Heart Failure

Heart failure is a clinical picture that occurs as a result of the inability of the heart to send the necessary and sufficient blood to the tissues and organs as a consequence of a decrease in heart performance [1]. It often develops as a result of conditions such as cardiovascular disease, heart attack, high blood pressure (hypertension), and heart valve disease that impair heart performance or increase the workload of the heart. Heart failure is usually detected in its advanced stages. In the so-called congestive heart failure, fluid leakage (edema) occurs in the lungs, feet, legs, and, in some cases, in the liver and abdominal cavity [2]. Heart failure can develop at any age, but the incidence increases with age. In the community, the prevalence is 1% in people under 65 years of age, while the prevalence is 7% in people aged 75–84 and 15% in people over 85 years of age [3].

How Does a Normal Heart Work?

The heart consists of two chambers that contract simultaneously. There are also 2 smaller chambers that direct blood to the heart from these chambers. Thus, the heart consists of four cavities: two spaces on the right and two spaces on the left. The small chambers in the upper part of the heart are called the “atrium,” and the large chambers in the lower part are called the “ventricle.” Basically, the gaps that provide the pump power of the heart are the ventricles, and most of the pump power between the ventricles is carried out by the left ventricle. Each ventricle has a valve at the entrance and exit to prevent blood from escaping back. The walls of the chambers in the heart consist of unique heart muscles. The atria and ventricles work in harmony by contracting simultaneously and sequentially. At the beginning of each heartbeat, an electrical signal extracted from a specialized focus for the contraction of the heart spreads to the entire heart, causing the heart muscle to contract. First, the atriums contract and push blood from their open valves to the ventricle. Then, when the electrical impulse travels towards the ventricular muscle, it causes the ventricles to contract, sending blood out of the heart to the lungs and the entire body. As the ventricles contract, the atria relax to fill with blood, allowing the next beat to begin [4].

Figure 1: The structure of the normal heart

How Does Heart Failure Happen?

Heart failure is caused by the heart’s inability to pump blood to the lungs and the whole body. Insufficiency in pump function can be caused by a decrease in performance in the contraction of the heart muscle or abnormalities in the relaxation of the heart muscle. If there is a decrease in the strength of the heart contraction, it is usually accompanied by an abnormality in the relaxation of the heart muscle. However, heart muscle relaxation abnormalities alone can cause heart failure, especially in the elderly, hypertensive, diabetic, and female cases [5]. Heart failure can occur for many reasons. Cardiovascular disease and previous heart attacks are the causes of heart failure in 2/3 of the cases of heart failure. Hypertension, one of the most common diseases in the community, can cause heart failure by causing thickening of the heart wall and relaxation abnormalities in the heart muscle. Heart valve diseases, heart rhythm disturbances, heart muscle infections, congenital heart diseases, and hereditary heart muscle diseases are among the other causes of heart failure [6].

If the heart has lost part of its contractile strength and cannot contract enough, it is incapable of pumping the amount of blood needed by the organs and tissues. If the heart cannot empty and relax enough, the amount of blood entering the heart decreases, so the amount of blood pumped from the heart is also reduced. Due to the inability to send enough blood to the tissues and organs, complaints such as weakness, fatigue, decrease in effort capacity, and shortness of breath as a result of fluid accumulation in the lungs and body due to the inability of the heart to translate the blood coming to its own occur [7].

Figure 2: Blood flow in normal and abnormal hearts

What are the Changes that Occur in Heart Failure?

In heart failure, on the one hand, the heart tries to provide as much blood as necessary to the tissues and organs, while the tissues and organs try to adapt to the heart failure situation. The condition is the adaptation of the heart and tissues to heart failure. For this adaptation, the heart increases the number of beats per minute to pump more blood (tachycardia). It increases in size to receive and pump a greater volume of blood, and enlargement of the heart cavities occurs. In other words, heart growth occurs (dilatation). To improve its performance and to provide better pump power, the heart walls thicken (hypertrophy). With the activation of many hormonal mechanisms in the body, the amount of circulating blood is increased and directed to vital organs. However, over time, adaptation mechanisms begin to become inadequate, and in the future, these adaptation mechanisms may initiate harmful processes rather than good ones. The condition of heart failure worsens [8].

Figure 3: Shape of the heart in systolic and diastolic states during heart failure.

Symptoms

The symptoms of heart failure can be summarized as follows:

  • Dyspnea
  • Throb
  • Quick Fatigue
  • Foot or Leg Swelling
  • Swelling or Pain in the Abdomen
  • Fast Weight Gain
  • Cough
  • Dizziness, Loss of Attention, Fainting, Dizziness
  • Chest Pain
  • Loss of Appetite/Nausea [9]
Figure 4: Weakened and thickened heart structures that cause heart failure.

Progression of Heart Failure

Heart failure is a chronic disease that gets worse over time. As in the majority of cases, it continues for life. However, in a very small proportion of cases, it follows a clinical course in the form of a temporary picture. The development and progression of heart failure vary from person to person, depending on the cause. In chronic heart failure, the decrease in heart performance progresses gradually over months and years, and the expansion of the heart cavities (heart enlargement) gradually increases. From time to time, deterioration in the clinical picture and the need for hospitalization for treatment arise. Heart failure drugs that are prescribed by a doctor for the treatment of heart failure and should be used for the rest of one’s life to prevent or slow the progression of heart failure over time, worsening the clinical picture, causing expansion of heart cavities and decreasing heart performance, and preventing deaths due to heart failure [10].

Figure 5: The difference between an enlarged heart and a healthy heart.

Diagnosis and Treatment

Early diagnosis and treatment are very important in the treatment of heart failure. Today, with the cooperation of physicians and patients, many heart failure patients can continue their normal daily lives. If you have been diagnosed with heart failure, your doctor will start you on several medications and recommend that you change your lifestyle as required by your disease.

The operation may be recommended and performed in cases that are the cause of heart failure or that worsen the heart failure clinic and will correct heart failure or provide significant benefit when corrected by the operation. Although the operation to be performed does not completely correct heart failure, the benefit of the surgery will only be greater than the possible risks that may occur due to surgery. The most common operations and interventional procedures to correct or reduce heart failure are coronary artery bypass operation, valve repair, and replacement surgery, heart transplantation (heart transplantation), balloon application to blockages and stenosis in the heart vessels, stent application, permanent pacemaker placement to increase heart performance in selected patients. These operations and interventional procedures can be performed largely due to existing medical facilities and developments [11].

References:

  1. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics–2012 update: a report from the American Heart Association. Circulation. 2012;125:e2–e220.
  2. van Riet EE, Hoes AW, Limburg A, et al. Prevalence of unrecognized heart failure in older persons with shortness of breath on exertion. Eur J Heart Fail. 2014;16:772–777.
  3. Cherubini A, Oristrell J, Pla X, et al. The persistent exclusion of older patients from ongoing clinical trials regarding heart failure. Arch Intern Med. 2011;171:550–556.
  4. https://www.chop.edu/pages/how-normal-heart-works
  5. Patterson SW, Piper H, Starling EH. The regulation of the heart beat. J Physiol 1914; 48: 465-573.
  6. https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142#:~:text=Heart%20failure%20occurs%20when%20the,to%20appear%20blue%20(cyanotic).
  7. https://www.nhs.uk/conditions/heart-failure/
  8. Poole-WiisunP. Relationofpathophysiolcgicmechaniis to outcomein
  9. heart f&we. J AmColiCardiol1993;22(supplA):WA.
  10. https://www.nhs.uk/conditions/heart-failure/symptoms/
  11. Hein S, Arnon E, Kostin S, Schonburg M, Elsasser A et al (2003) Progression from compensated hypertrophy to failure in the pressure-overloaded human heart: structural deterioration and compensatory mechanisms. Circulation 107:984–991
  12. SwedbergK.ClelandJ.DargieH.DrexlerH.FollathF.KomajdaM et al. Guidelines for the diagnosis and treatment of chronic heart failureEur Heart J2005 26 1115 1140

Figure References:

  1. https://www.chop.edu/pages/how-normal-heart-works
  2. https://www.heartfoundation.org.nz/your-heart/heart-conditions/heart-failure
  3. https://www.netmeds.com/health-library/post/heart-failure-symptoms-causes-types-and-treatment
  4. https://www.nature.com/articles/nrdp201758
  5. https://www.mayoclinic.org/diseases-conditions/enlarged-heart/symptoms-causes/syc-20355436

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