Heart Failure

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Summary

Heart failure (sometimes known as congestive heart failure [CHF]) is a serious condition in which the heart is not pumping efficiently. It is a chronic condition that is the result of other cardiac conditions.

In the late stages of heart failure, the heart is unable to meet the body's demand for oxygen. In addition, it may cause congestion in the lungs or other problems throughout the body. As a result of the lack of oxygen-rich blood flowing to the body, the heart tries to work harder, which only makes the problem worse.

Conditions that could lead to heart failure include:

  • Coronary artery disease
  • High blood pressure (hypertension)
  • Heart attack
  • Diabetes mellitus
  • Cardiomyopathy
  • Heart valve disease (e.g., valvular stenosis or valvular regurgitation)
  • Infection in the heart valves valvular endocarditis or of the heart muscle myocarditis
  • Congenital heart disease (cardiac conditions present since birth)
  • Severe lung disease (e.g., pulmonary hypertension) or obstructive sleep apnea
  • Pericardial disease (pericarditis)

According to current statistics from the American Heart Association, there are about five million heart failure patients in the United States, and 550,000 new cases of heart failure diagnosed in the  United States every year. This includes 10 out of every 1,000 people over the age of 65. Of newly diagnosed patients under the age of 65, about 80 percent of the men and 70 percent of the women will die within eight years. In people diagnosed with heart failure, sudden cardiac death occurs at six to nine times the rate of the general population.

About heart failure

Heart failure is a serious condition in which the heart's pumping action is compromised. In the early stages, heart failure may not have any symptoms. In the later stages, the patient may have severe symptoms because their weakened heart is unable to pump enough oxygen-rich blood with each contraction to satisfy the body. These symptoms may include shortness of breath (dyspnea) that initially occurs only during exercise, and later even while at rest.

Heart failure is a chronic and complex condition. By itself, heart failure is not considered a disease. Rather, it is the result of other conditions that damaged the heart. These other conditions include diseases of the coronary arteries that lay on the surface of the heart, heart valve disorders, high blood pressure and damage to the heart muscle itself.

According to the American Heart Association, heart failure affects about 5 million Americans, with more than half a million new cases diagnosed every year. Interestingly, while the incidence of other cardiac diseases remains stable or varies only slightly, the incidence of heart failure has increased significantly over the last three decades. This is because of the aging population and physicians' increased ability to treat other cardiac diseases. In the 1970s, high blood pressure was the leading cause of heart failure. Today, coronary artery disease is the leading cause because of the increased survival due to treatments such as bypass surgery and balloon angioplasty.

In spite of its name, heart failure does not mean the heart has completely stopped, which is the case when someone has gone into cardiac arrest. Heart failure means the heart is not operating efficiently and therefore must work harder to make up for the shortcoming. For example, the heart may pump more frequently to compensate for its weakened pumping ability, or the size of its chambers may increase, especially the left ventricle.

The longer the heart must overwork to compensate for its shortcomings, the more its pumping ability is damaged and the more likely that serious pumping failure will result. Before a pumping failure occurs, however, various physical changes may take place in the heart and throughout the body as a result of the heart failure. They include:

  • Remodeling. This significant physical change occurs with heart failure. Remodeling is most notably characterized by enlargement and thinning of the left ventricle. This results in an increased use of oxygen, a greater degree of mitral valve regurgitation and decreased ejection fraction. The process is a complex one. Contributing factors include the release of hormones in response to inflammation caused by heart failure and certain genetic factors that affect how the heart reacts to disease or injury. Whatever the causes, left ventricular remodeling sets in motion an unhealthy domino effect, as progressive damage to heart cells leads to reduced cardiac output and more severe heart disease. This weakening may be &global,& as in cardiomyopathy, or regional, affecting only part of the left ventricle.
  • Hypertrophy of the heart walls. The heart walls may thicken in an attempt to strengthen their pumping ability.

     

  • Tachycardia. An abnormally fast heartbeat that could result from the heart's attempt to function more efficiently.

     

  • Kidney malfunction. Initially, the kidneys respond to the heart's low volume output by retaining water and salt. This is because the kidneys perceive a low volume state, as if the person is dehydrated, and respond in kind. Unfortunately, the kidneys' response actually worsens the fluid buildup and can contribute to high blood pressure. This places added stress on the filters in the kidneys (nephrons) and is a major cause of kidney failure.

Although the term heart failure usually refers to the chronic condition described in this article, there is also a condition known as acute heart failure. It is sudden in onset and usually results from a sudden catastrophic change in the heart (e.g., massive heart attack, endocarditis, ruptured or torn heart valve leaflets, aortic dissection). In acute heart failure, the heart muscle does not have time to hypertrophy and enlarge. This condition is often fatal, even if emergency medical treatment is received immediately.

Related conditions for heart failure

There are a variety of conditions that could lead, or are associated with, heart failure. These conditions include:

  • Coronary artery disease (CAD). The most common causes of heart failure in the United States, CAD is a chronic disease in which there is a &hardening& of the arteries (atherosclerosis) on the surface of the heart. The term &hardening& refers to a condition that causes the arteries to become so narrowed and stiff that they block the free flow of blood. Severely reduced blood flow to the heart may weaken the heart muscle or cause a heart attack.

     

  • Arrhythmia (abnormal heart rhythm). A serious arrhythmia  can diminish the effectiveness of the heart's pumping ability.

     

  • Heart attack (myocardial infarction). Following a heart attack, part of the heart muscle is replaced with scar tissue, which prevents the heart from working efficiently. As the weakened heart muscle struggles to pump blood, the muscle fibers of the heart stretch, resulting in enlarged and weakened chambers in the heart remodeling. The AHA estimates that about 22 percent of patients who suffer a heart attack will become disabled with heart failure within six years.
  
  • High blood pressure (hypertension). High blood pressure used to be the single most common risk factor for the development of heart failure. Uncontrolled high blood pressure causes the heart muscle to overwork as it pumps blood under high pressure throughout the body. Increases in blood pressure are also associated with a greater incidence of heart attack.

     

  • Cardiomyopathy. A type of chronic heart disease in which the heart muscle becomes abnormally enlarged, thickened and/or stiffened. As a result, the heart muscle's ability to pump blood can become increasingly weakened, leading to heart failure. This condition is seen with viral infections or alcohol abuse, but in many patients, the cause is never found.

     

  • Valvular heart disease. Narrowing stenosis or leaking regurgitation of one or more of the heart's four valves. The resulting blood flow restriction (in stenosis) or overload of blood (in regurgitation) can lead to heart failure. These patients are initially treated with medication, but will often require valve surgery. There may also be an infection in the heart valves valvular endocarditis. Valvular disease is often a result of aging, but may also be a type of congenital heart disease (present from birth). Less commonly, it results from rheumatic heart disease.
 

 

 
  • Congenital heart disease. A heart–related problem that is present from birth. It involves one or more defects in the heart (e.g., ventricular septal defect, atrial septal defect), the veins leading to the heart, the arteries leaving the heart or connections among these various parts of the body. Heart failure may develop if the congenital defect creates a blood flow problem (e.g., because of a hole in the heart) or a heart muscle strength problem (e.g., because of a narrowed valve).

     

  • Severe lung disease (e.g., pulmonary hypertension). When the right side of the heart cannot generate enough force to pump blood through a diseased pair of lungs, heart failure can result.

Other conditions that are associated with heart failure include:

  • Obstructive sleep apnea (OSA). A condition commonly found among individuals with heart failure. Muscles in the back of the throat normally work to keep the throat open, but the airway can become blocked if the muscles relax during sleep. When the brain detects a drop in oxygen from not breathing, it quickly sends a signal to the chest muscles and diaphragm to gulp in air. As a result, the sleeper makes a gasping or snorting sound and is awakened. This struggle to breathe and arousal from sleep causes tension in the left ventricle and increases in heart rate, blood pressure, and the body's demand for oxygen. This increases the risk for developing ischemia, arrhythmia, chronic high blood pressure, pulmonary hypertension and carotid artery disease. Treatment includes continuous positive airflow pressure (CPAP), in which a bedside machine delivers air continuously through a plastic mask over the nose. The predetermined air pressure acts as a splint to keep the airway open, while still allowing the person to exhale. CPAP has shown to be effective in lowering blood pressure and increasing ejection fraction, suggesting that the relief of obstructive sleep apnea can also impact on symptoms of heart failure.

     

  • Anemia. Anemia is a deficiency in red blood cells and/or hemoglobin, the iron–rich, oxygen–carrying molecules in red blood cells. Chronic, severe anemia can be a cause of heart failure and can worsen as heart failure progresses. Even mild to moderate anemia is a common finding in patients with heart failure. This is because the heart must work harder in order to circulate a decreased number of red blood cells throughout the body. Studies have shown that correcting anemia can improve heart failure. Patients treated with a combination of intravenous (IV) iron and injections of erythropoietin (a protein that increases red blood cell production) have exhibited an increased ejection fraction, decreased need for diuretics, and improved New York Heart Association (NYHA) class.

     

  • Clinical depression. There appears to be a link between clinical depression and overall cardiovascular health, with recent studies showing that heart failure patients who suffer from depression are more likely to experience an increase in their heart failure symptoms and a decrease in their overall quality of life over time. It is believed that clinical depression may trigger higher levels of stress hormones (e.g., adrenaline), which may help to explain why the hearts of clinically depressed people beat faster, even during sleep. Studies have also shown that people with both heart disease and clinical depression have reduced heart rate variability (the heart's ability to handle stress).

     

  • Diabetes mellitus. Diabetes is a strong risk factor for developing coronary artery disease or heart attack, which may lead to heart failure and also cardiomyopathy. In addition, people with diabetes who also have heart failure should use caution when taking thiazolidinediones (TZDs), a class of drugs for patients with type 2 diabetes. TZDs may increase fluid retention in some people with heart failure. Joint recommendations from the American Heart Association and the American Diabetes Association state that people with moderate to severe (New York Heart Association [NYHA] class III or IV) heart failure should not take TZDs. Patients who are taking medications for diabetes are encouraged to discuss their condition with their physician.

Other conditions that be associated with heart failure include lupus, rheumatoid arthritis, hyperthyroidism, certain chemotherapy drugs, alcohol abuse and abuse of some types of drugs (primarily amphetamines and cocaine).

The risk of developing heart failure is also increased by the presence of certain risk factors, which include:

  • Smoking
  • Obesity (a body mass index [BMI] of 30 or greater)
  • Lack of exercise
  • Dietary habits, such as high salt intake or the failure to take medication properly
  • Arrhythmias
  • Worsening lung disease (emphysema) or pulmonary embolism
  • Infection
  • Emotional distress
  • Certain medications
  • Fluid overload
  • Hyper- or hypothyroidism (thyroid diseases)

Types and differences of heart failure

There are a number of different ways that physicians and medical institutions classify and define heart failure. It may be classified by the portion of the heart that it affects or by its involvement with the heart rhythm. Alternatively, heart failure may be defined by the symptoms that are present or by the progressive stage of the condition.

Heart failure may be classified by which side of the heart it affects:

  • Left-sided heart failure occurs when the left ventricle cannot adequately pump oxygen-rich blood from the heart to the rest of the body. The main symptoms include shortness of breath, fatigue and coughing, especially at night or while lying down. There may also be lung congestion (with both blood and fluid).

     

  • Right-sided heart failure (cor pulmonale) takes place when the right ventricle is not pumping adequately, which tends to cause fluid build-up in the veins and swelling (edema) in the legs and ankles. Right-sided heart failure usually occurs as a direct result of left-sided heart failure. It can also be caused by severe lung disease (e.g., chronic obstructive pulmonary disease, pulmonary hypertension) in which the right side of the heart cannot generate enough force to pump blood through a diseased pair of lungs.

Heart failure is also commonly defined by which portion of the cardiac cycle is affected:

  • Systolic heart failure means that the heart is unable to pump adequate amounts of blood during its contraction (systole). Lung congestion and swelling (edema) of the lower extremities are typical symptoms of systolic heart failure. This is most commonly caused by coronary artery disease, high blood pressure and heart valve disease.

     

  • Diastolic heart failure refers to the heart's inability to relax between contractions (diastole) and allow enough blood to enter the ventricles. Symptoms may be identical to systolic heart failure. Diastolic heart failure is often a precursor to systolic heart failure. Patients with diastolic heart failure may or may not have normal systolic function. Diastolic dysfunction causes about one-third of all heart failure in people over age 65 and occurs more often among women. This is most commonly caused by coronary artery disease, high blood pressure and cardiomyopathy.

To better understand the differences between systolic and diastolic heart failure, picture the heart as a balloon. Systolic heart failure is when the heart muscle is weak and flabby, like an old, worn-out balloon. Diastolic heart failure is when the heart muscle is stiff and hard, like a brand-new, never-inflated balloon. Neither extreme allows the heart to function properly, leading to a build up of blood in the lungs and shortness of breath (dyspnea).

In addition to these classifications, heart failure may be defined by how it affects patients. The New York Heart Association has developed a system that defines heart failure by the functional limitation it imposes on the patient. These levels are as follows (with approximate percentage of patients):

  • Class I: No obvious symptoms, no limitations on patient physical activity (35 percent of heart failure patients).

     

  • Class II: Some symptoms during or after normal activity, mild physical activity limitations (35 percent of heart failure patients).

     

  • Class III: Symptoms with mild exertion, moderate to significant physical activity limitations (25 percent of heart failure patients).

     

  • Class IV: Significant symptoms at rest, severe to total physical activity limitations (5 percent of heart failure patients).

The American Heart Association (AHA) and American College of Cardiology have developed a way to define heart failure that groups patients by their risk of developing heart failure. This system is useful because it helps physicians design a therapeutic approach to heart failure. The AHA/ACC stages are:

  • Stage A: The patient at high risk for heart failure, but has no heart abnormalities.

     

  • Stage B: The patient has structural abnormalities of the heart, particularly the left ventricle, but no symptoms.

     

  • Stage C: The patient has past or present symptoms associated with heart failure.

     

  • Stage D: The patient has end-stage heart disease, requiring specialized treatment (e.g., continuous intravenous (I.V.) drug therapy, left ventricular assist device, heart transplant) or severely symptomatic heart failure.

Risk factors for heart failure

Heart failure itself is not considered a disease. Rather, heart failure is the product of another condition that damaged the heart muscle. Thus, the development of heart failure is intimately connected to the prevalence of other cardiac diseases. Also, as medical knowledge advances and allows people to live longer and survive severe heart conditions such as coronary artery disease (CAD), the prevalence of heart failure is rising. Today, the American Heart Association estimates that nearly five million Americans have heart disease and more than half a million new cases are diagnosed every year.

Comparing the incidence and course of heart failure between Caucasian and black Americans is provocative. Studies have found that, in Caucasian patients, heart failure most often occurs as a result of CAD, such that CAD develops directly into systolic heart failure. Black Americans, however, tend to progress more gradually from hypertension (high blood pressure), to heart wall thickening, to diastolic heart failure and finally to systolic heart failure. Statistics also show black American heart failure patients to be younger and more likely female, as compared to Caucasian patients. In addition, black Americans with heart failure are more likely to be diagnosed with hypertension and diabetes. While some studies have shown that black Americans have higher heart failure mortality rates than whites, other studies have shown similar survival rates between the two racial groups. The reasons for these differences are still being investigated.

Research has uncovered a significant difference in the way heart failure appears in older patients, according to a study sponsored by the National Heart, Lung and Blood Institute. The Cardiovascular Health Study examined the rates and types of heart failure found in more than 5,800 individuals age 65 and over. Incidences of heart failure were greater among men in the trial than women and increased progressively with age. In addition, heart failure rates were higher among patients with a history of diabetes, atrial fibrillation (a heart rhythm disorder) or mild kidney failure.

Signs and symptoms of heart failure

There are two major underlying causes of the symptoms in heart failure: excess fluid accumulation that may occur in the lungs or elsewhere, and symptoms associated with reduced cardiac output that worsens with exertion. These symptoms may develop over a lengthy span of time, even over a period of years. Because they may not seem important on their own, people may not seek treatment until heart failure has caused significant damage. Specific symptoms include:

  • Shortness of breath (dyspnea). This is one of the earliest symptoms of heart failure. The patient gets winded and fatigued more quickly than before, just by doing regular daily activities or even lying in bed. There is also decreased tolerance to exercise, and the muscles may feel weaker than before.

     

  • Swelling (edema) of the legs is another common symptom in heart failure, though it could also be caused by unrelated conditions.

     

  • Swollen neck veins.

     

  • Abdominal discomfort such as swelling, pain or nausea.

     

  • Mental confusion.

     

  • Racing or pounding heartbeat (palpitations).

     

  • Kidney malfunction or failure (in the later stages of heart failure).

In addition to the symptoms listed above, which the patient may notice, the physician may also be able to detect signs of congestive heart failure, which may include: 

  • An abnormal heart murmur (a telltale sign of a valve-related disorder). 

     

  • A crackling sound of fluid in the lungs (rales), which is a sign of pulmonary congestion.

     

  • A rapid heartbeat (tachycardia) or abnormal heart rhythm (arrhythmias).

     

  • Swelling and fluid retention (edema) in the liver or gastrointestinal tract (in advanced stages of heart failure).

     

  • Hypertrophy or enlargement of the heart.

     

  • Liver malfunction.

Diagnosis methods for heart failure

There is no single test that can diagnose heart failure. Rather, the diagnosis is usually based upon a medical history and complete physical examination, which includes a blood pressure check, listening to the patient's heart through a stethoscope and taking the patient's pulse. Additional tests that a physician may use to determine the cause and severity of heart failure include:

  • Blood tests. Traditional tests evaluate potential causes of heart failure, such as anemia and thyroid function, and electrolytes and kidney function. However, a new test may be effective in diagnosing heart failure. The blood test measures levels of B–type natriuretic peptide (BNP), a protein that is produced by the heart as it fails.

     

  • Echocardiogram of the heart and major arteries. This test uses ultrasound technology to closely examine the overall muscle function of the heart, allowing the physician to evaluate the size, thickness and pumping action of the heart, as well as evaluate how well the heart valves are functioning. A stress echocardiogram may also be useful in assessing how well the heart is functioning at rest and during exercise. An echocardiogram is the single most important test for the diagnosis of heart failure.

     

  • Electrocardiogram (EKG). A test that measures the heart's electrical activity. It is designed to detect any abnormal heart rhythms, heart enlargement, cardiac ischemia or heart attack.

     

  • Exercise stress test. A test in which an EKG is performed at rest and then under the physical stress of exercise, to evaluate the heart's performance at rest and during times of physical exertion.

     

  • Radionuclide imaging tests, such as a radionuclide stress test or ventriculogram. These provide contrast images of the heart, which can pinpoint areas of damage and/or dysfunction and determine how well the heart is pumping.

     

  • Chest x-ray to evaluate the size and shape of the heart, as well as to view the lungs and any fluid that may have built up.

More invasive tests may be ordered in conjunction with, or instead of the above. These tests include a coronary angiogram, in which a contrast dye is delivered by catheter to the coronary arteries to visualize the blood vessels and identify heart damage or dysfunction.

Treatment options for heart failure

Heart failure is usually a chronic condition that has taken years to develop and worsen. Treatment for heart failure is generally designed for three purposes: to improve any symptoms, to slow progression of the heart failure, and to prolong survival. In addition, physicians may choose to treat the underlying conditions that contributed to the heart failure.

Finally, most patients are advised to make lifestyle changes, regardless of the severity of their condition. These may include modifying their diet, limiting salt intake, achieving and maintaining a healthy weight, learning and practicing stress management skills, quitting smoking, and getting regular exercise, depending on the severity of the illness.

Lifestyle choices that are more specific to heart failure may include:

  • Limiting physical activity until approved by one's physician, and then staying as active as possible. Heart failure patients who exercise regularly typically show significant improvement, whereas heart failure patients who are inactive show a clear decline. In studies, Tai Chi (an ancient Chinese workout involving slow, relaxing movements) has been shown to benefit patients living with heart failure. However, exercise in any form is beneficial. Patients should consult their physician before beginning an exercise program.

     

  • Scheduling relaxation and rest periods throughout the day.

     

  • Avoiding excessive fluid intake.

     

  • Keeping a diary of one's daily weight, and notifying one's physician if there is a weight gain of three or more pounds in a single week (which may indicate fluid retention and the need for an immediate change in treatment). Patients experiencing weight loss in spite of what appears to be adequate calorie intake should also discuss their situation with their physician. A study has found that some patients with heart failure may need to adjust their diet to meet increased energy needs.

     

  • Avoiding excessive salt intake, which may contribute to fluid retention.

     

  • Limit alcohol intake.

Patients with heart failure should always consult their physician before taking any over-the-counter medicines, vitamins or herbal supplements.

Depending upon the nature of the underlying damage or malfunction that led to heart failure, medications may be prescribed to reduce the heart's workload, affect remodeling, counter abnormal hormonal levels, increase blood flow, widen vessels or eliminate excess water from the body. Because the medications have different effects, they may be used in combination. Medications used to treat heart failure and related conditions include:

  • ACE inhibitors. A type of vasodilator that expands blood vessels to allow blood to flow easier and more freely, allowing the heart to pump more efficiently. ACE inhibitors act by preventing the production of a chemical that causes blood vessels to expand so the heart does not have to work as hard to pump blood. Reports from the National Institutes of Health indicate that the use of ACE inhibitors has been the most significant factor in heart failure survival rate improvement over recent years. They also have a favorable impact on the heart itself (e.g., affecting remodeling).

     

  • Angiotensin II receptor blockers may also be used in conjunction with ACE inhibitors. They can also be used in patients who cannot take ACE inhibitors or beta blockers.

     

  • Beta blockers. May prevent progression of the disease and improve symptoms by slowing the heart's contraction rate and reducing its pumping action, thus lessening the heart's workload. For many years beta blockers were considered inappropriate for people with heart failure because they can potentially weaken the heart muscle and cannot be used when the patient's health is unstable. Recent studies have shown that selected beta blockers may be very helpful in treating heart failure. They have been shown to decrease mortality and improve left ventricular function in these patients. Beta blockers also reduce the likelihood that these patients will suffer from significant heart rhythm problems.

     

  • Diuretics. Often referred to as water pills, these reduce the symptoms of congestion by helping to flush excess salt and fluids from the body. They are very useful in treating people with heart failure and fluid retention. Spironolactone, a &potassium-sparing& diuretic, has been found to be effective therapy in patients with severe heart failure.

     

  • Inotropes. Intravenous (I.V.) drugs that increase the force of the heart's contractions, allowing the heart to beat less frequently and more effectively. Individuals with severe heart failure often benefit from being hospitalized and being given these powerful medicines intravenously for 24 to 48 hours.

     

  • Digoxin. A weak inotrope, digoxin appears to have an effect on hormones that make heart failure worse. It helps the heart contract more vigorously and effectively, and helps to reduce the symptoms of heart failure. It is most often used to control the fast heart rate of atrial fibrillation. 

     

  • Nitrates. These medications dilate the blood vessels, reduce the amount of blood returning to the heart, reduce the pressure in the arteries and make it easier for the heart to pump blood

In some cases, the physician will also seek to treat the underlying condition that caused the heart failure in the first place. Although not common, heart failure can be reversed once the underlying condition has been treated. For most people, however, heart failure is a chronic and progressive condition that can be managed but rarely cured.

If the heart failure was caused by coronary artery disease, the patient may be recommended for:

  • Balloon angioplasty. A catheter-based procedure in which plaque is pressed back against artery walls to make more room for blood to flow through the artery.

     

  • Coronary stenting. The insertion of a wire mesh metal tube called a stent into a clogged vessel in order to help keep it open. This usually occurs in conjunction with balloon angioplasty.
  
  • Coronary artery bypass surgery, for patients with severe or total artery blockage

Other surgical and invasive therapies used to treat underlying conditions that contribute to heart failure include:

  • Heart valve surgery, in patients with severe valvular regurgitation or valvular stenosis

     

  • Pacemaker insertion to correct the slow heart rhythm (bradycardia) that can worsen heart failure.

     

  • Cardiac resynchronization (e.g., biventricular pacemaker) to coordinate the contraction of the right and left ventricles in patients with heart failure.

     

  • Implantable cardioverter defibrillator (ICDs) to monitor for and, if necessary, correct episodes of life threatening arrhythmias. ICDs are sometimes used in combination with a biventricular pacemaker. 

     

  • Aneurysm surgery in selected patients.

     

  • Heart transplant surgery, in the most severe cases. 

     

  • Insertion of a left ventricular assist device prior to transplant surgery.

Future considerations for heart failure

A variety of new therapies are currently being studied for use in treating heart failure. They include:

  • Total artificial heart. The Food and Drug Administration (FDA) has approved clinical trials for a fully implantable total artificial heart. The grapefruit-sized device is powered by a battery that can be recharged from outside the body without the need for tubes to pass through the skin. Subjects of the study are end-stage heart failure patients who are not eligible for a heart transplant, cannot be helped by other available therapies and are at imminent risk of death.

     

  • Vascular endothelial growth factor (VEGF). A form of therapeutic angiogenesis currently being studied in a trial named VIVA (VEGF for Ischemia in Vascular Angiogenesis). Phase I clinical trials of intracoronary (directly into the heart) and intravenous (IV) injection of VEGF have shown promising results. Researchers found that patients experienced significant improvement in angina and quality of life by day 120 of the trial. Research is ongoing.

     

  • Heart jacket. A synthetic, elastic material that is surgically attached and wrapped around the heart surface. The mesh-like fabric supports the ventricles (the heart's lower chambers), providing a snug fit but without constricting the heart. The goal is to reverse remodeling of the left ventricle. Remodeling was assumed to be irreversible. But recent successes with beta blockers and ventricular assist devices show that remodeling can be improved. In earlier animal and now human studies, the heart jacket support device demonstrated that it does more than keep the left ventricle from enlarging. It can actually reshape and restore it to a more normal form. This led to a significant decrease in the self-destruction of heart muscle cells – another hallmark of heart failure. There was a rise in cardiac output as well as improved ejection fraction. Even with the success of the device so far, it is expected that patients receiving heart jackets would continue their medications (e.g., beta blockers).

     

  • Heart valve repair. When a heart becomes enlarged it often prevents the heart's valves from properly closing, allowing blood to leak back in the wrong direction regurgitation. Certain heart valve surgeries can implant an annuloplasty ring to restore the normal dimensions of the valve, allowing it to come together properly. These surgeries are common as treatments for valvular heart disease and have recently been shown to be successful treating heart failure.

Prospects for recovery from heart failure

Many patients who are hospitalized for heart failure – almost one million each year in the United States alone – can return to a modified version of their everyday routine within weeks or months, depending upon the severity of their condition. Regardless of the nature and severity of heart failure, each patient is encouraged to avoid physical and emotional stress as much as possible, rest often (although supervised exercise can be beneficial to certain patients), avoid extreme temperatures and report to a physician any symptom changes (e.g., weight gain) that may be a sign of fluid retention.

Nevertheless, heart failure is a serious condition. According to the American Heart Association, 80 percent of men and 70 percent of women under age 65 who are diagnosed with heart failure will die within 8 years. Chances of survival are based on the cause and severity of heart failure, as well as lifestyle changes that the patient chooses to make (e.g., taking all medications as instructed, eating a heart-healthy diet and quitting smoking).

The earlier the condition is diagnosed and treatment begins, the better a patient’s prospects for an improved quality of life down the road.

Questions for your doctor

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to heart failure:

  1. Do I suffer from heart failure?

     

  2. How serious is my condition?

     

  3. Are there any tests I can take to give you a better idea of my condition?

     

  4. Are there any underlying conditions causing my heart failure?

     

  5. What type of treatment do you recommend for my condition?

     

  6. Will my condition require any type of surgery?

     

  7. How urgently do I need to begin treatment for this condition?

     

  8. Are there any lifestyle changes I can make to improve my condition?

     

  9. Can heart failure affect my pregnancy in any way?
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