Heart Failure (Cardiac Insufficiency)

What Is Heart Failure?

Heart failure is a weakness of the heart or the myocardium. It results in an insufficient blood supply, including the oxygen and other nutrients dissolved in it, to the body organs. The heart is also unable to guarantee sufficient return flow from the periphery. As a result, increased amounts of waste products and harmful substances remain in the body.

Heart failure is one of the most occurring chronic diseases in internal medicine. It affects around 10 percent of people over the age of 75, with the number of cases rising steadily as life expectancy increases.

The WHO defines heart failure as a syndrome of fatigue and shortness of breath with underlying heart disease.

What Are the Causes of Heart Failure?

Causes of heart failure vary. It is most commonly the result of coronary heart disease (CHD), which is usually caused by lifestyle and other factors, such as narrowed blood vessels (arteriosclerosis), which leads to an undersupply of oxygen to the heart.

Another cause is poorly controlled or untreated high blood pressure (hypertension). This increased pressure in the vessels requires the heart to work harder to pump blood out of the heart against the pressure. Since heart cells cannot duplicate, the heart has no regenerative ability like the skin; they must grow larger.

For a short time, this strategy works (compensated heart failure). The heart gets a thicker wall and can withstand the increased pressure. If this continues, the cells become even larger. The cells cannot get enough oxygen, and the heart loses its strength (decompensated heart failure).

Other causes include congenital/acquired inflammation or disease of the myocardium, valvular disease, and congenital heart defects. Lung diseases that lead to increased pressure in the bloodstream can also cause heart failure. Likewise, addictive alcohol and drug use also damage the heart in such ways.

How Does Heart Failure Manifest?

In compensated heart failure, patients rarely complain about symptoms. Shortness of breath and exhaustion usually appear only during exertion. The problem is that these symptoms in the early stage are typically dismissed as accompanying signs of old age, and a visit to the doctor does not take place, which leads to worsening symptoms over time until the stage of decompensated heart failure is reached when the symptoms already predominate at rest.

In addition to shortness of breath due to backed-up blood in the lungs (because the heart cannot move blood fast enough), there is general fatigue and exhaustion. In most cases, the body's oxygen supply is insufficient for essential consumption in the late stages.

During the day, water retention occurs in the legs (leg edema) because the heart can no longer build up enough pressure to transport the blood back against gravity. When the patient is lying down at night, there is an increased return flow of fluid, resulting in the urge to urinate at nighttime. Later, water retention may also occur in the abdomen, liver, intestines, lungs, and neck veins.

In clinical practice, heart failure is classified into four degrees of severity, according to the New York Heart Association (NYHA I-IV), in conformity with the symptoms, where grade I is corresponding to existing heart disease without physical limitations, and grade IV to a heart disease with symptoms at rest that lead to a bedridden patient.

Dieser beginnt meist mit der Anamnese (Krankheitsgeschichte). Nach den ersten Hinweisen folgt die körperliche Untersuchung. Neben dem Abhören und Abklopfen von Herz und Lunge, könne auch weitere Zeichen wie Beinödeme, Wassereinlagerung im Bauch und Pulsqualität bei der Einschätzung des Schweregrads helfen.

How Is Heart Failure Diagnosed?

In most cases, heart failure does not lead sufferers to consult an internist, cardiologist, or cardio-surgeon until the later stages.

It usually begins with a medical history. After the first indications, the physical examination follows. In addition to auscultating and percussing the heart and lungs, other signs such as leg edema, water retention in the abdomen, and pulse quality can also help assess the severity.

Another important tool for diagnosing heart failure is ECG. It is used to measure electrical currents in the heart, and typical changes associated with heart failure may be visible.

Since the symptoms are not always noticed, and neither are the visible signs in the ECG, a long-term ECG measurement may also be necessary, where the ECG device is usually worn on the body for 24 hours. After that, the data is evaluated by the cardiologist or cardio-surgeon.

In the next step, a radiologist will take an X-ray of the chest, where changes in heart size, dilated vessels of the heart and lungs, and possibly pre-existing water retention in the lungs can be seen.

An additional diagnostic tool for heart failure is echocardiography. An ultrasound image of the heart can be taken from the outside or through the esophagus (TEE = trans-esophageal-echocardiography) used to assess heart action, heart walls, heart valves, heart defects, etc.

How Is Heart Failure Treated?

The primary goal is to identify and treat the underlying disease. For example, suppose the condition is untreated high blood pressure. In that case, it can be normalized with medication and sometimes with lifestyle changes such as exercise, a healthy diet, and abstinence from nicotine.

Constricted coronary arteries in coronary heart disease can be treated to a certain extent with medication. Later, dilation of the coronary vessels with balloon dilatation (PTCA) or even a bypass may become necessary.

The treatment of the symptoms follows the treatment of the causes. Its goal is to alleviate the symptoms and to support heart function. In most cases, this disease requires lifelong medication. If this therapy option is exhausted or insufficient, the implantation of a pacemaker may also be necessary. The very last option is heart transplantation or placing so-called heart support systems.

The list of medications for heart failure is long. Therefore, the treating cardiologist or internist will take the time to find precisely the right medication for the patient. Sometimes this may require adjustment of medications.

Heart Failure Medications

ACE inhibitors, AT-1 antagonists, beta-blockers, various forms of diuretics, aldosterone antagonists, and digitalis preparations all have different starting points in the body and regulate specific channels in the heart. They serve to adjust blood pressure, increase oxygen supply to the heart, etc.

Prognosis and Life Expectancy in Heart Failure

Optimal therapy is essential for the improvement of the general condition in the context of heart failure. Since it is a chronic disease and a cure of the damaged heart is not possible, the goal is to improve the symptoms, increase the quality of life, and prevent disease progression.

Regular visits to the doctor are important to check the physical condition and the medication settings and adjust them if necessary. Never discontinue medication, even if symptoms improve!

An unfortunately common consequence of heart failure is sudden cardiac death. The damaged heart is quickly thrown out of its balance, and life-threatening cardiac arrhythmias can occur unexpectedly, which are, among others, the cause of the high mortality rate of heart failure.

Sources:

http://knhi.de (Kompetenzzentrum Herzinsuffizienz)

Herold, Gerd: Innere Medizin. Köln, Eigenverlag 2012.

Arasteh, K. ; Baenkler, H.-W. ; Bieber, C. ; et al.: Innere Medizin. Stuttgart, Georg Thieme Verlag KG 2009.