Heart failure

Highlights

Heart Failure

Heart failure is a condition in which the heart does not pump enough blood to meet the needs of the body’s tissues. Heart failure can develop slowly over time as the result of other conditions (such as high blood pressure and coronary artery disease) that weaken the heart. It can also occur suddenly as the result of damage to the heart muscle.

Symptoms

Common signs and symptoms of heart failure include:

Treatment

Treatment for heart failure depends on its severity. Patients with very weakened hearts may need surgery or implanted devices, such as pacemakers or implantable cardioverter defibrillators. All patients need to make lifestyle changes, including restricting sodium (salt) in their diets.

Doctors usually treat heart failure, and the underlying conditions that cause it, with a combination of medications. These medications include:

Other medications that may be helpful include:

Introduction

Heart failure is a condition in which the heart does not pump enough blood to meet the needs of the body’s tissues. To understand what occurs in heart failure, it helps to be familiar with the anatomy of the heart and how it works. The heart is composed of two independent pumping systems, one on the right side, and the other on the left. Each has two chambers, an atrium and a ventricle. The ventricles are the major pumps in the heart.

Heart, front view
The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.

The Right Side of the Heart. The right system receives blood from the veins of the whole body. This is "used" blood, which is poor in oxygen and rich in carbon dioxide.

The Left Side of the Heart. The left system receives blood from the lungs. This blood is now rich in oxygen.

The Valves. Valves are muscular flaps that open and close so blood will flow in the right direction. There are four valves in the heart:


Click the icon to see an image of the internal structures of the heart.

The Heart's Electrical System. The heartbeats are triggered and regulated by the conducting system, a network of specialized muscle cells that form an independent electrical system in the heart muscles. These cells are connected by channels that pass chemically-triggered electrical impulses.


Click the icon to see an image of the conduction system of the heart.

Description of Heart Failure

Heart failure is a process, not a disease. The heart doesn't "fail" in the sense of ceasing to beat (as occurs during cardiac arrest). Rather, it weakens, usually over the course of months or years, so that it is unable to pump out all the blood that enters its chambers. As a result, fluids tend to build up in the lungs and tissues, causing congestion. This is why heart failure is also sometimes referred to as "congestive heart failure."

Ways the Heart Can Fail. Heart failure can occur in several ways:


Click the icon to see an image of the valves of the heart.

The specific effects of heart failure on the body depend on whether it occurs on the left or right sides of the heart. Over time, however, in either form of heart failure, the organs in the body do not receive enough oxygen and nutrients, and the body's wastes are removed slowly. Eventually, vital systems break down.

Failure on the Left Side (Left-Ventricular Heart Failure). Failure on the left side of the heart is more common than failure on the right side. The failure can be a result of abnormal systolic (contraction) or diastolic (relaxation) action:

Failure on the Right Side (Right-Ventricular Heart Failure). Failure on the right side of the heart is most often a result of failure on the left. Because the right ventricle receives blood from the veins, failure here causes the blood to back up. As a result, the veins in the body and tissues surrounding the heart to swell. This causes swelling in the feet, ankles, legs, and abdomen. Pulmonary hypertension (increase in pressure in the lung's pulmonary artery) and lung disease may also cause right-sided heart failure.

Ejection Fraction. To help determine the severity of left-sided heart failure, doctors use an ejection fraction (EF) calculation, also called a left-ventricular ejection fraction (LVEF). This is the percentage of the blood pumped out from the left ventricle during each heartbeat. An ejection fraction of 50 - 75% is considered normal. Patients with left-ventricular heart failure are classified as either having a preserved ejection fraction (greater than 50%) or a reduced ejection fraction (less than 50%).

Patients with preserved LVEF heart failure are more likely to be female and older, and have a history of high blood pressure and atrial fibrillation (a disturbance in heart rhythm).

Causes

Heart failure has many causes and can evolve in different ways.

In all cases, the weaker pumping action of the heart means that less blood is sent to the kidneys. The kidneys respond by retaining salt and water. This in turn increases edema (fluid buildup) in the body, which causes widespread damage.

High Blood Pressure

Uncontrolled high blood pressure (hypertension) is a major cause of heart failure even in the absence of a heart attack. In fact, about 75% of cases of heart failure start with hypertension. It generally develops as follows:

[For more information, see In-Depth Report #14:High blood pressure.]

Hypertension
Hypertension is a disorder characterized by consistently high blood pressure. Generally, high blood pressure consists of systolic blood pressure (the "top" number, which represents the pressure generated when the heart beats) higher than 140, or diastolic blood pressure (the "bottom" number, which represents the pressure in the vessels when the heart is at rest) over 90.

Coronary Artery Disease and Heart Attack

Coronary artery disease is the end result of a process called atherosclerosis (commonly called "hardening of the arteries"). It is the most common cause of heart attack and involves the build-up of unhealthy cholesterol in the arteries, with inflammation and injury in the cells of the blood vessels. The arteries narrow and become brittle. Heart failure in such cases most often results from a pumping defect in the left side of the heart. [For more information, see In-Depth Report #3: Coronary artery disease and angina; and In-Depth Report #23: Cholesterol.]


Click the icon to see an image of atherosclerosis.

People often survive heart attacks, but many eventually develop heart failure from the damage the attack does to the heart muscles. [For more information, see In-Depth Report #12: Heart attack.]

Valvular Heart Disease

The valves of the heart control the flow of blood leaving and entering the heart. Abnormalities can cause blood to back up or leak back into the heart.


Click the icon to see an image of the heart valves.

In the past, rheumatic fever, which scars the heart valves and prevents them from functioning properly, was a major cause of death from heart failure. Fortunately, antibiotics and other advances in industrialized countries have now made this disease a minor cause of heart failure. Birth defects may also cause abnormal valvular development. Although more children born with heart defects are now living to adulthood, they still face a higher than average risk for heart failure as they age.

Cardiomyopathy

Cardiomyopathy is a disorder that damages the heart muscles and leads to heart failure. There are several different types. Injury to the heart muscles may cause the heart muscles to thin out (dilate) or become too thick (become hypertrophic). In either case, the heart doesn't pump correctly. Viral myocarditis is a rare viral infection that involves the heart muscle and can produce either temporary or permanent heart muscle damage.

Dilated Cardiomyopathy. Dilated cardiomyopathy involves an enlarged heart ventricle. The muscles thin out, reducing the pumping action, usually on the left side. Although this condition is associated with genetic factors, the direct cause is often not known. (This is called idiopathic dilated cardiomyopathy.) In other cases, viral infections, alcoholism, and high blood pressure may increase the risk for this condition.

Hypertrophic Cardiomyopathy. In hypertrophic cardiomyopathy, the heart muscles become thick and contract with difficulty. Some research indicates that this occurs because of a genetic defect that causes a loss of power in heart muscle cells and, subsequently, lower pumping strength. To compensate for this power loss, the heart muscle cells grow. This condition, rare in the general population, is often the cause of sudden death in young athletes.


Click the icon to see an image of hypertrophic cardiomyopathy.

Restrictive Cardiomyopathy. Restrictive cardiomyopathy refers to a group of disorders in which the heart chambers are unable to properly fill with blood because of stiffness in the heart. The heart is of normal size or only slightly enlarged. However, it cannot relax normally during the time between heartbeats when the blood returns from the body to the heart (diastole). The most common causes of restrictive cardiomyopathy are amyloidosis and scarring of the heart from an unknown cause (idiopathic myocardial fibrosis). It frequently occurs after a heart transplant.

Severe Lung Diseases

Chronic obstructive pulmonary disease (severe emphysema) and other major lung diseases are risk factors for right-side heart failure.

Pulmonary hypertension is increased pressure in the pulmonary arteries that carry blood from the heart to the lungs. The increased pressure makes the heart work harder to pump blood, which can cause heart failure. The development of right-sided heart failure in patients with pulmonary hypertension is a strong predictor of death within 6 - 12 months.

Thyroid Disorders

An overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism) can have severe effects on the heart and increase the risk for heart failure.

Risk Factors

Nearly 6 million Americans are living with heart failure. About 670,000 new cases of heart failure are diagnosed each year. Although there has been a dramatic increase over the last several decades in the number of people who suffer from heart failure, survival rates have greatly improved.

Coronary artery disease, heart attack, and high blood pressure are the main causes and risk factors of heart failure. Other diseases that damage or weaken the heart muscle or heart valves can also cause heart failure. Heart failure is most common in people over age 65, African-Americans, and women.

Age

Heart failure risk increases with advancing age. Heart failure is the most common reason for hospitalization in people age 65 years and older.

Gender

Men are at higher risk for heart failure than women. However, women are more likely than men to develop diastolic heart failure (a failure of the heart muscle to relax normally), which is often a precursor to systolic heart failure (impaired ability to pump blood).

Ethnicity

African-Americans are more likely than Caucasians to develop heart failure before age 50 and to die from the condition.

Family History and Genetics

People with a family history of cardiomyopathies (diseases that damage the heart muscle) are at increased risk of developing heart failure. Researchers are investigating specific genetic variants that increase heart failure risk.

Diabetes

People with diabetes are at high risk for heart failure, particularly if they also have coronary artery disease and high blood pressure. Some types of diabetes medications, such as rosiglitazone (Avandia) and pioglitazone (Actos), have been associated with heart failure. Chronic kidney disease caused by diabetes also increases heart failure risk.

Obesity

Obesity is associated with both high blood pressure and type 2 diabetes, conditions that place people at risk for heart failure. Evidence strongly suggests that obesity itself is a major risk factor for heart failure, particularly in women.

Lifestyle Factors

Smoking, sedentary lifestyle, and alcohol and drug abuse can increase the risk for developing heart failure.

Medications Associated with Heart Failure

Long-term use of high-dose anabolic steroids (male hormones used to build muscle mass) increases the risk for heart failure. The drug itraconazole (Sporanox), used to treat skin, nail, or other fungal infections, has occasionally been linked to heart failure. The cancer drug imatinib (Gleevec) has been associated with heart failure. Other chemotherapy drugs, such as doxorubicin, can increase the risk for developing heart failure years after cancer treatment. (Cancer radiation therapy to the chest can also damage the heart muscle.)

Complications

Nearly 290,000 people die from heart failure each year. Nevertheless, although heart failure produces very high mortality rates, treatment advances are improving survival rates.

Cardiac Cachexia. If patients with heart failure are overweight to begin with, their condition tends to be more severe. Once heart failure develops, however, an important indicator of a worsening condition is the occurrence of cardiac cachexia, which is unintentional rapid weight loss (a loss of at least 7.5% of normal weight within 6 months).

Impaired Kidney Function. Heart failure weakens the heart’s ability to pump blood. This can affect other parts of the body including the kidneys (which in turn can lead to fluid build-up). Decreased kidney function is common in patients with heart failure, both as a complication of heart failure and other diseases associated with heart failure (such as diabetes). Studies suggest that, in patients with heart failure, impaired kidney function increases the risks for heart complications, including hospitalization and death.

Congestion (Fluid Buildup). In left-sided heart failure, fluid builds up first in the lungs, a condition called pulmonary edema. Later, as right-sided heart failure develops, fluid builds up in the legs, feet, and abdomen. Fluid buildup is treated with lifestyle measures, such as reducing salt in the diet, as well as drugs, such as diuretics.

Arrhythmias (Irregular Beatings of the Heart)

Angina and Heart Attacks. While coronary artery disease is a major cause of heart failure, patients with heart failure are at continued risk for angina and heart attacks. Special care should be taken with sudden and strenuous exertion, particularly snow shoveling, during colder months.

Symptoms

Many symptoms of heart failure result from the congestion that develops as fluid backs up into the lungs and leaks into the tissues. Other symptoms result from inadequate delivery of oxygen-rich blood to the body's tissues. Since heart failure can progress rapidly, it is essential to consult a doctor immediately if any of the following symptoms are detected:

Fatigue. Patients may feel unusually tired.

Shortness of Breath (Dyspnea).

Fluid Retention (Edema) and Weight Gain. Patients may complain of foot, ankle, leg or abdominal swelling. In rare cases, swelling can occur in the veins of the neck. Fluid retention can cause sudden weight gain and frequent urination.

Wheezing or Cough. Patients may have asthma-like wheezing, or a dry hacking cough that occurs a few hours after lying down but then stops after sitting up.

Loss of Muscle Mass. Over time, patients may lose muscle weight due to low cardiac output and a significant reduction in physical activity.

Gastrointestinal Symptoms. Patients experience loss of appetite or a sense of feeling full after eating small amounts. They may also have abdominal pain.

Pulmonary Edema. When fluid in the lungs builds up, it is called pulmonary edema. When this happens, symptoms become more severe. These episodes may happen suddenly, or gradually build up over a matter of days:

Abnormal Heart Rhythms. Patients may have episodes of abnormally fast or slow heart rate.

Central Sleep Apnea. This sleep disorder results when the brain fails to signal the muscles to breathe during sleep. It occurs in up to half of people with heart failure. Sleep apnea causes disordered breathing at night. If heart failure progresses, the apnea may be so acute that a person, unable to breathe, may awaken from sleep in panic.

Diagnosis

Doctors can often make a preliminary diagnosis of heart failure by medical history and careful physical examination.

A thorough medical history may identify risks for heart failure that include:

The following physical signs, along with medical history, strongly suggest heart failure:

Laboratory Tests

Both blood and urine tests are used to check for problems with the liver and kidneys and to detect signs of diabetes. Lab tests can measure:

Electrocardiogram

An electrocardiogram (ECG) is a test that measures and records the electrical activity of the heart. It is also called an EKG. An electrocardiogram cannot diagnose heart failure, but it may indicate underlying heart problems. The test is simple and painless to perform. It may be used to diagnose:

A completely normal ECG means that heart failure is unlikely.

ECG
The electrocardiogram (ECG, EKG) is used extensively to diagnose heart disease, from congenital heart disease in infants to myocardial infarction and myocarditis in adults. There are several different types of electrocardiograms.

Echocardiography

The best diagnostic test for heart failure is echocardiography. Echocardiography is a noninvasive test that uses ultrasound to image the heart as it is beating. Cardiac ultrasounds provide the following information:

Doctors use information from the echocardiogram for calculating the ejection fraction (how much blood is pumped out during each heartbeat), which is important for determining the severity of heart failure. Stress echocardiography may be needed if coronary artery disease is suspected.

Angiography

Doctors may recommend angiography if they suspect that blockage of the coronary arteries is contributing to heart failure. This procedure is invasive.


Click the icon to see an image of cardiac catheterization.

Radionuclide Ventriculography. Radionuclide ventriculography is an imaging technique that uses a tiny amount of radioactive material (called a trace element). It is very sensitive in revealing heart enlargement or evidence of fluid accumulation around the heart and lungs. It may be done at the same time as coronary artery angiography. It can help diagnose or exclude the presence of coronary artery disease and helps demonstrate how the heart works during exercise.

Other Imaging Tests

Chest x-rays can show whether the heart is enlarged. Computed tomography (CT) and magnetic resonance imaging (MRI) may also be used to evaluate the heart valves and arteries.

Exercise Stress Test

The exercise stress test measures heart rate, blood pressure, electrocardiographic changes, and oxygen consumption while a patient is performing physically, usually walking on a treadmill. It can help determine heart failure symptoms. Doctors also use exercise tests to evaluate long-term outlook and the effects of particular treatments. A stress test may be done using echocardiography or may be done as a nuclear stress test (myocardial perfusion imaging).

Treatment

Heart failure is classified into four stages (Stage A through Stage D) that reflect the development and progression of the condition. Treatment depends on the stage of heart failure.

The first two stages (Stage A and Stage B) are not technically heart failure, but indicate that a patient is at high risk for developing it.

Management of Risk Factors and Causes

Stage A. In Stage A, patients are at high risk for heart failure but do not show any symptoms or have structural damage of the heart. The first step in managing or preventing heart failure is to treat the primary conditions that cause or complicate heart failure. Risk factors include high blood pressure, heart diseases, diabetes, obesity, metabolic syndrome, and previous use of medications that damage the heart (such as some chemotherapy).

Important risk factors to manage include:

Treatment Based on Heart Failure Stage

Stage B. Patients have a structural heart abnormality seen on echocardiogram or other imaging tests but no symptoms of heart failure. Abnormalities include left ventricular hypertrophy and low ejection fraction, asymptomatic valvular heart disease, and a previous heart attack. In addition to the treatment guidelines for Stage A, the following types of drugs and devices may be recommended for some patients:

Stage C. Patients have a structural abnormality and current or previous symptoms of heart failure, including shortness of breath, fatigue, and difficulty exercising. Treatment includes those for Stage A and B plus:

Stage D. Patients have end-stage symptoms that do not respond to standard treatments. Treatment includes appropriate measures used for Stages A, B, and C plus:

Managing Triggers of Heart Failure Symptoms

Whenever heart failure worsens, whether quickly or chronically over time, various factors must be considered as the cause:

Medications

Many different medications are used in the treatment of heart failure. They include:

ACE Inhibitors

Angiotensin-converting enzyme (ACE) inhibitors are among the most important drugs for treating patients with heart failure. ACE inhibitors open blood vessels and decrease the workload of the heart. They are used to treat high blood pressure but can also help improve heart and lung muscle function. ACE inhibitors are particularly important for patients with diabetes, because they also help slow progression of kidney disease.

Brands and Indications. ACE inhibitors are used to treat Stage A high-risk conditions such as high blood pressure, heart disease, and diabetic nerve disorders (neuropathy). They are also used to treat Stage B patients who have had a heart attack or who have left ventricular systolic disorder, and Stage C patients with heart failure. Specific brands of ACE inhibitors include:

Side Effects of ACE Inhibitors:

Angiotensin-Receptor Blockers (ARBs)

ARBs, also known as angiotensin II receptor antagonists, are similar to ACE inhibitors in their ability to open blood vessels and lower blood pressure. They may have fewer or less-severe side effects than ACE inhibitors, especially coughing, and are sometimes prescribed as an alternative to ACE inhibitors. Some patients with heart failure take an ACE inhibitor along with an ARB.

Brands and Indications. ARBs are used to treat Stage A high-risk conditions such as high blood pressure and diabetic nerve disorders (neuropathy). They are also used to treat Stage B patients who have had a heart attack or who have left ventricular systolic disorder, and Stage C patients with heart failure. Specific brands include:

Common Side Effects

Beta Blockers

Beta blockers are almost always used in combination with other drugs, such as ACE inhibitors and diuretics. They help slow heart rate and lower blood pressure. When used properly, beta blockers can reduce the risk of death or rehospitalization.

Brands and Indications. Beta blockers treat Stage A high blood pressure. They also treat Stage B patients (both those who have had a heart attack and those who have not had a heart attack but who have heart damage). Patients with heart failure who take beta blockers should be monitored by a specialist. The three beta blockers that are best for treating Stage C patients with heart failure are:

Beta Blocker Concerns

Common Side Effects

Check with your doctor about any side effects. Do not stop taking these drugs on your own.

Diuretics

Diuretics cause the kidneys to rid the body of excess salt and water. Fluid retention is a major symptom of heart failure. Aggressive use of diuretics can help eliminate excess body fluids, while reducing hospitalizations and improving exercise capacity. These drugs are also important to help prevent heart failure in patients with high blood pressure. In addition, certain diuretics, notably spironolactone (Aldactone, generic), block aldosterone, a hormone involved in heart failure. This drug class is beneficial for patients with more severe heart failure (Stages C and D).

Patients taking diuretics usually take a daily dose. Under the directions and care of a doctor or nurse, some patients may be taught to adjust the amount and timing of the diuretic when they notice swelling or weight gain.

Diuretics come in many brands and are generally inexpensive. Some need to be taken once a day, some twice a day. Treatment is usually started at a low dose and gradually increased. Diuretics are virtually always used in combination with other drugs, especially ACE inhibitors and beta blockers. There are three main types of diuretics:

Potassium-sparing diuretics.

Thiazide diuretics. These include chlorothiazide (Diuril, generic), chlorthalidone (Clorpres, generic), indapamide (Lozol, generic), hydrochlorothiazide (Esidrix, generic), and metolazone (Zaroxolyn, generic).

Loop diuretics. These are considered the preferred diuretic type for most patients with heart failure.

Common Side Effects

Aldosterone Blockers

Aldosterone is a hormone that is critical in controlling the body's balance of salt and water. Excessive levels may play important roles in hypertension and heart failure. Drugs that block aldosterone are prescribed for some patients with symptomatic heart failure. They have been found to reduce death rates for patients with heart failure and coronary artery disease, especially after a heart attack. These blockers pose some risk for high potassium levels. Brands include:

Elevated levels of potassium in the blood are also a concern with these drugs. Patients should not take potassium supplements at the same time as this drug without their doctor's knowledge and may need to avoid foods with high potassium content.

Digitalis

Digitalis is derived from the foxglove plant. It has been used to treat heart disease since the 1700s. Digoxin (Lanoxin, generic) is the most commonly prescribed digitalis preparation. Digoxin decreases heart size and reduces certain heart rhythm disturbances (arrhythmias).

Unfortunately, digitalis does not reduce mortality rates, although it does reduce hospitalizations and worsening of heart failure. Controversy has been ongoing for more than 100 years over whether the benefits of digitalis outweigh its risks and adverse effects.

Digitalis may be useful for select patients with left-ventricular systolic dysfunction who do not respond to other drugs (diuretics, ACE inhibitors). It may also be used for patients who have atrial fibrillation.

Side Effects and Problems. While digitalis is generally a safe drug, it can have toxic side effects due to overdose or other accompanying conditions. The most serious side effects are arrhythmias (abnormal heart rhythms that can be life threatening). Early signs of toxicity may be irregular heartbeat, nausea and vomiting, stomach pain, fatigue, visual disturbances (such as yellow vision, seeing halos around lights, flickering or flashing of lights), and emotional and mental disturbances.

Many factors increase the chance for side effects.

Digitalis also interacts with many other drugs, including quinidine, amiodarone, verapamil, flecainide, amiloride, and propafenone.

For most patients with mild-to-moderate heart failure, low-dose digoxin may be as effective as higher doses. If side effects are mild, patients should still consider continuing with digitalis if they experience other benefits.

Hydralazine and Nitrates

Hydralazine and nitrates are two older drugs that help relax arteries and veins, thereby reducing the heart's workload and allowing more blood to reach the tissues. They are used primarily for patients who are unable to tolerate ACE inhibitors and angiotensin receptor blockers. In 2005, the FDA approved BiDil, a drug that combines isosorbide dinitrate and hydralazine. BiDil is approved to specifically treat heart failure in African-American patients.

Statins

Statins are important drugs used to lower cholesterol and to prevent heart disease leading to heart failure. These drugs include lovastatin (Mevacor, generic), pravastatin (Pravachol, generic), simvastatin (Zocor, generic), fluvastatin (Lescol), atorvastatin (Lipitor), rosuvastatin (Crestor), and pitavastatin (Livalo). Atorvastatin is specifically approved to reduce the risks for hospitalization for heart failure in patients with heart disease.

Anti-Platelet and Anticoagulant Drugs

Aspirin. Aspirin is a type of non-steroid anti-inflammatory (NSAID). Aspirin is recommended for protecting patients with heart disease, and can safely be used with ACE inhibitors, particularly when it is taken in lower dosages (75 - 81 mg).

Warfarin (Coumadin, generic). Warfarin is recommended only for patients with heart failure who also have:

Other Drugs

Nesiritide (Natrecor). Nesiritide is an intravenous drug that has been used for hospitalized patients with decompensated heart failure. Decompensated heart failure is a life-threatening condition in which heart failure progresses over the course of minutes or a few days, often as the result of a heart attack or sudden and severe heart valve problems. Because nesiritide may cause serious kidney damage and has been linked to an increased risk of death from heart failure, the drug is of limited value.

Erythropoietin. Many patients with chronic heart failure are also anemic. Treatment of these patients with erythropoietin has been shown to provide some benefit for heart failure control and hospitalization risk. However, erythropoietin therapy can also increase the risk of blood clots. The exact role of this drug for the treatment of anemia in patients with heart failure is not yet decided. [For more information, see In-Depth Report #57: Anemia.]

Tolvaptan. Tolvaptan (Samsca) is a drug approved for treating hyponatremia (low sodium levels) associated with heart failure and other conditions.

Levosimendan. Levosimendan is an experimental drug that is being investigated as a treatment for severely ill patients with heart failure. It belongs to a new class of drugs called calcium sensitizers that may help improve heart contractions and blood flow. The drug appears to reduce levels of BNP (brain natriuretic peptide), a chemical marker for heart failure severity.

Surgery and Devices

Revascularization Surgery

Revascularization surgery helps to restore blood flow to the heart. It can treat blocked arteries in patients with coronary artery disease and may help select patients with heart failure. Surgery types include coronary artery bypass graft (CABG) and angioplasty (also called percutaneous coronary intervention [PCI]). CABG is a traditional type of open heart surgery. Angioplasty uses a catheter to inflate a balloon inside the artery. A metal stent may also be inserted during an angioplasty procedure. [For more information, see In-Depth Report #03: Coronary artery disease.]

Coronary artery balloon angioplasty - series

Click the icon to see an illustrated series detailing coronary artery balloon angioplasty.
Heart bypass surgery - series

Click the icon to see an illustrated series detailing heart bypass surgery.

Pacemakers

Pacemakers, also called pacers, help regulate the heart’s beating action, especially when the heart beats too slowly. Biventricular pacers (BVPs) are a special type of pacemaker used for patients with heart failure. Because BVPs help the heart’s left and right chambers beat together, this treatment is called cardiac resynchronization therapy (CST).

BVPs are recommended for patients with moderate-to-severe heart failure that is not controlled with medication therapy and who have evidence of left-bundle branch block on their EKG. Left-bundle branch block is a condition in which the electrical impulses in the heart do not follow their normal pattern, causing the heart to pump inefficiently.

Implantable Cardioverter Defibrillators (ICDs)

Patients with enlarged hearts are at risk for having serious cardiac arrhythmias (abnormal heartbeats) that are associated with sudden death. Implantable cardioverter defibrillators (ICDs) can quickly detect life-threatening arrhythmias. The ICD is designed to convert any abnormal heart rhythm back to normal by sending an electrical shock to your heart. This action is called defibrillation. This device can also work as a pacemaker.

In recent years, certain ICD models and biventricular pacemaker-defibrillators have been recalled by the manufacturers because of circuitry flaws. However, doctors stress that the chance of an ICD or pacemaker saving a person’s life far outweigh the possible risks of these devices failing.

Ventricular Assist Devices

Ventricular assist devices are mechanical devices that help improve pumping actions. They are used as a bridge to transplant for patients who are on medications but still have severe symptoms and are awaiting a donor heart. In some cases, they may delay the need for a transplant. Therefore they may be used as short-term (less than 1 week) or longer term support.

Ventricular assist devices include:

The risks and complications involved with many of these devices include bleeding, blood clots, and right-side heart failure. Infections are a particular hazard.

Heart Transplantation

Patients who suffer from severe heart failure and whose symptoms do not improve with drug therapy or mechanical assistance may be candidates for heart transplantation. About 2,000 heart transplant operations are performed in the United States each year, but thousands more patients wait on a list for a donor heart.

The most important factor for heart transplant eligibility is overall health. Chronological age is less important. Most heart transplant candidates are between the ages of 50 - 64 years.

While the risks of this procedure are high, the 1-year survival rate is about 88% for men and 77% for women. Five years after a heart transplant, about 73% of men and 67% of women remain alive. In general, the highest risk factors for death three or more years after a transplant operation are coronary artery disease and the adverse effects (infection and certain cancers) of immunosuppressive drugs used in the procedure. The rejection rates in older people appear to be similar to those of younger patients.

Implantable Artificial Heart

Abiocor is a permanent implantable artificial heart. It is available only for patients who are not eligible for a heart transplant and who are not expected to live more than a month without medical treatment. The device requires a large chest cavity, which means that most women are not eligible for it.

Lifestyle Changes

Up to half of patients hospitalized for heart failure are back in the hospital within 6 months. Many people return because of lifestyle factors, such as poor diet, failure to comply with medications, and social isolation.

Rehabilitation

Programs that offer intensive follow-up to ensure that the patient complies with lifestyle changes and medication regimens at home can reduce rehospitalization and improve survival. Patients without available rehabilitation programs should seek support from local and national heart associations and groups. A strong emotional support network is also important.

Monitoring Weight Changes

Patients should weigh themselves each morning and keep a record. Any changes are important:

Dietary Factors

Sodium (Salt) Restriction. All patients with heart failure should limit their sodium (salt) intake to less than 1,500 mg a day, and in severe cases, very stringent salt restriction may be necessary. Patients should not add salt to their cooking and their meals. They should also avoid foods high in sodium. These salty foods include ham, bacon, hot dogs, lunch meats, prepared snack foods, dry cereal, cheese, canned soups, soy sauce, and condiments. Some patients may need to reduce the amount of water they consume. People with high cholesterol levels or diabetes require additional dietary precautions. [For more information on diet and heart health, see In-Depth Report #43: Heart-healthy diet. ]

Here are some tips to lower your salt and sodium intake:

Exercise

People with heart failure used to be discouraged from exercising. Now, doctors think that exercise, when performed under medical supervision, is extremely important for stable patients with stable conditions. Studies have reported that patients with stable conditions who engage in regular moderate exercise (three times a week) have a better quality of life and lower mortality rates than those who do not exercise. However:

Studies report benefits from specific exercises:

Bed Rest

Some people with severe heart failure may need bed rest. To reduce congestion in the lungs, the patient's upper body should be elevated. For most patients, resting in an armchair is better than lying in bed. Relaxing and contracting leg muscles is important to prevent clots. As the patient improves, a doctor will progressively recommend more activity.

Stress Reduction

Stress reduction techniques, such as meditation and relaxation response methods, may have direct physical benefits. Anxiety can cause the heart to work harder and beat faster.

Herbs and Supplements

Patients with heart failure may resort to alternative remedies. Such remedies are often ineffective and may have severe or toxic effects. Of particular note for patients with heart failure is an interaction between St. John's wort (an herbal medicine used for depression) and digoxin (a heart drug). St. John's wort can significantly interfere with this drug.

Fish Oil Supplements. Some research shows that a daily capsule of fish oil may help improve survival in patients with heart failure. Fish oil contains omega-3 polyunsaturated fatty acids, a healthy kind of fat. However, while evidence is not conclusive, some studies have suggested that fish oil supplements may not be safe for patients with implanted cardiac defibrillators.

Coenzyme Q10 and Vitamin E. Small studies suggested that coenzyme Q10 (CoQ10) may help patients with heart failure, particularly when combined with vitamin E. CoQ10 is a vitamin-like substance found in organ meats and soybean oil. More recent studies, however, have found that CoQ10 and vitamin E do not help the heart or prevent heart disease. In fact, vitamin E supplements may actually increase the risk of heart failure, especially for patients with diabetes or vascular diseases.

Other Vitamins and Supplements. A wide variety of other vitamins (thiamin, B6, and C), minerals (calcium, magnesium, zinc, manganese, copper, selenium), nutritional supplements (carnitine, creatine), and herbal remedies (hawthorn) have been proposed as treatments for heart failure. None have been adequately tested. There is no evidence that a particular vitamin or supplement can cure heart failure. In any case, vitamins are best consumed through the food sources contained in a healthy diet.

Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been several reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Resources

References

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Greenberg B and Kahn AM. Clinical assessment of heart failure. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011: chap 26.

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Khush KK, Waters DD, Bittner V, Deedwania PC, Kastelein JJ, Lewis SJ, et al. Effect of high-dose atorvastatin on hospitalizations for heart failure: subgroup analysis of the Treating to New Targets (TNT) study. Circulation. 2007 Feb 6;115(5):576-83. Epub 2007 Jan 29.

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McAlister FA, Ezekowitz J, Dryden DM, Hooton N, Vandermeer B, Friesen C, et al. Cardiac Resynchronization Therapy and Implantable Cardiac Defibrillators in Left Ventricular Systolic Dysfunction. Evidence Report/Technology Assessment No. 152 (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. 290-02-0023). AHRQ Publication No. 07-E009. Rockville, MD: Agency for Healthcare Research and Quality. June 2007.

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Review Date: 5/4/2011
Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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