Heart Failure

A five year mortality rate associated with heart failure cases is around 5-50 % depending upon how severe the case is and the left ventricular dysfunction. Hospitalization is frequent , quality of life is reduced along with exercise tolerance. Symptoms include dyspnea, fatigue, and retention of fluid.

Goals of therapy are ,

  1. Treatment of modifiable risk factors
  2. Avoid exacerbating factors
  3. Prevent disease progression
  4. Improve symptoms, exercise tolerance and quality of life
  5. reduce morbidity and mortality

Investigations

Performing a history, and physical examination and select lab tests are keys to providing an accurate diagnosis.

Doing these few tests are important in diagnosis :-

  • Transthoracic echocardiography or isotropic ventriculography (this will rule out any valvular and other myocardial abnormalities)
  • MRI, cardiac cathetrisation and angiography, EP testing (to understand the electrical activity of the heart )
  • The New York Heart Association functional classification is commonly used to describe patients with Heart Failure

The New York Hear Association classifies the heart failure stages into 4 different classes

ClassCharacteristics
INo ordinary activity
IISymptoms occur with ordinary activity
IIISymptoms occur with less ordinary activity
IVSymptoms occur with rest or minimal activity

For selected few patients Brain natriuretic peptide(BNP) or N-terminal proBNP , iron studies, ferritin and transferrin , HIV tests should be performed

For over all – Complete blood count , serum creatinine, electrolytes, urea, albumin, uric acid and aminotransferase, fasting plasma glucose and serum lipids, thyroid function tests, urinalysis.

Non Pharmacological choices

  • Manage simultaneously other problems such as hypertension, obesity, sleep apnea, supraventricular and ventricular arrhythmia.
  • Avoid exacerbating risk factors
  • Recommend moderate regular physical acitivity in stable patients
  • Alcohol consumption should be very limited in all patients, it could be no more than one alcoholic drink per day.
  • One of the important diet restriction is Sodium restriction, it should be below 2-3 g/day , 1-2 g/day , in patients with severe HF.
  • Annual Influenza vaccination in all patients
  • Pneumoccai vaccinaton in all patients
  • Patients who gain 0.5 kg/day on several consecutive days or 2 kg in 3 days is a matter of concern.

Pharmacological choices

ACE inhibitors have been recommended in all patients because they can improve the symptoms and reduce the risk of hospitalisation, MI death in patients with Heart Failure. For a start, patients are usually given a very low dose and titrated every 7-14 days intervals to the target dose . Serum creatinine measurement is important and it is expected to rise 30% after the start of ACE inhibitor therapy. Dysfunction of the kidney can be a major factor for disturbance in electrolyte levels. Taking regular measurements of kidney function is vital

Beta Blockers

In layman terms it slows the heart down and and protecting it from effects of adrenaline and nor adrenaline, ” fight or flight ” chemicals produced by the body.

Main one usually used are Bisoprolol, carvedilol and nebivolol.

Side effects can be dizziness, tiredness, blurred vision. But most people taking them have either no or very mild side effects that become less troublesome with time.

Angiotension Receptor Blockers

Work in a similar way as ACE inhibitors by relaxing blood vessels and reducing blood pressure. They seem to be used as an alternative to ACE inhibitors because they don’t cause cough, although might not be as effective as ACE inhibiors.

Eg- Candesartan, Losartan, Telmisartan, Valsartan

Hyperkalemia is one side effect that is common. Regular blood test is needed.

Mineralocorticoid receptor antagonists (MRA’s)

MRA’s make you pass more urine, but that is one way to reduce the pressure and reduce fluid around the heart. Potassium levels can increase to dangerous levels.

In women – increased hair growth can happen while in men enlarged breast tenderness have been reported.

Eg- Spironolactone

Diuretics

Also called water pills, again can make you pass more urine and help relieve ankle swelling and breathlessness caused by heart failure.

Furosemide and Bumetanide are two widely used ones.

Dehydration and reduced levels of Na and K in blood are common.

Ivabradine

It is a medicine that can reduce the heart speed. A useful alternative to beta blockers and if you can’t take them or if beta blockers are causing side effects.

Possible side effects include headaches, dizziness, blurred vision.

Sacubitril valsartan

Sacubitril valsartan is a single tablet that combines an ARB and a medication called neprilysin inhibitor. It’s suitable for people with more severe heart failure, whose heart is only able to pump a reduced amount of oxygenated blood around the body despite taking other medication.

The most common side effects are low blood pressure, high K and some kidney problems.

Hydralazine with nitrate

A combination with nitrate can help relax and open up blood vessels. These medicines are sometimes prescribed by heart specialists (cardiologists) for people who are unable to take an ACE inhibitor or ARB

Side effects can be headaches, fast heart beat, fluttering, irregular heartbeat (palpitation)

Digoxin

It can improve the symptoms by slowing down the heart rate or strengthens the contractions of the heart.

It’s normally only recommended for people who have symptoms despite treatment with ACE inhibitors, ARB’s, beta blockers and diuretics.

Possible side effects include dizziness, blurred vision, feeling and being sick, diarrhoea and an irregular heartbeat.

Living with Heart Failure

Healthy diet

A balanced diet can help improve the symptoms and general health, it should include –

  1. Plenty of fruits and vegetables – aim for at least 5 portions a day
  2. Meals based on starchy foods, such as potatoes , bread , rice, or pasta
  3. Some dairy or diary alternatives
  4. Some beans or pulses , fish, eggs.
  5. Low levels of saturated fat, salt and sugar

Patients are often advised to make dietary changes that can limit fluid intake to help cope up with heart failure.

Exercising regularly

A moderate physical activity can improve the symptoms and over all health. In fact the patient should be offered and exercise-based cardiac rehabilitation programme.

Education support, emotional support and exercise support are three essential things which should be included in the treatment.

Smoking and Alcohol

It is advised that if the heart failure is related to alcohol directly then it should be stopped immediately or entirely. Smoking in anyway is harmful for a lot of other conditions.

Speak to your doctor or pharmacist about how to get over the habit of smoking or how to quit it. There are treatments available for that.

Alcohol consumption on the other hand can be limited or its advised that no more than 14 alcohol units a week should be consumed

Regular reviews and monitoring

You will have to get regular check ups done at least once every 6 months. These appointments may involve – talking about your symptoms, such as whether they are affecting your normal activities or getting worse.

  • Talking about the symptoms, whether they are affecting your normal activities
  • a discussion about medications and any side effects, tests to monitor your health
  • the care team might suggest to weigh yourself regularly, usually any sudden change can be a problem

To be vigilant and to be conscious about the condition is the right way to deal a problem that stays life long. If the condition cant be cured, it can be monitored, reduced, halted and life can be prolonged.

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