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Heart Failure- American Heart Association The term "heart failure" makes it sound like the heart is no longer

working at all and there's nothing that can be done. Actually, heart failure means that the heart isn't pumping as well as it should be. Your body depends on the heart's pumping action to deliver oxygen- and nutrient-rich blood to the body's cells. When the cells are nourished properly, the body can function normally. With heart failure, the weakened heart can't supply the cells with enough blood. This results in fatigue and shortness of breath. Everyday activities such as walking, climbing stairs or carrying groceries can become very difficult. Heart failure is a serious condition, and usually there's no cure. But many people with heart failure lead a full, enjoyable life when the condition is managed with heart failure medications and healthy lifestyle changes. It's also helpful to have the support of family and friends who understand your condition. How the normal heart works The normal healthy heart is a strong, muscular pump a little larger than a fist. It pumps blood continuously through the circulatory system. The heart has four chambers, two on the right and two on the left:

Two upper chambers called atria (one is an atrium) Two lower chambers called ventricles

Oxygen-rich blood travels from the lungs to the left atrium, then on to the left ventricle, which pumps it to the rest of the body. The right atria takes in oxygen-depleted blood from the rest of the body and sends it back out to the lungs through the right ventricle. The heart pumps blood to the lungs and to all the body's tissues by a sequence of highly organized contractions of the four chambers. For the heart to function properly, the four chambers must beat in an organized way. What is heart failure? Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood through to meet the body's needs for blood and oxygen. Basically, the heart can't keep up with its workload. At first the heart tries to make up for this by:

Enlarging. When the heart chamber enlarges, it stretches more and can contract more strongly, so it pumps more blood. Developing more muscle mass. The increase in muscle mass occurs because the contracting cells of the heart get bigger. This lets the heart pump more strongly, at least initially. Pumping faster. This helps to increase the heart's output.

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 brain.

These temporary measures mask the problem of heart failure, but they don't solve it. Heart failure continues and worsens until these substitute processes no longer work. 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. The body's compensation mechanisms help explain why some people may not become aware of their condition until years after their heart begins its decline. (It's also a good reason to have a regular checkup with your doctor.) Heart failure can involve the heart's left side, right side or both sides. However, it usually affects the left side first Classes of Heart Failure Doctors usually classify patients' heart failure according to the severity of their symptoms. 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 I Functional Capacity: How a patient with cardiac disease feels during physical activity Patients with cardiac disease but resulting in no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea or anginal pain. Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea or anginal pain. Patients with cardiac disease resulting in marked limitation of


physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain. IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort increases.

Class Objective Assessment A B No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity. Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest. Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during lessthan-ordinary activity. Comfortable only at rest. Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest.


For Example: A patient with minimal or no symptoms but a large pressure gradient across the aortic valve or severe obstruction of the left main coronary artery is classified: o Function Capacity I, Objective Assessment D

A patient with severe anginal syndrome but angiographically normal coronary arteries is classified:

Functional Capacity IV, Objective Assessment A

Warning signs By themselves, any one sign of heart failure may not be cause for alarm. But if you have more than one of these symptoms, even if you haven't been diagnosed with any heart problems, report them to a healthcare professional and ask for an evaluation of your heart.

If you have been diagnosed with heart failure, it's important for you to keep track of symptoms and report any sudden changes to your healthcare team .This table lists the most common signs and symptoms, explains why they occur and describes how to recognize them. Sign or Symptom People with Heart Failure May Experience... ...breathlessness during activity (most commonly), at rest, or while sleeping, which may come on suddenly and wake you up. You often have difficulty breathing while lying flat and may need to prop up the upper body and head on two pillows. You often complain of waking up tired or feeling anxious and restless. ...coughing that produces white or pink blood-tinged mucus. Why It Happens 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.

Shortness of breath (also called dyspnea)

Persistent coughing or wheezing

Fluid builds up in the lungs (see above). 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.

Buildup of excess fluid in body tissues (edema) ...swelling in the feet, ankles, legs or abdomen or weight gain. You may find that your shoes feel tight.

Tiredness, fatigue

...a tired feeling all the The heart can't time and difficulty with pump enough everyday activities, blood to meet

such as shopping, climbing stairs, carrying groceries or walking.

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.

Lack of appetite, nausea

...a feeling of being full The digestive or sick to your stomach. system receives less blood, causing problems with digestion. ...memory loss and feelings of disorientation. A caregiver or relative may notice this first. ...heart palpitations, which feel like your heart is racing or throbbing. Changing levels of certain substances in the blood, such as sodium, can cause confusion. To "make up for" the loss in pumping capacity, the heart beats faster.

Confusion, impaired thinking

Increased heart rate

All of us lose some blood-pumping ability in our hearts as we age, but heart failure results from the added stress of health conditions that either damage the heart or make it work too hard. All of the lifestyle factors that increase your risk of heart attack and stroke smoking, being overweight, eating foods high in fat and cholesterol and physical inactivity can also contribute to heart failure. Learn more about what you can do to reduce your risk for heart failure by making lifestyle changes that last. Conditions that may lead to heart failure If you have heart failure, chances are you have (or had) one or more of the conditions listed below. Some of these can be present without you knowing it. Typically these conditions cause the "wear and tear" that leads to heart failure. Having more than one of these factors dramatically increases your risk. Conditions that may lead to heart failure

Coronary artery disease

When cholesterol and fatty deposits build up in the heart's arteries, less blood can reach the heart muscle. This build-up is known as atherosclerosis. The result may be chest pain (angina) or, if blood flow becomes totally obstructed, a heart attack. Coronary artery disease can also contribute to having high blood pressure which, over time, may lead to heart failure. Past heart attack (myocardial infarction) High blood pressure (hypertension) Abnormal heart valves Heart muscle disease (dilated cardiomyopathy, hypertrophic cardiomyopathy) or inflammation (myocarditis) Heart defects present at birth (congenital heart disease) Severe lung disease Diabetes Sleep Apnea

To determine whether you have heart failure, your healthcare team may do some or all of these diagnostic tests and procedures. Common tests for heart failure

Physical examination
How it's done:

You'll be asked about your medical history and symptoms. Usually you have to fill out forms with this information before your examination. The doctor or a healthcare assistant may ask you the questions again during the exam. Your blood pressure will be taken. You'll be weighed.

A healthcare professional will listen to your heart and lungs using a stethoscope. The physical exam is generally painless.

Tips for success: Don't be afraid to "look bad." For instance, if you smoke, eat a lot of high-fat foods or are physically inactive, be honest. That information helps determine your risk for heart failure. Your doctor can't make an accurate diagnosis without full input from you. Think of your healthcare providers as your partners you have to work together to be successful.

Follow all instructions for preparing for your exam. You may be told not to eat or drink anything for a certain amount of time before your appointment. Bring all your medications or a list of all your medications to your appointment. That includes over-the-counter drugs, vitamins and supplements as well as prescriptions.

Blood Tests Chest X-Rays Electrocardiogram (abbreviated as EKG or ECG) Echocardiography (abbreviated as "echo") Exercise Stress Test Radionuclide Ventriculography or Multiple-Gated Acquisition Scanning (abbreviated as MUGA) Cardiac Catheterization Ejection Fraction Heart Failure Measurement The ejection fraction (EF) is an important measurement in determining how well your heart is pumping out blood and in diagnosing and tracking heart failure. A significant proportion of patients with heart failure happen to have a normal ventricular ejection fraction at echocardiography during examination. Previously called diastolic heart failure, it is nowadays referred to as heart failure with normal ejection fraction (HFNEF) or HF with preserved ejection fraction. 1. Perserved ejection fraction (HFpEF) also referred to as diastolic heart failure. The heart muscle contracts normally but the ventricles do not relax as they should during ventricular filling (or when the ventricles relax)

2. Reduced ejection fraction (HFREF) also referred to as systolic heart failure. The heart muscle does not contract effectively and less oxygen-rich blood is pumped out to the body. What it is? A measurement of how much blood the left ventricle pumps out with each contraction.

What it means. An ejection fraction of 60 percent means that 60 percent of the total amount of blood in the left ventricle is pushed out with each heartbeat. What's normal?

A normal heart's ejection fraction may be between 55 and 70. You can have a normal ejection fraction reading and still have heart failure. If the heart muscle has become so thick and stiff that the ventricle holds a smaller-than-usual volume of blood, it might still seem to pump out a normal percentage of the blood that enters it. In reality, though, the total amount of blood pumped isn't enough to meet your body's needs.

What's too low?

A measurement under 40 may be evidence of heart failure or cardiomyopathy. An EF between 40 and 55 indicates damage, perhaps from a previous heart attack, but it may not indicate heart failure. In severe cases, EF can be very low.

What's too high? EF higher than 75 percent may indicate a heart condition like hypertrophic cardiomyopathy. Tests for measuring EF:

Echocardiogram (Echo) MUGA scan CAT scan Cardiac catheterization Nuclear stress test

Cardiac Medications At-A-Glance

(Also known as Blood Thinners.) Commonly prescribed include:

Dalteparin (Fragmin), Danaparoid (Orgaran) Enoxaparin (Lovenox) Heparin (various) Tinzaparin (Innohep) Warfarin (Coumadin)

What the Medication Does Decreases the clotting (coagulating) ability of the blood. Sometimes called blood thinners, although they do not actually thin the blood. They do NOT dissolve existing blood clots. Used to treat certain blood vessel, heart and lung conditions. Reason for Medication

Helps to prevent harmful clots from forming in the blood vessels. May prevent the clots from becoming larger and causing more serious problems. Often prescribed to prevent first or recurrent stroke.

Antiplatelet Agents
Commonly prescribed include:

Aspirin Ticlopidine Clopidogrel (Plavix) Dipyridamole

What the Medication Does Keeps blood clots from forming by preventing blood platelets from sticking together. Reason for Medication

Helps prevent clotting in patients who have had a heart attack, unstable angina, ischemic strokes, TIA (transient ischemic attacks, or "little strokes") and other forms of cardiovascular disease. Usually prescribed preventively when plaque buildup is evident but there is not yet a large obstruction in the artery.

Angiotensin-Converting Enzyme (ACE) Inhibitors

Commonly prescribed include:

Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Moexipril (Univasc) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik)

What the Medication Does Expands blood vessels and decreases resistance by lowering levels of angiotensin II. Allows blood to flow more easily and makes the heart's work easier or more efficient. Reason for Medication

Used to treat or improve symptoms of cardiovascular conditions including high blood pressure and heart failure.

Angiotensin II Receptor Blockers (or Inhibitors)

(Also known as ARBs, Angiotensin-2 Receptor Antagonists and AT-2) Commonly prescribed include:

Candesartan (Atacand)

Eprosartan (Teveten) Irbesartan (Avapro) Losartan (Cozaar) Telmisartan (Micardis) and Valsartan (Diovan)

What the Medication Does Rather than lowering levels of angiotensin II (as ACE inhibitors do) angiotensin II receptor blockers prevent this chemical from having any effects on the heart and blood vessels. This keeps blood pressure from rising. Reason for Medication

Used to treat or improve symptoms of cardiovascular conditions including high blood pressure and heart failure.

Beta Blockers
(Also known as Beta-Adrenergic Blocking Agents) Commonly prescribed include:

Acebutolol (Sectral) Atenolol (Tenormin) Betaxolol (Kerlone) Bisoprolol/hydrochlorothiazide (Ziac) Bisoprolol (Zebeta) Carteolol (Cartrol) Metoprolol (Lopressor, Toprol XL) Nadolol (Corgard) Propranolol (Inderal) Sotalol (Betapace) Timolol (Blocadren)

What the Medication Does

Decreases the heart rate and cardiac output, which lowers blood pressure and makes the heart beat more slowly and with less force. Reason for Medication

Used to lower blood pressure. Used with therapy for cardiac arrhythmias (abnormal heart rhythms) and in treating chest pain (angina). Used to prevent future heart attacks in patients who have had a heart attack.

Calcium Channel Blockers

(Also known as Calcium Antagonists or Calcium Blockers) Commonly prescribed include:

Amlodipine (Norvasc, Lotrel) Bepridil (Vascor) Diltiazem (Cardizem, Tiazac) Felodipine (Plendil) Nifedipine (Adalat, Procardia) Nimodipine (Nimotop) Nisoldipine (Sular) Verapamil (Calan, Isoptin, Verelan)

What the Medication Does Interrupts the movement of calcium into the cells of the heart and blood vessels. May decrease the heart's pumping strength and relax blood vessels. Reason for Medication

Used to treat high blood pressure, chest pain (angina) caused by reduced blood supply to the heart muscle and some arrhythmias (abnormal heart rhythms).


(Also known as Water Pills) Commonly prescribed include: Amiloride (Midamor) Bumetanide (Bumex)

Chlorothiazide (Diuril) Chlorthalidone (Hygroton) Furosemide (Lasix) Hydro-chlorothiazide (Esidrix, Hydrodiuril) Indapamide (Lozol) and Spironolactone (Aldactone)

What the Medication Does Causes the body to rid itself of excess fluids and sodium through urination. Helps to relieve the heart's workload. Also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods. Reason for Medication

Used to help lower blood pressure. Used to help reduce swelling (edema) from excess buildup of fluid in the body.

(Also known as Nitrates. Nitroglycerin tablets are a form of vasodilator.) Commonly prescribed include: Isosorbide dinitrate (Isordil) Nesiritide (Natrecor)

Hydralazine (Apresoline) Nitrates Minoxidil

What the Medication Does Relaxes blood vessels and increases the supply of blood and oxygen to the heart while reducing its workload. Can come in pills to be swallowed, chewable tablets and as a topical application

(cream). Reason for Medication

Used to ease chest pain (angina).

Digitalis Preparations
(Also known as Digoxin and Digitoxin) Commonly prescribed include: Lanoxin What the Medication Does Increases the force of the heart's contractions, which can be beneficial in heart failure and for irregular heart beats. Reason for Medication

Used to relieve heart failure symptoms, especially when the patient isn't responding to ACE inhibitors and diuretics. Also slows certain types of irregular heartbeat (arrhythmias), particularly atrial fibrillation.

Common types of cholesterol-lowering drugs include:

statins resins nicotinic acid (niacin) gemfibrozil clofibrate

What the Medication Does Various medications can lower blood cholesterol levels. They may be prescribed individually or in combination with other drugs. They work in the body in different ways. Some affect the liver, some work in the intestines and some interrupt the formation of cholesterol from circulating in

the blood. Reason for Medication

Used to lower LDL ("bad") cholesterol, raise HDL ("good") cholesterol and lower triglyceride levels.