Heart Failure Facts & Information
Many people with heart failure lead normal, active lives. They do so because they have learned to take good care of themselves by better understanding heart failure.
Heart failure is a progressive condition in which the heart’s muscle gets injured from something like a heart attack or high blood pressure and gradually loses its ability to pump enough blood to supply the body’s needs. The heart can be affected in two ways, either become weak and unable to pump blood (we call this situation systolic heart failure) or it become stiff and unable to fill with blood adequately (we call this situation diastolic heart failure). Ultimately, both conditions lead to retention of extra fluid or congestion. So when patients develop symptoms we call it congestive heart failure. Many people don’t even know they have it because symptoms are often mistaken for signs of getting older. Heart failure does not develop overnight – it’s a progressive disease that starts slowly and gets worse over time.
Heart failure is very common. Although we have made progress in the treatment of many forms of heart disease, heart failure is a growing problem in the United States. Current estimates are that nearly 6.5 million Americans over the age of 20 have heart failure. One major study estimates there are 960,000 new heart failure cases annually. Not only is heart failure a major problem affecting many people, heart failure is also a major killer. Heart failure directly accounts for about 8.5% of all heart disease deaths in the United States. And, by some estimates heart failure actually contributes to about 36% of all cardiovascular disease deaths. One study notes that heart failure is mentioned in one in eight death certificates. Hospitalizations for heart failure are a huge burden on our healthcare system. In fact, it remains the number one cause of hospitalizations in our Medicare population.
Although heart failure may strike at any age, it is more common in people as they get older, making age an important risk factor. The risk of heart failure increases dramatically after the age of 65.
Other risk factors include the following :
- High blood pressure (hypertension)
- Fat deposits creating blockages in the heart’s arteries (coronary artery disease)
- Heart attack (myocardial infarction)
- Damage to the heart valves or history of a heart murmur (valvular heart disease)
- Heart muscle disease and enlargement of the heart (cardiomyopathy)
- Heart defects at birth (congenital heart disease)
- Family history of enlarged heart (Familial cardiomyopathy)
- Sleep apnea (Cor pulmonale)
- Severe lung disease (Cor pulmonale)
The symptoms of heart failure may be subtle and are often mistaken for normal signs of aging. Common symptoms of heart failure are due to extra fluid or congestion. Typically starting with congestion of the lungs, then congestion of different parts of the body. At advance stages, the cardiac output decreases. These three stages of symptoms can come sequentially or together.
Breathing Difficulties (congestion of the lung and left side of the heart)
- Shortness of breath from walking stairs or simple activities (dyspnea)
- Trouble breathing when resting or lying down
- Waking up breathless at night (paroxysmal nocturnal dyspnea)
- Needing more than two pillows to sleep (orthopnea)
- Tiring Easily (Exercise Intolerance)
- Frequent coughing
- Coughing that produces a mucus or pink, blood-tinged sputum
- Dry, hacking cough when lying flat in bed
Congestion of the right heart (and congestion of the other part of the body)
- Swelling of feet, ankles or legs (edema)
- Increased need to urinate at night
- Swelling of the abdomen (ascites)
- Lack of appetite and nausea
Low cardiac output
- Cold legs and arms
- Difficulty concentrating
Heart failure is diagnosed by a constellation of symptoms and signs of fluid overload due to either a weak heart (heart failure with reduced ejection fraction) or a strong heart with poor heart relaxation (heart failure with preserved ejection fraction). Symptoms include shortness of breath, dry cough often worse at night, poor appetite +/- nausea, and fatigue. Signs include leg swelling and increase abdominal girth. Medical providers often order an echocardiogram, or “echo” to determine the strength of the heart. An echocardiogram is an ultrasound of the heart that measures the ejection fraction (EF), wall thickness, and the flow of blood through valves in your heart. People with a healthy heart have an EF of about 60%, while people with heart failure have either a reduced ejection fraction with EF < 40% (HFrEF) or a preserved ejection fraction with EF >50% (HFpEF). Medical therapy including pills and devices are dependent on your stage of heart failure and your functional state. With careful supervision, medical therapy, exercise, and compliancy with diet and fluid restriction, many patients with heart failure can enjoy their everyday activities and have a more normal life expectancy.
Life expectancy for a patient depends on many factors and there is no one answer for an individual patient. When you look at large groups of patients with heart failure, overall, 50% of patients will have an average life expectancy of 5 years. Patients that have less severe heart failure, are well treated with medications, have good renal function, normal blood sugar, and live a healthy life-style, can have much better life expectancy than the average heart failure patient. Patients with more severe or advanced heart failure and non-cardiac conditions such as poorly controlled diabetes mellitus and poor kidney function have a much lower life expectancy. For patients with severe or advanced heart failure only around 10 to 20% of patients will be alive after one year.
Early detection and treatment of heart failure allow you to continue living an active lifestyle for a longer period of time, while reducing the risk for hospitalization. Your initial treatment regimen will vary depending on the type of heart failure and the severity of your condition. Treatment regimens generally include a combination of medications, lifestyle changes (smoking cessation, diet, exercise), and surgical procedures that allow your heart to continue meeting the demands of your body. You may even be eligible for a heart transplant at some point depending on the severity of your condition and a variety of other factors.
To best optimize your care, a medical provider will use a multi-disciplinary approach. This will consist of physicians, nurse practitioners/physician assistants, pharmacists, nursing staff, and dietitians working collaboratively to modify treatments in order to best suit your changing needs. Above all, you are the most important part of the treatment puzzle. Through focused education, the team will teach you to look for certain signs and symptoms that may be signals to adjust or change treatment. As we continue to make strides in our understanding of heart failure, new medications and procedures will continue to become available that offer improvement in survival and quality of life.
Common Medications: Your doctor will place you on a combination of the medications below. These medications work together to help your heart regain strength over time, while also controlling some of the more bothersome symptoms of heart failure.
|Medication Class||Medications||Why It is Useful|
|ACE-Inhibitors (ACE-I) or Angiotensin Receptor Blockers (ARB)||
ACE-I: Captopril, Enalapril, Lisinopril, Ramipril
ARB: Losartan, Valsartan, Olmesartan, Candesartan
|Lowers blood pressure and reduces the workload of the heart so that it can regain strength|
|ARB + Neprilysin Inhibitor||Sacubitril-Valsartan||Lowers blood pressure and reduces the workload of the heart so that it can regain strength; may be used instead of an ACE or ARB|
|Beta-Blockers||Carvedilol, Metoprolol Succinate||Slows your heart rate and allows your heart to more efficiently pump blood. Also helps your heart regain strength.|
|Mineralocorticoid Antagonists||Eplerenone, Spironolactone||Removes excessive fluid and prevents loss of potassium.|
|Nitrates||Isosorbide + Hydralazine||Lowers blood pressure and reduces the workload of the heart so that it can regain strength; may be particularly useful in African American patients|
|Cardiac Glycosides||Digoxin||Helps the heart beat stronger and pump blood more efficiently|
|Diuretics||Bumetanide, Furosemide, Torsemide||Remove extra fluid that accumulates in your lungs and legs causing discomfort|
|Procedure||Why It is Useful|
|Defibrillator (ICD) Placement||Heart failure can increase your risk of developing harmful heart rhythms, which may lead to cardiac arrest. An ICD will provide an electrical shock to prevent this from occurring.|
|Cardiac Resynchronization Therapy (CRT)||If the left and right side of your heart are not beating simultaneously, a pacemaker device may be implanted to synchronize the two sides; this can lead to improvements in your heart failure over time and reduce symptoms.|
|Left Ventricular Assist Device (LVAD)||For those with end-stage heart failure, mechanical support with an LVAD may be necessary to prevent the heart from completely failing. The device will help the left side of the heart continue to pump blood throughout the circulation. These devices are portable and patients are able to lead normal lives post-implantation following recovery.|
|Heart Transplant||For eligible patients with end-stage heart failure who have failed medical therapy (medications, LVAD, etc), a heart transplant may be an option. A healthy heart from a deceased donor is transplanted into the recipient. This requires the recipient to be on lifelong immune suppressing medications.|
While heart failure is a life-altering disease, with appropriate management and lifestyle changes, individuals are able to maintain a consistent quality of life for a longer period of time. Understanding your condition and remaining educated will be crucial to success. By incorporating the steps below and making sure you have a clear understanding of each, you can stay one step ahead of the disease.
Education: Knowledge is power! It is essential that both you and your family understand what heart failure is, what the symptoms are, what you should do if your symptoms change and how your doctor treats the disease.
Medication Adherence: Taking your prescribed medications as directed is crucial to the health of your heart. While the doses of your medications will be fine-tuned over time, never stop taking a medication before consulting with your medical team. If you have concerns about side effects or the way a medication is making you feel, reach out to the team right away.
Dietary Choices: Watching your salt consumption and fluid intake (water, soda, juice, etc.) is necessary to prevent your heart from having to worker harder than it needs to. Talk with your dietitian to ensure you understand what foods will work best for you and your heart.
Exercise: In addition to medicine and diet, exercise will help your heart and keep you physically strong. Make sure to talk with your doctor before beginning an exercise program, as they may want you to gradually build towards certain goals.
Daily Weight: You should also be weighing yourself on a daily basis. Large changes in weight may be a signal that your medications or diet needs an adjustment.
In order to determine the best course of therapy, physicians often assess the stage of heart failure (HF) as well as their functional status .The American College of Cardiology/American Heart Association classification of heart failure has four stages.
STAGES OF HEART FAILURE (HF)
|A||High risk for HF but without structural heart disease or symptoms of HF|
|B||Structural heart disease but without signs or symptoms of HF|
|C||Structural heart disease with prior or current symptoms of HF|
|D||Refractory HF requiring specialized interventions|
The patients functional status is also assessed according to the New York Heart Association (NYHA) functional classification system. This system relates symptoms to everyday activities and the patient’s quality of life.
NYHA CLASSIFICATION FOR HEART FAILURE (HF)
|NYHA Class||Patient Symptoms|
|Class I (Mild)||No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).|
|Class II (Mild)||Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.|
|Class III (Moderate)||Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.|
|Class IV (Severe)||Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.|
The prevalence of heart failure is expected to increase from 6.5 million Americans to >8 million by 2030. This is attributed to many factors including a growing elderly population, an increase in prevalence of risk factors like hypertension, improved survival after myocardial infarction, and improved survival with heart failure. With a growing number of heart failure patients, total cost of care for those in the United States is expected to rise from $30.7 billion in 2012 to 69.7 billion in 2030.(2) The good news is that we now know a great deal more about heart failure and the importance of early diagnosis and treatment. Studies have shown that heart failure patients treated with American Heart Association/American College of Cardiology guideline-recommended therapies are more likely to survive over the next two years. Every 10 percent improvement in the use of guideline-recommended therapies has been associated with a 13 percent lower risk of death among heart failure patients over the next two years. The science continues to evolve with development of new drugs, as well as advances in mechanical support devices for heart failure. As more and more people become aware of heart failure and are better able to recognize its symptoms, they will hopefully go see their physicians who can prescribe medications that not only help them feel better, but also significantly slow the progression of the disease and help them live longer. Ultimately, this is good news for patients who, with proper treatment, can lead a more normal and fulfilling life.
- Yancy CW, Jessup M, Bozkurt B et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013;128:e240-327.
- Benjamin EJ, Blaha MJ, Chiuve SE et al. Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association. Circulation 2017;135:e146-e603.
- National Center for Health Statistics. Available at http://www.cdc.gov/nchs/data_access/Vitalstatsonline. Last accessed September 12, 2017.
- Causes of Heart Failure. Available at: http://www.heart.org/HEARTORG/Conditions/HeartFailure/CausesAndRisksForHeartFailure/Causes-of-Heart-Failure_UCM_477643_Article.jsp#.WbWtIE3ru5s Last accessed on September 11, 2017.
- Warning Signs of Heart Failure. Available at http://www.heart.org/HEARTORG/Conditions/HeartFailure/WarningSignsforHeartFailure/Warning-Signs-of-Heart-Failure_UCM_002045_Article.jsp#.WbfrA02otHk Last accessed on September 12, 2017.
- How is Heart Failure Treated? Available at https://www.nhlbi.nih.gov/health/health-topics/topics/hf/treatment Last accessed on 9/7/17.
- Heart Failure Classes. Available at http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes-of-Heart-Failure_UCM_306328_Article.jsp#.WbL0RU2ovyN last assessed on 9/7/17.
- Heart Failure Fact Sheet. Available at https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm Last accessed on 9/7/17.
- Fonarow GC, Albert NM, Curtis AB et al. Associations between outpatient heart failure process-of-care measures and mortality. Circulation 2011;123:1601-10.