An inefficiency of the pumping action of the heart because oj some underlying disease or problem. The heart can fail suddenly and seriously, often as the result of a heart attack (myocardial infarction), and life is endangered. This is called acute heart failure.

The heart can also succumb to the long-term strain of an inadequate blood supply (coronary artery disease) or of pumping against resistance (high blood pressure). Such chronic heart failure sets in slowly and gradually.

Either way, whether heart failure is acute or chronic, it’s nearly always the left ventricle (the heart’s main pumping chamber) that cannot cope, which means that the back pressure causes fluid to pool first in the lungs and later in the feet. This is why in acute heart failure the person is said to “drown” in their own fluids as the lungs fill very rapidly and gaseous exchange is halted.

Doctors also describe RIGHT- and LEFT-sided heart failure. The right side of the heart serves the lungs via the pulmonary artery and a blockage there causes the right ventricle to fail. Lung disease, such as chronic obstructive pulmonary disease, also causes right-sided heart failure because the right ventricle eventually becomes too weak to overcome the resistance imposed by diseased lung tissue. Left-sided heart failure is due to persistendy high blood pressure and coronary artery disease, particularly after a heart attack.

Acute Heart Failure

A sudden deterioration in the pumping action of the heart, usually the left ventricle, is called acute heart failure and leads to an accumulation of fluid in the lungs. If not treated immediately, it is life-threatening.

Chronic Heart Failure

People with chronic heart failure are suffering from long-standing inefficient pumping action of the heart, which leads to poor circulation of the blood and accumulation of fluid in body tissues.

Causes of Heart Failure

The heart is made of tough, durable, specialized muscle which beats with impressive reliability for a lifetime. It follows that most cases of heart failure result from a heart attack or atherosclerosis of the blood supply to the heart. These both diminish the amount of blood flowing through the heart and so reduce how well the muscle can pump, as well as leaving areas of damaged muscle which pump less efficiently.

Other common causes are high blood pressure and irregular heart rhythm outside the normal 60-90 beats per minute. This rhythm allows for efficient flow of blood around the body. This efficiency is reduced if the heart beats very fast (above about 120 bpm), very slowly (below about 40 bpm), or irregularly (see Palpitations). There are other uncommon causes of heart failure. Heart failure affects about 1% of those over the age of 65. It used to carry a grim outlook but this has changed in recent years thanks to the latest medication.

Acute Heart Failure

The most common cause of acute heart failure is a heart attack that damages a large area of
heart muscle. Right-sided acute heart failure is rare and is usually due to a blood clot blocking the pulmonary artery (pulmonary embolism).

Symptoms of Heart Failure

The earliest symptoms of gradual heart failure are tiredness, breathlessness and swelling of the ankles. These result from the sluggish flow of blood, which is poorly supplied with oxygen. The body responds to the failing heart by retaining salt and water, and a back-pressure effect swells the legs. Eventually fluid also builds up in the lungs, leading to increased breathlessness especially when lying flat, which is why people with heart failure find they need to sleep propped upright and wake breathless during the night if they roll off the pillows. Certain basic investigations should be done, for example chest X-ray, blood count and ECG.

Acute heart failure

This usually follows a heart attack; there is breathlessness and coughing of frothy phlegm. The victim often turns blue because of poorly oxygenated blood. Heart failure can often be diagnosed on examination. The doctor hears characteristic sounds of fluid on the lungs and notices neck veins distended with blood returning from the head that the heart cannot pump away fast enough. There are also signs of fluid on a chest X-ray and of heart strain on an ECG.

The symptoms of acute heart failure usually develop rapidly and include:

  • severe shortness of breath
  • wheezing
  • cough with pink, frothy sputum
  • pale skin and sweating.

If heart failure is caused by a pulmonary embolism, you may cough up blood and have sharp chest pain that is worse when breathing in.

Chronic Heart Failure

The symptoms of chronic heart failure develop gradually, are often vague and may include:

  • fatigue
  • shortness of breath, which is worse during exertion or when lying flat
  • loss of appetite
  • nausea
  • swelling of the feet and ankles
  • in some cases, confusion.

People with chronic heart failure may also have sudden attacks of acute heart failure, with symptoms of severe shortness of breath, wheezing and sweating. These attacks generally occur during the night. Occasionally, acute heart failure develops if the heart is put under additional strain due to a heart attack or a lung infection such as bronchitis. Acute heart failure is a medical emergency and needs immediate hospital treatment.

What Might be Done

  • Acute heart failure is a medical emergency and requires immediate hospital treatment.
  • You will be advised to sit in an upright position to make breathing easier, and oxygen may be given to you through a face mask.
  • You may need electrocardiography (EGG) and echocardiography to evaluate the function of the heart and to look for the cause of heart failure.
  • A chest X-ray usually confirms the presence of fluid in the lungs.
  • You may also have coronary angiography.

Diuretics given intravenously and appropriate medication to promote the efficiency of the heart, such as ACE inhibitors and beta- blockers, usually bring relief.

Treatment

For immediate treatment of heart failure, diuretic drugs arc taken by mouth or, in urgent cases, injection is used to force fluid out of the lungs and cause a high output of urine. This reduces the volume of blood to be pumped around the body and also reduces blood pressure, relieving strain on the heart. These are life-saving measures.

For long-term treatment many people with heart failure need continuous low dosages of diuretics such as frusemide or bumetanide. A class of drugs called ACE inhibitors has also emerged as being highly effective in improving heart function; these drugs are increasingly used to treat heart failure in all age groups.

Several other less common causes are eminently treatable, for example severe anaemia, thyrotoxicosis (see Thyroid problems) or problems in the valves of the heart. Diseased coronary arteries can be treated by CABG.

Open Surgery

Most operations are carried out using open surgery. An incision is made in the skin large enough to see clearly the internal body parts that require treatment and the surrounding tissues. Although a large incision provides easy access, it may leave an obvious scar.
Most open surgery is carried out under general anaesthesia. Once you are fully anaesthetized, the surgeon makes an incision through the skin and the layers of fat and muscle below it. The skin and the muscles may be held back by clamps, and organs and tissues that are not being operated on are pulled out of the way by retractors. When the area to be worked on is clearly visible, the surgeon is then able to carry out the procedure.

Blood vessels that have to be severed during surgery are sealed in order to prevent serious loss of blood. The surgeon checks that there is no internal bleeding before he or she sews up the wound. The wound may be covered with a sterile dressing.
All surgical procedures, whether major or minor, involve some risk. A general anaesthetic can provoke changes in heart rhythm during or after surgery. An allergic reaction to the anaesthetic may also occur. Rarely, if blood vessels are not fully sealed, excessive bleeding may occur during the operation, or there may be persistent bleeding afterwards. In both cases, a blood transfusion may be required.

To avoid the risk of clots developing following surgery, you will be encouraged to move around as soon as you can afterwards. You may be asked to wear pneumatic stockings, which rhythmically inflate and deflate to keep the blood flowing normally through your veins, or elastic support stockings. Drugs that prevent blood clotting may be necessary. Analgesics may also help prevent the formation of blood clots by relieving pain and allowing you to move around more easily. Antibiotics are often given before, during or after surgery to help prevent infection.

Commonly Asked Questions

Can heart failure be cured?

It cannot really be cured but it can be controlled. Common measures to control it are to treat high blood pressure, to lose weight and to reduce salt intake.

What is the role of a heart transplant?

This is reserved for otherwise healthy people, including those who have suffered heart attacks in the past for whom all other measures have failed. It is a marvellous treatment with a steadily rising success rate, despite the need to stay on powerful anti-rejection medication.

Other Common Problems

Aortic Aneurysm

Enlargement of a section of the aorta due to weakness in the artery wall. More common after age 65, more common in males, sometimes runs in families. Smoking, a high-fat diet, lack of exercise and excess weight are risk factors.

Ectopic Beats

Extra contractions of the heart that are out of the normal rhythmic pattern but are nonetheless normal. We all have them occasionally. Most people have at least one ectopic beat every day.

Superficial Thrombophlebitis

Inflammation of a superficial vein (a vein just beneath the surface of the skin) that may cause a blood clot to form in it. More common after age 20, more common in women and sometimes runs in families. Intravenous drug abuse is a risk factor. A blood clot of this kind rarely breaks off and travels because the inflammation holds it firmly within the vein.

Cardiac Arrest

A sudden failure of the heart to pump blood, which is often fatal. The most common cause is a heart attack but excessive loss of blood, hypothermia, drug overdose and shock can also result in cardiac arrest. A person with cardiac arrest collapses suddenly, with loss of consciousness, absence of pulse and no breathing. Cardiac arrest is more common in males and more common with increasing age.

Complementary treatment of Heart Failure

Do not abandon conventional approaches. Western herbalism – treatments for water retention might be useful.

Chinese herbalism remedies can strengthen the heart and circulatory system. Diet – a registered naturopath or nutritional therapist will be able to advise on how you can switch to a balanced diet, low in saturated fats. Healing can be effective in promoting circulatory function. Yoga and tai chi/chi kung are gentle forms of exercise with much to offer.

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