Heart failure (heart failure) is a higher-aged disease in which the heart is no longer able to pump the necessary amount of blood through the body. On the one hand, this causes a deficit of blood or oxygen on the end organs, such as the brain or the kidneys; On the other hand, there is a backflow of blood in front of the heart and thus fluid retention especially in the legs, but also in the lungs.
The culprits: high blood pressure and calcified vessels
Many pre-existing conditions of the heart or other organ systems can result in heart failure. In the industrialized nations, insufficiently treated hypertension and coronary heart disease (CHD) are the main causes of heart failure. In rarer cases, however, cardiac arrhythmias, heart valve defects as well as diseases of the heart muscle can be considered the cause of cardiac insufficiency.
Acute or chronic
The symptoms of heart failure can start suddenly or slowly. The acute heart failure occurs within a few hours to days and usually needs emergency care, as it represents a life-threatening condition.
Chronic heart failure, however, develops over weeks, months or even years. At the beginning it often has a decreasing efficiency, which first becomes noticeable only in the case of heavy, but later also with always easier physical exertion. Added to this are quick fatigue and shortness of breath. Increased deposits of fluids in the feet and lower legs are also a classic symptom of heart failure.
Without therapy, it gets worse and worse
If a heart failure is detected, it should be treated. Otherwise, the disease progresses and leads sooner or later to ever greater restrictions in everyday life and ultimately to death.
Various options are available for the treatment of heart failure. On the one hand, the treatment of the causative disease plays a major role, on the other hand, both discomfort and prognosis can be improved by a targeted drug therapy. In very severe cases, the last resort may require a heart transplant.
Cardiac insufficiency or heart failure summarizes all functional states of the heart in which the organ is no longer able to pump the required amount of blood through the bloodstream. This results, on the one hand, in a reduced supply of oxygen and nutrients to the end organs; On the other hand, it also leads to a backflow of blood into the venous vessels connected to the heart and thus to accumulations of water throughout the body, which in turn can lead to multiple symptoms such as shortness of breath.
Illness of old age
In Germany, the overall prevalence of heart failure is around 1-2%. However, the disease increases significantly with increasing age in frequency. For example, the incidence of over 60-year-olds increases to about 10%, whereas cardiac insufficiency hardly occurs in young age groups.
Heart failure is a very complex disease that occurs on different levels of the body. With the help of so-called pathophysiology, disease mechanisms, symptoms as well as therapeutic aspects of heart failure can be clearly explained, which is why it should be briefly outlined here.
Well meant, but counterproductive
In the context of heart failure, the heart is no longer able to pump the necessary blood volume from the venous into the arterial vasculature. As a result, gaps in the supply of oxygen and nutrients to the end organs, causing the body in a state of distress and induced him to produce various messengers and release into the blood, which stabilize the circulation and improve the supply of blood to the end organs should.
Unfortunately, these measures, which can be understood as a kind of stress reaction, only have a short-term effect. In the long term, they additionally burden the heart muscle and worsen the situation, which is why many drugs for the treatment of heart failure are based precisely on these altered levels of messenger substances.
Fast and ineffective
A decrease in the blood volume pumped initially leads to an increased release of stress hormones such as epinephrine or norepinephrine, which in turn lead to an increase in the heart rate. Due to the increased frequency, however, the heart is only incompletely filled with blood between the individual heartbeats and, in consequence, even less blood is pumped from the venous to the arterial system. Furthermore, too fast a heartbeat can lead to an overload of the heart muscle and ultimately to its failure.
The drug therapy of choice in such a case are beta-blockers, because they reduce the frequency and the oxygen consumption in the heart and ultimately ensure that the delivered stroke volume does not decrease further by a compensatory increase in heart rate.
Kidneys are sensitive
If the insufficient heart pumps less volume into the system, it reduces the blood flow to the entire end organ. Especially the kidneys react very sensitively to falling blood pressure and release the neurotransmitter renin, which leads to the formation of further messenger substances.
An increase in the concentration of renin in the blood leads to an increased formation of the protein angiotensin II, which is responsible for a narrowing of the peripheral vessels. In addition, angiotensin II causes less salt and water to be eliminated via the kidneys. Both effects result in an increase in blood pressure, which should contribute to an increased blood flow to the end organs.
What has been set up very intelligently by the body, has a major disadvantage in the context of heart failure: The increased blood volume, the heart is even more burdened than before and thus further damaged.
To break this vicious circle and relieve the heart, medications such as ACE inhibitors, AT1 receptor antagonists and aldosterone antagonists can be used as they counteract the above messengers, reduce angiotensin II-mediated blood pressure increase and improve cardiac output.
Heart failure can come from very different causes. In many cases, it forms the endpoint of other pre-existing diseases of the heart, such as arterial hypertension or coronary heart disease, which are the most common causes of heart failure. In addition to causes in the heart itself, there are various diseases of other organs, which can lead to heart failure.
Arterial hypertension overwhelms the heart
Untreated or poorly regulated hypertension (arterial hypertension) is one of the most common causes of heart failure. If the blood pressure is too high, the heart has to use a lot of force to pump the blood further into the arterial vasculature.
In the long run, what is easily possible in the short term leads to an overload of the heart muscle, which subsequently thickens (hypertrophied), becomes stiffer and can carry less and less blood over time. The consequence is a reduced blood volume in the arterial blood circulation, while the blood back into the venous system.
Supply shortage: calcified coronary arteries
Coronary heart disease (CHD) is one of the most common diseases in the industrialized nations. Due to an unhealthy lifestyle, it leads to a progressive calcification of the coronary arteries, which supply the heart muscle with oxygen and nutrients. Especially cigarette smoke and a morbid increase in blood lipids and blood sugar favor the development of CHD.
If too much Calcium is deposited on the vessel walls of the coronary arteries, supply bottlenecks occur on the heart muscle tissue. While this only occurs during exercise at baseline, as the disease progresses, oxygen and nutrient deficiencies are increasingly common. The heart can then fill its function to pump blood into the systemic circulation, worse and worse. It creates a heart failure.
In addition to the development of CHD, limescale deposits on the coronary vessels can also harbor another danger: the heart attack. Now and then it can happen that limescale plaques are detached from the vessel wall and carried away with the blood stream. As the coronary vessels continue to narrow, the dissolved plaques eventually get stuck and clog the vessel. Since no more blood can flow, it comes to the affected heart muscle section to an acute undersupply of oxygen and as a result, under certain circumstances, to a dying of the area. If the area is large, heart failure can develop as a result of a heart attack.
Heart valve diseases can be acquired or innate in the course of life. If heart failure already occurs in childhood, an innate valve defect is responsible in most cases.
In the course of life it can come, similarly as with the KHK also, to calcification of the valves, whereby the blood flow through the heart is only more difficult possible and the heart must pump against an increased pressure. Furthermore, heart valves can "leach" over time, so that once pumped blood flows back and the heart is burdened by an increased volume. In both cases, causative diseases at valves of heart are not established, gradually an overload of heart and as a result heart failure.
Heart out of rhythm
For the heart to carry neither too much nor too little blood into the body or the pulmonary circulation, it has to beat within a certain frequency range. If the rate of beats per minute is too low, not enough blood will flow from the venous into the arterial system. However, if the heart beats too fast, it can no longer adequately fill with blood between beats, which also pumps less blood.
Especially in the latter case, there is an overstrain of the heart and an undersupply of the heart muscle tissue with oxygen, whereby the heart gradually loses its power and can develop in the course of heart failure.
Sick heart muscle
Heart muscle disorders can be due to many different causes. What they all share is that they significantly increase the risk of developing heart failure, as many of them are chronic and often recognized late. The main diseases of the heart muscle, which may be the cause of heart failure, are:
- Inflammation of the heart muscle tissue (myocarditis) by viruses, bacteria or fungi, but also by the use of certain medications, chemotherapy, radiation, drug or alcohol abuse
- Cardiomyopathy (various diseases of the heart muscle), caused by stress, overload or on the basis of a hereditary condition
- Damage to the heart muscle due to certain storage diseases such as iron storage disease (hemochromatosis)
Diseases outside the heart
Not only diseases of the heart can lead to the development of heart failure. Also, certain diseases that are not directly on the heart, can affect the heart and cause the development of heart failure.
Common causes of acute heart failure include untreated hyperthyroidism (hyperthyroidism) or fever. In both cases, the metabolism is strongly stimulated, the heart beats much faster and can be acutely overloaded. But even in the context of anemia, the heart has to do more than normal, beats faster and may be overused.
If the diseases responsible for cardiac insufficiency are detected and treated at an early stage, the function of the heart usually normalises again without serious damage remaining.
Important questions about causes and risk
Heart failure can be classified according to various aspects. Probably the most common form is the division into four stages based on the NYHA classification (New York Heart Association). On the one hand, this forms the severity of the disease, but on the other hand, it also provides guidance for the treatment of cardiac insufficiency, since different drug combinations can be used at each stage of the disease.
Subjectively, in the first stage, there are no restrictions on performance. However, examinations of the heart provide initial indications of a slightly reduced cardiac output and thus mark the onset of heart failure.
In NYHA stage II, the first symptoms of heart failure appear, but only under stress: climbing stairs or walking fast seems more strenuous. Fatigue, fatigue, and shortness of breath occur faster than they used to.
The third stage of the disease is characterized by a limitation of physical performance in the performance of everyday things. Even light physical work, such as vacuuming or shopping, can lead to distress and disproportionate fatigue.
In the fourth and last stage of heart failure, shortness of breath, shortness of breath and fatigue already occur at rest. At this stage, not even the lightest movements, such as dressing or washing, can be done independently, so hospitalization is usually required.
Furthermore, the following divisions can be used to classify the heart failure:
a) after the affected heart area:
- left ventricular failure
- right heart failure
- Global insufficiency (combined failure of the right and left heart)
b) after the course of the disease:
- acute heart failure
- chronic heart failure
c) according to pathophysiological aspects:
- Systolic heart failure: The heart is unable to pump existing blood volume into the arterial circulation.
- Diastolic heart failure: The heart can not absorb the volume of blood in the venous circulation. Blood present in the ventricles, however, can be transported further, unlike systolic heart failure.
- combined systolic and diastolic heart failure
d) according to echocardiographic aspects:
In echocardiography, the pumping power of the heart is assessed. This may be moderate to profound, depending on the stage of the disease.
The symptoms of heart failure can be very diverse. In general, acute heart failure results in a very rapid increase in discomfort, which in the worst case can result in shock and require an ambulance. In chronic heart failure, however, the symptoms develop creeping over a longer period of time and can usually be recognized and treated well.
In addition to the classification into an acute and chronic form, the symptoms of heart failure can be differentiated depending on the affected half of the heart.
1. General symptoms
General symptoms are complaints that occur independently of the affected half of the heart, are very unspecific and yet typical of heart failure.
Performance kink and frequent toilets
At the very beginning, in many cases, decreasing performance and faster fatigue in physical or psychological stress situations. Typically, you feel more tired than usual, easily get out of breath, and are already overly exhausted after a low load. If the disease is more advanced, exhaustion and tiredness can occur even at rest, without any burden.
A typical symptom of heart failure is still the nocturnal urination. This is due to water retention, which accumulate during the day, especially in the legs. When lying down, the water passes from the legs back into the vascular system and can be excreted via the kidneys. Because of this, it can happen that you wake up at night and do not have to lose significant amounts of water.
Another symptom, which is often not noticed, is the faster heartbeat as well as new cardiac arrhythmias, which represent a compensatory attempt of decreasing cardiac output, especially at the beginning of heart failure.
2. Symptoms of left ventricular failure
The left half of the heart receives venous blood from the lungs, which has been enriched with oxygen, and forwards it into the arterial circulation. This is ultimately responsible for the supply of all organs and the extremities with acidic and nutrient-rich blood.
In a left ventricular failure on the one hand, the blood is not transported away from the left heart (backward failure) and on the other hand not properly forwarded into the systemic circulation (forward failure), which can be derived from the main symptoms:
Intoxication out of breath
The backward failure and the consequent backflow of blood into the pulmonary vessels leads to a partly massive fluid accumulation in the lungs. This causes dizziness (dyspnea), which often occurs at the beginning only during exercise and later also at rest.
The stagnation of blood in the pulmonary circulation is reinforced by lying, which is why it can often come to nocturnal coughing fits with shortness of breath. This phenomenon is also called "asthma cardiale", in principle an asthma attack due to the poor pumping power of the heart.
In the worst case, the massive backwater of blood in the pulmonary lungs can lead to pulmonary edema, which is manifested by very severe airlessness and means a medical emergency.
The brain can also be affected
Forward failure leads to reduced blood flow to vital end organs such as the brain or kidneys in left heart failure. As a result, feelings of weakness as well as confusion and vigilance decrease. Blood pressure can drop sharply, causing you to feel increasingly weak and tired.
3. Symptoms of Right Heart Failure
The right heart is at the service of the pulmonary circulation. Its function is to receive acid and nutrient-poor blood from the body and to transmit it to the lungs, where it is enriched with oxygen and transported on to the system of the left heart. Also in the context of right heart failure, a distinction can be made between a backward and a forward failure.
In backward failure, the blood in front of the right heart constricts back into the venous system of the systemic circulation. This leads to accumulations of fluid in the organs, which precedes the heart and are particularly rich in blood. This leads to an increased blood volume in the end vessels of the extremities and thus to an increased fluid leakage into the tissue. The developing edema spreads first of all on the dorsum and the lower leg front and increase during the day.
Blood congestion in all organs
Furthermore, the blood is increasingly stagnated back into the liver, which can lead to an enlargement of the organ (hepatomegaly), but also to liver pain, a yellowing of the skin (jaundice) as well as to an accumulation of fluid in the abdomen (ascites). A backwater of the blood can be noticeable in many other organs by different complaints. For example, nausea and loss of appetite in the stomach and functional impairment in the kidneys may occur.
In most cases, right and left heart failure are not separate, but in common, so there are both signs of right and left heart failure. This condition is called global heart failure.
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Questions about symptoms and complaints
Heart failure is assessed by several diagnostic criteria. As a rule, your doctor will start with an extensive initial consultation (anamnesis). This is followed by a physical examination, a blood sample and equipment of the heart such as an electrocardiogram (ECG), an ultrasound examination or an X-ray examination of the chest. Furthermore, CT or MRI examinations may become necessary during the course of the disease.
Targeted questions: the anamnesis
A detailed medical history forms the basis of every diagnosis. In the context of heart failure diagnostics, the following aspects or questions are of great importance to your doctor:
- Do you suffer from pre-existing conditions? In particular, diseases of the heart such as a CHD or a past myocardial infarction are important here.
- How much alcohol do you consume?
- Do you take any medications, or have there been any changes in your medication lately? In particular, NSAID pain relievers are repeatedly discussed as a trigger for heart failure decompensation.
Following the anamnesis interview, your doctor will examine you physically. Among other things, he listens to the heart and lungs and scans the belly. Measuring blood pressure is also very important in this context.
Listening to the heart is primarily used to detect valve changes that may be the cause of heart failure. In turn, as a result of heart failure, fluid can accumulate in the lungs, which a skilled physician with the stethoscope can hear when listening to the lungs. Furthermore, the filling state of the jugular veins can be examined, which is usually too high in heart failure.
Laboratory chemical diagnosis
A blood test is part of every diagnosis of heart failure. On the one hand, it serves to rule out diseases that can cause heart failure (for example, hyperthyroidism or severe anemia); On the other hand, a specific heart failure marker can be determined in the blood.
The so-called natriuretic B-type peptide (BNP) is released by overloading or stretching of the heart cavities and is usually always elevated in the context of cardiac insufficiency. The degree of BNP increase not only indicates the presence of cardiac insufficiency, but also indicates its severity: the higher the BNP level in the blood, the more severe the heart failure.
Apparative examination methods
On the one hand, research methods are used to verify the diagnosis of heart failure, while others are used to investigate the causes. In detail, the following methods are used depending on the problem:
- ECG: An ECG is always performed for initial diagnostics. Depending on the cause of the heart failure can be found by the derivation of the heart currents diverse abnormalities that can explain a heart failure. These include, for example, arrhythmia or an expired infarct.
- Echocardiography: The ultrasound examination of the heart is an important basis for the diagnosis of heart failure. It can be used to assess whether the heart cavities are of normal size, whether there is a thickening of the heart muscle, whether the heart valves have changes and whether the cardiac actions are normal. The results of echocardiography are fast, cost effective and accurate, which is a key advantage of this method.
- X-ray thorax: In the chest X-ray, the X-ray examination of the chest, the heart and lungs can be shown in the overview. As part of heart failure, the heart is often greatly enlarged and has a very characteristic shape, the so-called wooden shoe shape. The lungs, in turn, can be examined for stasis signs, which indirectly provide evidence of decreased cardiac output.
- Cardiac MRI: Magnetic resonance imaging of the heart is a very special examination, which is only used for special problems, for example suspected viral myocarditis or a storage disease that can also manifest in the heart.
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Everything about diagnostics and relevant examinations
As well as the causes, the treatment options of heart failure are very diverse and must be individually tailored. At the top of the therapy is the treatment of underlying diseases, which are suspected to have caused the heart failure.
Furthermore, the heart can be relieved by a targeted drug therapy. In some cases, cardiac surgery or the use of a pacemaker may relieve the symptoms.
1. Treatment of the underlying diseases
There are a number of diseases that can result in heart failure. In many cases, the heart failure sets in only years, why a timely treatment of underlying diseases is essential for the prevention of heart failure.
As a result of long-term high blood pressure, heart failure can develop. Therefore, increased blood pressure should always be lowered consistently. This is usually done with ACE inhibitors or AT1 receptor antagonists, which are also the drug of choice for drug therapy of heart failure. A normalization of blood pressure protects the heart from overloading and thus from the development of heart failure.
In addition to arterial hypertension, coronary heart disease is a very important risk factor for the development of heart failure. However, a CHD can only be prevented by a healthy lifestyle consisting of exercise, healthy nutrition and non-smoking. A drug therapy that could cure a once formed KHK, however, does not exist. However, in severe constrictions of the coronary vessels stents or bypasses can be set.
Valvular heart disease
Heart valve diseases can be congenital or acquired. Especially at a young age heart valve diseases should be treated early. As a rule, this is done by replacing the diseased flap, either by a biological flap of the pig or by an artificially produced, so-called mechanical heart valve.
Cardiac arrhythmias: Cardiac arrhythmias can lead to both too rapid (tachycardia) and to a too slow heart rhythm (bradycardia). In both cases heart failure can develop as a result. Bradycardia cardiac arrhythmias are often treated by the use of a pacemaker that drives a heart beating too slowly. Tachycardiac arrhythmias, on the other hand, can be treated by frequency-lowering drugs, such as beta-blockers.
2. Drug therapy of heart failure
There are a number of medicines that have a positive effect on heart failure, alleviate the symptoms of the disease, and improve prognosis. Which drugs are used depends on the one hand on the NYHA stage of the disease, on the other hand also on concomitant and underlying diseases of heart failure.
ACE inhibitors take the pressure out
ACE inhibitors reduce the development of angiotensin II, which in the physiological state leads to an increase in blood pressure via a narrowing of the vessels as well as a reduced excretion of water via the kidneys. ACE inhibitors are used at every stage of heart failure, as they not only reduce blood pressure, they also have a positive effect on the heart and can slow the progression of the disease. The most common ACE inhibitors are:
- Ramipril (Delix®, Vasotope®)
- Enalapril (Xabef®)
Alternative for side effects: AT1 blocker
AT1 receptor antagonists have the same effect as ACE inhibitors and are also used in the NYHA stages I-IV for the treatment of heart failure. They are often used as an alternative to ACE inhibitors when they are not tolerated due to the very common side effect of irritating cough. The AT1 blockers include:
- Candesartan (Atacand®, Blopressid®)
- Lorsartan (Lozaar®)
- Valsartan (Cordinate®, Diovan®, Provas®)
Beta blockers slow down the heart
Beta-blockers regulate the heartbeat and protect the heart from the effects of frequency-increasing stress hormones like adrenaline or norepinephrine. The use of beta-blockers is usually necessary from stage II, but is also used in stage I of heart failure after suffered myocardial infarction. As well as ACE inhibitors and AT1 blockers, beta blockers improve the prognosis of heart failure as they have protective effects on the heart muscle. Used medications are:
- Metoprolol (Beloc®, Beloc ZOK®, Lopresor®)
- Nebivolol (Nebilet®)
- Bisoprolol (bisoprolol®, Concor®)
Relief with diuretics
Diuretics, colloquially referred to as water tablets, have a hypotensive effect by promoting the excretion of salts and water through the kidneys. Diuretics can in principle be used at any stage of heart failure. Their use, however, is always essential if it comes to water retention in the body (edema) or the lungs.
Treatment with diuretics must always be well monitored as it can affect the blood salts (sodium and potassium) and kidney levels. For this reason, regular blood collections are necessary.
Digitalis preparations: well-tried, but not without
Digitalis products are among the oldest medications used to treat heart failure. Its effect is to increase the pumping power of the heart, which can alleviate the symptoms of heart failure.
Unlike many other medicines, however, they do not improve the prognosis of the disease. Furthermore, their use must be monitored very strictly, as overdoses can easily occur and sometimes have serious consequences. Digitalis preparations are therefore given more and more restrained.
The most common preparations include:
- Digitoxin (Digimed®, Digimerck®)
- Digoxin (Digacin®, Lanico®, Lenoxin®)
3. Surgical treatment methods
As a last-resort remedy, severe heart failure can result in replacement of organs. However, heart transplants are only performed in Germany at around 500 affected persons a year due to the small number of donor organs.The waiting lists for a suitable donor heart are long, which is why more and more people are looking for ways to avoid a heart transplant.
There are already first beginnings of mechanical art hearts, which take over a part or even the entire pumping power of the heart. The disadvantage of these artificial hearts is that they can only be worn for a limited period of time and increase the risk of developing strokes.
The prognosis of heart failure depends on the stage of the disease and its course. Left untreated, the disease progresses rapidly, significantly worsening the prognosis. Under a guideline-based therapy, however, survival can be significantly improved.
The one-year mortality rate in heart failure is expressed as a percentage of the NYHA stage:
- Stage I: <10%
- Stage II: approx. 15%
- Stage III: about 25%
- Stage IV: approx. 50%
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Questions and answers about history and prognosis
In developed countries, coronary heart disease is sometimes the leading cause of heart failure. The development of a CHD could be avoided in many cases. The most important preventive measures for the prevention of disease development are:
- the consistent adjustment of blood pressure to a normal level
- the absolute smoke waiver
- the setting of elevated blood lipid and blood glucose levels
- the reduction of obesity
- a healthy diet
- sufficient exercise or exercise
- the reduction of alcohol
Especially in this country, prevention is the most important and effective "therapy" for heart failure!
Here are a few pointers:
Everyday life with heart failure
Author: Lisa Wunsch
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C. Hurni https://econtent.hogrefe.com/doi/pdf/10.1024/0040-5930/a000635, last accessed on 06.03.2018.
AMWF: National Health Insurance Guide for Chronic Heart Failure: http://www.awmf.org/uploads/tx_szleitlinien/nvl-006p_S3_Heartbreath_Patient_version_replaced.pdf, last accessed 06/03/2018.