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HEART
FAILURE
Questions and Answers About Heart Failure
1. What is heart
failure?
2. How common is heart
failure?
3. What causes heart
failure?
4. Is there only one type
of heart failure?
5. How quickly does heart
failure develop?
6. What are the symptoms of
heart failure?
7. How do doctors diagnose
heart failure?
8. What other tests might
be done?
9. How is heart failure
classified?
10. How is heart failure
treated?
11. What you and your
doctor should know.
12. What doctors treat heart
failure at UAMS Medical Center?
Making an Appointment
at UAMS Medical Center
To make an appointment, call 1-501-686-8000.
1. What is heart
failure?
Heart failure is a serious condition. However, by learning more about heart failure
and how to take care of yourself, you can live longer while feeling healthy.
The heart is a muscle that pumps blood through the body.
The term "heart failure" sounds pretty scary-as if the heart has
"failed" or stopped beating. When you have heart failure, it means your
heart’s pumping power cannot keep up with the body’s needs. Blood flow from your
heart to your muscles and organs becomes weaker causing you to feel tired and run down.
Also, blood backs up in your veins. As a result, fluid can seep out of the veins and build
up in the lungs and other parts of the body. You may experience difficulty in breathing,
and your legs, ankles, and abdomen may become swollen.
Usually the heart has been weakened over time by an
underlying problem, such as clogged arteries, high blood pressure, a defect in its
muscular walls or valves, or some other medical condition. The term heart failure suggests
a sudden and complete stop of heart activity. But actually, the heart does not suddenly
stop. Rather, heart failure usually develops slowly, often over years, as the heart
gradually loses its pumping ability and works less efficiently. Some people may not become
aware of their condition until symptoms appear years after their heart began its decline.
The severity of the condition determines the impact it has
on a person’s life. At one end of the spectrum, the mild form of heart failure may
have little effect on a person’s life; at the other end, severe heart failure can
interfere with even simple activities and prove fatal. Between those extremes, treatment
often helps people lead full lives. But all forms of heart failure, even the mildest, are
a serious health problem, which must be treated. To improve their chance of living longer,
patients must take care of themselves, see their physician regularly, and closely follow
treatments.
2. How common is
heart failure?
If you’ve been diagnosed with heart failure or know someone who has, you’re
not alone. Nearly five million Americans are currently living with this condition, with
400,000 new cases diagnosed each year. The condition is slightly more common among men and
is twice as common among African Americans as whites. Heart failure affects people of all
ages, from children and young adults to the middle-aged, and senior citizens. However, it
is more common among older people. Therefore, as the older population grows over the next
few decades, so will the number of people living with heart failure, or caring for a loved
one who has the condition.
In a sense, heart failure’s growing
presence as a health problem reflects the nation’s changing population. More people
are living longer. People aged 65 and older represent the fastest growing segment of the
population, and the risk of heart failure increases with age. The condition affects 1% of
people aged 50-59, but 10% of people aged 80-89.
3. What causes
heart failure?
All of us lose some blood-pumping ability in our hearts as we age. But the more
serious loss that we call heart failure results from the added stress of health conditions
that either damage the heart or make it work too hard. In fact, all of the behaviors that
you probably associate with heart disease or heart attack--such as smoking, being
overweight, eating foods high in fat and cholesterol, and not exercising, hypertension
(persistent high blood pressure), diabetes and abnormal blood sugar levels--can also cause
heart failure.
If someone experiences heart failure, chances
are they have (or had) one or more of the following. Some of these can be present without
the person even knowing it.
Coronary artery disease
When cholesterol and fatty deposits build up in the heart’s arteries, less blood
reaches the heart muscle. This damages the muscle, and the healthy heart tissue that
remains has to work harder.
Past heart attacks (myocardial infarction)
A heart attack occurs when an artery that supplies blood to the heart gets blocked.
The loss of oxygen and nutrients causes damage to the heart’s muscle tissue - part of
it essentially "dies." The remaining healthy tissue has to pump even harder to
keep up.
High blood pressure (hypertension)
Uncontrolled blood pressure doubles a person’s risk of developing heart failure.
When pressure within the blood vessels is too high, the heart has to pump harder than
normal to keep the blood circulating. This takes a toll on the heart, and over time the
chambers get larger and weaker.
Abnormal heart valves
Heart valve problems can result from disease, infection (endocarditis) or a defect
present at birth. When the valves don’t open or close completely during each
heartbeat, the heart muscle has to pump harder to keep the blood moving. If the workload
becomes too great, heart failure results.
Heart muscle disease (cardiomyopathy) or
inflammation (myocarditis)
Any damage to the heart muscle, whether because of drug or alcohol use, viral
infection or unknown reasons increase the risk of heart failure.
Heart defects at birth (congenital heart
disease)
If the heart and its chambers don’t form correctly, the healthy parts have to
work harder to make up for it.
Severe lung disease
When the lungs don’t work as they should, the heart has to work harder to get
available oxygen to the rest of the body.
Diabetes
Diabetes puts extra strain on the heart, increasing risk for heart failure. People
with diabetes also tend to be overweight and have high blood pressure and high
cholesterol-all of which make the heart work harder, and lead to coronary artery disease.
Typically, these conditions cause the
"wear and tear" that leads to heart failure. A combination of any of the above
factors dramatically increases risk.
Less commonly, an otherwise healthy heart may
become temporarily unable to keep up with the body’s needs. This can happen in people
who have:
Low red blood cell count (severe anemia)
When there aren’t enough red blood
cells to carry oxygen, the heart tries to move the small number of cells at a faster rate.
It can become overtaxed from the effort.
An overactive thyroid gland
(hyperthyroidism)
This condition causes the body to work at a
faster pace, and the heart can be over-worked trying to keep up.
Abnormal heart rhythm (arrhythmia or
dysrhythmia)
When the heart beasts too fast, too slow or
irregularly, it may not be able to pump enough blood for all of the body.
In these cases, the person may experience
heart failure symptoms until the underlying problem is identified and treated.
Finally, genetics contributes to the risk
for certain types of heart disease, which in turn can lead to heart failure. However, in
most instances, a specific genetic link to heart failure has not been identified.
4. Is there only one
type of heart failure?
The term congestive heart failure is often used to describe all patients with heart
failure. In reality, congestion (build up of fluid) is just one feature of the condition
and does not occur in all patients. There are two main categories of heart failure. It can
involve systolic heart failure or diastolic heart failure.
Systolic heart failure - This occurs when the
heart’s ability to contract decreases. The heart cannot pump with enough force to
push a sufficient amount of blood into the circulation. Blood coming into the heart from
the lungs may back up and cause fluid to leak into the lungs, a condition known as
pulmonary congestion.
Diastolic heart failure - This occurs when the
heart has a problem relaxing. The heart cannot properly fill with blood because the muscle
has become stiff, losing its ability to relax. This form may lead to fluid accumulation,
especially in the feet, ankles, and legs. Some patients may have lung congestion.
5. How quickly does
heart failure develop?
Heart failure is usually a chronic disease, meaning that it’s a long-term
condition that tends to gradually become worse. By the time someone is diagnosed, chances
are that the heart has been losing pumping capacity little by little for quite a while. At
first the heart tries to make up for this by:
Enlarging. When the heart chamber
enlarges, it stretches more and more and contracts more strongly, so it pumps more blood.
Developing more muscle mass. More heart
muscle fibers allow the heart to pump more strongly.
Pumping faster. This helps to increase
the output of the heart.
The body also tries to compensate in other
ways. The blood vessels narrow to keep blood pressure up, trying to make up for the
heart’s loss of power. The body diverts blood away from less important tissues and
organs to maintain flow to the most vital organs, the heart and the brain. These temporary
measures mask the problem of heart failure, but they don’t solve it. This helps
explain why some people may not become aware of their condition until years after the
heart begins its decline. (It’s also a good reason to have a regular check up with
your doctor.) Eventually the heart and body just can’t keep up, and the person
experiences the fatigue, breathing problems or other symptoms that usually prompt a trip
to the doctor.
6. What are the
symptoms of heart failure?
A number of symptoms are associated with heart failure, but none is specific for the
condition. Perhaps the best known symptom is shortness of breath ("dyspnea"). In
heart failure, this may result from excess fluid in the lungs. The breathing difficulties
may occur at rest or during exercise. In some cases, congestion may be severe enough to
prevent or interrupt sleep.
Once a person has been diagnosed with heart
failure it’s important for them to keep track of symptoms and report any sudden
changes to their physician.
People with heart failure may experience:
Shortness of breath (also called dyspnea)
Blood "backs up" in the pulmonary veins (the vessels that return blood from the
lungs to the heart) because the heart can’t keep up with the supply. This causes
fluid to leak into the lungs. . . . breathlessness during activity (most commonly), at
rest, or while sleeping, which may come on suddenly and wake them up. They often have
difficulty breathing while lying flat and may need prop up the upper body and head on two
pillows. They often complain of waking up tired or feeling anxious and restless.
Persistent coughing or wheezing
Fluid builds up in the lungs (see above). . . . coughing that produces white or pink
blood-tinged phlegm.
Buildup of excess fluid in body tissues
(edema)
As blood flow out of the heart slows, blood returning to the heart through the veins
backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose
of sodium and water, also causing fluid retention in the tissues. . . . swelling in the
feet, ankles, legs or abdomen or weight gain. They may find that their shoes feel tight.
Tiredness, fatigue
The heart can’t pump enough blood to meet the needs of body tissues. The body
diverts blood away from less vital organs, particularly muscles in the limbs, and sends it
to the heart and brain. . . . a tired feeling all the time and difficulty with everyday
activities, such as shopping, climbing stairs, carrying groceries or walking.
Lack of stomach
The digestive system receives less blood, causing problems with digestion. . . . a
feeling of being full or sick to their appetite, nausea.
Confusion, impaired thinking
Changing levels of certain substances in the blood, such as sodium, can cause
confusion. . . . memory loss and feelings of disorientation. A caregiver or relative may
notice this first.
Increased heart rate
To "make up for "the loss in pumping capacity, the heart beats faster. . . .
heart palpitations, which feel like the heart is racing or throbbing.
Because heart failure usually develops slowly,
the symptoms may not appear until the condition has progressed over years. The heart
remedies the underlying problem by making adjustments that delay-but do not prevent-the
eventual loss in pumping capacity. The heart adjusts, or compensates, in three ways to
cope with and hide the effect of heart failure:
Enlargement ("dilatation"), which
allows more blood into the heart;
Thickening of muscle fibers
("hypertrophy") to strengthen the heart muscle, which allows the heart to
contract more forcefully and pump more blood; and
More frequent contractions, which increases
circulation.
By making these adjustments, or compensating,
the heart can temporarily make up for losses in pumping ability, sometimes for years.
However, compensation has its limits. Eventually, the heart cannot offset the lost ability
to pump blood, and the signs of heart failure appear.
7. How do doctors
diagnose heart failure?
Talk to a doctor if you or a family member have any of the potential signs of heart
failure or associated risk factors. The doctor will want to perform a complete physical
examination and ask about medical history and symptoms. Be as honest as you can, and try
not to be afraid to "look bad." For instance, if you or your family member
smoke, tend to eat high-fat foods, or don’t really exercise, your doctor needs to
know that. Your accurate input is important for the diagnosis. Think of your doctor as
your healthcare partner-you have to work together as a team to be successful.
In many cases, doctors diagnose heart failure
during a physical examination. Readily identifiable signs are shortness of breath,
fatigue, and swollen ankles and feet. The doctor will also check for the presence of risk
factors, such as hypertension, obesity, and a history of heart problems. Using a
stethoscope, the doctor can listen to a patient breathe and identify the sounds of lung
congestion. The stethoscope also picks up the abnormal heart sounds indicative of heart
failure.
If neither the symptoms nor the patient’s
history point to a clear-cut diagnosis, the doctor may recommend any of a variety of
tests. These tests can help determine whether the heart is working as well as it should
be, and if it is not, where the problem lies.
Echocardiography is a means of
evaluating heart function from outside the body. Sound waves bounced off the heart are
recorded and translated into images. The pictures can reveal abnormal heart size, shape,
and movement. Echocardiography also can be used to calculate a patient’s ejection
fraction, a measure of the amount of blood pumped out when the heart contracts. The echo
can also tell the doctor how thick the heart muscle is.
Another possible test is the chest x-ray,
which also determines the heart’s size and shape, as well as the presence of
congestion in the lungs. The chest x-ray also helps rule out other possible causes of a
patient’s symptoms. For instance, the symptoms of heart failure can result when the
heart is made to work too hard, instead of from damaged muscle. Conditions that overload
the heart occur rarely and include severe anemia and thyrotoxicosis (a disease resulting
from an overactive thyroid gland).
Another test often used is the radionuclide
ventriculography or multiple-gated acquisition scanning (MUGA). This nuclear
medicine test involves injecting a small amount of radioactive dye into a vein and then
taking pictures as it pumps blood. Like an echo, this test indicates how much blood the
heart can pump with each beat.
These tests also allow the doctor to determine
the nature of the problem with the heart’s larger lower chambers, the ventricle.
These chambers may have lost some of their power to contract (pump blood to the body) or
relax (open and fill with blood). The doctor uses this information, along with the
ejection fraction reading, to determine what treatments would be most effective.
Someone with a normal ejection fraction
reading can still have heart failure. If the heart muscle has become so thick and stiff
that the ventricle holds a smaller volume of blood than usual, it might still appear to be
pumping out a normal percentage of the blood that enters it. In reality, though, the total
amount of blood pumped is not enough to meet the body’s needs.
8. What other tests
might be done?
Angiography (Catheterization) - An x-ray is taken after injecting dye into the
coronary arteries through a tube placed in the groin or the arm. . . . to look for any
blockages in the coronary arteries.
Exercise Stress Test - This test
records the heart’s activity during exercise, either walking on a treadmill or
pedaling a stationary bike. . . . to see if the heart responds normally to the stress of
exercise.
Blood Tests - A blood sample is tested
for levels of important substances, such as sodium and potassium (sometimes called
electrolytes), albumin (a type of protein), and creatinine (which is connected with kidney
function. . . . to check for abnormal levels that may indicate strain on the body’s
organs (such as the kidneys and liver), which often results from heart failure.
9. How is heart
failure classified?
Doctors usually classify patient’s heart failure according to how severe their
symptoms are. The table below describes the most commonly used classification system, the
New York Heart Association (NYHA) Functional Classification. It places patients in one of
four categories based on how much they are limited during physical activity.
Class Percentage of Patients How They Feel
I 35% No symptoms and no limitation in
ordinary physical activity
II 35% Mild symptoms and slight limitation
during ordinary activity. Comfortable at rest.
III 25% Marked limitation in activity due to
symptoms, even during less-than ordinary activity. Comfortable only at rest.
IV 5% Severe limitations. Experiences symptoms
even while at rest.
10. How is heart
failure treated?
Heart failure is a serious condition, and there is usually no cure. But we deliberately
use the phrase "living with heart failure" because that is what people who have
it learn to do. In most cases, heart failure can be managed by taking medications and
making healthy changes in habits such as diet and exercise. The help of families and
friends can be beneficial as well. These changes are often the key to leading a full,
enjoyable life.
Heart failure caused by an excessive workload
is curable by treating the primary disease, such as anemia or thyrotoxicosis. Also curable
anatomical problems, such as a heart valve defect, can usually be surgically corrected.
The most important goal of treatment is to
make it easier for your heart to pump blood. For the common forms of heart failure-those
due to damaged heart muscle-no known cure exists. But treatment for these forms may be
quite successful. The treatment seeks to improve the patient’s quality of life and
length of survival through lifestyle change and drug therapy.
We tend to think of treatment as something
doled out by our doctors-like a pill or a surgical procedure. While that may be true for
some medical conditions, it’s not the case with heart failure. Rather, successful
treatment depends on your willingness to get involved in managing this condition, whether
you’re the one diagnosed or you’re the one caring for someone who is. You and
your family become key members of the healthcare team by following through on the
strategies and goals set forth by your doctor. These include:
Lifestyle changes
Medications
Surgery
11. What you and
your doctor should know.
At one time, very little was known about heart failure and how to treat it. We still
don’t have all the answers, but we have come a long way during the past two decades,
especially in regard to systolic heart failure, the more common form. And, our knowledge
is expanding every day, thanks to the tireless efforts of medical researchers such as
those at UAMS.
We now know that systolic heart failure gets
worse when the body produces too much of certain hormones. One of the first and most
important steps in treating heart failure is to "block" these hormones with
medication, typically given in the form of a pill that must be taken regularly. Many
studies have confirmed that these drugs can prolong life for heart failure patients.
It is critically important for all heart
failure patients to be on any one of several angiotensin-converting enzyme (ACE) blockers.
These drugs have names that end in "-pril," including captopril, enalapril,
quinapril, ramipril, lisinopril, benazepril, and fosinopril. (These are chemical names;
the brand names may vary.) If you’re not sure you are taking one of these drugs,
contact your physician.
Depending on your condition, you may benefit
from additional medications, such as a beta blocker, which blocks a specific hormone call
adrenaline. Some examples of beta blockers include carvedilol, metoprolol, and bisoprolol.
(Again, these are chemical names; brand names may vary.)
Another drug that may help certain heart
failure patients is spironolactone, which blocks a hormone called aldosterone and also
acts as a diuretic, reducing fluid build-up in the body. Additional diuretics, or water
pills, may be prescribed to keep fluid levels down. Digoxin, a drug that makes the heart
pump a little harder, may be helpful for some patients.
Knowledge about treating diastolic heart
failure, the less common form, is limited, but the above drugs (ACE blockers and beta
blockers) may be helpful. Among other drugs, called calcium channel blockers, which block
uptake of calcium into the heart cells, may also be helpful.
Depending on the cause of your heart failure
and the condition of your heart, you may benefit from angioplasty or bypass surgery. In
angioplasty, a tiny balloon is inserted into a heart vessel and inflated to push the
plaque against the walls in an attempt to repair blockage. In bypass surgery, a surgeon
uses blood vessels from some other part of the body to pass over any obstruction in the
major arteries that carry blood from the heart to the rest of the body. Usually, the blood
vessels needed for the bypass are taken from the leg or from beneath the patient’s
breast bone. While these procedures have certain risks, both are commonly performed and
have saved many lives.
12. What doctors treat
heart failure at UAMS Medical Center?
Heart Surgeons
Tamim
Antakli, M.D.
Acting Chief;
Assistant Professor of Surgery;
Program Director
Aytekin
Ozdemir, M.D.
Assistant Professor of Surgery
Eugene
S. Smith, M.D.
Assistant Professor of Medicine
H.
Gareth Tobler, M.D.
Assistant Professor of Surgery
Making an Appointment at
UAMS Medical Center
To make an appointment, call 1-501-686-8000.
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