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Congestive Heart Failure / Cardiac Failure :
Definition, Types, Sign & Symptoms, Diagnosis and Home Treatment of Congestive
Heart Failure
Definition of Congestive Heart Failure Cardiac
failure
Heart failure is a pathophysiological state in which the heart is not able to
pump adequate amounts of blood to meet the demands of the body. When the heart
muscles become weak, it loses the capacity to pump the blood to different parts
of the body or, because of some reason or other, the blood reaching the heart
becomes less in quantity. Because of these two reasons, heart failure results.
Functionally, heart failure can be divided into right or left heart failure,
depending on the side of the chamber which fails initially.
Right-sided heart failure:- The bad blood coming from various parts of the
body reaches the right side of the heart. This part pumps the blood into the
lungs for purification.
When the right side of the heart-for whatever be the reason-becomes weak, it
fails to pump the blood completely into the lungs. And because of back pressure,
the quantity of blood in the right part of the heart increases, and the liver
suffers from extra pressure. The systolic output of the right ventricle and/or
the right atrium falls. Common causes include pulmonary hypertension in mitral
stenosis, atrial septal defect, and cor pulmonale; pericardial diseases,
pulmonary stenosis, right sided cardiomyopathy, massive pulmonary embolism and
tricuspid stenosis. Right heart failure leads to rise in right atrial pressure
(manifested as jugular venous pressure), and systemic venous congestion
(manifested as tender hepatomegaly and dependent edema).
Left-sided heart failure :
Blood purified by receiving oxygen in the lungs reaches the left side of the
heart, and from there to other parts of the body. When the left side becomes
weak, it loses its capacity to pump the purified blood to other parts of the
body. Then the lungs suffer from back pressure and as a result, fluid will be
stored in them.
The fluid thus stored there, obstructs the receiving of oxygen or the
releasing of carbon-dioxide. The patient thus becomes breathless for want of
enough As a result, water and salt enter all the tissues of the body, and
inflammation of the legs and expansion of the liver result. Lower abdomen loses
its strength and looks distended.
It is caused by primary dysfunction of the left ventricle or left atrium.
Common causes are acute myocardial infarction, chronic ischemic heart disease,
systemic hypertention, aortic valvular disease, mitral incompetence, and mitral
stenosis. Left sided heart failure leads to pulmonary congestion and pulmonary
edema (manifested as orthopnea and paroxysmal nocturnal dyspnea). Persistent
left-sided heart failure gives rise to pulmonary hypertension which results in
right-sided heart failure as well.
How serious is Heart Failure?
Heart failure is a serious condition that may not be detected at its earliest
stages. In its later stages it can have a major effect on quality of life and
feeling of wellbeing. In advanced stages, patients may become inactive or bed
ridden and unable to perform normal functions and it can be life-threatening.
Heart failure is a major cause of sudden death due to production of arrhythmias.
Persons with diabetes have a much greater risk of developing heart failure than
those without because diabetes is associated with other heart failure risk
factors such as high blood pressure, obesity and high cholesterol levels.
Symptoms of Heart Failure / Cardiac Failure
Commonest symptom is dyspnea, which is more marked in left-sided heart
disease. Orthopnea, paroxysmal nocturnal dyspnea and Cheyne-Stokes respiration
are seen in left-sided heart failure.Weakness, fatigue, and apathy are
suggestive of low cardiac output states. Oliguria and nocturia may develop even
before dependent edema manifests. Nocturia occurs in the early stages of heart
failure. During daytime when the patient is ambulant cardiac function is
impaired and fluid accumulates. At night, with recumbency edema fluid is
reabsorbed into the circulation, cardiac function improves with rest, and the
excess fluid is eliminated.
Edema is the most prominent symptom in right-sided heart failure. Initially
the edema is dependent, later it becomes generalized. In the early stages the
edema readily pits on pressure but in long standing cases the part becomes
indurated and pigmented. Hepatic congestion manifests with upper abdominal pain
and tender hepatomegaly, In longstanding congestive heart failure, weight loss
and emaciation develop as a result of inadequate intake of food and wasting of
tissues. This picture is termed "cardiac cachexia ". Alterations in the
cytokine system, especially increase in levels of tumor necrosis factor,
interferon gamma and interleukin III also playa part in the production of
cardiac cachexia.
Diagnosis of Heart Failure:-
- Pulse and blood pressure: The pulse becomes rapid as a result of
compensatory adrenergic activity. Pulsus altemans is suggestive of
left ventricular failure. The blood pressure is not generally affected in mild
and moderately severe cases. But in severe heart failure the systolic pressure
may fall due to reduction in cardiac output. The diastolic pressure is
maintained by increase in the peripheral resistance.
- Engorgement of the Jugular vein: This is seen characteristically
in right-sided and combined heart failure. Abnormality of the hepatojugular
reflux can be demonstrated even before the jugular venous pressure is
elevated.
- Examination of the precordium: In the majority of cases the heart is
dilated, though in many cases (e.g., mitral stenosis, acute myocardial
infarction, myocarditis, and constrictive pericarditis) it may not be so.
Evidence of the underlying heart disease may be found. In left ventricular
failure a protodiastolic gallop (S3) may be heard over the apex beat, and it
is better heard during expiration. In right ventricular failure S3 gallop is
heard over the lower left sternal border and it is better heard during
inspiration. Rise in pulmonary arterial pressure gives rise to accentuation of
the pulmonary second sound. Dilatation of the ventricle gives rise to valvular
incompetence. Functional pansystolic murmurs arising from the mitral or
tricuspid valves may be audible, which disappear when the heart size returns
to normal.
- Abdomen: The liver is enlarged, soft and tender and this may be evident
even before overt edema manifests. Hepatic enlargement persists for varying
periods after edema clears up with treatment, but with intensive therapy it
recedes completely. Mild jaundice and impairment of hepatic function may
occur. In longstanding right-sided heart failure with cardiac cirrhosis, the liver is firm and nontender. It does not recede with treatment at
this stage. Mild to moderate splenomegaly occurs in some cases initially due
to passive venous congestion, later the organ may become fibrotic. Significant
splenomegaly should suggest the possibility of infective endocarditis. Ascites
may develop as a result of passive venous congestion. Prominent ascites occurs
in organic tricuspid valve disease, constrictive pericarditis, and right.
ventricular endomyocardial fibrosis.
- Lungs: Pulmonary abnormalities are more pronounced in left-sided heart
failure. These are the presence of rales over the infrascapular regions,
bronchospasm, unior bilateral hydrothorax, frequent respiratory infections
(pneumonia, bronchopneumonia or bronchitis) and pulmonary infarcts.
- Urine: The volume is small and urine is concentrated. Proteinuria may
occur as a result of renal congestion even in the absence of renal disease.
- Blood: The erythrocyte sedimentation rate is generally lowered.
- Radiology:- Left-sided heart failure gives rise to abnormalities in the
chest radiograph. These include dilatation of the upper lobe veins, dilatation
of the main pulmonary artery and its branches, interstitial edema and pleural
effusion. Acute pulmonary edema gives a characteristic butterfly-shaped
opacity extending on both sides.
The electrocardiogram may reveal the underlying cardiac abnormality. Though
ECG is not directly diagnostic of cardiac failure, which is predominantly a
mechanical event, many findings such as ischemia, ventricular hypertrophy,
conduction defects and arrhythmias give indirect clues to the underlying
structural and electrical abnormalities.
The systolic and diastolic dysfunction can be well brought out by
echocardiography. In addition to anatomical abnormalities, complications
secondary to cardiac failure such as intracardiac thrombi can be identified.
Causes of Congestive Heart Failure
Coronary artery disease :-When cholesterol and fatty deposits build up in the
heart's arteries, less blood reaches the heart muscle. This damages the muscle,
and the healthy heart tissue that remains has to work harder.
Past heart attacks (myocardial infarction) :-A heart attack occurs when an
artery that supplies blood to the heart gets blocked. The loss of oxygen and
nutrients damages the heart's muscle tissue - part of it essentially "dies." The
remaining healthy tissue has to pump even harder to keep up.
High blood pressure (hypertension) :-Uncontrolled high blood pressure increases
a person's risk of developing heart failure by two to three times. When pressure
in the blood vessels is too high, the heart has to pump harder than normal to
keep the blood circulating. This takes a toll on the heart, and over time the
chambers get larger and weaker.
Abnormal heart valves :-Heart valve problems can result from disease, infection
( endocarditis ) or a defect present at birth. When the valves don't open or
close completely during each heartbeat, the heart muscle has to pump harder to
keep the blood moving. If the workload becomes too great, heart failure results.
Heart muscle disease ( cardiomyopathy ) or inflammation (myocarditis) :-Any damage to the heart
muscle - whether because of drug or alcohol use, viral infections or unknown
reasons - increases the risk of heart failure.
Heart defects present at birth (congenital heart disease) :-If the heart and its
chambers don't form correctly, the healthy parts have to work harder to make up
for it.
Severe lung disease :-When the lungs don't work properly, the heart has to work
harder to get available oxygen to the rest of the body.
Diabetes :-Diabetes puts extra strain on the heart, increasing risk for heart
failure. People with diabetes also tend to be overweight and have high blood
pressure and high cholesterol - all of which make the heart work harder |
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