Basic

Heart failure is a very common heart disease.

Over many years of our experience in treating heart failure, we have learned one fact. Those patients who know heart failure in detail can manage it well survives longer and better.

Probably you are reading this article as you have been diagnosed to have heart failure or you are caretaker of a patient with heart failure. Feel free to ask questions and comments.

The aim is to empower all heart failure patients with the help of each other and ultimately to live a better life.

What is heart failure

To understand what is heart failure, we need to quickly understand how the heart works. The heart pumps the blood to meet the body requirements. Normal Heart has a volume of around 100 ml and out of this, it pumps around 50 to 70ml of blood with each heartbeat. When the heart fails to pump out this blood, we call heart failure.

Heart fails to pump out blood adequately. The heart pumps out less percentage of blood. ( heart dilates as a result )

What is EF

• This is very easy to understand term. People also say percentages.
• This is Echocardiographic term.
• EF% means the percentage of blood volume pumped out with each heartbeat.
• Normal value varies between 55 % to 65 %
• Lower the EF, sicker the heart
• Note, not all patients of heart failure have low EF.
• Not all patients with low EF are sick.

Symptoms of heart failure

• breathlessness-getting out of breath even with milder exertion
• swelling over the legs and face – persistent swelling of legs and then over tummy and face.
• easy fatigue – extreme tiredness and lack of energy to do day to day activity
• palpitations – even milder exertion causes heart to race and takes long to get quiet
• fainting episodes – episodic loss of consciousness

Tests for diagnosis of heart failure. Causes of heart failure

Heart failure is usually the end result of a massive heart attack or repeated heart attack. Less commonly, Heart failure is primarily due to abnormality of heart muscles.

Heart attack

• The heart is a muscle and heart attack damages the heart muscle, sometimes permanently. This leaves weakness in part of muscles of heart, resulting in efficient umping.
• Degree of damage and rapidity of damage of heart attack decides the severity of heart failure.
• Timely treated heart attack leaves heart unaffected.

Cardiomyopathy

• Disease of the muscle of the heart.
• Some unknown viral infections of heart leave the damage behind, causing the heart muscle to pump ineffectively. ( Dilated Cardiomyopathy )
• Genetic diseases of heart muscles lead to very thick, over powerful but inefficient heart muscles, leading to Heart failure. ( Hypertrophic Cardiomyopathy)
• Deposition of abnormal substances within heart muscle fibres leads to improper/inadequate relaxation of the heart muscle, eventually leading to inadequate filling of heart and pumping of the heart. ( Restrictive Cardiomyopathy)

Valve diseases

Diseases valve makes the heart work at higher forces for a long time, eventually leading to heart failure.

There can be narrowed or leaking heart valves. If not operated at the proper time, the heart starts dilating as it can not generate the very high force required to pump out blood through this damaged heart valves.

Pregnancy-related HF( Peripartum dilated cardiomyopathy)

During the last trimester and up to 5 months after pregnancy, some pregnant females develop heart failure.

Incidence is one in 500.

Usually, it is reversible with normalisation of heart-pumping function after delivery in around 50% of the cases

Chances of redeveloping heart failure in next pregnancy remain very high and the patient needs to consult their cardiologist before planning for the next pregnancy.

Toxins

Alcohol, some pesticides, poisons, heavy metals may lead to weakness of heart leading to heart failure.

BNP

• Its a blood test
• Increased creatinine means kidney failure, and increased white blood cell counts mean infection, Increased BNP means heart failure
• When excessive loading stretches heart fibres and damages heart muscle fibres, they release a protein called BNP.
• Normal value is 0-300 but it may be high up to 1000 in old age persons.
• In a sick patient suffering from symptoms of heart failure, the usual value is around 5 to 8 thousands.
• Very high values suggest acute rapid damage of heart failure.
• Fall in BNP with treatment suggests improvement in patient’s condition.
• Kidney failure patients do have disproportionately higher BNP values.

Heart failure with normal pumping/HF with normal EF/ Diastolic heart failure

• Not all heart failure patient have low pumping.
• Heart activity has two parts – pumping and relaxation. fast relaxation of the heart muscle is needed to rapidly fill the heart with blood so that it can be pumped out.
• If heart muscle fibres fail to relax adequately in a given time, the heart can not be filled with adequate blood.
• The pressure in lungs vessels increases in an attempt to fill the blood with high force.
• This results in wet lungs and symptoms of heart failure.
• It is as common as heart failure due to lower pumping capacity/low EF.
• This is also called as Diastolic heart failure or heart failure with preserved ejection fraction.
• Hypertension is one of the leading cause of this type of heart failure.

Anaemia and heart failure

Low HB is one of the causes of heart failure like symptoms. When I say heart failure like means, heart as such does not fail. Anaemia leads to increased body water volume and ultimately excessive loading on heart muscles, leading to Heart failure like symptoms.

Heart failure patients need adequate haemoglobin to supply oxygen to vital organs. Low Haemoglobin makes heart failure patients symptomatic more. It does not weaken the heart muscle directly but loads heart unnecessarily.

We advise routine blood tests to detect low haemoglobin and low iron stores. Correction of low iron stores usually needs an intravenous injection of iron.

Vaccination in heart failure

Heart failure patients do have very high chances of getting lung infections.

Prognosis of pneumonia is also poorer in heart failure patient as compared to the general population.

Heart failure means increased loading forces in the heart. The heart gets oxygen-rich blood from the lungs. High loading forces in the heart lead to high back pressure forces in lung vessels leading to congestion in the lungs. This is what we call wet lungs, ideal for bacteria and viruses.

Bacterial and viral infections of lungs can be prevented by vaccination.

All Heart failure patient need to get vaccinated for the prevention of this life-threatening pneumonia.

The bacterial vaccine is given every five years and influenza vaccine repeated every year before the monsoon.

Kidney and heart failure

kidney failure patient developing HF

• Chronic Kidney Failure patients often do have hypertension, high body volumes, thick heart muscles, anaemia and AV Fistulas (arm vein connected to an artery, to facilitate hemodialysis). This all leads to high loading forces on heart muscles and eventually heart failure like symptoms.
• EF need not to be very low and symptoms may be severe.
• BNP is usually in thousands.
• Good quality dialysis usually prevents this all unnecessary volume overload.
• Kidney failure patient eventually develops Coronary artery blockages leading to heart attack and a subsequent weak heart.

Heart failure patients developing renal failure

In advanced stages of HF, the heart is so sick that it can not generate enough pressure to send blood to kidneys. Kidney tubes do not get enough blood/oxygen to maintain their function. This leads to Kidney failure. This can be rapid with a rapid decline in patient’s heart condition or chronic.

This type of problem does not get corrected with hemodialysis alone and requires mechanical support to failing heart.

Prognosis and survival- terms of Acute decompensation and hospital readmission

This patient do have very high mortality.

But here, we are more concerned about the high morbidity. Our aim is to make patient live a long life and the good quality of life.

Good exercise capacity, freedom to move around without symptoms, ability to carry out personal errands, not having repeated admissions for acute decompensation, having good nutrition, stressed free cheerful mind and satisfactory sexual life are the goals.

Acute decompensation: All patients with this problem are not always symptomatic. The body develops adjustment and balances with low EF and high body volumes. But it loses the reserve. Any new insult, like bleeding, infection, surgery stress, missed medication, small heart attack- this all seemingly minor problem may tilt the balance towards waterlogging. This causes acute worsening of breathlessness requiring admission and treatment with injectables to force water out of lungs and respiratory support, which could be ventilator also.

Our aim to decrease acute decompensation by taking care of all other minor precipitating factors.

Treatment of heart failure

Treatment starts from prevention ends with heart transplantation. Control of conventional risk factors like hypertension control helps a lot. Preventive measures aimed at Coronary risk factors like Sugar control, quitting smoke, doing regular exercise, controlling blood cholesterol level go a long way in preventing heart attack and subsequent heart failure. Here, we will discuss mainly treatment measures specific to heart failure.

Medicines:

We do not want you to self medicate as it is a vast science and we will be discussing only the salient features/facts to be known about the medicine used in the treatment of heart failure.

1. Diuretics: increases urine production, causes loss of sodium and potassium in the urine, dose titration is based on amount of waterlogging, kidney function, sodium and potassium level and initial response to diuretics, examples, Lasix, dytor, tide.
2. B Blockers: used to control an excessive increase in heart rate with exertion. Also prevents life-threatening arrhythmias. examples, metoprolol, carvedilol, bisoprolol. Caution for use, low heart rate.
3. ACE inhibitors: used to control blood pressure and protect the kidney and heart. When used for long, prevents heart dilatation. examples, Ramipril, lisinopril. Do not combine this drug with pain killers.
4. Nitrates: alleviates high lung pressures and relieves the pressure within the body so that heart can pump into it effectively. example, isolazine, monotrate,imdur, It may cause headache in the first days of its use. Do not combine this with sildenafil or tadalafil like drugs.
5. Digoxin: increases heart pumping, to be taken 5 days a week, that is why you may find 5/7 written behind this medicine. example, Lanoxin, dixin, Overdose may cause vomiting.
6. Spironolactone: Also a diuretic, but milder one. Used mainly to prevent heart dilatation and not to increase urine production. This maintains potassium in the body. example, Aldactone, In some male patients this drug may cause an increase in the size of the breast with mild pain. Its due imbalance in sex hormones, completely reversible on stopping the medicine.

Pacemaker Devices in heart failure: ICD and CRT

ICD

ICD stands for Intra Cardiac defibrillator. Its type of pacemaker capable of delivering a measured shock into the heart muscle. When a patient’s heart pumping remains less than 30% despite optimum treatment and he suffers from the risk of life-threatening fast heart rates, in the range of 150-200 or more, we advise ICD.

This device monitors heart rhythm continuously. Whenever it notices an increase in heart rate, treatment part of the device gets activated and it delivers an impulse to control the heart rate. Initially, it takes over the pacing function to terminate the fast rhythm. If this fails, then it delivers a shock of 11 joules to 34 joules inside the heart muscles. This terminates the fast heart rate.

CRT

CRT stands for Cardiac Resynchronisation Therapy. If during clapping, our both hands do not collide with each other at the perfect time, the clapping sound is feeble. If the heart’s front and opposite wall do not contract at the same time, the overall contraction of the heart becomes weak.

CRT has three wires. One wire in the upper chamber. another two-wire on two walls of the left chamber of the heart. This makes sure that both walls of the heart get electric stimuli at the same time.

Indication of putting CRT is of course low pumping, but not all patient require this. His symptoms, his response to medicines, his type of ECG abnormality, Echo parameters all give a clue to the clinician about the possible benefit of this type of pacemaker.

Vaccination, Correction of Anemia

All patients should undergo a scheduled vaccination programme. Correction of anaemia and iron stores helps a lot.

Newer drugs

• Since last few years, a new drug, called ARNi, or sacubitril-valsartan is available for the treatment of heart failure patients.
• Results in terms of mortality and quality of life are excellent. If you are not on this drug, you should ask your clinician regarding the feasibility of this medicine in your case.
• The use of this drug requires a little experience on clinician part and you should be cautious about this.
• Monitoring potassium, sodium, creatinine and blood pressure are utmost importance. Examples are Vymada and Cidmus

Importance of daily symptom tracker

Heart failure patients need to be consistent in monitoring their vitals and symptoms on paper on a daily basis. We need them to monitor their weight, heart rate and blood pressure. Apart from this vital, important information about the mood, energy and symptoms should also be noted down.

We have pre-formatted formats available for this, kindly see the attachment. Ask your clinician for this type of .pdf.

Importance of body weight monitoring

Heart failure means waterlogging for simple understanding. Increased water in the lungs means breathlessness. High water in the stomach(Liver actually ) means abdominal pain and decreased appetite with vomiting. Increased water in arms and legs and face means swelling.

Now, remember one fact: for oedema/swelling to appear on body, there has to be 5 to 7 kg of extra water accumulated in the body.

We do not want this much of water to get accumulated before it gets noticed. its late.

Hence, we measure body weight. It reflects body water content when measured serially over days.

For understanding, Imaging one patient with a weight of 60 kg on Monday and after three days, on Thursday, his weight is 63 kg. This means he has accumulated 3 litres of water in his body and if not excreted out, it will cause breathlessness. if the dose of diuretics is increased at this point in time, the weight will come down to 60 again and the patient can get rid of extra accumulated water. Now he can take a lower dose of diuretics again.

This prevents the side effects of high daily doses of diuretics and also protects the patient from decompensation.

Importance of salt and water intake measurement

Same like body weight measurement, all patient with heart failure need to keep the measurement of their water intake. The gross measurement may suffice in patients without much symptoms and with stable weight. But patients with increasing symptoms and with highly variable bodyweight need to measure their water intake precisely. We advise the use of a one-litre water bottle for easy measurement. All the liquid consumed in a day also to be counted and the same amount of water to be discarded from the bottle after intake of other liquids like tea, buttermilk.

Salt retains the water. High salt intake causes swelling over the body. It makes some of the medicines ineffective.

Restricted salt intake is advised in Heart failure patients. Salt used in cooking is allowed but table salt is avoided. Foods rich in salt content, packed foods, canned foods, prickles all are prohibited. All types of salt are the same for the body in terms of heart failure, as its sodium content matters not the purity of taste.

Heart failure and exercise

Cardiac rehabilitation is the mainstay for the recovery of the patient after a major heart attack. This basically means increasing cardio exercise in a graded manner with monitoring of heart rate and symptoms. Our Cardiac Physiotherapist will be able to help you a lot in this regard. Ask your physician about the exercise programme and get enrolled into it for the first month, once confident, you can carry out this at home.

Exercise improves oxygen uptake, lung capacity and mood of the patient. Monitoring for heart-rate and symptoms prevents any worsening of the condition.

Heart Transplantation / Artificial heart-LVAD

When all attempted measures fail to give a good quality life in an advanced stage of this disease patients, the only option left is to replace the pump. This can be another person’s heart or a mechanical pump.

Advanced heart failure patients are those who had repeated admissions in ICU for acute worsening with the need for injectable drugs for increasing urine output and maintaining heart’s pumping. Without injectables, this patient goes into a downward spiral with increasing waterlogging loading the heart more and decreasing function of the other vital organs of the body like kidney, liver and brain.

Timely performed heart transplantation gives very good quality of life and with good survival, data are available all over the world.

There are many factors which patient needs to be aware and I recommend my another specific article on heart transplantation for this information.

When the patient is a candidate for the heart transplantation but it can not be performed due to non-availability of donor’s heart or due to other patient-related contraindications, then we offer an artificial heart as a bridge to the destination, or bridge to transplant. This is an open-heart surgery in which the surgeon will implant an artificial pump called LVAD( Left ventricular assist device) into the left chamber of the heart. This makes the patient improve over time and then he may become candidate/fit for heart transplantation.