to a weakened heart to help it pump blood throughout the body. Implanted heart pumps can significantly extend and improve the lives of some people with end-stage Heart Failure who are waiting for a new heart or who aren't qualified for a heart transplant.
2.	Pacemakers & ICDs - Implanted devices can control arrhythmias (abnormal heart rhythms) that may result from Heart Failure. Devices include pacemakers to treat a too-slow heart rate and implantable cardioverter defibrillators (ICDs) to stop a too-rapid heart rate that could be life threatening. Sometimes a biventricular pacemaker is combined with an ICD for people with severe Heart Failure.
3.	Coronary Artery Bypass Grafting Surgery - The most common surgery for Heart Failure is bypass surgery, if Heart Failure is caused by coronary artery disease and there are blockages that can be "grafted" or bypassed.
4.	Coronary Stenting - This refers to the insertion of a wire mesh metal tube called a stent into a clogged vessel to help keep it open. This usually occurs in conjunction with balloon angioplasty. Balloon angioplasty is a catheter-based procedure in which plaque is pressed back against artery walls to make more room for blood to flow through the artery.
5.	Heart Valve Surgery - Diseased heart valves can be treated both surgically (traditional heart valve surgery) and non-surgically (balloon valvuloplasty).
6.	Infarct Exclusion Surgery (Modified Dor or Dor Procedure) - When a heart attack occurs in the left ventricle (left lower pumping chamber of the heart), a scar forms. The scarred area is thin and can bulge out with each beat. The bulging thin area is called an aneurysm. When Heart Failure occurs after a heart attack, the surgeon may choose to combine bypass surgery and/or valve repair, with removal of the infarcted (dead) area of heart tissue or the aneurysm. Infarct exclusion surgery allows the surgeon to return the left ventricle to a more normal shape. Reducing the size of and reshaping the left ventricle help restore normal function to the pumping mechanism.
7.	Cardiac Resynchronization - Cardiac resynchronization is designed to correct a condition called ventricular dysynchrony in which the two lower chambers of the heart (known as the left and right ventricles) do not beat at the same time. The surgery helps the two sides of the heart beat together again and improve the heart’s efficiency. In this procedure, a biventricular pacemaker is implanted to coordinate, or synchronize, muscle contractions in the ventricles.
8.	Heart Transplant - A heart transplant is considered when Heart Failure is so severe that it does not respond to all other therapies. Heart transplants have dramatically improved the survival and quality of life of people with severe Heart Failure. But the availability of a donor heart is a big problem.
9.	Cardiac Wrap Surgery - Researchers are studying a technique that wraps a failing heart in a mesh bag, to prevent its further failure. A surgeon pulls the mesh wrap over the base of the heart and attaches it with stitches. The goal is to prevent a weakened heart from enlarging (dilating) and failing further.
10.	Enhanced External Counterpulsation (EECP) - This noninvasive technique has been used as a treatment for heart-related chest pain, and researchers are studying whether it is beneficial for people with Heart Failure. Inflatable pressure cuffs are placed on the calves, thighs and buttocks. These cuffs are inflated and deflated in sync with the heartbeat. The theory is that EECP increases blood flow back to the heart.

HOW IS ACUTE HEART FAILURE TREATED?

Acute heart failure is a condition when symptoms especially breathlessness suddenly become severe and distressing and usually requires admission to hospital. The primary cause for acute heart failure is excessive collection of fluid in the lungs that interfere with proper oxygenation of blood. It is treated with diuretic medicines that are injected directly into the vein to help remove this excessive fluid. A strong painkiller like morphine may be given to help reduce anxiety and an oxygen mask to ease breathing.

WHEN SHOULD I SEE MY DOCTER?

Initially, after the diagnosis of CHF, you will have to see your cardiologist and your GP regularly, perhaps every 4-6 weeks. You will be started on a number of drugs to reduce the amount of fluid in the body, relax the heart and relax blood vessels. Later, once you are beginning to feel better, you will only need to see your doctor every 6 months or when you feel unwell.

“This is only a general information meant for education. Treatment has to be advised and supervised by a qualified specialist”