What is heart failure?

The definition of heart failure has been evolving over the years. It used to represent weakening of heart muscle (of the left ventricle which is the heart pumping chamber) and the heart cannot pump sufficient blood to supply the body need. The current concept is that heart failure is not a disease but rather a syndrome resulting from the abnormal function of the pumping chamber heart muscle:

1.  Systolic heart failure. The heart pumping chamber is weak (decrease systolic function) and cannot provide adequate blood supply to body tissue/organ.
2. Diastolic heart failure. There is abnormality of the heart muscle to relax during the period of blood return to the heart (abnormal diastolic function)
3. Combination of both problems.

These abnormalities create changes in circulatory and neurohormonal system that bring on symptoms and signs or heart failure syndrome. The symptoms may range from mild to severe. Symptoms can be constant or can come and go.

Heart failure is a serious condition. Most of heart failure end up with chronic condition and not reversible. However proper management from both healthcare team and patient self care with  medications and healthy lifestyle changes can improve the signs and symptoms of heart failure and help them live longer. Lifestyle changes, such as exercising, reducing salt in your diet, managing stress and keeping proper weight, can improve the quality of life. It’s also helpful to have the support of family and friends who understand the patient condition.

Pathophysiology of heart failure

The pathophysiology of heart failure is complex and not well understood. Various heart or circulatory diseases may lead to abnormality of systolic and diastolic function of the pumping chamber. This abnormality stimulates neurohormonal systems (sympathetic, renin-angiotensin-aldosterone system and others). The result are cardiac remodeling and peripheral vascular maladaptation. Majority of the patients will have fluid retention and increase ventricular diastolic (or filling) pressures which are the main cause of tissue/organ congestion.

Ejection fraction (EF)

Ejection fraction is the measurement of the efficiency of the heart pumping chamber (the left ventricle). It calculate from percentage of amount of blood that the pumping chamber eject per each systole. Normal range is 50 to 65% or higher. Systolic heart failure has ejection fraction <40% with a new terminology of Heart Failure with reduced Ejection Fraction (HFrEF), while diastolic heart failure has ejection >40% with a new terminology of Heart Failure with preserved Ejection Fraction HFpEF). Ejection fraction can be measured by echocardiogram (most common), radioisotope study, angiogram, CT scan, MRI scan.

Types of heart failure

There have been several types or heart failure. Those heart failure types that are useful for current practice:

• Left heart failure. Most common
• Right heart failure
• Acute heart failure. Usually require admission
• Chronic heart failure.
• Systolic heart failure or Heart Failure with reduced Ejection (HFrEF)
• Diastolic heart failure or Heart Failure with preserved Ejection Fraction (HFpEF)

Heart failure syndrome symptoms and signs

1. From fluid retention
   • In the lung: causing dyspnea (shortness of breath), orthopnea (cannot lay down flat), cough (particularly when lay down) or wheezing.
   • In the legs: causing leg swelling.
   • In the abdomen: causing liver swollen and discomfort, other gastrointestinal symptoms.
   • Weight gain from fluid retention
2. From insufficiency blood supply
   • Weak, easily fatigue
   • Brain effect: confusion, dizziness

Causes of heart failure syndrome

Heart conditions or diseases that can cause abnormal heart systolic and/or diastolic function and heart failure syndrome.

1. Coronary artery disease. Coronary artery disease is the most common form of heart disease and the most common cause of heart failure.
2. Hypertension
3. Cardiomyopathy
4. Heart valve disease
5. Arrhythmia, particular sustained tachycardia
6. Infection and immunologic process
7. Substances such as heavy alcohol consumption, certain drugs.
8. Many other smaller number conditions

 How is heart failure diagnosed?

1. Medical history
2. Physical examination, particular evidence of fluid retention in various location
3. Laboratory tests
   1. Test to help diagnosis of heart failure condition
      1. Blood tests
      2. Electrocardiogram (ECG or EKG)
      3. Chest x-ray
      4. Echocardiogram
      5. Ejection fraction
   2. Tests to help finding the conditions or diseases that cause heart failure
      1. Stress test
      2. Cardiac catheterization, angiogram
      3. CT scan, MRI scan

Treatment for heart failure

1. Lifestyle changes can often help relieve signs and symptoms of heart failure and prevent or slowing down the disease worsening. These changes include:
   • Daily weight. It may warn you that you’re retaining fluids.
   • Low salt diet
   • Medication compliance
   • Proper exercise
   • No smoking
   • What to do if symptoms are worsening
   • Limited alcohol consumption
   • Limited daily fluid intake for patient with fluid retention
   • Maintain proper body weight
   • Limit fats and cholesterol intake
   • Reduce stress.
   • Sleep easy. If you snore you should check for sleep apnea
2. Medications
   • Neurohormonal antagonists
     • Angiotensin-convertor enzyme inhibitors (ACEI)
     • Angiotensin II receptor blockers (ARB)
     • Beta- blockers
     • Aldosterone antagonists
   • Non neurohormonal antagonists
     •  Diuretics
     • Combined Hydralazine and nitrate
     •  Lanoxin
     • Inotropes
   • Other medications for other associated conditions
   • Avoid medications that have deleterious effects. Patient should check with the health care team.
3. Devices treatment
   • Cardiac resynchronization therapy (CRT) or Biventricular pacing. When use appropriately, it can improve symptoms and prolong life.
   • Internal cardioverter defibrillator (ICD) can prolong life but no effect on symptom.
   • Left ventricular assist device (LVAD), biventricular assist device. It has been used as a bridging therapy waiting for heart transplantation or destination therapy in advance heart failure.
4. Surgery
   • Coronary artery bypass graft (CABG), if coronary artery disease is considered to be the cause of heart failure.
   • Valve replacement, if heart valvular disease is considered to be the cause of heart failure.
   • Cardiac transplantation in advance heart failure.

 
Heart failure clinic at Bangkok Heart Hospital service and outcome

• Consultation for “heart failure” patient.
• Extensive patient and family education.
• Promotion of evidence-based and uniform practice.
• Transtelephonic follow up.
• Advanced In-patient to out-patient transition program.
• Multidisciplinary management center.
• Data collection and future clinical research.

Bangkok Heart Hospital Heart failure program has been certified by Joint Commission International (JCI) since 2008 indicating the high international standard of heart failure care.

Performance measure data that has been achieved include:

• Very high percentage utilization of guideline directed medication such as ACEI/ARB (84%, IPD), Beta Blocker (94%, OPD), and aldosterone antagonist.
• Extensive education for patients, families and discharge instruction (98%, IPD)
• Smoking cessation counselling (100%, IPD)
• Appropriate prescription of anticoagulation in patient with atrial fibrillation (98%, IPD)
• Appropriate discussion of device therapy (IPD)
• Low 30 days readmission rate (12%)