What is heart-failure?
The heart has four chambers. The left ventricle (LV), right ventricle (RV), left atrium (LA) and right atrium (RA). The function of the heart is to act as a pump to supply blood which is a carrier of oxygen, nutrients and energy to the different parts of the body to enable normal functioning. The main chamber of the heart which acts as the pump is the left ventricle. The normal pumping efficiency of the heart called ejection fraction (EF) is 55-70%. The EF increases normally with activities and with severe exercise the EF can be higher than normal to meet the demands of the body.
Video: Hear Failure – What you need to know.
What are the types of Heart-failure?
Heart failure is essentially of two types but known by several names.
Heart failure with reduced Ejection Fraction (HFrEF): The normal pumping function of the LV is 55-70%. When the pumping is reduced it is called HFrEF.
Heart failure with preserved Ejection Fraction (HFpEF):In these patients there is no pumping failure. The LVEF remains normal, but the heart muscle is stiff and there is an impairment of the blood filling the heart chamber, which can cause back pressure in the lungs and breathlessness and heart-failure symptoms.
Systolic heart-failure:Heart failure is a complex condition where the pumping efficiency of the heart is affected. This results in poor oxygen and nutrient supply to the various tissues and organs, affecting their normal and effective functioning. Heart failure is of different types and the commonest one is where the pumping function is reduced. Depending on the EF they can be graded as mild, moderate and severe heart failure. When the LV EF is < 30% it is called severe heart-failure. This is also called systolic heart failure.
Diastolic heart failure: Heart failure need not always be because of pumping inefficiency. It can also result from inadequate filling of the pumping chambers.
Right heart failure: Heart failure can also be due to abnormalities of the right chamber of the heart or the right ventricle or even due to both left and right ventricles being affected.
Chronic Heart Failure: Chronic Heart Failure is the term used to categorize patients who are suffering from Heart Failure for a long period of time, usually more than three months.
Acute Heart Failure: Acute Heart Failure, as the name implies is a pumping failure which occurs suddenly, as occurs with a massive heart attack. In this situation the heart pump fails suddenly and the patient suddenly becomes breathless and can go into a shock with severe blood pressure fall, needing hospitalization and intra-venous medications to maintain the blood pressure. There are devices or machines which are currently available to manage acute heart failure with excellent results. These are the Extra-Corporeal Membrane Oxygenation (ECMO), Impella device and Intra-Aortic Balloon Pump (IABP). (See respective sections)
Decompensated Heart Failure or Acute on Chronic Heart Failure: Chronic heart failure patients also can suddenly deteriorate needing hospitalization and intra-venous medications and device therapy. This condition is also called decompensated heart failure.
What are the common causes of heart-failure?
Heart failure can result from numerous causes but the commonest cause of systolic failure or HFrEF is from damage of the heart muscle from heart attacks called ischaemic cardiomyopathy. Hypertension and conditions called Restrictive cardiomyopathy are commoner causes of diastolic heart failure or HFpEF.
What are the symptoms of heart-failure?
The commonest symptom is breathlessness on exertion or activities. Initially the breathlessness is only with unaccustomed activities and as the severity of heart-failure progresses the breathlessness becomes more prominent and occurs even while performing day to day personal activities like walking inside the house, changing clothes and bathing and later even at rest. No activity is possible for the patent without an increase in breathing difficulty.
Paroxysmal nocturnal dyspnea:The patient can also get sudden episodes of breathlessness in the night, a few hours into sleeping which can last for more than 20 minutes, associated with sweating, called paroxysmal nocturnal dyspnea, which often necessitates hospitalization, oxygen and IV medications. This occurs because of fluid accumulating in the air spaces of the lungs or alveoli.
Orthopnoea: This is a symptom of heart-failure, where the person gets breathless on lying down.
Other symptoms: Besides breathlessness, tiredness, swelling of feet, palpitations are some of the other symptoms and signs of heart-failure.
Is heart-failure a serious condition?
Heart failure is commonly a progressive condition. However, there are many conditions causing heart-failure which can be prevented if identified and treated early. Prevention has a key role in the management of this condition. Periodic check-up and an early diagnosis is important. However, once heart-failure has set in, timely treatment and close follow up play a vital role in delaying the progression of heart failure. However if un attended and un treated, heart failure is generally progressive and progresses from mild to severe heart failure with a steady fall in the pumping efficiency which can result in poor quality of life, repeated hospitalizations and death. Heart failure can also result in sudden cardiac death where the patient dies suddenly because of abnormal fast heart beats and rhythm called ventricular tachycardia or ventricular fibrillation.
Management of heart-failure:
The mainstay for management of heart failure is medications and life-style modifications. There are numerous highly effective medications which can effectively control symptoms, improve quality of life and delay its progression.
Device therapy in heart-failure:
Some patients with severe heart failure and patients who are prone for developing sudden cardiac death may benefit from device therapy with Implantable Cardioverter Defibrillator (ICD), Cardiac Re-synchronization Therapy (CRT) and other Bridge to transplant devices like Ventricular Assist Devices (VAD). (Read respective sections)
Heart-transplantation:
Heart-transplantation is the gold-standard in the care of heart-failure. But heart-transplantation is advised only in patients with advanced heart-failure, when medications fail and the patient requires repeated hospitalizations with intravenous drugs and oxygen administration to control symptoms of heart-failure. However, cardiac transplantation is possible only if done before the pressures in the lung become very high. (Read respective sections)
Expertise: Dr Binoy John is an expert in the management of Advanced Heart-Failure and also in the device therapy for heart-failure and trained in heart-failure and heart transplant medicine at Cedars-Sinai Medical Centre, Los Angeles, U.S.A.
Video: Talk on Advanced Heart Failure and Heart Transplant candidacy (Cardiological Society of India, Chennai, Nov 2024)
