Heart Failure : Causes, Types, Symptoms and Medications

Heart Failure Overview

Heart failure affects about 5 million Americans. Roughly 550,000 people are diagnosed with heart failure each year. It is the leading cause of hospitalization in people older than 65.

What Is Heart Failure?

Heart failure does not mean the heart has stopped working. Rather, it means that the heart's pumping power is weaker than normal. With heart failure, blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart respond by stretching to hold more blood to pump through the body or by becoming more stiff and thickened. This helps to keep the blood moving for a short while, but in time, the heart muscle walls weaken and are unable to pump as strongly. As a result, the kidneys often respond by causing the body to retain fluid (water) and sodium. If fluid builds up in the arms, legs, ankles, feet, lungs or other organs, the body becomes congested, and congestive heart failure is the term used to describe the condition.

What Causes Heart Failure?

Heart failure is caused by many conditions that damage the heart muscle, including:

• 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 or severely narrowed, the heart becomes starved for oxygen and nutrients.
• 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. All or part of the heart muscle becomes cut off from its supply of oxygen. A heart attack can damage the heart muscle, resulting in a scarred area that does not function properly.
• Cardiomyopathy. Damage to the heart muscle. Causes include artery or blood flow problems, infections, and alcohol and drug abuse.
• Conditions that overwork the heart. Conditions including high blood pressure (hypertension), heart valve disease, thyroid disease, kidney disease, diabetes or heart defects present at birth can all cause heart failure. In addition, heart failure can occur when several diseases or conditions are present at once.

What Are the Types of Heart Failure?

Systolic dysfunction (or systolic heart failure) occurs when the heart muscle doesn't contract with enough force, so there is less oxygen-rich blood that is pumped throughout the body.
Diastolic dysfunction (or diastolic heart failure) occurs when the heart contracts normally, but the ventricle – the main pumping chamber -- does not relax properly, reducing the amount of blood that can enter the heart.
A test called the ejection fraction (EF) is used measure how well your heart pumps with each beat to help determine if systolic or diastolic dysfunction is present. The ejection fraction is a measure of the percentage of blood that your heart pumps out with each beat. Your doctor can discuss which condition you have.
In patients with systolic heart failure, the ejection fraction is less than 40%. Imaging studies such as X-ray and an echocardiogram (heart ultrasound) show the heart is enlarged and pumps out less than a normal amount of blood with each beat.
In contrast, patients with diastolic heart failure usually have a normal ejection fraction, normal heart pumping capability, but the imaging studies show that the heart does not fill up with blood properly during the heart relaxation phase that occurs between beats.

Stages of Heart Failure

In 2001, the American Heart Association (AHA) and American College of Cardiology (ACC) developed the "Stages of Heart Failure." These stages, which were updated in 2005, will help you understand that heart failure is often a progressive condition and can worsen over time. They will also help you understand why a new medication was added to your treatment plan and may help you understand why lifestyle changes and other treatments are needed.
The stages classified by the AHA and ACC are different than the New York Heart Association (NYHA) clinical classifications of heart failure that rank patients as class I-II-III-IV, according to the degree of symptoms or functional limits. Ask your doctor what stage of heart failure you are in.

Check the table below to see if your therapy matches what the AHA and ACC recommend. Note that you cannot go backward in stage, only forward.

The table below outlines a basic plan of care that may or may not apply to you, based on the cause of your heart failure and your special needs. Ask your doctor to explain therapies that are listed if you do not understand why you are or are not receiving them.

Stage	Definition of Stage	Usual Treatments
Stage A	People at high risk of developing heart failure (pre-heart failure), including people with: Hypertension Diabetes Coronary artery disease Metabolic syndrome History of cardiotoxic drug therapy History of alcohol abuse History of rheumatic fever Family history of cardiomyopathy	Exercise regularly. Quit smoking. Treat hypertension. Treat lipid disorders. Discontinue alcohol or illegal drug use. An angiotensin converting enzyme inhibitor (ACE inhibitor) or an angiotensin II receptor blocker (ARB) is prescribed if you've had coronary artery disease or if you have diabetes, high blood pressure, or other vascular or cardiac conditions. Beta-blockers may be prescribed if you have high blood pressure or if you've had a previous heart attack.
Stage B	People diagnosed with systolic left ventricular dysfunction but who have never had symptoms of heart failure (pre-heart failure), including people with: Prior heart attack Valve disease Cardiomyopathy The diagnosis is usually made when an ejection fraction of less than 40% is found during an echocardiogram test.	Treatment methods above for Stage A apply. All patients should take an angiotensin converting enzyme inhibitor (ACE inhibitors) or angiotensin II receptor blocker (ARB). Beta-blockers and an aldosterone inhibitor should be prescribed for patients after a heart attack. Surgery options for coronary artery repair and valve repair or replacement (as appropriate) should be discussed. If appropriate, surgery options should be discussed for patients who have had a heart attack.
Stage C	Patients with known systolic heart failure and current or prior symptoms. Most common symptoms include: Shortness of breath Fatigue Reduced ability to exercise	Treatment methods above for Stage A apply. All patients should take an angiotensin converting enzyme inhibitor (ACE inhibitors) and beta-blockers. African-American patients may be prescribed a hydralazine/nitrate combination if symptoms persist. Diuretics (water pills) and digoxin may be prescribed if symptoms persist. An aldosterone inhibitor may be prescribed when symptoms remain severe with other therapies. Restrict dietary sodium (salt) Monitor weight Restrict fluids (as appropriate) Drugs that worsen the condition should be discontinued. As appropriate, cardiac resynchronization therapy (biventricular pacemaker) may be recommended. An implantable cardiac defibrillator (ICD) may be recommended.
Stage D	Patients with systolic heart failure and presence of advanced symptoms after receiving optimum medical care.	Treatment methods for Stages A, B ,& C apply. Patient should be evaluated to determine if the following treatments are available options: heart transplant, ventricular assist devices, surgery options, research therapies, continuous infusion of intravenous inotropic drugs, and end-of-life (palliative or hospice) care.

Heart Failure Symptoms

What Are Heart Failure Symptoms?

You may not have any heart failure symptoms, or the symptoms may be mild to severe. Symptoms can be constant or can come and go. Heart failure symptoms are related to the changes that occur to your heart and body, and the severity depends on how weak your heart is. The symptoms can include:

• Congested lungs. A weak heart causes fluid to back up in the lungs. This can cause shortness of breath with exercise or difficulty breathing at rest or when lying flat in bed. Lung congestion can also cause a dry, hacking cough or wheezing.
• Fluid and water retention. A weak heart pumps less blood to your kidneys and causes fluid and water retention, resulting in swollen ankles, legs, and abdomen (called edema) and weight gain. This can also cause an increased need to urinate during the night as your body attempts to get rid of this excess fluid. Bloating in your stomach may cause a loss of appetite or nausea.
• Dizziness, fatigue, and weakness. Less blood to your major organs and muscles makes you feel tired and weak. Less blood to the brain can cause dizziness or confusion.
• Rapid or irregular heartbeats. The heart beats faster to pump enough blood to the body. This can cause a fast or irregular heartbeat.

If you have heart failure, you may have one or all of these symptoms or you may have none of them. In addition, your symptoms may not be related to how weak your heart is; you may have many symptoms but your heart function may be only mildly weakened. Or you may have a more severely damaged heart but have few symptoms.

How Can I Lessen My Symptoms?

To lessen symptoms:

• Maintain fluid balance. Your doctor may ask you to keep a record of the amount of fluids you drink or eat and how often you go to the bathroom. Remember, the more fluid you carry in your blood vessels, the harder your heart must work to pump excess fluid through your body. Limiting your fluid intake to less than two liters per day will help decrease the workload of your heart and prevent symptoms from recurring.
• Limit how much salt (sodium) you eat.
• Monitor your weight and lose weight if needed. Learn what your "dry" or "ideal" weight is. This is your weight without extra water (fluid). Your goal is to keep your weight within four pounds of your dry weight. Weigh yourself at the same time each day, preferably in the morning, in similar clothing, after urinating but before eating, and on the same scale. Record your weight in a diary or calendar. If you gain 2 pounds in one day or 5 pounds in one week, call your doctor. Your doctor may want to adjust your medications.
• Monitor your symptoms. Call your doctor if new symptoms occur or if your symptoms worsen. Do not wait for your symptoms to become so severe that you need to seek emergency treatment.
• Take your medications as prescribed.Medications are used to improve your heart's ability to pump blood, decrease stress on your heart, decrease the progression of heart failure, and prevent fluid retention. Many heart failure medications are used to decrease the release of harmful hormones. These drugs will cause your blood vessels to dilate or relax (thereby lowering your blood pressure).

Heart Failure - Medications

You probably will need to take a combination of medicines to treat heart failure, even if you do not have symptoms yet. Medicines do not cure heart failure. But they can help you manage your symptoms.

The goals of drug treatment are to relieve or control symptoms of heart failure, improve daily function and quality of life, slow the progression of the disease, and reduce the risk of complications, hospital stays, and premature death.

Medicines are used to treat the problems associated with heart failure, including:

• Fluid buildup, swelling, and water retention (edema).
• The reduced pumping ability of the heart.
• The effects of the body's attempt to compensate for heart failure.
• Other conditions that can lead to heart failure, such as coronary artery disease, high blood pressure, or diabetes.
• Prevention of complications, such as stroke.

It is extremely important that you take your medicines exactly as recommended by your doctor. If you don't, your heart failure may get worse or you may develop sudden heart failure. For more information, see:

 Heart failure: Taking your medicines properly.

Medicine Choices

A combination of medicines is often needed to control symptoms and slow the progression of heart failure. Some medicines are used to treat pumping problems  systolic heart failure), and others are used to treat problems with filling (diastolic heart failure). The most commonly used and effective classes of medicines are as follows:

Medicines for pumping problems (systolic heart failure)

These include:

• ACE inhibitors (angiotensin-converting enzyme inhibitors). ACE inhibitors allow blood vessels to relax and widen (dilate), making it easier for blood to flow through the vessels.
• ARBs (angiotensin II receptor blockers). Like ACE inhibitors, ARBs allow blood vessels to relax and widen (dilate), making it easier for blood to flow through the vessels.
• Diuretics. Diuretics stimulate the kidneys to remove more water and salt (sodium) from the body.
• Aldosterone receptor antagonists. These medicines cause the kidneys to get rid of extra salt and fluid, and they help hold on to (retain) potassium by inhibiting the action of the hormone aldosterone.
• Digoxin. Digoxin slows and strengthens heart contractions, enabling the heart to pump more blood with each beat.
• Beta-blockers. Beta-blockers control symptoms of heart failure by either slowing the heart rate or making the blood vessels wider so blood flows more easily.
• Vasodilators. Vasodilators lower blood pressure and reduce the workload on the heart. Vasodilators like hydralazine are often used along with nitrates.

Medicines for filling problems (diastolic heart failure)

• Beta-blockers
• Diuretics
• ACE inhibitors
• ARBs (angiotensin II receptor blockers)
• Calcium channel blockers
• Direct renin inhibitors

If your heart failure is related to another condition, such as irregular rapid heartbeats (arrhythmias), impaired blood flow to the heart muscle (ischemia), or high blood pressure, you may take specific drugs for these conditions.

• Anticoagulants thin the blood and make it less likely to clot. These drugs may help prevent strokes.
• Antiarrhythmics prevent rapid and sometimes irregular heart rhythms.
• Antianginals control chest pain (angina) caused by impaired blood flow to the heart muscle.
• Antihypertensives lower blood pressure.