Heart failure - Causes, symptoms and treatment. MF.

Heart failure is a condition due to the fact that the heart can not cope with its pump functions that ensure normal blood circulation. With heart failure, the heart is not able to effectively pump blood, which is why there is a violation of the circulation of oxygen and nutrients in the body, which leads to stagnation of blood. It appears as a result of ischemic heart disease, heart defects, arterial hypertension, lung diseases, myocarditis, rheumatism.

Heart failure is the inability of the heart to fully perform its pumping( contractile) function, and also provide the body with the necessary amount of oxygen contained in the blood. Heart failure is not an independent disease. As a rule, it is a complication or result of various diseases and conditions. In the United States heart failure affects about 1% of the population( 2.5 million people).The incidence of heart failure increases with age. In the same USA, it affects 10% of the population older than 75 years.

Causes of heart failure

In the vast majority of cases, heart failure is the natural outcome of many diseases of the heart and blood vessels( valvular heart disease, coronary heart disease( CHD), cardiomyopathy, arterial hypertension, etc.).Only occasionally heart failure is one of the first manifestations of heart disease, for example, dilated cardiomyopathy. In hypertensive illness, many years can pass from the onset of the disease to the appearance of the first symptoms of heart failure. Whereas, as a result, for example, of an acute myocardial infarction, accompanied by the death of a significant part of the heart muscle, this time can be several days or weeks. In the event that heart failure progresses for a short time( minutes, hours, days), they speak of acute heart failure .All other cases are attributed to of chronic heart failure .In addition to cardiovascular disease, febrile conditions, anemia, increased thyroid function( hyperthyroidism), alcohol abuse, etc. contribute to the appearance or aggravation of heart failure manifestations.

Development of heart failure

The timing of onset of cardiac failure is individual for each patient and his cardiovascular disease. Depending on which heart ventricle suffers more as a result of the disease, the right and left ventricular heart failure is distinguished.
In cases of right ventricular heart failure excess volume of fluid is retained in the vessels of the circulatory system, resulting in swelling of the , firstly in the area of ​​the feet and ankles. In addition to these basic signs for right ventricular heart failure is characterized by fast fatigue , explained by low oxygen saturation of blood, and sensation of bursting and pulsation in the neck region of .

Left ventricular heart failure is characterized by fluid retention in the pulmonary circulation, resulting in a decrease in the amount of oxygen entering the blood. As a result, there are dyspnea , which is aggravated by physical exertion, and weakness and fast fatigue .

The sequence of appearance and severity of symptoms of heart failure are individual for each patient. In diseases accompanied by a lesion of the right ventricle, symptoms of heart failure appear faster than in cases of left ventricular failure. This is due to the fact that the left ventricle is the most powerful department of the heart. It usually takes a long time before the left ventricle "surrenders" its positions. But if it does happen, heart failure develops with catastrophic rapidity. Symptoms of heart failure.

Cardiac failure may manifest with different symptoms depending on which heart department is more affected. There may be shortness of breath, arrhythmias, dizziness, darkening in the eyes, fainting, swelling of the cervical veins, pallor of the skin, swelling of the legs and pain in the legs, enlarged liver, ascites( free fluid in the abdominal cavity).The patient does not suffer even a small physical load. In the later stages of the complaint, complaints arise not only under stress, but also at rest, the work capacity is lost completely. Because of insufficient blood supply, all organs and systems of the body suffer in varying degrees.

Symptoms of heart failure depend on which side of the heart, right, left or both, is ineffective. If the right side of the heart does not work well, blood overflows the peripheral veins and as a result seeps into the tissues of the legs and abdominal cavity, including the liver. This causes swelling and enlargement of the liver. If the left side is affected, the blood overflows the vessels of the small circle of blood circulation and the heart and partially passes into the lungs. Rapid breathing, cough, frequent heart rhythm, bluish or pale skin color are characteristic for this case of heart failure. Symptoms can be of varying severity, possibly fatal.

Complaints of patients with heart failure

Edemas are one of the first symptoms of right ventricular heart failure. Initially, patients are concerned about minor swelling, usually affecting the feet and lower legs. Swelling evenly affects both legs. Swelling occurs later in the evening and goes to the morning. With the development of deficiency, edema becomes dense and completely by morning do not pass. Patients note that ordinary shoes are no longer suitable for them, they often feel comfortable only in household slippers. With further spread of swelling in the direction of the head increase in the diameter of the shin and thigh.

fluid then accumulates in the of the abdominal cavity of ( ascites).When anasarca develops, the patient usually sits, as in the prone position there is a sharp shortage of air. Developed hepatomegaly - increase in the liver in size due to overflow of its venous network with a liquid part of the blood. Patients with enlarged liver often notice discomfort( unpleasant sensations, heaviness) and pain in the right upper quadrant. When hepatomegaly in the blood accumulates pigment bilirubin, which can stain sclera( "proteins" of the eyes) in a yellowish color. Sometimes -like icterus scares the patient, which is the reason for going to the doctor.

Fast fatigue is a symptom characteristic of both right and left ventricular failure. Initially, patients report a lack of strength in the performance of previously well tolerated physical activity. Over time, the length of periods of physical activity decreases, and pauses for rest - increases.

Shortness of breath is the primary and often first symptom of chronic left ventricular failure. During dyspnea, patients breathe more often than usual, as if trying to fill their lungs with the maximum volume of oxygen. Initially, patients notice shortness of breath only when performing intense physical exertion( running, fast climbing stairs, etc.).Then, as progression of heart failure progresses, patients can note shortness of breath during normal conversation, and sometimes - in a state of complete rest. Paradoxical as it sounds, patients themselves do not always realize the presence of shortness of breath - it is noticed by the people around them.

Paroxysmal cough , which occurs mainly after intensive exercise, is often perceived by patients as a manifestation of chronic lung diseases, for example, bronchitis. Therefore, when a doctor is questioned, patients, especially smokers, do not always complain about coughing, believing that it has nothing to do with heart disease. Rapid heartbeat( sinus tachycardia) is perceived by patients as a feeling of "fluttering" in the chest, which occurs with some motor activity and disappears after a while after its completion. Often, patients get used to the rapid heartbeat, not fixing on it their attention.

Diagnosis of heart failure

Heart failure is due to of various diseases and conditions of both cardiovascular and others. In order to establish the presence of heart failure, sometimes a normal medical examination is sufficient, whereas may require the use of a number of diagnostic methods to clarify its causes.

Electrocardiography ( ECG) helps physicians to detect signs of hypertrophy and insufficiency of blood supply( ischemia) of the myocardium, as well as various arrhythmias. As a rule, these ECG-signs can take place with various diseases, i.e.are not specific for heart failure.

Based on the ECG, the so-called exercise tests have been developed and widely used, consisting in the fact that the patient must overcome gradually increasing levels of load. For these purposes, special equipment is used to dose the load: a special modification of the bicycle( veloergometry) or "running track"( treadmill).Such tests provide information on the reserve capabilities of the pumping function of the heart.

The basic and currently available method for diagnosing diseases that occur with heart failure is the ultrasound of the heart - echocardiography ( EchoCG).With this method, you can not only establish the cause of heart failure, but also evaluate the contractile function of the ventricles of the heart. Currently, only one EchoCG is sufficient to diagnose congenital or acquired heart disease, to presume the presence of IHD, arterial hypertension and many other diseases. This method can also be used to evaluate the results of treatment.

X-ray examination of chest in heart failure reveals stagnation of blood in a small circle of blood circulation and enlargement of the cavities of the heart( cardiomegaly).Some heart diseases, for example, valvular heart defects, have their characteristic radiographic "picture".This method, as well as EchoCG, can be useful for monitoring ongoing treatment.
Radioisotope methods of heart examination, in particular, radioisotope ventriculography, allow to estimate the contractile function of the ventricles of the heart, including the volume of blood they contain, with high accuracy in patients with heart failure. These methods are based on the introduction and subsequent distribution in the body of radioisotope drugs.

One of the latest advances in medical science, in particular, the so-called nuclear diagnostics, is the method positron emission tomography ( PET).This is a very expensive and still uncommon study. PET allows using a special radioactive "tag" to identify zones of viable myocardium in patients with heart failure in order to be able to adjust the treatment.

Treatment of heart failure

In acute heart failure, the patient is hospitalized. It is mandatory to comply with the regime with limited physical exertion( physiotherapy is chosen by the doctor);a diet rich in proteins, vitamins, potassium is necessary, with restriction of table salt( for large edema it is a salt-free diet).Assign cardiac glycosides, diuretics, vasodilators, calcium antagonists, potassium preparations.

In contrast to past years, at present, the achievements of modern pharmacology have allowed not only to prolong, but also to improve the quality of life of patients with heart failure. However, before starting the medication treatment of heart failure, it is necessary to eliminate all possible factors that provoke its appearance( febrile conditions, anemia, stress, excessive intake of table salt, alcohol abuse, and the use of drugs that promote fluid retention in the body, etc.).
The main emphasis in treatment is made both by on elimination of the causes of the most heart failure , and on correction of its manifestations .

Among the general measures for the treatment of heart failure should be noted rest .This does not mean that the patient needs to lie all the time. The physical load of is permissible and desirable, but it should not cause significant fatigue and discomfort. If the load tolerance is significantly limited, the patient should sit as far as possible and not lie down. In periods of absence of severe shortness of breath and swelling recommend walking in the fresh air. It should be remembered that the performance of physical activity in patients with heart failure should be deprived of any elements of the competition.
Sleeping with heart failure is more convenient with a raised head end of the bed or on a high pillow. Patients with leg edema are also recommended to sleep with a slightly raised leg end of the bed or a thin cushion placed under the feet, which helps to reduce the severity of swelling.
The diet should be with a reduced salt content, ready foods should not be dosed. It is very important to achieve a reduction in excess weight, as it creates a significant additional burden on the diseased heart. Although with far-gone heart failure, weight can decrease by itself. To control the weight and timely detection of fluid retention in the body should be carried out daily weighing at the same time of day.

Currently, the following medications are used to treat heart failure:
• increased myocardial contractility;
• decreased vascular tone;
• reduction of fluid retention in the body;
• elimination of sinus tachycardia;
• prevention of thrombosis in the cavities of the heart.

Among the medicinal agents that increase myocardial contractility , we can mention the so-called cardiac glycosides ( digoxin, etc.) used for several centuries. Cardiac glycosides increase the pump function of the heart and urination( diuresis), and also promote better tolerance of physical exertion. Among the main side effects observed with their overdose, I note nausea, the appearance of arrhythmias, a change in color perception. If in past years, cardiac glycosides were prescribed to all patients with heart failure, they are now prescribed primarily by a patient with heart failure in combination with a so-called ciliary arrhythmia.

To medicinal means, reducing the tone of the vessels , refer to the so-called vasodilators ( from the Latin words vas and dilatatio - "vessel expansion").There are vasodilators with a predominant effect on the arteries, veins, as well as drugs of mixed action( arteries + veins).Vasodilators that dilate the arteries, contribute to reducing the resistance created by the arteries during cardiac contraction, resulting in cardiac output increases. Vasodilators, expanding the veins, contribute to an increase in venous capacity. This means that the volume of venous blood is increased, so that the pressure in the ventricles of the heart decreases and cardiac output increases. The combination of the effects of arterial and venous vasodilators reduces the severity of myocardial hypertrophy and the degree of dilatation of the heart cavities. Mixed-type vasodilators include the so-called angiotensin-converting enzyme inhibitors ( ACE).I will mention some of them: captopril, enalapril, perindopril, lisinopril, ramipril. Currently, ACE inhibitors are the main drugs used to treat chronic heart failure. As a result of the action of ACE inhibitors significantly increases the tolerance of exercise, improves heart filling and cardiac output, and increases urination. The most common side effect associated with the use of all ACE inhibitors is dry irritating cough( "as if brushing in the throat tickling").This cough does not indicate any new disease, but it can bother the patient. Cough can pass after a short-term withdrawal of the drug. But, unfortunately, it is the cough that is the most common reason for stopping ACE inhibitors.
As an alternative to ACE inhibitors in the emergence of cough, so-called angiotensin II receptor blockers ( losartan, valsartan, etc.) are currently used.
To improve the blood filling of the ventricles and increase the cardiac output in patients with chronic heart failure in combination with IHD, preparations of nitroglycerin , a vasodilator that acts mainly on the veins, are used. In addition, nitroglycerin dilates and arteries, blood supplying the heart itself - coronary arteries.

To reduce the excess fluid retention in the body, various diuretics ( diuretics) are prescribed, differing in strength and duration of action. So-called loop diuretics( furosemide, ethacrynic acid) begin to act very quickly after they are taken. Due to the use of furosemide, in particular, it is possible to get rid of several liters of liquid in a short time, especially with its intravenous administration. Usually the severity of the existing dyspnea decreases directly "in front of".The main side effect of loop diuretics is a decrease in the concentration of potassium ions of blood, which can cause weakness, convulsions, and irregularities in the heart. Therefore, simultaneously with loop diuretics prescribe potassium preparations, sometimes in combination with so-called potassium-saving diuretics( spironolactone, triamterene, etc.).Spironolactone is often used independently in the treatment of chronic heart failure. To diuretics of average strength and duration of action, used in the treatment of chronic heart failure, include so-called thiazide diuretics( hydrochlorothiazide, indapamide, etc.).Thiazide drugs are often combined with loop diuretics to achieve a greater diuretic effect. Since thiazide diuretics, like loop diuretics, reduce the potassium content in the body, it may need to be corrected.

To reduce the heart rate of , the so-called β-( beta) adrenoblockers are used. Due to the effect of these drugs on the heart, its blood filling is improved, and, consequently, cardiac output is increased. To treat chronic heart failure, β-adrenergic blocker carvedilol was administered, initially initially administered in minimal doses, ultimately contributing to the increase of the contractile function of the heart. Unfortunately, the side effect of some β-blockers, in particular, the ability to cause bronchoconstriction and increase blood glucose, may limit their use in patients with bronchial asthma and diabetes mellitus.

To prevent thrombus formation of in the heart chambers and the development of thromboembolism, the so-called anticoagulants are prescribed, which depress the activity of the blood coagulation system. Usually prescribed the so-called indirect anticoagulants( warfarin, etc.).When using these drugs, regular monitoring of the parameters of the blood coagulation system is necessary. This is due to the fact that during an overdose of anticoagulants, various internal and external( nasal, uterine, etc.) bleedings can occur.

Treatment of attack of acute left ventricular failure , in particular, pulmonary edema, is performed in a hospital. But already doctors of "emergency medical care" can be introduced loop diuretics, oxygen inhalation and other urgent measures are carried out. In the hospital, the therapy will be continued. In particular, a permanent intravenous injection of nitroglycerin, as well as drugs that increase cardiac output( dopamine, dobutamine, etc.) can be established.

If the current arsenal of medicines used to treat chronic heart failure is inadequate, surgical treatment of may be recommended. The essence of the operation cardiomyoplasty consists in surgically cutting out a flap from the so-called latissimus muscle of the back of the patient. Then this heart for the improvement of the contractile function envelops the heart of the patient. In the future, electrostimulation of the transplanted muscle flap is performed simultaneously with contractions of the patient's heart. The effect after the operation of cardiomyoplasty is manifested in an average of 8-12 weeks. Another alternative is implantation( stitching) in the heart of a patient's auxiliary circulation, the so-called of the artificial left ventricle .Such operations are costly and uncommon in Russia. And, at last, special pacemakers are currently being developed and used, which improve the blood filling of the ventricles of the heart primarily by providing synchronous operation. Thus, modern medicine does not abandon attempts to interfere with the natural course of heart failure.

As a rule, medical supervision for heart failure is necessary throughout life.