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Heart failure basics

What is heart failure?

  • Affecting at least 15 million adults in Europe,1 heart failure occurs when the heart is unable to pump enough blood to meet body’s needs for oxygen and important nutrients.2 This means that the body is unable to function normally, often causing great suffering and disability.
  • Heart failure can happen either when the heart muscles are too weak or too stiff to function properly.3
  • The causes of damage to the heart muscles are many and varied (see What causes heart failure?’ below). Regardless of the cause, all patients with heart failure will need medical attention and ongoing treatment.
  • Heart failure is a chronic condition with acute episodes, interrupting a plateau phase where the heart function remains stable (see Figure 1 below) That is to say, that once heart failure has occurred, it is an irreversible condition that may lead to sudden episodes of worsened symptoms that may require admission to hospital.
  • Each acute episode can worsen the chronic condition further, reducing the ability of the heart to function resulting in increased disability and risk of death.4

hf-basics-graph

Figure 1. Progression of acute heart failure. A shows a good recovery after the first acute episode followed by a stable period. B shows that the first episode is not survived. C shows poor recovery followed by deterioration. D shows ongoing deterioration with intermittent acute episodes and an unpredictable death point. Graph from Cowie et al, 2014.8

What causes heart failure?

Heart failure can occur very suddenly or it can develop slowly over many years, and there are many different reasons why someone might be diagnosed with heart failure.

Heart failure is not an illness in itself, but is the end product of a number of illnesses which damage the heart and interfere with its normal functioning. Some of the most common causes of heart failure are illustrated in Figure 2.

Heart failure can also present with multiple co-morbidities such as anaemia and kidney disease. These co-morbidities make the management of heart failure more complex for patients and heath care professionals.

In addition to the causes shown in Figure 2, heart failure may also be caused by other factors – for example, by a virus that attacks the heart or as a result of heart problems that arise during pregnancy (peripartum cardiomyopathy). These underlying causes of heart failure are not preventable and can occur in people of any age.

hf-basics-circles

Figure 2. Common causes of heart failure. Adapted from Cowie et al. 2014.9

 

What are the types of heart failure?

There are two main types of heart failure10:

  • Heart failure with reduced ejection fraction which happens when the left ventricle is enlarged and the muscle does not contract effectively. This means that a smaller proportion of the blood is ejected in each heart contraction. This type of heart failure is shortened to HFrEF and can also be known as systolic heart failure.
  • Heart failure with preserved ejection fraction is caused by enlargement of the left ventricle wall. This reduces the size of the ventricle, meaning that the volume of the blood ejected may be lower than normal, but the proportion of blood ejected is the same. This type is shortened to HFpEF and is also known as diastolic heart failure.

 

hf-basics-hearts

Figure 3. Diagrams of the heart showing normal functioning, systolic, and diastolic heart failure. (a) represents the normal functioning heart where approximately 50% of the blood is ejected as the chambers contract. (b) shows HFrEF or Systolic heart failure where the issue regards blood pumping. Enlarged ventricles mean that the contractility is reduced, and so a smaller proportion of the blood is ejected. (c) shows HFpEF or Diastolic heart failure where the issue refers to filling of the heart chambers. The thickened ventricle wall reduces the overall volume of blood in the ventricle, meaning the proportion of blood ejected is normal or close to normal and that pressure inside the heart may be increased. Diagram from Cowie et al, 2014.11

 

What are the symptoms of heart failure?

The three ‘red flag’ symptoms of heart failure are fatigue, breathlessness and swelling of the limbs (usually ankles).12 These symptoms are often hard for patients to identify and they may not recognize the need to see a health practitioner quickly. Some patients (and doctors) may dismiss symptoms as the natural consequence of ageing.13

 

How is heart failure diagnosed?

Diagnosis of HF is difficult for health professionals as the symptoms are not specific to heart failure.

The non-specific symptoms in conjunction with low awareness of heart failure in the public and health care professionals means diagnosis is often delayed.14

There is no one diagnostic test for heart failure. Many tests may be used to investigate and diagnose heart failure, including15:

  • Blood tests – these can show if heart failure or another condition such as anaemia, diabetes or liver disease is causing the symptoms. The most commonly used tests measure the presence of natriuretic peptides in the blood – namely the B-type natriuretic peptide (BNP) and N-terminal pro B-type natriuretic peptide (NT-pro-BNP). These hormones are released when the heart is diseased or under stress.
  • Breathing tests – to rule out lung problems creating the breathlessness.
  • Chest x-rays – to see if the heart muscle is enlarged or for any abnormalities in the lungs.
  • Electrocardiogram – looks at the electrical activity of the heart for abnormal rhythms caused by thickened or enlarged heart muscle.
  • Echocardiogram – visualises the heart to show any abnormalities in ventricle volumes, valves and wall thickness. It is also used to see how well the ventricle is pumping blood around the body by looking at the ejection fraction. Echocardiograms are the method of choice when investigating heart failure for reasons of accuracy, availability, safety and cost.

 

How is heart failure treated?

Treatment for heart failure is critical to improve survival and quality of life, relieve symptoms, prevent future hospital admissions for patients. Additionally, it is vital to treat any co-morbidity or underlying cardiac problems alongside the treatment for heart failure.

Treatments for heart failure are evolving all the time. For up-to-date recommendations from leading European clinical experts, see the European Society of Cardiology (ESC) guidelines.16

 

Can heart failure be prevented?

Some of the illnesses that cause heart failure can be prevented, and measures to prevent all these causes may help prevent development of heart failure. These include:17

  • high blood pressure
  • coronary heart disease
  • diabetes
  • heart valve disease
  • heart muscle disease (e.g. alcohol-related)

However, some heart diseases that cause heart failure cannot be prevented – for example, heart failure may be caused by a virus that attacks the heart or as a result of heart problems that arise during pregnancy (peripartum cardiomyopathy). In these cases, heart failure cannot be prevented, however appropriate treatment and management remain critical to help improve outcomes for patients.

 

Why is self-management important for people with heart failure?

It is likely that patients will have to follow a treatment plan with medication for the rest of their lives. And so when living with heart failure, self-management is very important. There are many ways in which patients with heart failure can help keep their condition under control18:

  • Limiting salt and alcohol intake
  • Quitting smoking
  • Monitoring body weight and tracking fluid intake19
  • Regular physical exercise at appropriate levels
  • Taking medication as prescribed
  • Monitoring any symptom changes

Along with these self-management techniques, there will also normally be medicine to strengthen the heart.

 

  • 1. Dickstein K, Cohen‐Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008‡. European journal of heart failure 2008;10(10):933-89

  • 2. Stewart S, Ekman I, Ekman T, Oden A, Rosengren A. Population Impact of Heart Failure and the Most Common Forms of Cancer A Study of 1 162 309 Hospital Cases in Sweden (1988 to 2004). Circ Cardiovasc Qual Outcomes 2010; 3:573-580.

    3. Ponikowski P, et al. European Society of Cardiology WHFA. Heart Failure. Preventing disease and death worldwide. 2014. http://www.escardio.org/communities/HFA/Documents/WHFA-whitepaper-15-May-14.pdf?hot=highlighton

  • 2. Stewart S, Ekman I, Ekman T, Oden A, Rosengren A. Population Impact of Heart Failure and the Most Common Forms of Cancer A Study of 1 162 309 Hospital Cases in Sweden (1988 to 2004). Circ Cardiovasc Qual Outcomes 2010; 3:573-580.

  • 3. Ponikowski P, et al. European Society of Cardiology WHFA. Heart Failure. Preventing disease and death worldwide. 2014. http://www.escardio.org/communities/HFA/Documents/WHFA-whitepaper-15-May-14.pdf?hot=highlighton

  • 4. Cowie M, et al., Heart Failure Association of the ESC. Improving care for patients with acute heart failure. Before, during and after hospitalisation. 2014. http://www.oxfordhealthpolicyforum.org/reports/acute-heart-failure/improving-care-for-patients-with-acute-heart-failure

  • 5. Bui A, et al. Epidemiology and risk profile of heart failure. Nat Rev Cardiol 2011; 8:30-41.

  • 6. Remme WJ, McMurray JJ, Rauch B, et al. Public awareness of heart failure in Europe: first results from SHAPE. European heart journal 2005;26(22):2413-21.

  • 7. American Heart Association. "Common tests for Heart Failure". 2015. Retrieved 17 September, 2015. http://www.heart.org/HEARTORG/Conditions/HeartFailure/SymptomsDiagnosisofHeartFailure/Common-Tests-for-Heart-Failure_UCM_306334_Article.jsp

  • 8. Murray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European journal of heart failure 2012;14(8):803-69.

  • 9. Heart Failure Society of America. "Living with Heart Failure”. 2015. Retrieved 17 September, 2015. http://www.hfsa.org/hfsa-wp/wp/living-with-heart-failure/

  • 3. Ponikowski P, et al. European Society of Cardiology WHFA. Heart Failure. Preventing disease and death worldwide. 2014. http://www.escardio.org/communities/HFA/Documents/WHFA-whitepaper-15-May-14.pdf?hot=highlighton

    4. Cowie M, et al., Heart Failure Association of the ESC. Improving care for patients with acute heart failure. Before, during and after hospitalisation. 2014. http://www.oxfordhealthpolicyforum.org/reports/acute-heart-failure/improving-care-for-patients-with-acute-heart-failure

  • 7. American Heart Association. "Common tests for Heart Failure". 2015. Retrieved 17 September, 2015. http://www.heart.org/HEARTORG/Conditions/HeartFailure/SymptomsDiagnosisofHeartFailure/Common-Tests-for-Heart-Failure_UCM_306334_Article.jsp

    8. Murray JJ, Adamopoulos S, Anker SD, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. European journal of heart failure 2012;14(8):803-69.