Signs, Symptoms and Treatment Options
By Alan M. Kaneshige, MD, FACC, FASE
Heart failure (HF) is a major healthcare issue for the United States. Because of the aging population, HF is one of the three cardiac conditions increasing in prevalence, the others being degenerative valvular heart disease and atrial fibrillation. There are 5.8 million patients with symptomatic HF in the United States and an estimated 23 million patients worldwide. Patients between the ages of 40 to 80 have a one in five chance for developing HF during their lifetime. Approximately 670,000 patients will be diagnosed with HF this year and 283,000 deaths will be attributed to HF. Acute decompensated HF will account for 1.1 million hospital admissions. In 2010, total HF costs amounted to $39.2 billion of which $21 billion was for hospitalizations alone.
To emphasize the severity of HF, it is believed that 20% of patients will die within one year of their diagnosis.
WHAT IS HEART FAILURE?
Heart failure is a cardiac syndrome, a collection of symptoms that occurs when the heart is not able to meet the metabolic needs of the body. In most cases, HF occurs when the heart is not able to pump enough blood to meet the demands of the body (reduced ejection fraction).
Normal hearts will pump out about 60% of the blood that fills the left ventricle with each heartbeat (ejection fraction 60%). Hearts with ejection fractions of less than 50% are considered impaired.
About half of HF cases are due to diastolic dysfunction, the inability of the left ventricle to fill with blood due to increased wall stiffness. In this condition, symptoms of HF occur even with normal pump function. Because of the inability of the heart to keep up with the demands of the organ systems, powerful neurohormones such as epinephrine, norepinephrine, endothelin, and aldosterone are released to maintain adequate perfusion. Persistently high levels of these neurohormones cause progressive cardiac dysfunction and ultimate failure.
WHAT CAUSES HEART FAILURE?
The causes of HF are numerous. The most common cause of HF today is coronary artery disease. Other common causes of HF include hypertension and valvular heart disease, particularly degenerative aortic and mitral valve disease.
Risk factors that contribute to the development of HF include cigarette smoking, diabetes, and obesity and obstructive sleep apnea. Prevention of HF requires early detection and treatment of these conditions.
WHAT ARE THE SYMPTOMS?
The most common symptom caused by HF is shortness of breath (dyspnea). A patient with HF will initially notice dyspnea with exertion. The effort required to cause dyspnea becomes less as HF progresses. Dyspnea may eventually occur at rest. Fatigue is another common symptom associated with HF.
Over time, the HF patient will need to keep his or her head elevated when lying down in order to breathe comfortably and not feel smothered. This symptom is known as orthopnea. The patient may suddenly awaken at night from a sound sleep with a sense of breathlessness, even panic, as lung congestion occurs because of HF. That sensation is known as paroxysmal nocturnal dyspnea.
With later stages of HF, patients will notice discomfort in the right upper quadrant of their abdomen due to swelling of the liver, leading to nausea, anorexia, and the feeling of fullness before consuming a complete meal. Abdominal bloating and lower extremity swelling are late signs of HF as these represent fluid retention and dysfunction of the right ventricle. Another sign of HF is the onset of palpitations and dysrhythmias and may lead to loss of consciousness (syncope) and possibly sudden death.
HOW IS HEART FAILURE TREATED?
Treatment for HF is based on a multi-level approach involving lifestyle changes, education, medical therapy, and close follow-up with specialists, as well as a HF specialty clinic.
Lifestyle changes are important to the successful treatment of HF. Adjustments include sodium/salt restriction to two grams or less a day, diet, regular exercise, and weight reduction. Diet therapy encompasses the American Heart Association low fat diet, the Mediterranean diet, and the DASH diet as ways to maintain adequate nutrition. Regular exercise, such as moderate paced walking 30 minutes a day, five days a week, prevents deconditioning and weight gain.
Avoiding nonsteroidal anti-inflammatory medications (NSAIDs) is important as these medications, both prescription and non-prescription, contribute to salt retention, swelling, and kidney dysfunction, all poorly tolerated by the HF patient. Advanced HF patients will even have to follow a fluid restriction of two liters or less a day to avoid fluid retention and progression of symptoms.
Medical therapy for the HF patients is a cornerstone for maintaining quality of life and to increase lifespan, as well as slow disease progression. Diuretics mobilize salt and water from the body. Angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), beta-blockers, and aldosterone inhibitors block the effects of harmful neurohormones that lead to HF progression. Physicians try to maximize these medications to approach the dosages that have shown benefit in large clinical trials.
When HF patients show progression of symptoms and failure to respond to conventional lifestyle and medical treatments, more advanced therapy can be instituted. For some patients, biventricular pacing devices improve heart function. Ultrafiltration is utilized in volume-overloaded HF patients not responding to diuretic therapy. With ultrafiltration, fluid can be removed at a controlled rate so as not to significantly impact kidney function or blood pressure.
Surgical treatment for advanced HF includes high-risk coronary artery bypass surgery to attempt to improve pump function. For HF patients with severe mitral regurgitation, mitral valve repair can reshape the failing left ventricle and improve symptoms. Left ventricular assist devices (LVADs) are now approved for select refractory end-stage HF patients for prolonging life without the possibility of transplant (called destination therapy). These LVADs are also used to bridge advanced HF patients to transplant.
The ultimate surgical therapy at this time is a cardiac transplant. Because of limited organ supply, this option is only available to very select, advanced, end-stage HF patients. The totally artificial heart remains investigational.
Heart failure is a costly and growing problem for our healthcare system. Aggressive medical therapy, lifestyle changes, and education, as well as close medical following are key features to effective treatment. Advanced treatment is available to patients with progressive disease. A combined effort is needed to adequately provide a good quality of life and survival of the HF patient.