Detailed Overview
"Heart failure" is a term used to describe the inability of the heart to pump enough blood as forcefully and vigorously as it should to provide the food and oxygen that the body cells need. It is a common condition affecting nearly five million people in the United States, and it is the most common reason for adults who are over 65 to be admitted to the hospital.
In fact, unlike many other heart conditions that are becoming less common, heart failure is on the increase. Most likely, this is because we have made great progress in the treatment of heart attacks, high blood pressure and heart valvular diseases. People are now living much longer with these conditions and as a late consequence of having these heart conditions, they are experiencing heart failure. When a person has an episode of acute congestion in the lungs due to heart failure it is called congestive heart failure.
The good news in that there have been recent major advances in the field of heart failure. Treatment formerly focused on relief of symptoms, however, now medications, devices and management programs (such as PAMF's Heart Failure Program) also help slow the progression of the disease so that people can live longer, more fulfilling lives.
One key element in this program is education. The Heart Failure Program at PAMF is designed to teach patients about their disease, explain some of the terms that are used and describe the self-care management responsibilities of each person in their treatment.
Circulation
Your heart functions as a pump. The right side of the heart collects blood from the body and pumps it to your lungs where it receives fresh oxygen. Oxygen is a vital fuel for the body cells. From there, the blood flows to the left side of the heart and is then pumped out around the body again. The heart has its own timer that tells the heart muscle when to tighten up and squeeze the blood out of the heart to the body. When your pulse is taken, that is measuring how many times a minute the heart is squeezing to pump the blood out. When your blood pressure is measured, it measures how hard the heart has to work to get the blood out into the circulatory system.
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Causes of Heart Failure
Anything that causes the heart muscle to pump less efficiently will cause problems throughout the entire body. All body systems depend on the blood supply to bring fuel and nutrients. The most common cause of heart failure is coronary artery disease. People who have had one or more heart attacks have areas of scar tissue in the heart muscle that do not contract well. This leads to changes in the shape of the heart and to an overall weakness and inefficiency of the heart pumping action.
Other people develop heart failure because they have a condition known as cardiomyopathy. This is a condition where the muscle damage is caused by a genetic condition, an unknown injury, alcohol or drug abuse, or by some of the medicines used to treat cancer and other diseases. The muscles stretch out in their weakened state and are unable to squeeze the blood out as forcefully.
A third common cause is valvular heart disease. The heart has four valves, which separate the different chambers of the heart. The valves are normally one way and keep the blood moving forward, however sometimes the valves begin to leak blood back into the previous chamber. This causes enlargement of the heart chambers and eventually the heart is less able to pump effectively.
High blood pressure that goes untreated or under treated for a long period of time can also cause the heart muscle to grow very stiff, then slowly weaken and lose its pumping force.
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Common Symptoms
As the heart begins to pump blood less well, the body starts sending out alarm messages. These alarm messages trigger compensating actions to try to correct for the lowered amount of blood getting pumped out. The body is trying to compensate for what it recognizes as a decrease in amount of blood. If the person were injured and losing blood, these coping mechanisms might help the person survive; however with heart failure they only aggravate the problem.
One coping response of the body is to increase the heart rate. If the heart can not pump out enough blood with one squeeze, pumping faster may make up the difference. Another response is triggered in the kidneys. A hormonal message is sent signaling that not enough blood is getting to the kidneys, and the kidneys begin to save water and sodium so that there is more fluid volume in the body. Lowered blood pressure triggers the release of substances called catecholamines which cause blood vessels to narrow or constrict. This helps raise the blood pressure so that the brain and other organs will get enough blood.
A situation is created in which the body attempts to help the person survive what the body interprets as a blood loss emergency. The body increases body fluid volumes, increases blood pressure, and increases heart rate. This increases the workload of the already weakening heart and it starts to dilate even more and pump even less forcefully, thus triggering the cycle to continue. The fluid retention can cause people to have leg swelling called edema. When it accumulates in the lungs due to the increased pressures inside the heart it causes cough, breathlessness and at times chest discomfort. Low blood pressure causes lightheadedness, fatigue and cool extremities. Low heart output causes breathlessness with exertion, weakness, and fatigue. People who have heart failure often have some or all of the following symptoms:
Symptoms -- How someone describes this:
Fatigue
"Too tired"
"Run out of steam"
"Get pooped right away"
"The next day, I'm wiped out"
Shortness of breath
"Can't catch my breath"
"Can't take a full breath"
"Start gasping"
"Breathing too fast"
Edema
swelling
"Legs feel tight"
"Ankles get fat"
"Shoes are too tight"
Paroxysmal nocturnal dyspnea
severe shortness of breath
"I wake up choking"
"Feel like I'm smothering"
"Coughing wakes me"
Orthopnea
shortness of breath when laying down
"I have to get up for air"
"I'm uncomfortable in bed"
"I feel better with my head up''
Abdominal distention
"I get bloated"
"My belly swells up"
"I can't buckle my belt"
"I fill up right away"
Weight gain
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Diagnosing Heart Failure
If a patient comes to the doctor with some or most of the symptoms of heart failure, the physician will try to determine what might be the underlying cause or causes of the heart losing its ability to pump as well. One common test is to order a chest X-ray to look for fluid build up in the lungs and a larger than usual heart. Another common test is an EKG or electrocardiogram to look at how regularly the heart is beating and whether there is any evidence that the heart muscle has areas that are not getting enough oxygen. The doctor may order an echo to look at the thickness and movement of the walls of the heart chambers, and the functioning of the heart valves that separate the different heart chambers. Another common test is performed in the Nuclear Medicine Department and involves injecting dye in order to more accurately measure the amount of blood that the heart is able to pump out with each beat as well as look at how well the valves and the heart muscles work.
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Treatment
Medications
Treatment of heart failure requires a cooperative partnership of the patient and the health team. Because this is a chronic problem, adjustments will need to be made frequently to keep the heart pumping as effectively as possible and the clinician relies on the patient to make observations of changes in symptoms and body weight. It is very helpful for you to know the names, doses and schedule for your medications. Carrying a list with you in your wallet or purse will help your health care providers make adjustments based on what you are currently taking. Allowing oneself to run out of medications may be life threatening! Try to keep at least a seven day supply on hand and give your pharmacist several days to obtain refill orders.
Medications are used to block the body alarm messages and to help promote effective heart pumping. There are several types of medications commonly used:
ACE inhibitors
ACE stands for Angiotensin-converting Enzyme Inhibitors. These medications are vasodilators that help to keep the blood vessels from narrowing and driving the blood pressure up. The lower pressure helps keep the blood moving out of the heart so that the weakened muscles do not have to pump as hard. In large scale clinical trials of both symptomatic and asymptomatic patients, ACE inhibitors have been shown to improve quality of life and prolong survival.Diuretics
These medications enhance urine output to help alleviate the fluid overload. Potassium supplements are often used with some diuretics that cause the body to lose potassium with the extra fluid.Digoxin
This medication is used to help the heart muscle pump more forcefully which helps the blood flow out of the heart and around to the body cells that need the oxygen and nutrients. It is also used for people that have rapid or irregular heartbeats.Beta-blockers
These medications are used to prevent the heart rate from speeding up and to help lower the blood pressure so that the heart can pump the blood out to the body against less resistance.Spironolactone
This medication has been recently noted to help block the alarm messages that the kidneys send out and may help slow the disease process when used along with ACE inhibitor medications.Diet
Most people who have heart failure need to restrict how much salt or other sodium containing products are in their diet. This is because sodium makes the body retain water which goes into the circulatory system and makes the heart work harder to pump the extra volume around. Many people also find they also have to cut down on how much liquid they drink. Restricting the salt and other sodium containing foods to 2000 mg. daily is often recommended as is limiting fluids to 2 quarts daily. Your health care providers should help you determine how much of a restriction is necessary.
People who have heart failure due to coronary artery disease or narrowing of the blood vessels, may also need to restrict the amount of fats that are in their food.
There are many good books available to help you prepare flavorful, low-salt, low-fat foods at home. A dietitian is also available at the Palo Alto Clinic to advise you. Getting good information is particularly helpful if you eat out frequently or rely on frozen prepared foods.
Weight Monitoring
An early warning signal that the heart is not able to pump effectively, is rapid weight gain. This indicates that the body is retaining fluid. Everyone who has heart failure needs to weigh themselves regularly. Purchasing a scale that is easily readable is a crucial step in maintaining your health. Get into the habit of weighing yourself each morning when you get up, after emptying your bladder. You can have light pajamas on or no clothes as long as you do it the same way every day. Write it down on a calendar kept in the bathroom next to the scale. Weight gains of three to five pounds in two to three days usually indicates extra fluid is accumulating and your medications may need adjusting. Review the symptoms of congestive heart failure. Do you notice anything new? Weight gains usually precede worsening symptoms of heart failure. This is the time to check in with your health care provider, before things get out of hand and emergency measures are necessary.
Activity
In the past, people with heart failure were advised to rest and take life as easy as possible. We now know that some activity each day helps you stay healthier and feel better. Most people are able to gradually increase their activity level with regular walking or other exercise programs that have been approved by your doctor. You will need to monitor your symptoms. A good rule of thumb is that you should be able to carry on a normal conversation without being short of breath in any activity you do. If you begin to feel like it is beginning to be difficult, stop. You should not feel exhausted after exercising. Listen to your body. If you are wiped out the next day, you did too much. It may help to divide your activity into several shorter periods. On good days, try to get outdoors or walk around some. Your health care provider can help you figure out how much activity is advisable.
Relaxation
Having a chronic disease is stressful. It may require you and anyone you live with to make many changes in the ways you are used to living. Some people react to all these changes by feeling depressed. Others pretend that nothing has changed and continue lifestyles that further reduce the heart's pumping abilities. You may not like to have to ask for help with things that used to be easy for you. Family members may nag you or worry excessively over you. Learning techniques to slow your breathing down and calm yourself may reduce the workload on your heart. Talking to other people who have similar changes going on may give you a good deal of support. Attending the monthly meeting held at hte Palo Alto Clinic allows you to learn more about heart failure and to share your concerns in a supportive setting.
Other Treatments
In some people, the heart needs assistance in maintaining its rhythm. Pacemakers can be used to keep the heart from beating too slow. Sometimes a biventricular pacemaker is used to help both sides of the left pumping chamber to contract at the same time. This improves the flow of blood from the heart. A defibrillator can be used to terminate abnormally fast heart rhythms.
Other treatments that are used in certain cases are corrective surgeries or procedures to open blockages in the arteries that supply the heart muscle. Repairing or replacing heart valves may help heart failure.
Be a partner in your care!
You know your own body best. Work with your doctor to help keep your heart pumping as well as it can. Being an active participant in the management of your health will help you feel more in control of your life and may help you to avoid trips to urgent care and the emergency room. We welcome your input as to what topics you would like to have covered in our monthly meetings. The heart failure program is coordinated by Dody Lapworth, N.P.
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