by
MEDICINE - UP TO THE MINUTE
by
Charles A. Bertrand, M.D., FACP, DIM-CD (Ret.)
Associate Clinical Professor of Medicine at New York Medical College
and at the Medical University of South Carolina

HEART FAILURE - WHAT IT IS AND WHAT IT ISN’T

What does heart failure mean? It means that the heart fails to adequately perform its major function, i.e. to pump blood. Normally, the heart of an average sized adult pumps about five quarts of blood per minute and this is called cardiac output. Under exercise conditions it may pump seven quarts, ten quarts or even more.

There are consequences when the heart’s output is reduced - at first these may be rather subtle but as deterioration occurs symptoms become more pronounced. Early on the blood flow to the kidneys is decreased; as kidney function is impaired and the kidneys excrete less salt in the urine and salt is retained in the body. Salt and water go together and as fluid is retained and congestion occurs. At first this usually is in the lungs, causing shortness of breath on exertion and later(if severe) even at rest. Other changes occur as well. As the heart pumps less and less, further congestion results in enlargement of the liver and fluid is retained in the lower extremities (called edema). This represents a typical picture of heart failure or, as it’s often called, congestive heart failure.

The basic cause (or etiology) may be one of many types - hardening of the arteries of the heart (coronary arteriosclerosis), or high blood pressure (hypertension) being the two most common. Thus, heart failure itself is not a specific disease entity or disorder but occurs as a result of some underlying type of heart disease and so it is a manifestation of diminished heart function.

A typical example would involve a male in his fifties or sixties who has previously had one or more heart attacks (called myocardial infarction). As a result of the heart attacks there is scarring and remodeling of the anatomy of the heart and thus the heart increases in size and pumps less blood. The patient may then develop shortness of breath as fluid accumulates in the lungs and later even congestion of the liver and swollen ankles. When this occurs he may gain five or ten pounds, or in extreme cases more than forty pounds - all due to fluid accumulation.

Treatment involves multiple approaches to the problem. One of the first would be the use of a diuretic. This promotes the excretion of both salt and water and therefore tends to correct one of the initial aspects of heart failure. Salt should be a dietary no-no, at times alcohol as well, and fat restriction too, along with weight control. In addition, a class of medicines known as ACE inhibitors are used so the heart can pump more readily, thus improving a different aspect of the problem. Digitalis has been used for many years to help the mechanical pumping of the heart and increase cardiac output. So, this represents a three pronged approach to the patient with heart failure. A selection of other medicines may be used as well and this involves individual judgment on the part of the treating doctor. Most patients do well and life expectancy has increased considerably during the past decade, although there still are about five million people in the U.S. with heart failure and about 250,000 die each year

In general, medical management is the treatment of heart failure. On occasion, however, surgery is also utilized - after the patient’s condition has improved and (hopefully) he is in good enough condition to withstand a heart operation. An example of this would be a patient with rheumatic heart disease who develops scarring of one or more valves of the heart; this causes heart enlargement and congestive heart failure. In this situation it is often advisable to operate and correct the valvular problems - the results are generally good and there are many patients who have lived for years following successful heart surgery - at times even decades.

There are warning signs that should be heeded by the patient and, if present, should necessitate a visit to either the hospital emergency room or the treating physician, depending on the circumstances. As noted above, any shortness of breath, swollen abdomen or edematous lower extremities should demand prompt attention. Also, patients who have warning signs of a heart attack should also see a physician or go to the emergency room promptly. In the latter situation it might be chest pain, unexpected heaviness in the chest, or pain or heaviness occurring during exertion. A very early sign of heart failure might be unexpected increase in weight due to fluid retention. For example, if one’s weight suddenly increases by several pounds in a day or two it is cause for investigation.

If any doubt at all exists, then one should seek immediate medical attention.

The advice provided on this website is intended to be general in nature and should not be relied upon for specific treatment. If you need personal medical attention please contact your physician.

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