Chronic heart failure is an increasingly common, serious and complex problem which is associated with often debilitating symptoms, a poor long term outlook and frequent hospitalisation. With increasing age and better treatments, particularly of other heart disease, more people are living to develop heart failure. 30,000 new cases are diagnosed each year in Australia – 65% of sufferers do not survive 5 years from diagnosis.
Fortunately there are new treatments which are improving life expectancy, reducing symptoms and hospitalisation.
Heart failure develops because the heart is failing as a pump. There are 2 broad mechanisms which cause this failure:
- the left ventricle of the heart is unable to contract strongly enough to eject the blood within it (called systolic heart failure – SHF) or
- the heart muscle cannot relax adequately between beats to allow enough blood to flow into the heart chambers, and then be pumped out - however the left ventricle itself is still able to pump the blood entering it - this was previously known as diastolic heart failure – now called HFPEF (Heart Failure with Preserved Ejection Fraction)
The two forms are roughly equal in incidence.
The outcome has traditionally been worse in systolic heart failure, but in recent years there has been significant improvements in the treatments for SHF, with improved mortality. Unfortunately there has been no real improvement in diastolic heart failure treatment.
Symptoms of heart failure have traditionally been described as those due to “left heart failure’ – shortness of breath on exercise, shortness of breath lying down and episodes of marked shortness of breath during the night caused by fluid accumulating in the lungs, or those due to “right heart failure” – swelling of the legs, raised pressure in the veins, and later ascites (fluid in the abdomen, liver and intestines). Heart failure is often associated with general fatigue, listlessness and loss of appetite.
Diagnosis is confirmed by echocardiogram (heart ultrasound) which measures the size and various functions of the heart – the ‘ejection fraction’ can be calculated from echocardiogram measurements – this is the percentage of the volume of the left ventricle pumped out with each heart beat – the normal ejection fraction is between 50% and 75%. In heart failure the ejection fraction is less than 50% and in severe cases less than 35%.
There is a standardised classification of the symptom severity due to heart failure- the New York Heart Association Functional Classification :
Class 1 abnormal left ventricular function but no symptoms
Class 11 symptoms during normal activity
Class 111 symptoms with less than normal activity
Class 1V symptoms at rest
The most common causes of the heart disease which results in chronic heart failure are:
- ischaemic heart disease
- hypertension
- heart valve disease
- idiopathic dilated cardiomyopathy
less common causes include a number of other causes of cardiomyopathy ( diabetes, alcohol, some drugs used in chemotherapy, thyroid disease, iron overload etc), congenital heart disease, myocarditis, amyloid disease and others.
Coexisting conditions which make heart failure worse, and which should be attended to include:
-Cardiac ischaemia – angina / coronary artery disease
-Obstructive sleep apnoea
-Emphysema and chronic obstructive lung disease
-Anaemia
-Iron deficiency ( iron is important in muscle contraction)
-Atrial fibrillation – heart rate needs to be kept less than 80/min
-Obesity – increases symptoms but also increases the load on the heart (however being very underweight is equally bad in heart failure)
-Thyroid gland either being over or under active
-Impaired kidney function
Medications which must be avoided in chronic heart failure include:
-Calcium channel blockers (used in high blood pressure, other heart problems)
-Anti- inflamtories – used in arthritis etc and including over the counter preparations of Ibuprofen (Nurofen, Brufen, Advil ) and Voltaren
-Oral Steroids
-Anti-arrhythmic drugs (except beta blockers and amiodarone)
-Tricyclic antidepressants e.g. Endep
-‘Glitazones’ – used in diabetes
-those containing a lot of sodium e.g. Ural
-Clozapine
Non medication management which should be undertaken:
-Restrict salt (sodium) intake to less than 2 gm / day – no added salt on food, avoid salted foods and high sodium sports drinks.
-Restrict fluid intake – less than 2 litres per day with mild failure and less than 1.5 litres if severe (need to relax restrictions in heat waves )
-Cease smoking
-No more than 2 standard drinks of alcohol per day – with at least 2 consecutive alcohol free days a week. If alcohol is the cause of the underlying cardiomyopathy, complete abstinence is required
-*Weigh daily especially for Class 111 and IV symptoms - this should be at the same time of the day with the same scales – a weight gain of 2kg or more in 2 days requires an urgent appointment with the doctor as this reflects sudden worsening of heart failure
-Regular activity and exercise as tolerated – prolonged bed rest should be avoided except in acute flare ups
-Everyone should have an annual influenza vaccination and be immunised with Pneumovax
Medications used in treatment of Systolic Heart Failure:
1 Diuretics (such as Frusemide) are used to remove excess fluid from the body and may require a high dose at least initially. While diuretics reduce the symptoms they do not improve mortality
2 ACE or ARB Inhibitors – ALL patients with chronic heart failure should be taking an ACE or ARB inhibitor as it is the most effective treatment to improve outcomes – they reduce the chance of a heart attack by 20%, reduce cardiovascular death by 26% and reduce overall mortality by 16% compared with not taking them – the dose taken should be the maximum recommended dose if tolerated (possible side effects including cough, low blood pressure and electrolyte disturbances may occur)
3 Beta Blockers are also indicated for all patients with chronic heart failure, as in combination with an ACE inhibitor they provide the best improvement in mortality – a 34% improvement.
Beta blockers can’t be commenced until the heart failure is stabilised. They are started at a low dose which should be gradually increased to the maximum tolerated. Patients with true asthma or who are on steroids for COPD may not be able to have a beta blocker.
4 Spironolactone – has been shown to improve symptoms and reduce mortality in all grades of heart failure – electrolytes need monitoring to ensure that potassium levels remain normal. It can’t be used in those with chronic renal failure
5 Digoxin – reduces symptoms and hospitalisation but not mortality – it is especially useful in the presence of atrial fibrillation. Digoxin is also a problem in the presence of renal failure.
6 Nitrates may be useful especially when ACE or ARB inhibitors are not tolerated – they should be taken as tablets, not patches.
NOTE – these medications (except diuretics) should be taken AT NIGHT – there are less side effects and overall outcome is better than if taken in the morning.
Other medication:
Anticoagulants are indicated with atrial fibrillation
Aspirin does not help unless there is also ischaemic heart disease
Omega 3 ethyl esters reduce mortality by 9% (1gm/day)
Pacemakers:
Some patients with severe chronic heart failure may be suitable for either :
- a biventricular pacemaker ( if ejection fraction <35% and there is significant lack of synchronisation between the left and right sides of their heart) or
- an implantable defibrillator if they are prone to cardiac arrest or ventricular tachycardia
Treatment of Diastolic Heart Failure:
Treatment is much more limited and less effective than with SHF – no medications make the heart muscle relax without impairing its ability to contract and effectively pump.
Treatments include :
-Reducing fluid build up with diuretics (however dehydration must be avoided as this will reduce the blood flow back to the heart and can result in fainting episodes and general weakness)
- control blood pressure (<130/80)
- ensure pulse rate less than 80 in atrial fibrillation
- coronary bypass or stents if there is ischaemic heart disease
A Heart Specialist will be involved in the diagnosis and treatment of all but the milder stages of chronic heart failure. Regular monitoring by your GP and/ or Cardiologist is essential.
Fortunately there are new treatments which are improving life expectancy, reducing symptoms and hospitalisation.
Heart failure develops because the heart is failing as a pump. There are 2 broad mechanisms which cause this failure:
- the left ventricle of the heart is unable to contract strongly enough to eject the blood within it (called systolic heart failure – SHF) or
- the heart muscle cannot relax adequately between beats to allow enough blood to flow into the heart chambers, and then be pumped out - however the left ventricle itself is still able to pump the blood entering it - this was previously known as diastolic heart failure – now called HFPEF (Heart Failure with Preserved Ejection Fraction)
The two forms are roughly equal in incidence.
The outcome has traditionally been worse in systolic heart failure, but in recent years there has been significant improvements in the treatments for SHF, with improved mortality. Unfortunately there has been no real improvement in diastolic heart failure treatment.
Symptoms of heart failure have traditionally been described as those due to “left heart failure’ – shortness of breath on exercise, shortness of breath lying down and episodes of marked shortness of breath during the night caused by fluid accumulating in the lungs, or those due to “right heart failure” – swelling of the legs, raised pressure in the veins, and later ascites (fluid in the abdomen, liver and intestines). Heart failure is often associated with general fatigue, listlessness and loss of appetite.
Diagnosis is confirmed by echocardiogram (heart ultrasound) which measures the size and various functions of the heart – the ‘ejection fraction’ can be calculated from echocardiogram measurements – this is the percentage of the volume of the left ventricle pumped out with each heart beat – the normal ejection fraction is between 50% and 75%. In heart failure the ejection fraction is less than 50% and in severe cases less than 35%.
There is a standardised classification of the symptom severity due to heart failure- the New York Heart Association Functional Classification :
Class 1 abnormal left ventricular function but no symptoms
Class 11 symptoms during normal activity
Class 111 symptoms with less than normal activity
Class 1V symptoms at rest
The most common causes of the heart disease which results in chronic heart failure are:
- ischaemic heart disease
- hypertension
- heart valve disease
- idiopathic dilated cardiomyopathy
less common causes include a number of other causes of cardiomyopathy ( diabetes, alcohol, some drugs used in chemotherapy, thyroid disease, iron overload etc), congenital heart disease, myocarditis, amyloid disease and others.
Coexisting conditions which make heart failure worse, and which should be attended to include:
-Cardiac ischaemia – angina / coronary artery disease
-Obstructive sleep apnoea
-Emphysema and chronic obstructive lung disease
-Anaemia
-Iron deficiency ( iron is important in muscle contraction)
-Atrial fibrillation – heart rate needs to be kept less than 80/min
-Obesity – increases symptoms but also increases the load on the heart (however being very underweight is equally bad in heart failure)
-Thyroid gland either being over or under active
-Impaired kidney function
Medications which must be avoided in chronic heart failure include:
-Calcium channel blockers (used in high blood pressure, other heart problems)
-Anti- inflamtories – used in arthritis etc and including over the counter preparations of Ibuprofen (Nurofen, Brufen, Advil ) and Voltaren
-Oral Steroids
-Anti-arrhythmic drugs (except beta blockers and amiodarone)
-Tricyclic antidepressants e.g. Endep
-‘Glitazones’ – used in diabetes
-those containing a lot of sodium e.g. Ural
-Clozapine
Non medication management which should be undertaken:
-Restrict salt (sodium) intake to less than 2 gm / day – no added salt on food, avoid salted foods and high sodium sports drinks.
-Restrict fluid intake – less than 2 litres per day with mild failure and less than 1.5 litres if severe (need to relax restrictions in heat waves )
-Cease smoking
-No more than 2 standard drinks of alcohol per day – with at least 2 consecutive alcohol free days a week. If alcohol is the cause of the underlying cardiomyopathy, complete abstinence is required
-*Weigh daily especially for Class 111 and IV symptoms - this should be at the same time of the day with the same scales – a weight gain of 2kg or more in 2 days requires an urgent appointment with the doctor as this reflects sudden worsening of heart failure
-Regular activity and exercise as tolerated – prolonged bed rest should be avoided except in acute flare ups
-Everyone should have an annual influenza vaccination and be immunised with Pneumovax
Medications used in treatment of Systolic Heart Failure:
1 Diuretics (such as Frusemide) are used to remove excess fluid from the body and may require a high dose at least initially. While diuretics reduce the symptoms they do not improve mortality
2 ACE or ARB Inhibitors – ALL patients with chronic heart failure should be taking an ACE or ARB inhibitor as it is the most effective treatment to improve outcomes – they reduce the chance of a heart attack by 20%, reduce cardiovascular death by 26% and reduce overall mortality by 16% compared with not taking them – the dose taken should be the maximum recommended dose if tolerated (possible side effects including cough, low blood pressure and electrolyte disturbances may occur)
3 Beta Blockers are also indicated for all patients with chronic heart failure, as in combination with an ACE inhibitor they provide the best improvement in mortality – a 34% improvement.
Beta blockers can’t be commenced until the heart failure is stabilised. They are started at a low dose which should be gradually increased to the maximum tolerated. Patients with true asthma or who are on steroids for COPD may not be able to have a beta blocker.
4 Spironolactone – has been shown to improve symptoms and reduce mortality in all grades of heart failure – electrolytes need monitoring to ensure that potassium levels remain normal. It can’t be used in those with chronic renal failure
5 Digoxin – reduces symptoms and hospitalisation but not mortality – it is especially useful in the presence of atrial fibrillation. Digoxin is also a problem in the presence of renal failure.
6 Nitrates may be useful especially when ACE or ARB inhibitors are not tolerated – they should be taken as tablets, not patches.
NOTE – these medications (except diuretics) should be taken AT NIGHT – there are less side effects and overall outcome is better than if taken in the morning.
Other medication:
Anticoagulants are indicated with atrial fibrillation
Aspirin does not help unless there is also ischaemic heart disease
Omega 3 ethyl esters reduce mortality by 9% (1gm/day)
Pacemakers:
Some patients with severe chronic heart failure may be suitable for either :
- a biventricular pacemaker ( if ejection fraction <35% and there is significant lack of synchronisation between the left and right sides of their heart) or
- an implantable defibrillator if they are prone to cardiac arrest or ventricular tachycardia
Treatment of Diastolic Heart Failure:
Treatment is much more limited and less effective than with SHF – no medications make the heart muscle relax without impairing its ability to contract and effectively pump.
Treatments include :
-Reducing fluid build up with diuretics (however dehydration must be avoided as this will reduce the blood flow back to the heart and can result in fainting episodes and general weakness)
- control blood pressure (<130/80)
- ensure pulse rate less than 80 in atrial fibrillation
- coronary bypass or stents if there is ischaemic heart disease
A Heart Specialist will be involved in the diagnosis and treatment of all but the milder stages of chronic heart failure. Regular monitoring by your GP and/ or Cardiologist is essential.
