Centers of Excellence in Interventional Cardiology and Radiology

INTERVENTIONAL CARDIOLOGY

Cardiac failure

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Generalities

Heart failure, sometimes known as congestive heart failure (CHF), occurs when your heart muscle doesn’t pump blood as well as it should. Conditions such as narrowed arteries in your heart (coronary artery disease) or high blood pressure gradually leave your heart too weak or stiff to fill and pump efficiently.

Not all conditions that lead to heart failure can be reversed, but treatments can improve the signs and symptoms of heart failure, increase the quality of life and also it help you live longer.

Lifestyle changes, such as exercising, reducing salt in your diet, managing stress and especially losing weight, can improve your quality of life.

The best way to prevent heart failure is to control conditions that cause heart failure, such as coronary artery disease, high blood pressure, diabetes or obesity.

Symptoms

Heart failure can be ongoing – chronic or your condition may start suddenly – acute ( in this case it can be the first sign of disease or it can be the sudden aggravating of a chronic disease).

Symptoms of heart failure include:

Shortness of breath (dyspnea) when you exert yourself or in rest or when you lie down,

Fatigue and weakness

Swelling (edema) in your legs, ankles and feet – in most cases; when cardiac failure is severe the aedema may be generalized – swelling of your abdomen (ascites), in pleural cavity ( pleural effusion ), in pericardic sack (pericardic effusion) or fluid can accumulate into lungs (condition know as pulmonary edema), wich represents a medical urgence

Sudden weight gain from fluid retention

Rapid or irregular heartbeat

Reduced ability to exercise

Persistent cough or wheezing with white or pink blood-tinged phlegm

Increased need to urinate ( especially at night)

Lack of appetite and nausea and, secondary, loss of weight and severe nutrients defficiency

Difficulty concentrating or decreased alertness

Sudden, severe shortness of breath and coughing up pink, foamy mucus

Elevated blood pressure

Chest pain – secondary to cardiac pump deficiency with poor heart muscle vascularisation or secondary to cardiac failure ( in case of coronary artery disease wich can lead even to a heart attack).
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See your doctor if you think you might be experiencing signs or symptoms of heart failure. You should seek emergency treatment when your symptoms are severe, such as:

Chest pain

Fainting or severe weakness

Rapid or irregular heartbeat associated with shortness of breath, chest pain or fainting

Sudden, severe shortness of breath and coughing up pink, foamy mucus

Although these signs and symptoms may be due to heart failure, there are many other possible causes, including other life-threatening heart and lung conditions. It’s that why you should seek for emergency treatment. Emergency room health care providers will try to stabilize your condition and determine if your symptoms are due to heart failure or something else.

If you have a diagnosis of heart failure and if any of the symptoms suddenly become worse or you develop a new sign or symptom, it may mean that existing heart failure is getting worse or not responding to treatment. Contact your doctor promptly.

Causes

Heart failure often develops after other conditions have damaged or weakened your heart. Over time, the heart can no longer keep up with the normal demands placed on it to pump blood to the rest of your body. The main pumping chambers of your heart (the ventricles) may become stiff and not fill properly between beats. Also, your heart muscle may weaken, and the ventricles stretch (dilate) to the point that the heart can’t pump blood efficiently throughout your body.

The term “congestive heart failure” comes from blood backing up into — or congesting — the liver, abdomen, lower extremities and lungs. However, not all heart failure is congestive. You might have shortness of breath or weakness due to heart failure and not have any fluid building up.

Heart failure can involve the left side, right side or both sides of your heart. Typically, heart failure begins with the left side — specifically the left ventricle, your heart’s main pumping chamber.

Type of heart failure Description
Left-sided heart failure Fluid may back up in your lungs, causing shortness of breath, your cardiac

debit decreases and signs of this include: weakness, fatigue, lower exercise

capacity, syncope, loss of weight, difficulty concentrating or decreased alertness,

anemya, palor, cianosis, sweating, renal impairment

Right-sided heart failure Fluid may back up into your abdomen, legs and feet, causing swelling.
Systolic heart failure The left ventricle can’t contract vigorously, indicating a pumping problem.
Diastolic heart failure

(also called heart failure with normal ejection fraction)

The left ventricle can’t relax or fill fully, indicating a filling problem.

Any of the following conditions can damage or weaken your heart and can cause heart failure. Some of these can be present without your knowing it:

Coronary artery disease and heart attack. Coronary artery disease is the most common form of heart disease and the most common cause of heart failure. Over time, arteries (coronary arteries)that supply blood to your heart muscle narrow from a buildup of fatty deposits, a process called atherosclerosis. Blood moves slowly through narrowed arteries, leaving some areas of your heart muscle weak and chronically deprived of oxygen-rich blood. In some cases, the blood flow to the muscle is just enough to keep the muscle alive but not functioning well. A heart attack occurs if plaques formed by the fatty deposits in your arteries rupture. This causes a blood clot to block blood flow to an area of the heart muscle, weakening the heart’s pumping ability and often leaving permanent damages.

High blood pressure (hypertension). Blood pressure is the force of blood pumped by your heart through your arteries. If your blood pressure is high, your heart has to work harder than it should to circulate blood throughout your body. Over time, the heart muscle may become thicker to compensate for the extra work it must perform. Eventually, your heart muscle may become either too stiff or too weak to effectively pump blood.

Faulty heart valves. The valves of your heart keep blood flowing in the proper direction through the heart. A damaged valve, due to a heart defect, coronary artery disease or heart infection, forces your heart to work harder to keep blood flowing as it should. Over time, this extra work can weaken your heart. Faulty heart valves, however, can be fixed or replaced if found in time.

Damage to the heart muscle (cardiomyopathy). Some of the many causes of heart muscle damage (cardiomyopathy) include infections, alcohol abuse, and the toxic effect of drugs such as cocaine or some drugs used for chemotherapy. Genetic factors play an important role in two common types of cardiomyopathy: one is hypertrophic cardiomyopathy — a condition of abnormally thick heart muscle, the other is dilated cardiomyopathy — a condition where the heart muscle is weak and the heart enlarges.

Myocarditis. Myocarditis is an inflammation of the heart muscle. It’s most commonly caused by a virus and can lead to left-sided heart failure.

Congenital heart defects (heart defects you’re born with). If your heart and its chambers or valves haven’t formed correctly, the healthy parts of your heart have to work harder to pump blood through your heart, which in turn may lead to heart failure.

Abnormal heart rhythms (heart arrhythmias). Abnormal heart rhythms may cause your heart to beat too fast. This creates extra work for your heart. Over time, your heart may weaken, leading to heart failure. A slow heartbeat may prevent your heart from getting enough blood out to the body and may also lead to heart failure.

Other diseases. Chronic diseases such as diabetes, hyperthyroidism, hypothyroidism, emphysema, or a buildup of iron (hemochromatosis) or protein (amyloidosis), beri-beri disease ( vitamin B1 defficiency), respiratory diseases (such as: sleep apnea) also may contribute to heart failure.

Causes of acute heart failure ( either as first manifestation, either as aggraveting of chronic cardiac failure) include:

viruses that attack the heart muscle

severe infections (pulmonary, renal, biliar, cardiac – myocarditis, infective endocarditis)

allergic reactions

blood clots in the lungs (pulmonary embolism)

arrhytmias or atrio-ventricular blocks

hypertensive emergencies

anaemia, beri-beri disease, arterio-venous fistulas

hypoxemia ( lack of oxygen: sleep apnea, altitude >3000m)

the use of certain medications ( antiinflammatory drugs : steroids or non-steroids, digitalis )

tyroid disfunction

inadequate treatment and lifestyle: use of salt, alcohol, excesive exercise, inadequate medical treatment

Risk factors

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A single risk factor may be enough to cause heart failure, but a combination of factors also increases your risk. Risk factors include:

High blood pressure

Coronary artery disease

Heart attack

Diabetes – having diabetes increases your risk of high blood pressure and coronary artery disease.

Some diabetes medications. The diabetes drugs rosiglitazone (Avandia) and pioglitazone (Actos) have been found to increase the risk of heart failure. Don’t stop taking these medications on your own, though. If you’re taking them, discuss with your doctor whether you need to make any changes.

Sleep apnea – the inability to breathe properly at night results in low blood oxygen levels and increased risk of abnormal heart rhythms. Both of these problems can weaken the heart.

Congenital heart defects

Viral infections

Alcohol use

Irregular heartbeats

Complications

Complications can include:

Kidney damage or failure: heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. Kidney damage from heart failure can require dialysis for treatment. In addition, cardiac failure treatment may have also some consequences on your renal function, so proper and periodic evaluation is needed.

Heart valve problems: the valves of your heart, which keep blood flowing in the proper direction through your heart, may not function properly if your heart is enlarged, or if the pressure in your heart is very high due to heart failure.

Liver damage: heart failure can lead to a buildup of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it more difficult for your liver to function properly.

Stroke: because blood flow through the heart is slower in heart failure than in a normal heart, it’s more likely you’ll develop blood clots, which can increase your risk of having a stroke.

Some people’s symptoms and heart function will improve with proper treatment. However, heart failure can be life-threatening. People with heart failure may have severe symptoms, and some may require heart transplantation or support with an artificial heart device.

Preparing for your appointment

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there’s anything you need to do in advance, such as restrict your diet. For some imaging tests, for example, you may need to fast for a period of time beforehand.

Write down any symptoms you’re experiencing, including any that may seem unrelated to heart failure.

Write down key personal information, including a family history of heart disease, stroke, high blood pressure or diabetes, and any major stresses or recent life changes. Find out if anyone in your family has had heart failure. Some heart conditions that cause heart failure run in families. Knowing as much as you can about your family history can be important.

Make a list of all medications, vitamins or supplements that you’re taking.

Be prepared to discuss your diet and exercise habits.

Write down questions to ask your doctor.

Don’t forget that is never to late for life style changes: stop smoking, reduce salt use, exercise periodically, eat healthy. This kind of measures can prevent or improve signs and symptoms of heart failure.

Tests and diagnosis

To diagnose heart failure, your doctor will take a careful medical history and perform a physical examination. Your doctor will also check for the presence of risk factors such as high blood pressure. After the physical exam, your doctor may also order some of these tests:

Blood tests

Chest X-ray

Electrocardiogram (ECG)

Echocardiogram – an echocardiogram helps distinguish systolic heart failure from diastolic heart failure in which the heart is stiff and can’t fill properly. An echocardiogram uses sound waves to produce a video image of your heart. This image can help doctors determine how well your heart is pumping by measuring the percentage of blood pumped out of your heart’s main pumping chamber (the left ventricle) with each heartbeat. This measurement is called the ejection fraction. The echocardiogram also can look for valve problems or evidence of previous heart attacks, as well as some unusual causes of heart failure.

Stress test – stress tests measure how your heart and blood vessels respond to exertion. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Or you may receive a drug intravenously that stimulates your heart similar to exercise. Stress tests help doctors see if you have coronary artery disease. Stress tests also determine how well your body is responding to your heart’s decreased pumping effectiveness and can help guide long-term treatment decisions. If your doctor also wants to see images of your heart while you’re exercising, he or she may order a nuclear stress test or a stress echocardiogram. It’s similar to an exercise stress test, but it also uses imaging techniques to visualize your heart during the test.

Cardiac computerized tomography (CT) scan or magnetic resonance imaging (MRI).

Coronary catheterization (angiogram). In this test, a thin, flexible tube (catheter) is inserted into a blood vessel at your groin or in your arm and guided through the aorta into your coronary arteries. A dye injected through the catheter makes the arteries supplying your heart visible on an X-ray. This test helps doctors identify narrowed arteries to your heart (coronary artery disease) that can be a cause of heart failure. The test may include a ventriculogram — a procedure to determine the strength of the heart’s main pumping chamber (left ventricle) and the health of the heart valves.

Myocardial biopsy. In this test, your doctor inserts a small flexible biopsy cord into a vein in your neck or groin, and small pieces of the heart muscle are taken. This test is performed to diagnose certain types of heart muscle diseases that cause heart failure.

Treatments and drugs

Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and symptoms of heart failure can improve and the heart sometimes becomes stronger. Treatment may help you live longer and reduce your chance of dying suddenly. Doctors sometimes can correct heart failure by treating the underlying cause (for example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure).

But for most people, the treatment of heart failure involves a life style change, a balance of the right medications, and in some cases, devices that help the heart beat and contract properly.

As we pointed above, life style changes are very important, so you should stop smoking and alcohol use, loss weight, exercise periodically, have a lower sald diet, eat healthy.

Medications

Doctors usually treat heart failure with a combination of medications, wich are proved to be effective in this condition. Tipically, the treatment begins with low doses that must be increse over time, according to some parameters wich must be periodically evalute, so treatment beneffit will be the best.

Depending on your symptoms, you might take one or more of these drugs:

Angiotensin-converting enzyme (ACE) inhibitors. Examples include enalapril (Vasotec), lisinopril (Prinivil, Zestril), captopril (Capoten), tritace, zofenopril, quinapril…but your doctor should choose the right drug for you, at right doses

Angiotensin II receptor blockers. These drugs have many of the same benefits as ACE inhibitors. They may be an alternative for people who can’t tolerate ACE inhibitors. They incvlude: telmisartan, valsartan, irbesartan, losartan, olmesartan

Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in systolic heart failure.

Beta blockers : carvedilol, metoprolol, bisoprolol, nebivolol

Diuretics: furosemide, nefirx, torasemide, bumetanide. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Diuretics also decrease fluid in your lungs, so you can breathe more easily. Because diuretics make your body lose potassium and magnesium, your doctor also may prescribe supplements of these minerals. If you’re taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.

Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). They are potassium-sparing diuretics but also have additional properties that may reverse scarring of the heart and help people with severe systolic heart failure live longer. Unlike some other diuretics, spironolactone can raise the level of potassium in your blood to dangerous levels, so talk to your doctor if increased potassium is a concern, and learn if you need to modify your intake of food that’s high in potassium.

Inotropes. These are intravenous medications used in severe heart failure patients to improve heart pumping function and maintain blood pressure.

You’ll probably need to take two or more medications to treat heart failure. Your doctor may prescribe other heart medications as well — such as nitrates for chest pain, a statin to lower cholesterol or blood-thinning medications to help prevent blood clots — along with heart failure medications.

You may be hospitalized if you have a flare-up of heart failure symptoms. While in the hospital, you may receive additional medications to help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen through a mask or small tubes placed in your nose. If you have severe heart failure, you may need to use supplemental oxygen long term.

These drugs aren’t without side effects, and sometimes these can be life-threatening. That’s why proper, periodically evaluation is needed: labs test ( for renal function, potassium and natrium levels, hemogram, liver function). As we pointed above, in main to obtain maximum beneffit, treatment must include drugs that are proved to be effective in cardiac failure, but in right doses. These doses are increased over time, according to your labs, but also to other parameters, such as weight, blood pressure, cardiac frequency, diuresis)

Beside medical treatment, there are also some modern techniques ( interventional or surgical techniques) that can be used for cardiac failure improvmment and better prognosis.

In some cases your doctor may recommend surgical treatment for your coronary artery disease ( CABG -Coronary bypass surgery – in this procedure, blood vessels from your leg, arm or chest bypass a blocked artery in your heart to allow blood to flow through your heart more freely), valve defects or congenital cardiac defects ( in this case there also modern, minimally invasive techiques).

Sometimes, maintaining cardiac pump can be extremely difficile, so you may need some devices:

Implantable cardioverter-defibrillators (ICDs). An ICD is a device similar to a pacemaker. It’s implanted under the skin in your chest with wires leading through your veins and into your heart. The ICD monitors the heart rhythm. If the heart starts beating at a dangerous rhythm, or if your heart stops, the ICD tries to pace your heart or shock it back into normal rhythm. An ICD can also function as a pacemaker and speed your heart up if it is going too slow.

Cardiac resynchronization therapy (CRT), or biventricular pacing. A biventricular pacemaker sends timed electrical impulses to both of the heart’s lower chambers (the left and right ventricles) so that they pump in a more efficient, coordinated manner. Many people with heart failure have problems with their heart’s electrical system that cause their already-weak heart muscle to beat in an uncoordinated fashion. This inefficient muscle contraction may cause heart failure to worsen. Often a biventricular pacemaker is combined with an ICD for people with heart failure.

Heart pumps (left ventricular assist devices, or LVADs). These mechanical devices are implanted into the abdomen or chest and attached to a weakened heart to help it pump. Doctors first used heart pumps to help keep heart transplant candidates alive while they waited for a donor heart. LVADs are now sometimes used as an alternative to transplantation.

Heart transplant. Some people have such severe heart failure that surgery or medications don’t help. They may need to have their diseased heart replaced with a healthy donor heart. Heart transplants can dramatically improve the survival and quality of life of some people with severe heart failure. However, candidates for transplantation often have to wait a long time before a suitable donor heart is found. Some transplant candidates improve during this waiting period through drug treatment or device therapy and can be removed from the transplant waiting list.

Lifestyle changes

Making lifestyle changes can often help relieve signs and symptoms of heart failure and prevent the disease from worsening. These changes may be among the most important and beneficial you can make:

Stop smoking. Smoking damages your blood vessels, raises blood pressure, reduces the amount of oxygen in your blood and makes your heart beat faster. You can’t be considered for a heart transplant if you continue to smoke. Avoid secondhand smoke too.

Weigh yourself daily. Do this each morning after you’ve urinated, but before you’ve had breakfast. Notify your doctor if you have a weight gain of 5 pounds (2.3 kilograms) or more in a week. It may mean that you’re retaining fluids and need a change in your treatment plan. Record your weight every morning and bring the record with you to your doctor’s visits.

Restrict salt in your diet. Too much sodium contributes to water retention, which makes your heart work harder and causes shortness of breath and swollen legs, ankles and feet. For people with heart failure, the daily recommended amount of dietary sodium is generally less than 2,000 milligrams — check with your doctor for the restriction recommended for you. Keep in mind that most of this salt is already added to prepared foods, and be careful when using salt substitutes.

Maintain a healthy weight. If you’re overweight, your dietitian will help you work toward your ideal weight. Even losing a small amount of weight can help.

Limit fats and cholesterol. In addition to avoiding high-sodium foods, limit the amount of saturated fat, trans fat and cholesterol in your diet. A diet high in fat and cholesterol is a risk factor for coronary artery disease, which often underlies or contributes to heart failure.

Limit alcohol and fluids.

Be active. Moderate aerobic activity helps keep the rest of your body healthy and conditioned, reducing the demands on your heart muscle. Before you start exercising though, talk to your doctor about an exercise program that’s right for you. Your doctor may suggest a walking program. Check with your local hospital to see if it offers a cardiac rehabilitation program; if it does, talk to your doctor about enrolling in the program.

Reduce stress.

Sleep easy. If you’re having shortness of breath, especially at night, sleep with your head propped up at a 45-degree angle using a pillow or a wedge. If you snore or have had other sleep problems, make sure you get tested for sleep apnea. To improve your sleep at night, prop up your head with pillows and avoid big meals right before bedtime. Also, discuss with your doctor changing the time for taking medications, especially diuretics. Taking diuretics earlier in the day may decrease the need to urinate as often during the night.

The key to preventing heart failure is to reduce your risk factors. You can control or eliminate many of the risk factors for heart disease — high blood pressure and coronary artery disease, for example — by making lifestyle changes along with the help of any needed medications.

Lifestyle changes you can make to help prevent heart failure.

Important!

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Although any causes of cardiac failure aren’t reversible, life style changes and a proper treatment may relieve symptoms, increase quality of life, decrease hospitalization because of cardiac failure and increase survival.

It’s very important that you collaborate with your doctor so the result can be the best. Watch out for any simptoms, any change so you can ask for help.

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