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Heart Failure

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Ismail Munir

Overview

Heart failure is a broad term encompassing a condition where the heart&#39;s ability to pump blood is compromised, leading to inadequate circulation of blood and oxygen to the body&#39;s tissues. 
&nbsp;

As per research, an estimated 64 million people worldwide are affected by heart failure (HF). The prevalence typically varies across countries and regions, with the highest numbers reported in Central Europe and North Africa. The numbers are expected to rise further due to aging populations, increased rates of risk factors (such as hypertension and diabetes), and improved survival rates from other cardiovascular diseases<a href="#accordion">[1]</a>. In Pakistan, approximately 2.8 million people experienced heart failure in 2006<a href="#accordion">[2]</a>. 
&nbsp;

The implications of HF are far-reaching, extending to <a href="https://merisehat.pk/article/accessing-quality-healthcare-online-doctors-in-pakistan">healthcare</a> expenditures on a global scale. In 2012, the financial burden of HF was already significant, with estimated costs of $30.7 billion in the USA alone. However, this figure is predicted to undergo a staggering increase of 127%, reaching $69.8 billion by 2030<a href="#accordion">[1]</a>.

As HF prevalence continues to climb, the economic impact intensifies, posing challenges for healthcare budgets and resource allocation. 
&nbsp;

Heart failure can be classified into different types based on the underlying causes and mechanisms that lead to the condition<a href="#accordion">[3][4]</a>.The two main types of heart failure are:

<ul>
	<li>Systolic Heart Failure (HFrEF - Heart Failure With Reduced Ejection Fraction) - In this type of heart failure, the heart&#39;s ability to contract and pump blood is compromised. The left ventricle, which is responsible for pumping oxygen-rich blood to the body, becomes weakened and has difficulty pumping blood out effectively. This results in a reduced ejection fraction, which is the percentage of blood pumped out of the ventricle with each heartbeat. A normal ejection fraction is typically around 55-70%, but in systolic heart failure, it is often below 40%. Common causes include coronary artery disease, heart attacks, and cardiomyopathies. 
	&nbsp;</li>
	<li>Diastolic Heart Failure (HFpEF - Heart Failure With Preserved Ejection Fraction) - In diastolic heart failure, the heart&#39;s ability to relax and fill with blood during the resting phase (diastole) is impaired. This leads to decreased filling of the ventricles and reduced cardiac output, despite a relatively normal ejection fraction. The left ventricle becomes stiff and less compliant, making it difficult for blood to flow into the ventricle during relaxation. Conditions that can contribute to diastolic heart failure include high blood pressure, hypertrophic cardiomyopathy, and valvular heart diseases. 
	&nbsp;</li>
</ul>

Additionally, heart failure can be further classified based on its origin:

<ul>
	<li>Left-Sided Heart Failure - This type involves dysfunction of the left ventricle, leading to inadequate pumping of blood from the lungs to the rest of the body. It can result in the accumulation of fluid in the lungs (pulmonary edema), causing symptoms like shortness of breath and coughing. 
	&nbsp;</li>
	<li>Right-Sided Heart Failure - This type occurs when the right ventricle fails to effectively pump blood to the lungs for oxygenation. It often leads to fluid accumulation in the body&#39;s peripheral tissues, causing swelling in the legs, ankles, and abdomen. 
	&nbsp;</li>
	<li>Biventricular Heart Failure - Both the right and left sides of the heart are affected, causing symptoms of right-sided and left-sided heart failure. 
	&nbsp;</li>
</ul>

Signs and Symptoms

Heart failure is characterized by a range of signs and symptoms that reflect the heart&#39;s inability to pump blood effectively and meet the body&#39;s demands for oxygen and nutrients. The severity and specific symptoms can vary based on the type and stage of heart failure. Common signs and symptoms include:

<ul>
	<li>Shortness Of Breath (Dyspnea) - One of the hallmark symptoms of heart failure is difficulty breathing, especially during physical exertion or when lying down. This occurs due to fluid accumulation in the lungs, which can make it challenging to take deep breaths and get enough oxygen. 
	&nbsp;</li>
	<li>Fatigue And Weakness - The reduced ability of the heart to pump blood can lead to inadequate delivery of oxygen and nutrients to the body&#39;s tissues. This can result in feelings of <a href="https://merisehat.pk/disease/chronic-fatigue-syndrome">fatigue</a>, weakness, and decreased stamina, even with mild activities. 
	&nbsp;</li>
	<li>Swelling (Edema) - Fluid retention in the body, often noticeable in the legs, ankles, feet, and abdomen, can cause swelling. This swelling occurs due to increased pressure in the veins and the heart&#39;s reduced ability to effectively pump blood through the circulatory system. 
	&nbsp;</li>
	<li>Rapid Or Irregular Heartbeat (Palpitations) - Heart failure can lead to abnormal heart rhythms, including rapid or irregular heartbeats. These palpitations may be felt as a fluttering sensation in the chest. 
	&nbsp;</li>
	<li>Persistent Cough Or Wheezing - Fluid accumulation in the lungs can result in a chronic cough that may produce white or pink-tinged mucus. Wheezing and breathlessness can also occur. 
	&nbsp;</li>
	<li>Reduced Appetite And Nausea - Poor blood circulation can affect the digestive system, leading to symptoms like reduced appetite, indigestion, and nausea. 
	&nbsp;</li>
	<li>Increased Urination At Night (Nocturia) - Heart failure can cause fluid to accumulate in the body during the day and be reabsorbed at night when lying down, leading to increased urination during nighttime hours. 
	&nbsp;</li>
	<li>Sudden Weight Gain - Due to fluid retention, individuals with heart failure may experience rapid weight gain over a short period. 
	&nbsp;</li>
</ul>

Note: It&#39;s important to note that these symptoms can overlap with those of other medical conditions, and some individuals with heart failure may not experience all of these symptoms. Early detection and proper management are crucial to improving quality of life and preventing further complications. If someone is experiencing symptoms suggestive of heart failure, they should seek medical attention for a comprehensive evaluation and diagnosis. 
&nbsp;

Causes

Heart failure can have various underlying causes, which can lead to the heart&#39;s reduced ability to pump blood effectively. Some common causes include<a href="#accordion">[5]</a>:

<ul>
	<li>Coronary Artery Disease (CAD): Narrowing or blockage of the coronary arteries that supply blood to the heart muscle can lead to reduced blood flow and damage to the heart muscle. CAD is responsible for more than 70% of heart failure cases. 
	&nbsp;</li>
	<li>Heart Attack (Myocardial Infarction): A heart attack occurs when blood flow to a part of the heart muscle is blocked, leading to tissue damage and impaired heart function. 
	&nbsp;</li>
	<li>High Blood Pressure (Hypertension): Persistent high blood pressure puts strain on the heart, causing it to work harder and potentially leading to heart muscle thickening and weakening. 
	&nbsp;</li>
	<li>Cardiomyopathy: Various types of cardiomyopathy, such as dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy, can directly affect the heart&#39;s muscle structure and function. 
	&nbsp;</li>
	<li>Lung Diseases: Chronic lung diseases like chronic obstructive pulmonary disease (COPD) can increase pressure in the lung arteries, putting stress on the right side of the heart and potentially causing heart failure. 
	&nbsp;</li>
	<li>Heart Valve Disorders: Conditions like valvular stenosis or regurgitation can strain the heart and lead to heart failure by affecting blood flow within the heart. 
	&nbsp;</li>
	<li>Arrhythmias: Irregular heart rhythms can disrupt the heart&#39;s pumping ability and contribute to heart failure. 
	&nbsp;</li>
</ul>

Other causes of heart failure include diabetes, obesity, thyroid disorders, anemia, infections, congenital heart defects, alcohol and substance abuse, and certain medications. 
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Doctors use a combination of clinical assessment, medical history, physical examination, and diagnostic tests to screen people who are at risk for heart failure. Blood tests, such as measuring B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, can provide valuable information about the heart&#39;s function. Elevated levels of these markers can suggest heart failure. Echocardiography and ECG are also recommended for screening people at risk for heart failure<a href="#accordion">[7][8]</a>. 
&nbsp;

Diagnosis

Healthcare professionals diagnose heart failure through a combination of clinical assessment, medical history, physical examination, and a series of tests and imaging studies. These diagnostic tools help evaluate the heart&#39;s structure, function, and overall health to determine the presence and severity of heart failure.

<ul>
	<li>Medical History And Clinical Assessment - Healthcare professionals begin by gathering information about the patient&#39;s medical history, including any existing health conditions, symptoms, risk factors, and family history of heart disease. A thorough clinical assessment helps guide the diagnostic process. 
	&nbsp;</li>
	<li>Physical Examination - A comprehensive physical examination is conducted to assess signs and symptoms associated with heart failure, such as fluid retention (edema), abnormal heart sounds (murmurs), and abnormal breathing sounds. 
	&nbsp;</li>
	<li>Blood Tests - Blood tests are used to measure specific markers that indicate heart function and any underlying issues. B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels are often measured. Elevated levels of these markers suggest heart failure. 
	&nbsp;</li>
	<li>Imaging Studies - Various imaging studies provide detailed images of the heart&#39;s structure, function, and blood flow:</li>
</ul>

<ol>
	<li>Echocardiography (Echo) - This ultrasound-based test visualizes the heart&#39;s chambers, valves, and pumping function. It measures the ejection fraction (EF), a critical parameter indicating the heart&#39;s pumping ability.</li>
	<li>Electrocardiogram (ECG Or EKG) - An ECG records the heart&#39;s electrical activity. It can detect abnormal heart rhythms and signs of previous heart attacks.</li>
	<li>Chest X-Ray - X-rays provide images of the heart and lungs. Enlargement of the heart and signs of fluid accumulation in the lungs can be indicative of heart failure.</li>
	<li>Cardiac MRI - This advanced imaging technique provides detailed images of the heart&#39;s structure and function. It can reveal abnormalities, including scar tissue from previous heart attacks.</li>
	<li>Nuclear Stress Test - This test combines a stress test with the injection of a radioactive dye to assess blood flow and heart function.</li>
	<li>Computed Tomography (CT) Scan - CT scans create cross-sectional images of the heart and blood vessels, helping to identify structural abnormalities and blockages. 
	&nbsp;</li>
</ol>

<ul>
	<li>Exercise Stress Test - This test measures the heart&#39;s response to physical activity. It can reveal abnormal heart rhythms, reduced exercise tolerance, and other signs of heart problems. 
	&nbsp;</li>
	<li>Holter Monitor or Event Monitor - These devices record the heart&#39;s electrical activity over an extended period, helping to identify irregular heart rhythms that might not be captured during a brief ECG. 
	&nbsp;</li>
</ul>

The combination of these tests and imaging studies allows healthcare professionals to evaluate the heart&#39;s structure, function, electrical activity, and overall health. The collected information helps them diagnose heart failure, determine its type and severity, and create an appropriate treatment plan.

Note: If you suspect you have heart-related symptoms or risk factors, it&#39;s crucial to consult a healthcare provider for a thorough evaluation and diagnosis. 
&nbsp;

<h5>Stages Of Heart Failure</h5>

Heart failure is categorized into stages and classes to help healthcare professionals better understand its progression and severity. The stages of heart failure, as identified by the American Heart Association (AHA) are as follows<a href="#accordion">[6]</a>: 
&nbsp;

Stage A - At Risk For Heart Failure

Individuals in this stage are at risk for heart failure but do not yet have symptoms or structural/functional heart disease. Risk factors include hypertension, coronary vascular disease, diabetes, obesity, exposure to cardiotoxic agents, genetic variants for cardiomyopathy, and family history of cardiomyopathy. 
&nbsp;

Stage B - Pre-Heart Failure&nbsp;&nbsp;

People in this stage do not currently show symptoms of heart failure, but they have structural heart disease, increased filling pressures in the heart, or other risk factors. 
&nbsp;

Stage C - Symptomatic Heart Failure

Individuals in this stage experience current or previous symptoms of heart failure. The severity of symptoms can vary, and this stage is divided into classes based on the patient&#39;s limitations of physical activity. 
&nbsp;

Stage D - Advanced Heart Failure

People in this stage have heart failure symptoms that significantly interfere with daily life functions or result in repeated hospitalizations. 
&nbsp;

The classes of heart failure are defined based on the severity of symptoms using the New York Heart Association (NYHA) Functional Classification system:

<ul>
	<li>Class I - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or shortness of breath.</li>
	<li>Class II - Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath, or chest pain.</li>
	<li>Class III - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath, or chest pain.</li>
	<li>Class IV - Symptoms of heart failure even at rest. Any physical activity causes further discomfort. 
	&nbsp;</li>
</ul>

Healthcare professionals use this classification to assess the severity of symptoms, monitor progress, and determine the effectiveness of treatment for individuals with heart failure. 
&nbsp;

Treatment

Treatment options for heart failure (HF) encompass a range of non-pharmacological, pharmacological, and surgical interventions. The choice of treatment depends on the underlying cause of HF, the severity of symptoms, and the individual patient&#39;s condition. 
&nbsp;

<h5>Non-Pharmacological Interventions</h5>

<ul>
	<li>Lifestyle Changes: Including dietary modifications, weight management, sodium and fluid restriction, and smoking cessation.</li>
	<li>Physical Activity: Regular exercise under medical guidance can improve symptoms and quality of life.</li>
	<li>Fluid Monitoring: Keeping track of daily weight and fluid intake helps manage fluid retention.</li>
	<li>Symptom Management: Managing sleep apnea and other conditions that worsen HF symptoms.</li>
	<li>Comorbid Conditions: Treating underlying health issues like hypertension, diabetes, and high cholesterol.</li>
	<li>Alcohol And Drug Cessation: Avoiding substances that can exacerbate HF. 
	&nbsp;</li>
</ul>

<h5>Pharmacological Interventions</h5>

<ul>
	<li>Angiotensin-Converting Enzyme (ACE) Inhibitors: Improve blood flow, lower blood pressure, and decrease strain on the heart.</li>
	<li>Angiotensin II Receptor Blockers (ARBs): Offer similar benefits to ACE inhibitors for those who can&#39;t tolerate them.</li>
	<li>Angiotensin Receptor Plus Neprilysin Inhibitors (ARNIs): A combination medicine (sacubitril-valsartan) for certain HF cases.</li>
	<li>Beta-Blockers: Slow heart rate, lower blood pressure, improve symptoms, and enhance heart function.</li>
	<li>Diuretics: Reduce fluid buildup by promoting urination and easing breathing.</li>
	<li>Potassium-Sparing Diuretics: Aldosterone antagonists that help severe HF patients live longer.</li>
	<li>Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors: First-line treatment for HF, even in non-diabetic patients.</li>
	<li>Digoxin: Enhances heart contractility and reduces HF symptoms.</li>
	<li>Hydralazine And Isosorbide Dinitrate (BiDil): Added for severe HF when other medications haven&#39;t helped.</li>
	<li>Vericiguat: An oral soluble guanylate cyclase (sGC) stimulator for chronic HF.</li>
	<li>Positive Inotropes: Given intravenously in severe HF cases to improve blood pumping.</li>
	<li>Other Medications: Nitrates for chest pain, statins for cholesterol, and blood thinners for clot prevention. 
	&nbsp;</li>
</ul>

<h5>Surgical And Device Interventions</h5>

<ul>
	<li>Coronary Bypass Surgery: It is typically used for severely blocked arteries contributing to HF, and improves blood flow.</li>
	<li>Heart Valve Repair/Replacement: Addresses HF caused by damaged heart valves.</li>
	<li>Implantable Cardioverter-Defibrillator (ICD): Prevents complications of HF by correcting heart rhythm.</li>
	<li>Cardiac Resynchronization Therapy (CRT): Sends signals to coordinate heart chamber contractions.</li>
	<li>Ventricular Assist Device (VAD): Helps pump blood when heart function is severely impaired.</li>
	<li>Heart Transplant: Replaces a severely failing heart with a healthy donor heart. 
	&nbsp;</li>
</ul>

The treatment of heart failure is highly individualized and requires close collaboration between the patient and the healthcare team. It may involve a combination of non-pharmacological strategies, medication management, and, in severe cases, surgical interventions to alleviate symptoms, improve heart function, and enhance the patient&#39;s overall quality of life. 
&nbsp;

If left untreated, heart failure can lead to the following complications:

<ul>
	<li>Congestive heart failure</li>
	<li>Heart attack</li>
	<li>Stroke</li>
	<li>Arrhythmias</li>
	<li>Kidney dysfunction 
	&nbsp;</li>
</ul>

The following factors increase the risk of heart failure:

<ul>
	<li>Coronary artery disease</li>
	<li>Hypertension</li>
	<li>Diabetes</li>
	<li>Valve disease</li>
	<li>Smoking</li>
	<li>Obesity 
	&nbsp;</li>
</ul>

The following measures can help reduce the risk of developing heart failure:

<ul>
	<li>Limiting sodium intake.</li>
	<li>Maintaining a healthy weight.</li>
	<li>Engaging in regular physical activity.</li>
	<li>Consuming a balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats. Limiting saturated and trans fats, sodium, and added sugars.</li>
	<li>Keeping blood pressure within a healthy range by following a low-sodium diet, exercising regularly, and taking prescribed medications if needed.</li>
	<li>Managing diabetes through medication, diet, exercise, and regular monitoring.</li>
	<li>Quitting smoking. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>Heart failure is a chronic medical condition where the heart&#39;s ability to pump blood efficiently is impaired, leading to inadequate oxygen and nutrient delivery to the body&#39;s tissues.</li>
	<li>Heart failure can result from various conditions, including coronary artery disease, hypertension, cardiomyopathy, heart valve diseases, and congenital heart defects.</li>
	<li>Heart failure can be categorized as systolic heart failure (reduced ejection fraction) or diastolic heart failure (preserved ejection fraction), based on the heart&#39;s ability to contract and relax.</li>
	<li>Common symptoms include shortness of breath, fatigue, swollen legs and ankles (edema), rapid weight gain, persistent cough, and reduced exercise tolerance.</li>
	<li>Diagnosis involves a combination of medical history, physical examination, blood tests (e.g., BNP, NT-proBNP), electrocardiogram (ECG/EKG), echocardiogram, and other imaging tests.</li>
	<li>Medications like ACE inhibitors, beta-blockers, diuretics, ARBs, and ARNIs are used to improve heart function, control blood pressure, and manage symptoms.</li>
	<li>Surgical options may include coronary artery bypass grafting (CABG), heart valve repair or replacement, implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), and heart transplantation.</li>
	<li>Heart failure can lead to complications such as arrhythmias, fluid buildup (congestion) in the lungs and other organs, kidney dysfunction, and increased risk of hospitalization.</li>
</ul>

[1] Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: a comprehensive and updated review of epidemiology [published correction appears in Cardiovasc Res. 2023 Jun 13;119(6):1453]. Cardiovasc Res. 2023;118(17):3272-3287. doi:10.1093/cvr/cvac013

[2] Martinez-Amezcua P, Haque W, Khera R, et al. The upcoming epidemic of heart failure in South Asia. Circulation: Heart Failure. 2020;13(10). doi:10.1161/circheartfailure.120.007218

[3] InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Types of heart failure. 2018 Jan 25.

[4] Types of Heart Failure. American Heart Association.

[5] Hajouli S, Ludhwani D. Heart Failure and Ejection Fraction. [Updated 2022 Dec 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

[6] Classes And Stages Of Heart Failure. American Heart Association.

[7] Gallagher J, Watson C, Campbell P, Ledwidge M, McDonald K. Natriuretic Peptide-based Screening and Prevention of Heart Failure. Card Fail Rev. 2017;3(2):83-85. doi:10.15420/cfr.2017:20:1

[8] Writing Committee Members; ACC/AHA Joint Committee Members. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Card Fail. 2022;28(5):e1-e167. doi:10.1016/j.cardfail.2022.02.010