Chronic heart failure - Causes, symptoms and treatment. MF.

Causes of CHF
Symptoms of
Diagnosis of
Treatment and lifestyle
Complications and prognosis of

The health and well-being of the human body depends entirely on the ability of the heart to perform its functions. The heart, being a muscle "pump", receives oxygen-enriched blood from the lungs( a small circle of blood circulation) and pumps it into the aorta and arteries of all other organs( a large circle of blood circulation).The cardiac cycle consists of the phases of systole( contraction) and diastole( relaxation) of the atria and ventricles, that is, during the diastole of the ventricles, their relaxation occurs, so that blood from the atria is thrown into the ventricles without resistance, and in the systole of the ventricles, blood is pushed into large vessels -aorta and pulmonary arteries.

If any pathological processes develop in the cardiac tissues, for example necrosis( death), inflammation, trauma, connective tissue structure disorders( dysplasia), the cells undergo a number of changes leading to their dysfunction, which affects the contractility of the myocardium as a whole. These changes are called myocardial remodeling and are characterized by the replacement of myocytes( muscle cells) with scar tissue, stretching of myocytes, disturbance of balance between contraction and relaxation, hypertrophy( increase in size and mass), violation of the architectonics of the heart. The remaining part of healthy tissues for quite a long period of time is able to perform the work on pumping blood, but sooner or later decompensation comes - a condition in which the heart muscle can not carry out the proper amount of contractions to provide the body with oxygen. Then the cells of other organs and tissues will suffer from hypoxia - lack of oxygen, which will lead to dystrophic changes in vital organs and to an unfavorable outcome.

The described changes characterize such a disease as chronic heart failure ( CHF).This pathological condition occurs in the outcome of almost all cardiological and certain non-cardiac diseases( thyrotoxicosis, alcoholism, etc.), characterized by contractile dysfunction of the myocardium and as a result of stagnation of blood in small and large circles of circulation with damage to other organs and body systems.

There are right and left ventricular failure , but in the context of this pathology this is not an anatomical division, but the stages of a single process. In addition, according to the nature of pathological changes and according to the criteria of ultrasound diagnosis, it is customary to isolate diastolic and systolic types of left ventricular dysfunction .With diastolic type , the left ventricle is unable to fully relax and take proper blood volume, which causes an overload of the left atrial volume and congestion in the lungs. The fraction of the discharge of blood into the aorta is preserved. Systolic type is characterized by the presence of dilatation( expansion of the cavity) of the left ventricle, which leads to a violation of its contractility, and to a decrease in cardiac output, that is, internal organs receive less blood.

The figure shows dilated cardiomyopathy, which is characterized by a violation of myocardial contractility of the left ventricle.

Such a subdivision makes sense from the point of view of medical tactics, since with diastolic dysfunction, the myocardium can not relax, and when systolic, on the contrary, it can not contract normally, which entails a certain selection of cardiac drugs. Pure diastolic( restrictive) heart failure occurs in 20 to 30% of all cases of CHF.

Causes of Chronic Heart Failure

The following diseases can result in cardiac muscle deterioration:
- ischemic heart disease and myocardial infarction,
- myocarditis( viral, bacterial, rheumatic inflammatory processes),
- arterial hypertension( hypertonic heart),
- cardiomyopathies( hypertrophic, restrictive anddilatation),
- myocardial dystrophy( disturbance of metabolic processes in muscle cells),
- rhythm and conduction disorders( most often permanent form of atrial fibrillation),
- cardio,
- congenital and acquired heart diseases,
- bacterial endocarditis,
- exudate and adhesive pericarditis( accumulation of fluid in the heart cavity cavity, gluing of the pericardium sheets, which leads to limitation of myocardial relaxation),
- diseases of the bronchopulmonary system( chronic obstructive diseaselungs, bronchial asthma) lead to the formation of the pulmonary heart with the development of predominantly right ventricular failure,
- chronic alcohol intoxication,
-anizma.

Symptoms of chronic heart failure

The main manifestations of myocardial dysfunction are fast fatigue, dyspnea, flushing and bluish nail rash, stop( acrocyanosis), edema of the shins and feet, fluid accumulation in the abdominal cavity( ascites), in the thorax( hydrothorax), in the cavitypericardium( hydropericardium), "cardiac" asthma with episodes of pulmonary edema, anasarca( edema of the whole body).

The degree of symptom severity depends on the stage of the course of the insufficiency. In connection with this cardiology, Vasilenko and Strazhesko developed a classification, called by their names. It includes the following stages:

• Stage I is the stage of initial manifestations of chronic heart failure. The patient is concerned about the chilliness and coldness of the limbs, minor edema of the shins and feet, which appear later in the evening and pass in the morning, increased fatigue and general weakness due to a decrease in blood flow in the skin and skeletal muscles. During physical exertion( walking long distances, climbing stairs), shortness of breath, attacks of dry cough, palpitations, causing discomfort. Dyspnea and fast fatigue are the most frequent symptoms that occur at this stage. From the moment of the onset of the underlying disease to the severe clinical picture, insufficiency can last from several months to many years.
• Stage II A - stagnation of blood in one of the circulatory system. Characterized by a violation of blood flow in the small( light) or in the organs of a large range of blood circulation( liver, kidneys, skeletal muscles, brain, etc.).Venous congestion in the lungs is clinically manifested by the onset of attacks of "cardiac" asthma or episodes of pulmonary edema."Cardiac" asthma develops more often at night, as it is caused by the horizontal position of the person, in which the blood stagnates even more in the lungs. The patient is troubled by a feeling of suffocation, an obsessive dry cough, the inability to take a deep breath, anxiety, heart palpitations;relief may occur in a semi-sitting position or with a raised head end of the bed. For pulmonary edema, a noisy, bubbling breath, a wet cough with a foamy sputum of pink color( due to small capillary ruptures) is characteristic. Venous congestion in the organs of a large circle of blood circulation is manifested by severity and pain in the right hypochondrium, an increase in the abdominal circumference, jaundice of the skin and sclera( due to stagnation in the liver and its increase with impaired functions), swelling( including due to salt retentionin the body, as the work of the kidneys is disrupted), headaches, insomnia, poorly expressed disorders of the psyche and intellect( due to a violation of the blood supply to the brain).
• Stage II In , venous congestion and hemodynamic disturbances in both circulation circles, is manifested by symptoms characteristic of abnormalities in the functions of the above organs.
• Stage III - severe heart failure, irreversible dystrophic changes in all organs and tissues. The patient is worried about constant shortness of breath at rest, most of the time he spends in bed in a reclining position. Cardiac cirrhosis develops. Edema takes on the character of anasarca, the heart and lungs are squeezed by fluid in the thoracic and abdominal cavities, blood pressure is reduced. There is a complete depletion of the heart muscle, liver, kidneys, brain, and there is a fatal outcome.

In addition to clinical, there is also the functional classification of CHD , developed by the New York Heart Association, and designed to assess the physical reserves of the patient.

• For example, with the I functional class( FC) , the patient experiences certain difficulties only with very significant physical exertion, and the initial stages of heart changes may be suspected by ultrasound of the heart, and not on the basis of symptoms.
• II FC manifests a moderate restriction of physical activity, that is, complaints worry the patient when performing normal loads.
• III is characterized by a marked restriction of physical activity - small loads can provoke the appearance of symptoms;the patient feels comfortable only at rest.
• For IV FC is characterized by the presence of complaints with minimal household activity and at rest, the patient is not capable of self-service.

Diagnosis of Chronic Heart Failure

The diagnosis is based on the appropriate complaints, interview and examination of the patient. With auscultation of the chest, weakening of the heart tone, irregular heart rhythm with rhythm and conduction abnormalities, pathological tones and noises in heart diseases, dry or wet wheezing in the lungs while stasis of blood in them is heard.

The main method of diagnosing the disease is echocardiography( ultrasound of the heart).The method allows to identify the pathology that caused the development of failure, assess the overall contractility of the myocardium and distinguish between diastolic and systolic dysfunction of the myocardium, since in the first type the ejection fraction is normal or increased( more than 50%), while the second - reduced( less than 40%).

In addition to ultrasound of the heart, laboratory( general blood and urine tests, biochemical, immunological and hormonal blood tests) and instrumental diagnostic methods are prescribed. Of the latter, the following apply:

- ECG - reveals myocardial ischemia, signs of postinfarction cardiosclerosis, rhythm disturbances, atrial or ventricular hypertrophy, blockades and other signs. If necessary, daily monitoring of ECG and arterial pressure, ECG with load( treadmill test, veloergometry - for determining the functional class of angina and chronic heart failure) can be assigned.

- chest X-ray of the - may show enlargement of the heart shadow due to myocardial hypertrophyor ventricular dilatation, changes in the lower parts of the lungs or across all pulmonary fields( signs of venous stasis or pulmonary edema, respectively).

The chest radiograph shows an increase in all chambers of the heart, called cardiomegaly.

- coronarography can be shown to patients with ischemic heart disease to assess the permeability of the coronary arteries and determine the need for cardiac surgery
- Ultrasound of the liver, kidney reveals structural changes in the organs due to blood congestion and chronic hypoxia( hepatomegaly - liver enlargement, cardiac cirrhosisliver, secondary renal scarring)
- Thyroid ultrasound is assigned to identify diseases that can cause heart damage( nodular goiter,diffuse toxic goiter)

The list of necessary diagnostic methods is determined by the attending physician individually during the clinical examination.

Treatment of chronic heart failure

The goals of the treatment of this disease are to reduce the severity of symptoms of the underlying pathology, slow the progression of failure and improve the quality of life of patients. Medical treatment of is prescribed for a long time and continuously, with correction of the drugs, their dosages and combinations as necessary. Of the drugs for failure, the following main groups are shown:

- inhibitors of ACE .They have antihypertensive and organoprotective action, that is, they not only lower blood pressure, but also protect the target organs - the heart, blood vessels, kidneys, brain. These include prestarium, zocardis, hartil, etc.
- receptor antagonists for angiotensinogen II - have similar properties. Include such drugs as lorista, mycardis, vasotensia, etc.
- diuretics( diuretics) .Assigned to reduce the volume of circulating blood and, accordingly, "unloading" of organs in which blood stasis occurs. Include high-speed drugs - lasix( furosemide), diver( torasemide), prescribed mainly in severe edematous syndrome and in case of acute heart failure, for example, with pulmonary edema. This group also includes thiazide( hypothiazide, indapamide) and potassium-sparing diuretics( veroshpiron).
- betta - adrenoblockers .Lower heart rate, thereby reducing the need for myocardium in oxygen, which is important for the therapy of IHD, reduce the overall resistance of blood vessels, so that the blood is more freely pushed from the heart into the vessels. Include such drugs as bisogamma, rekardium, betalk.
- anticoagulants and antiplatelet agents .Affect the blood coagulation system, preventing the formation of blood clots. The first include clopidogrel( plavix), warfarin, to the second - aspirin preparations - acetcaridol, Cardiori aspirin, cardiomagnet, etc. The appointment of anticoagulants requires more regular( preferably monthly) monitoring of the blood system( INR, APTT, prothrombin time), soas the risk of bleeding increases.
- nitrates - nitroglycerin preparations have a relaxing effect on the veins, reducing blood flow to the heart, which contributes to a more effective cardiac output, and also expand the coronary vessels, increasing the blood supply of the myocardium. Short-acting drugs( nitroglycerin, nitromite, nitrospray) are used to stop angina attacks, medications of medium and long-acting( monochinkve, pectrol, isoket) are prescribed for angina pectoris III and IV, nitrates are also effective intravenously in the treatment of pulmonary edema, but in combination with drugs, increasing the tone of the vessels( to prevent a sharp drop in blood pressure and collapse).A side effect is a persistent headache in the first days of taking medications, caused by the expansion of cerebral vessels.
- lipid-lowering drugs have an effect on the exchange of cholesterol and lipids forming it, helping to lower the level of "bad" cholesterol in the blood. These include statins - atoris, lovakor, simlo and many others).
- cardiac glycosides are used to increase myocardial contractility and heart rate reduction. Assigned mainly in the presence of the patient's constant form of atrial fibrillation, and / or the presence of systolic dysfunction of the left ventricle, when the contractility is reduced( ejection fraction less than 40%).In the presence of normal PV or diastolic dysfunction, the appointment is not justified. The drugs of this group include digoxin( novodigal).
- calcium channel antagonists act on muscle cells of blood vessels and hearts, relaxing them, resulting in lowering blood pressure, expanding the coronary arteries, and the power of the heart. In connection with the latter effect, the appointment of drugs of this group is not justified in the presence of systolic LV dysfunction, since myocardial contractility is already suffering. This group includes nifedipine, verapamil and diltiazem( trade names - diltz, amlodipine, corinfar, etc.).

In addition to monopreparations, combinations of various active substances in one tablet can be prescribed, which greatly simplifies the regimen of taking medications and improves compliance - the patient's adherence to treatment. This group includes the pretest( amlodipine + perindopril), noliprel A and Abi forte( indapamide + perindopril), and others.

Surgical treatment of is to promptly correct the initial disease, if possible. All indications and contraindications are determined strictly individually, since it is very important to correctly assess the possible risks and to catch a fine line when the operation is already needed, but is not contraindicated due to the general severe condition of the organism, such as occurs with acquired heart defects. The operations are indicated for complex rhythm disturbances( radiofrequency ablation of pulmonary veins, pacemaker installation), with IHD( coronary stenting and coronary artery bypass grafting), LV aneurysm( excision and suturing of cicatrical protrusion), congenital and acquired heart defects.

Lifestyle in chronic heart failure

Lifestyle in this pathology consists of some components:

- regimen - the patient needs to organize the correct mode of work and rest, provide enough sleep time per day, more to stay or to walk outdoors.
- proper nutrition - a pledge of health not only of the heart muscle, but of the whole organism as a whole. It is necessary to organize a mode of food intake - food should be frequent, small portions( 5 - 6 times a day).When edematous syndrome is recommended to limit the amount of salt in the food. It is necessary to exclude alcohol, cigarettes, sharp, fatty dishes, limit the consumption of animal fats for food, fatty meat and fish, and more to consume fruits, vegetables and fermented milk products.
- physical activity - in the initial stages of CHF, it is possible to engage in physiotherapy exercises according to the doctor's prescription, at pronounced stages, to exclude physical and psychoemotional loads that promote the appearance of symptoms.
- compliance with medical prescriptions - is very important for preventing the development of complications and for delaying the progression of failure to visit a doctor on a timely basis and conduct prescribed examinations, as well as regularly taking medications.

Complications of chronic heart failure

Patients with chronic heart failure can develop such dangerous conditions as sudden cardiac death, acute heart failure, pulmonary edema, thromboembolic complications( heart attack, stroke, pulmonary artery thromboembolism), frequent and prolonged pneumonia. Prevention of their development is the use of prescribed medications, timely detection of indications for surgical treatment, the appointment of anticoagulants according to indications, antibiotic therapy in the defeat of the bronchopulmonary system.

Forecast

Prognosis in the absence of treatment is unfavorable, as most heart diseases lead to its wear and development and severe complications. When carrying out medical and / or cardiosurgical treatment, the prognosis is favorable, because there is a slowdown in the progression of the failure or a radical cure from the underlying disease.

Doctor therapist Sazykina O.Yu.