Photo: Shayne_ch13, Freepik
Written by Dr Gerald Thang
1. Symptoms of Heart Failure
Shortness of breath, leg swelling, water in the lungs, decreased stamina are just a few of the common symptoms of heart failure.
The heart is like an engine pump — it transports blood around the body, provides nutrients to the body, and keeps us alive. If the pump weakens or fails, blood doesn’t get pumped as efficiently. Hence, water leaks out into the body tissue resulting in water retention or edema. As edema occurs, the lung function drops due to decreased oxygen transfer across the lungs. Most people will think it is shortness of breath and a drop in stamina.
2. Heart failure is not always due to a heart attack
While heart attack commonly results in heart failure due to the death of heart muscles during a heart attack, it is not the only cause.
Long-term stress or injury from these factors (below) can cause and result in heart failure:
- Uncontrolled hypertension
- Obstructive sleep apnea
- Chronic lung disease
- Kidney failure
- Viral infections
- Thyroid disease
- Irregular heart rate/arrhythmias
- Rarer disease such as sarcoidosis or amyloidosis
3. Four Stages of Heart Failure
According to the New York Heart Association (NYHA) Functional Classification of Heart Failure, there are four classes:
Class I: Patients without limitation of physical activity.
Class II: Patients with slight limitation of physical capacity in which marked increase in physical activity leads to fatigue, palpitations, dyspnea, or angina pain; they are comfortable at rest.
Class III: Patients with marked limitation of physical activity in which minimal ordinary activity results in fatigue, palpitation, dyspnea, or angina pain; they are comfortable at rest.
Class IV: Patients who are not only unable to carry on any physical activity without discomfort but who also have symptoms of heart failure or the angina syndrome even at rest; the patient's discomfort increases if any physical activity is undertaken.
4. What are the different types of heart failure?
Heart failure can be classified as acute or chronic heart failure.
Acute heart failure is usually triggered or a complication of onset of another disease, such as sudden heart attack, severe infections (e.g. pneumonia or bacterial infections in the bloodstream), trauma from a severe car accident.
Chronic heart failure is a longer-term sequela of old heart attack, kidney failure, chronic lung disease, or even chronic myocarditis in HIV patients.
5. What can worsen heart failure?
Triggers that exacerbate heart failure include:
- Worsening of the root causes causing heart failure in the first place
- Fluid indiscretion by drinking too much water
- Inability to pass out the excessive water adequately
- Not taking medications or not taking medications on time and in the correct doses
- New infection resulting in additional stress on the heart that is not usually there
6. Heart failure can be treated, and worsening can be prevented and even reversed
Heart failure treatment is no longer just restricted to diuretics to help you pass out excessive water.
We must always treat the root cause of heart failure first.
There are many other medications besides diuretics. ACE inhibitors (angiotensin-converting enzyme inhibitors) and ARBs (angiotensin receptor blockers) are medicines that are also shown to increase survival by decreasing systemic resistance.
Newer agents such as combination drugs, such as Entresto (sacubitril/valsartan) is a relatively new class of drugs called angiotensin receptor neprilysin inhibitor (ARNI).
Cardiac specific beta-blockers, e.g. bisoprolol, metoprolol control heart rate and increase cardiac output and ejection fraction and provide a beneficial response to circulating epinephrine.
Spironolactone is a potassium-sparing diuretic that has long term benefits for heart failure patient.
Digoxin (Lanoxin) is a heart medication that may help increase cardiac output and control symptoms.
Lifestyle risk factor modification is another cornerstone of prevention of congestive heart failure, and these include weight loss, exercise and stop smoking.
People with end-stage congestive heart failure may require invasive treatments including left ventricular assist devices (LVAD), an implanted artificial pump that helps increase the heart's ability to squeeze, and heart transplantation.
In patients who are not transplant candidates, LVAD may be a permanent treatment. In all patients with heart failure, cardiac reconditioning is of benefit to the patient.
As heart failure is usually a complication of another disease, the above measures constitute tertiary prevention which is to reverse or prevent complications from getting worse and this is another core of Preventive Medicine.
7. Heart failure can be detected even if asymptomatic
You do not need to wait till you have symptoms before you check for heart failure. When one has a heart attack or chronic lung or kidney disease, you can screen for asymptomatic heart failure by doing an echocardiogram of the heart. This is a specialized ultrasound scan of the heart with real-time measurements of the blood flow and heart muscle contractions in the heart. With this, the heart function can be ascertained. Together with a treadmill stress test, the functional capacity of your body can be assessed as well.
MRI Heart has also progressed to allow us to have a clearer insight into the structure of the heart muscle itself and diagnose intracardiac ischemia/structural heart disease even before it becomes apparent to the patient himself.