Heart failure (cardiac insufficiency)

Heart muscle weakness (cardiac insufficiency, myocardial insufficiency) is the inability of the heart to supply the body tissues with sufficient blood and oxygen. The performance of the heart is then so low that the body's needs can no longer be met.

Incidence

is based on the assumption that around 375 out of 100,000 men and 290 out of 100,000 women contract the disease each year.

The number of new cases is growing rapidly and is due to an increase in the average age of the population.

In general, there is an earlier occurrence of heart muscle weakness in men. Nevertheless, both sexes are affected equally often. The number of new cases is highest between 70 and 80 years of age.

Types

Different types of heart failure can be distinguished:

• Systolic heart failure: in this type of failure, the pumping function and ejection capacity of the left ventricle are reduced (reduced ejection fraction).
• Diastolic heart failure: While the pumping function and the ejection capacity are inconspicuous, the filling of the heart is disturbed. Diastolic heart failure is particularly common in older women. The cause is considered to be an enlargement (hyperthrophy) of the left main chamber, which can result from years of excessively high blood pressure.

It is important to distinguish between these two types of heart failure, as this determines the form of therapy and the prognosis.
Von der Herzinsuffizienz können die rechte, die linke oder beide Herzhälften betroffen sein. Nach diesen Kriterien unterscheidet man zwischen

• Left-sided heart failure: In left-sided heart failure, the work of the left side of the heart is disturbed, which is why the blood backs up into the lungs (congested lung). Water then accumulates there. The consequences are reduced resilience, coughing and shortness of breath. In the worst case, pulmonary oedema can also form. Triggers are: high blood pressure (hypertension) or coronary heart disease (CHD), which leads to a weakening of the left ventricle.
• Right heart failure: Right heart failure occurs when the pressure in the pulmonary circulation increases and the right ventricle has to pump blood into the lungs against the increased pressure. This results in increased blood pressure in the pulmonary vessels (pulmonary hypertension), which leads to overload and damage to the heart (cor pulmonale, Latin for "pulmonary heart"). The cause of this lies not in the heart but in the lungs. This overload causes the right ventricle of the heart to thicken. If the heart is no longer able to cope with this work, blood is congested in the systemic circulation. The consequences are right heart failure with accumulation of water (oedema) in the body, especially in the legs, abdominal cavity or liver.
• Global heart failure: Here, the pumping function of both chambers of the heart is impaired, as well as symptoms of left and right heart failure.

The main cause of heart failure is calcification (arteriosclerosis)of the coronary vessels. This is also the cause of coronary heart disease (CHD). This often results in a heart attack and the death of the heart muscle tissue.

Another cause is high blood pressure (hypertension). High blood pressure is an extreme strain on the heart, which causes the pumping capacity to decrease over time.

The following are also considered risk factors:

• Heart muscle diseases (called cardiomyopathies): they can have genetic causes, but can also be triggered by infections or by other substances such as alcohol, cocaine or some medications.
• Heart muscle inflammations
• Cardiac arrhythmias
• Heart valve defects
• Pericardial effusion or constriction of the pericardium
• Metabolic diseases (diabetes mellitus, hypothyroidism/hyperthyroidism)
• Advanced lung disease such as COPD or emphysema may also be a factor for the less common right heart failure.

People dealing with severe traumatic experiences may suffer from life-threatening heart failure (stress cardiomyopathy). In most cases, however, heart function returns to normal over time.

NYHA classification

Based on the guidelines of the New York Heart Association, heart failure is divided into four stages (NYHA classification). An important role is played by the performance of the affected person.

Stages of chronic heart failure (NYHA):

Designation	Limitation	During physical exertion	At rest
NYHA I (no symptoms)	no physical limitations	Everyday physical exertion can be performed	no restrictions at rest
NYHA II (mild)	slight restriction of physical performance	greater physical exertion leads to exhaustion, dysrhythmia, shortness of breath or angina pectoris (e.g. walking uphill, climbing stairs)	there are no symptoms at rest or with little exertion
NYHA III (moderate)	Major limitations in physical performance during normal activity	shortness of breath or angina pectoris (e.g. when walking in a straight line on level ground)	exhaustion, dysrhythmia during low physical exertion
NYHA IV (severe)	Complaints occur during all physical activities and at rest	Complaints occur during all physical activities and at rest	Bedriddenness

Symptoms vary depending on whether right or left heart failure is present.

Left-sided heart failure: In left-sided heart failure, shortness of breath is initially only present during physical exertion. However, if the heart failure worsens, the shortness of breath becomes permanent (chronic, dry cough). Patients experience extreme states of exhaustion. In acute cases, tissue water accumulation in the lungs (pulmonary oedema) may occur. The characteristics are severe shortness of breath, restlessness, coughing, and "bubbling" breath sounds.

Right-sided heart failure: Right-sided heart failure is often manifested by swollen legs (oedema), mainly around the ankles. This condition disappears again overnight. The swelling can cause the skin to dry out. Because of the excessive pressure in the tissues, eczema can occur (stasis eczema), which can become sores (shin ulcers). This type of wound heals poorly.

In addition, there is an inadequate blood supply and associated inflammation. Due to the right-sided cardiac insufficiency, water accumulates in the organs, and here mainly in the liver. As a result, the abdominal organs swell and the abdominal girth increases. The congestion leads to a considerable impairment of organ function. In addition, there may be an accumulation of water in the abdominal cavity (ascites).

Global heart failure: In bilateral heart failure, symptoms of left and right heart failure occur.

In advanced disease progression, cardiac arrhythmias (ventricular arrhythmia) occur. These can cause a life-threatening condition and must therefore be treated immediately.

In order to diagnose heart failure, the doctor must take the patient's medical history into account. On the basis of this medical history, one can conclude on possible causes, as well as the degree of heart muscle weakness. This is followed by an examination of the heart to rule out a valvular defect as a possible cause. Other diseases that also manifest themselves in the form of chest pain or shortness of breath must also be ruled out.

During the physical examination, the doctor will determine whether there is water retention (oedema) in the lungs or legs: When listening to the lungs, you may notice typical rales that indicate water in the lungs. Edema in the legs is manifested by depressions around the ankles.

The heart function is checked by means of a heart ultrasound (echocardiography). The structures of the heart walls and valves, as well as the movement and wall thickness of the atria and ventricles, the size of the heart's inner chambers and the entire heart, as well as the ejection fraction are displayed.

A long-term ECG provides information about possible cardiac arrhythmias.

A cardiac catheter examination shows whether there are constrictions of the coronary vessels (CHD). In the course of this examination, the ejection fraction is also determined.

Further examinations reveal the causes or concomitant diseases. These examinations usually include a blood and urine test, as well as a blood pressure measurement.

The following values are determined in the basic diagnostics:

• Blood count
• Serum electrolytes (Na, K)
• Serum creatinine
• BNP (not necessarily recommended for outpatients)
• Fasting blood sugar
• Liver enzymes
• Urine status

These examinations are used to detect functional disorders of the liver, kidneys, thyroid, as well as elevated blood lipids or diabetes.

Medication

Heart failure can now be treated well with medication. However, lifestyle changes are also important to achieve success. Drug treatment aims to improve the quality of life and prevent complications of heart failure. It is therefore essential to find out the cause of the heart failure and to treat any underlying disease.

A variety of medications can be used to treat chronic heart failure. Some aim to improve the prognosis, others to alleviate the symptoms. Thanks to modern medicines, fewer and fewer people die of heart failure nowadays.

Some scientific studies have shown that, for example, ACE inhibitors or beta blockers have a life-prolonging effect. For this reason, care should be taken to ensure that the medication is taken at regular intervals.

Improving prognosis

• ACE inhibitors: This group of drugs have a blocking effect on the body's own protein ACE, which is involved in the production of angiotensin-II (AT-II). AT-II's job is to constrict blood vessels, thus keeping blood pressure high. When AT-II is throttled, the result is that the blood vessels in the body remain permanently wide and blood pressure drops. As a result, the heart has to work against a lower resistance, which leads to a relief. ACE inhibitors can also slow down the pathological remodelling of the heart muscle. In most cases, ACE inhibitors are well tolerated and improve the prognosis.
• AT1 antagonists: AT1 receptor antagonists (AT1 blockers, angiotensin II blockers, sartans) have the effect of blocking the hormone angiotensin I, which increases blood pressure. AT1 antagonists have the same mechanism of action as ACE inhibitors, but are used when the patient cannot tolerate ACE inhibitors.
• Beta-blockers: Beta-blockers lead to a reduction of the stress hormone (catecholamines) in the heart. They counteract life-threatening cardiac arrhythmias.
• Diuretics: These agents have a diuretic effect (aldosterone antagonists) and register an improvement in prognosis mainly in advanced stages. However, the exact mechanism of action is still unknown.

Reduce symptoms

• Diuretics: Diuretics are diuretic drugs that rid the body of stored, excess fluids, thus relieving the heart and blood vessels. As a result, shortness of breath and water retention at the ankles are reduced. Thiazide diuretics and loop diuretics are considered the most popular agents. The difference between these two agents is their different sites of action in the kidney.
• Digitalis (cardiac glycosides): Digitalis is one of the oldest drugs. A life-prolonging effect has not yet been proven, but they do increase quality of life and resilience in heart failure. In addition, medications with digitalis lead to an improvement in the pumping power of the heart.

In patients suffering from advanced heart failure, a biventricular pacemaker (CRT) together with a well-controlled drug therapy can improve cardiac function. If a patient has already survived a cardiac death or suffers from life-threatening cardiac arrhythmias, an implantable cardioverter-defibrillator (ICD) can help. It is used in a similar way to a pacemaker and delivers an electric shock as soon as a threatening arrhythmia occurs. In some cases, doctors may also use a combined device from both systems (CRT-ICD system).

If the heart failure worsens despite therapy, a heart transplant may have to be considered. There is a possibility that the affected person will receive either a donor heart or an artificial heart, or a support system.

Heart failure can rarely be completely cured. Nevertheless, the course of the disease can be positively influenced and each patient can additionally ensure a more favorable prognosis, for example, by changing his or her lifestyle.

The patient's compliance with the therapy is also decisive for a favourable course of the disease. This includes taking the medication carefully. The drugs commonly used today can prevent complications of heart failure and thus improve the patient's quality of life.

The following points are also crucial for a favourable prognosis in heart failure:

• Control examinations should be regularly noticed (at least twice a year sodium and potassium control, as well as kidney values. If the values are outside the norm, the checks should be carried out at shorter intervals).
• Daily weighing (weight monitoring)
• Regular exercise
• A balanced diet with special attention to salt consumption
• The daily drinking quantity agreed with the doctor should be adhered to.

Observe signs

Even though heart failure is a chronic condition, complications can be easily prevented by the person affected.
Ab und zu kann es vorkommen, dass sich die Pumpleistung des Herzens über einen kurzen Zeitraum verschlechtert, was an Wassereinlagerungen (Ödemen) im Körper zu erkennen ist. Diese wiederum merkt der Patient an einer plötzlichen Gewichtszunahme, sowie optisch an den Füßen und Unterschenkeln. Wasseransammlungen in der Lunge haben Atemnot zur Folge.

Check your weight

Weight should be checked regularly and, ideally, recorded daily in a diary. These records should be taken to the doctor and discussed. Weight fluctuations should be clarified and a decision made about tolerability and the need for action. A note should also be made of how often one has to get up to urinate during the night.

Immunizations: In addition, regular monitoring of cholesterol and blood sugar levels, as well as blood pressure should be done. Furthermore, necessary vaccinations should be clarified. For example, an annual vaccination against influenza is generally recommended for heart patients, but should be clarified with the doctor.