Heart Failure – Diagnosis, Symptoms, and Treatment

What is Heart Failure?

Heart Failure is a common name for several conditions that reduce the ability of the heart to supply blood to the organs in the body. There are many causes of heart failure, slowly progressive chronic conditions and acute illness can both result in heart failure.

Patients may experience difficulty breathing, exercise intolerance, and swelling in the legs – but one of the most dreadful complications is death. It is important for patients to recognize the symptoms, causes, and treatment of heart failure as with treatment its progression may be slowed or reversed. 

What Causes Heart Failure?

It can be categorized into two general types – systolic heart failure and diastolic heart failure.  Systolic heart failure is characterized by an impaired ability of the heart to contract and pump blood to other vital organs and tissues.  In contrast, diastolic heart failure is considered a reduced capacity of the heart to relax and fill with blood.

The most common cause of systolic heart failure is ischemic cardiomyopathy, damage due to insufficient blood flow to the heart itself. This can result from slow blockage of the blood vessels that serve the heart or a sudden blockage during a myocardial infarction (Heart attack).  Other causes include alcoholic cardiomyopathy from excessive alcohol use and viral myocarditis, a viral infection of the heart muscle itself. 

The most frequent cause of diastolic heart failure is high blood pressure (hypertension). There is a set of rare diseases known as Infiltrative diseases that stiffen the heart muscle and can cause diastolic heart failure. Sarcoidosis and hemochromatosis are the conditions that are best known for causing heart failure in this manner.  

How Common is Heart Failure?

Heart failure currently affects more than 5.8 million people in the United States alone.  Furthermore, there are more than >550,000 new cases diagnosed each year.  Heart failure is one of the leading causes of death in the United States.  The disease is especially problematic in the elderly population (individuals age >65 years) due to the presence of other medical conditions that increase both the prevalence and risk of complications from heart failure.

Signs and Symptoms

Heart failure of any type almost always begins with a general sense of fatigue and weakness. This may progress rapidly or stay relatively stable for many years depending upon the cause and severity of heart failure. Eventually, the heart “decompensates” which means that it can no longer overcome the damage it has sustained and one or more of the severe symptoms below will present:

• Shortness of breath
• Difficulty breathing when lying flat on one’s back
• Gasping for air at night
• Swelling in the legs
• Reduced exercise capacity

These symptoms occur because the heart cannot adequately get blood to other organs and essentially “backs up” like a plumbing system.  This backup of blood leads to blood pooling in the lungs – which causes difficulty breathing, especially at night.  It can also result in the accumulation of blood and fluid in the legs – which is responsible for leg swelling.

When you have fluid in the lungs, not only do you become short of breath, but you also have difficulty exerting yourself and exercising. These symptoms can be severe enough to prevent walking, climbing stairs, or even sitting upright in some cases. 

On physical examination, your doctor may look for “pitting edema” such that when he or she presses on your swollen legs, it forms “pits” that can last for seconds.  Your doctor will also listen to your heart and lungs, and observe for abnormal sounds.  Lastly, they may lie you down at an incline and check your neck veins to see if they are distended – another sign of heart failure known as jugular venous distention (JVD).

The most extreme presentation of heart failure is cardiogenic shock. This occurs when the bloodflow from the heart is so low that the organs cannot function. Cardiogenic shock presents with the following:

• Extreme sleepiness or inability to awaken
• Blue discoloration around the lips
• Pale and cold skin

Diagnosis

The diagnosis of heart failure may be suspected based on physical exam findings but requires advanced imaging studies to diagnose. Lab tests are also often done to determine the most likely cause of heart failure. 

The most common blood tests are a comprehensive metabolic panel (CMP), complete blood count (CBC), and urine analysis.  They may also order a test called a BNP (brain natriuretic peptide), which is increased when the heart is stressed from a backup of fluid.

Your doctor will obtain an ECG to evaluate the electrical activity of your heart, a chest x-ray to evaluate your heart size, and to see if there is fluid in your lungs.  Lastly, they will obtain an ultrasound (echocardiogram) to assess the structure and function of your heart. The results of the echocardiogram are critical in determining the type and severity of heart failure. Patients who are known to have heart failure will get regular echocardiograms to monitor the progression of the disease. 

Occasionally, if your condition is very severe, your cardiologist will perform a test called a “right heart catheterization.”  During this study, they will introduce a catheter into a large vein in your groin and advance the catheter until it reaches the right side of your heart.  Throughout the procedure, they measure various parameters such as the pressures in the chamber of the heart to better understand the severity of heart failure and determine the best course of treatment.

Heart Failure Treatment and Medication

The treatment of heart failure includes dietary changes such as restricting the amount of sodium and fluids you ingest.  It is also generally recommended that you avoid significant alcohol use, especially if the cause of your heart failure is due to alcohol.

Medications are typically prescribed to improve symptoms and sometimes improve life expectancy.  Drugs that are commonly prescribed include:

• Diuretics – Lasix (furosemide), Bumex (bumetanide)
• Beta blockers – Toprol (metoprolol), Coreg (carvedilol)
• Angiotensin converting enzyme (ACE) inhibitors – Zestril (lisinopril), Lotensin (benazepril)
• Angiotensin receptor blockers (ARBs) – Cozaar (losartan), Diovan (valsartan)

Diuretics are central to the treatment of heart failure, these medications decrease the amount of water in the body and help to relieve stress on the heart. ACE inhibitors and beta-blockers are prescribed to the majority of heart failure patients as they help to slow the progression of the disease.

Patients with severe cases may require the use of surgical interventions to prolong their life.  This may include a left ventricular assist device, which mechanically helps your heart pump more efficiently.  In some cases, patients may be candidates for heart transplantation.

 References:

1. Armstrong C. ACCF and AHA Release Guidelines on the Management of Heart Failure. Am Fam Physician. 2014 Aug 1;90(3):186-9. - https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20Programs/Heart%20Failure%20Roundtable%202016/Heart%20Failure%20Guidelines/HFG%203%202013%20ACCFAHA%20Guideline.pdf
2. Inamdar AA, Inamdar AC. Heart Failure: Diagnosis, Management and Utilization. J Clin Med. 2016 Jun 29;5(7). - https://www.ncbi.nlm.nih.gov/pubmed/27367736
3. Roger VL. Epidemiology of heart failure. Circ Res. 2013 Aug 30;113(6):646-59. - https://www.ncbi.nlm.nih.gov/pubmed/23989710