Heart failure

Despite its frightening name, heart failure - or congestive heart failure - doesn't mean your heart has stopped beating. In fact, it means that your heart is weak or stiff, so it may struggle to pump enough blood around your body, particularly when you exert yourself. This leads to symptoms like breathlessness, swollen ankles and fatigue (tiredness).

Heart failure is more common in men than women, and people over the age of 75 are most at risk.

There are a number of conditions that can lead to heart failure. These include: 

• Coronary Artery Disease: this is a condition caused by the build-up of plaque and fatty deposits in the lining of the arteries that supply blood to the heart (coronary arteries). This build-up causes the inside of the arteries to narrow and sometimes become blocked (a process called atherosclerosis), which can eventually lead to a heart attack or a stroke
• Heart Attack: a heart attack - or myocardial infarction - occurs when part of the heart muscle doesn't get enough blood. The more time that passes without treatment to restore blood flow, the greater the damage to the heart muscle. The main cause of heart attacks is coronary artery disease 
• Cardiomyopathy: this describes any condition that affects the workings of the heart muscle or its ability to pump blood around the body. In some cases, the heart rhythm also becomes disturbed. This is called arrhythmia. 
• Congenital Heart Defects (CHDs): some babies are born with a problem with their heart. These congenital heart defects might affect the structure of a baby's heart and the way it works; for example how blood flows through the heart, or how it is pumped to the rest of the body. CHDs can vary from mild (such as a small hole in the heart) to severe (such as missing or poorly formed parts of the heart)
• Diabetes: this disease affects your body’s ability to process blood glucose (blood sugar). Over the long-term, high glucose levels can lead to heart failure
• High blood pressure (hypertension): this is a common condition in which the force of the blood against the walls of your arteries is too strong. This means that your heart and blood vessels are working too hard, and over time can lead to health problems, including heart failure 
• Cardiac arrhythmia: this is an irregular heartbeat, and can occur when the electrical signals that coordinate the heart’s rhythm don't work properly. This may cause the heart to beat too fast (tachycardia), too slow (bradycardia) or irregularly
• Obesity: being very overweight is linked to many health problems, including diabetes, high blood pressure, certain cancers, and heart disease 
• Smoking and drug use: smoking can cause fatty deposits to form on the walls of your coronary arteries, in a process called atherosclerosis. Over time, this narrowing of the blood vessels puts strain on your heart muscle and can result in heart failure. Most illegal drugs can also have adverse cardiovascular effects, ranging from abnormal heart rate to heart attacks.

Heart failure can be either acute (which comes on suddenly and without warning) or chronic (long term). Physical symptoms of heart failure include: 

• Shortness of breath (also known as dyspnea): if your heart can't pump enough blood to meet your body's needs, you may find it hard to breathe with increased activity, or even when you are sitting still or lying down
• Fatigue and weakness: you may experience this all the time, even with everyday activities such as shopping, climbing stairs or walking. This is because the heart can't pump enough blood to meet the needs of your muscles 
• Swelling in the legs, ankles and feet (oedema): this is the result of fluid build-up in the tissues
• Rapid or irregular heartbeats (palpitations): this is caused by the heart beating faster to make up for its reduced pumping capacity
• Persistent cough or wheezing, with white or pink blood-tinged mucus: this is caused by blood backing up in the pulmonary veins, resulting in fluid build-up within the lungs
• Swelling of the abdomen (tummy): the result of fluid building up within the digestive system
• Very rapid weight gain: this is caused by water retention
• Nausea and lack of appetite: this is a result of a lack of blood flow to the digestive system, which causes digestive problems
• Difficulty concentrating or decreased alertness:  changing levels of certain substances in the blood (such as sodium) can cause memory loss, confusion and disorientation
• Chest pain (if heart failure is caused by a heart attack): chest pain or angina is experienced when your heart muscles do not receive enough oxygenated blood. The pain often feels like heaviness, tightness or pressure in the chest.

Although these symptoms may be signs of heart failure, there are many other possible causes. If you are worried about your symptoms and would like to speak to a GP, HCA offers same-day and next-day private GP appointments.

If your doctor suspects you may have heart failure, they will carry out a full assessment of your health, medical history, family history and lifestyle.
They will also carry out a physical examination, which will include:

• Blood pressure check: high blood pressure is often related to heart failure
• BMI: this stands for body mass index, and measures whether you are a healthy weight for your height. High BMI (being overweight or obese) is related to heart failure
• Measurement of your waist: men with a waist size over 37in and women with a waist size over 31.5in are at high risk of coronary heart disease and heart failure.

If your doctor thinks that you may have heart failure they will refer you for further tests. These may include:

Blood tests: these provide information about your heart muscle by measuring the enzymes, cholesterol and proteins in your blood

Breathing tests: you may be asked to blow into a tube to check whether a lung problem is contributing to your breathlessness. Common tests include spirometry and a peak flow test

Electrocardiogram (ECG): in this test, sensors are attached to your chest and the rate, rhythm and electrical activity of your heart are measured. It is a painless procedure which usually only takes a few minutes to complete and can detect many different types of heart problem

Exercise ECG (also known as a cardiac stress test): this is an ECG which is carried out whilst you are walking on a treadmill or on an exercise bike, to see how your heart responds to moderate exercise. This test usually takes around half an hour, and you will be monitored by a cardiologist throughout. You blood pressure will also be recorded

Echocardiogram: this is an ultrasound scan which is used to check whether your heart and valves are working properly. During the procedure (which is similar to a pregnancy ultrasound), you will be asked to lie on your back and side whilst the consultant applies a special gel to your chest and moves an ultrasound probe over the area. This type of scan uses sound waves and echoes to create a moving image of your heart. It is painless and usually takes around 20-30 minutes to complete

Imaging tests: these include chest X rays and MRI scans, which provide high-definition images of your heart and lungs to check whether your heart is bigger than it should be, or if there is fluid in your lungs (a sign of heart failure).

Your doctor will decide which tests are most appropriate for you and based on the results, recommend a treatment plan.

Treatment for heart failure usually aims to control the symptoms for as long as possible and slow down the progression of the disease. Treatment may include a combination of lifestyle changes, medication and surgery.

Lifestyle changes

• Eating a heart-healthy diet which is rich in fresh fruit and vegetables, and low in processed meats, fat and sugar
• Maintaining a healthy weight (losing weight if necessary)
• Cutting down on alcohol
• Giving up smoking
• Taking regular exercise: you will need to start slowly and build up your activity level gradually. Ask your doctor for advice before starting a new exercise regime.

Medication

There are a number of medications which can relieve the symptoms of heart failure, these include (but are not limited to) beta blockers, ACE inhibitors, diuretics and digoxin.

 

Beta blockers: these are sometimes prescribed to prevent angina attacks caused by heart failure. Beta blockers slow down the heart by reducing the amount of adrenaline your body produces

Ivabradine: this is an alternative to beta blockers which works in the same way

ACE (Angiotensin-converting enzyme) inhibitors: these reduce blood pressure by helping to relax the veins and arteries

Angiotensin II receptor blockers: if ACE inhibitors cause difficult side effects, you may be prescribed Angiotensin II receptor blockers (ARBs) to help relax your veins and arteries, lower blood pressure and make it easier for your heart to pump blood

Diuretics: these relieve the symptoms of heart failure by flushing excess water and salts from your body through urine

Mineralocorticoid receptor antagonists: these also increase urine production, help lower blood pressure and reduce fluid around the heart. The most widely used MRAs are spironolactone and eplerenone

Digoxin: this strengthens your heart muscle contractions and slows down your heart rate. It's usually only recommended for people who continue to have symptoms despite treatment with ACE inhibitors, ARBs, beta blockers and diuretics

Sacubitril valsartan: this combines an ARB with another type of medication, called a neprilysin inhibitor. It's suitable for people with severe heart failure, whose heart is only able to pump a small amount of oxygenated blood around the body

Hydralazine with nitrate: this drug combination works by dilating your arteries, which reduces pressure on the heart muscle. It is sometimes prescribed by cardiologists for people who are unable to take an ACE inhibitor or ARB.

Medical devices

Some patients with heart failure will need to have a small device implanted in their chest to help control their heart's rhythm. These devices include:

• Pacemakers: this device continuously monitors your heart rate and sends electrical pulses to your heart to keep it beating regularly and at the right speed. A pacemaker is implanted under the skin by a cardiologist, usually under local anaesthetic
• Cardiac resynchronisation therapy (CRT) devices: this is a special type of pacemaker which ensures that the left ventricle (the main pumping chamber of the heart) continues to beat in sync, and makes the heart pump more efficiently
• Implantable cardioverter defibrillators (ICDs): these are used for people with an abnormal heart rhythm. ICDs constantly monitor the heart rhythm and if the heart starts beating too fast, the ICD will try to slow it down by giving it a small, controlled electrical shock (defibrillation). As with pacemakers, ICDs are implanted in hospital, usually under local anaesthetic
• CRT-Ds: patients in need of both the cardiac synchronisation of a pacemaker and the defibrillation of an ICD are fitted with a device called a CRT-D.

Medical procedures and surgery

For people with severe heart failure, options include: 

• Heart valve surgery: if the valves of your heart are diseased or damaged, your cardiologist may recommend heart valve surgery. There are 2 types of valve surgery: valve replacement and valve repair. The type of surgery you have will depend on what's wrong with the valve and how serious the problem is. Your cardiology team will discuss the options with you
• Coronary angioplasty: a tiny balloon is used to inflate a narrowed artery, which is then held open by a stent (a small wire tube) to improve blood flow. This procedure can be used to treat the symptoms of coronary heart disease, angina and also as an emergency treatment following a heart attack 
• Coronary Artery Bypass Graft (CABG): an artery from another part of your body (usually the chest, leg or arm), is attached above and below the blocked section of coronary artery, to divert the blood flow (this is known as a graft). The operation is carried out under general anaesthetic (which means you will be asleep throughout the procedure) and lasts for between 3 and 6 hours. You may need more than one graft, depending on how severe your coronary artery disease is
• Left ventricular assist devices (LVADs): these are mechanical pumps that can help if your left ventricle - the chamber of your heart that does most of the pumping - isn't working properly and medication alone isn't helping. They can be used as a temporary measure while you wait for a transplant or a permanent treatment if you can't have a heart transplant