Introduction

Heart failure is a condition in which the heart loses the ability to pump enough blood to the body’s tissues.

As a result, the main body organs and other tissues do not receive enough oxygen and nutrients to function properly.

A person with heart failure suffers a build-up of fluid in the tissues, called oedema. Heart failure as a result of fluid build-up is called congestive heart failure. Where oedema occurs in the body depends on the part of the heart that is affected by heart failure. For most people, heart failure is a chronic disease with no cure.

However, it can be managed and treated with medications and changes in diet, exercise and lifestyle habits. Heart Valve Surgery, Coronary Artery Bypass Grafting, Mechanical Assist Devices and Heart transplantation is considered in some cases.

Causes

The most commonly causes of heart failure are:
• coronary heart disease and heart attack (which may be “silent”)
• cardiomyopathy (disease of the heart muscles)
• high blood pressure (hypertension)
• heart valve disease
• congenital heart disease
• alcoholism and drug abuse

In coronary heart disease, the arteries supplying blood to the heart become narrowed or blocked. A person has a heart attack when blood flow to an area of the heart is completely blocked. The heart muscle suffers damage when its blood supply is reduced or blocked. If the damage affects the heart’s ability to pump blood, heart failure develops. Some heart attacks go unrecognised.

Cardiomyopathy may be caused by coronary artery disease and various other heart problems. Sometimes, the cause cannot be found, in which case it is called idiopathic cardiomyopathy. Cardiomyopathy can weaken the heart muscle, leading to heart failure.

High blood pressure is another common cause of heart failure. High blood pressure makes the heart work harder to pump blood. After a while, the heart cannot keep up and the symptoms of heart failure develop. Defects of the heart valves, congenital heart diseases, alcoholism, and drug abuse cause damage to the heart that can all lead to heart failure.

Symptoms

A person with heart failure may experience the following:
• shortness of breath
• frequent coughing, especially when lying down
• swollen feet, ankles, and legs
• abdominal swelling and pain
• fatigue
• dizziness or fainting
• sudden death

A person with heart failure may have shortness of breath and coughing caused by the fluid build-up in the lungs. Pulmonary oedema may cause the person to cough up bubbly phlegm that contains blood. Other symptoms of heart failure include fluid build-up in the veins and body tissues causing swelling of the feet, legs and abdomen. When body tissues, such as organs and muscles, do not receive enough oxygen and nutrients, they cannot function well, leading to tiredness and dizziness.

Diagnosis

Diagnosis of heart failure is based on:
• symptoms
• medical history
• physical examination
• chest radiograph
• electrocardiogram (ECG; also called EKG)
• other imaging tests
• cardiac catheterisation

Symptoms can provide important clues to the presence of heart failure.

Shortness of breath while engaging in activities and episodes of shortness of breath during sleep are classic symptoms of heart failure.

During the physical examination, the physician listens to the heart and lungs with a stethoscope for tell-tale signs of heart failure such as irregular heart sounds, “gallops,” a rapid heart rate, and murmurs of the heart valves. If there is fluid in the lungs, crackling sounds may be heard. Rapid breathing or other changes in breathing may also be present. Patients with heart failure may also have a rapid pulse.

By pressing on the abdomen, the physician can feel if the liver is enlarged. The skin of the fingers and toes may have a bluish tint and feel cool if not enough oxygen is reaching them.

Chest radiographs can show if there is fluid in the lungs or if the heart is enlarged. Abnormalities of heart valves and other structures also may be seen on chest radiograph.

An electrocardiogram gives information on the heart rhythm and the size of the heart and shows if the heart chamber is enlarged or if there is damage to the heart muscle from blocked arteries.

Echocardiography can show if the heart wall or chambers are enlarged and if there are abnormalities of the heart valves. An echocardiogram can be used to find out how much blood the heart is pumping.

Radionuclide ventriculography also measures the ejection fraction by imaging with very low doses of an injected radioactive substance as it travels through the heart.

Cardiac catheterisation is used to measure pressure in the heart and the amount of blood pumped by the heart. This test can help find abnormalities of the coronary arteries, heart valves, heart muscle, and other blood vessels. Combined with echocardiography and other tests, cardiac catheterisation can help find the cause of heart failure. However, this is not always necessary.

Treatment

Heart failure is usually treated with lifestyle changes and medicines. Dietary changes to maintain proper weight and reduction of salt intake may be needed. Reducing salt intake helps to lessen swelling in the legs, feet and abdomen. Appropriate exercise such as walking, cycling, swimming, or low-impact aerobic exercises may be recommended, but it is important that heart failure patients begin an exercise programme with the advice of their doctors. The National Heart Centre Singapore offers good Cardiovascular Rehabilitation and Preventive Cardiology Programme for patients identified to have multiple risk factors for heart disease or who have just undergone open-heart surgery.

Other lifestyle changes that may reduce the symptoms of heart failure include stopping smoking or other tobacco use, eliminating or reducing alcohol consumption and not using harmful drugs.

One or more of the following types of medicines may be prescribed for heart failure:
• diuretics
• diagoxin
• vasodilators
• beta blockers
• angiotensin converting enzyme inhibitors (ACE inhibitors)
• angiotensin receptor blockers (ARBs)
• calcium channel blockers

Diuretics eliminate excess salt and water through the kidneys by making patients urinate more often. This helps reduce the swelling caused by fluid build-up in the tissues. Digoxin helps the heart muscles have a stronger pumping action. Vasodilators, ACE inhibitors, ARBs and calcium channel blockers lower blood pressure and expand the blood vessels making it easier for the heart to pump blood through the vessels.

Sometimes, surgery is needed to correct abnormalities of the heart or heart valves that cause heart failure.

Congenital heart defects and abnormal heart valves can be repaired with surgery. Blocked coronary arteries can usually be treated with angioplasty or coronary artery bypass surgery.

With severe heart failure, the heart muscle may become so damaged that available treatments do not help. Patients with end-stage heart failure are usually considered for Mechanical Assist Devices and heart transplantation when all other treatments do not work.