ABSTRACT

Heart failure (HF) has been singled out as an epidemic and is a staggering clinical and
public health problem, associated with significant mortality, morbidity, and healthcare
expenditures, particularly among those aged 65 and older. The case mix of HF is
changing over time with a growing proportion of cases presenting with preserved
ejection fraction for which there is no specific treatment. Despite progress in reducing
HF-related mortality, hospitalizations for HF remain very frequent and rates of
readmissions continuing to rise. To prevent hospitalizations, a comprehensive
characterization of predictors of readmission in patients with HF is imperative and must
integrate the impact of multimorbidity related to coexisting conditions. New models of
patient-centered care that draw upon community-based resources to support HF
patients with complex coexisting conditions are needed to decrease hospitalizations.

INTRODUCTION
The term "heart failure" makes it sound like the heart is no longer working at all and
there's nothing that can be done. Actually, heart failure means that the heart isn't
pumping as well as it should be. Congestive heart failure is a type of heart failure which
requires seeking timely medical attention, although sometimes the two terms are used
interchangeably.

Your body depends on the heart's pumping action to deliver oxygen- and nutrient-rich
blood to the body's cells. When the cells are nourished properly, the body can function
normally.

With heart failure, the weakened heart can't supply the cells with enough blood. This
results in fatigue and shortness of breath and some people have coughing. Everyday
activities such as walking, climbing stairs or carrying groceries can become very difficult

DEFINITION AND CLASIFICATION

A complex clinical syndrome that is frequently, but not exclusively, characterised by an
underlying structural abnormality or cardiac dysfunction that impairs the ability of the
left ventricle (LV) to fill with or eject blood, particularly during physical activity.
Symptoms of CHF (e.g. dyspnoea and fatigue) can occur at rest or during physical
activity
As HF is a syndrome and not a disease, its diagnosis relies on a clinical examination and
can be challenging.

TYPES OF HEART FAILURE

Left-sided heart failure

The heart's pumping action moves oxygen-rich blood as it travels from the lungs to the
left atrium, then on to the left ventricle, which pumps it to the rest of the body. The
left ventricle supplies most of the heart's pumping power, so it's larger than the other
chambers and essential for normal function. In left-sided or left ventricular (LV) heart
failure, the left side of the heart must work harder to pump the same amount of blood.

There are two types of left-sided heart failure. Drug treatments are different for the
two types.

Systolic failure: The left ventricle loses its ability to contract normally. The
heart can't pump with enough force to push enough blood into circulation.

Diastolic failure (also called diastolic dysfunction): The left ventricle loses its
ability to relax normally (because the muscle has become stiff). The heart can't
properly fill with blood during the resting period between each beat.

Right-sided heart failure

The heart's pumping action moves "used" blood that returns to the heart through
the veins through the right atrium into the right ventricle. The right ventricle
then pumps the blood back out of the heart into the lungs to be replenished with
oxygen.

Right-sided or right ventricular (RV) heart failure usually occurs as a result of

left-sided failure. When the left ventricle fails, increased fluid pressure is, in
effect, transferred back through the lungs, ultimately damaging the heart's right
side. When the right side loses pumping power, blood backs up in the body's
veins. This usually causes swelling or congestion in the legs, ankles and swelling
within the abdomen such as the GI tract and liver (causing ascites).

Congestive heart failure

Congestive heart failure (CHF) is a type of heart failure which requires seeking
timely medical attention, although sometimes the two terms are used
interchangeably.
As blood flow out of the heart slows, blood returning to the heart through the
veins backs up, causing congestion in the body's tissues. Often swelling (edema)
results. Most often there's swelling in the legs and ankles, but it can happen in
other parts of the body, too.
 Sometimes fluid collects in the lungs and interferes with breathing, causing
shortness of breath, especially when a person is lying down. This is called
pulmonary edema and if left untreated can cause respiratory distress.
Heart failure also affects the kidneys' ability to dispose of sodium and water. This
retained water also increases swelling in the body's tissues (edema).

EPIDEMIOLOGY
Heart failure (HF) is a major public health problem, with a prevalence of over 5.8
million in the USA, and over 23 million worldwide. In 1997, HF was singled out as an
emerging epidemic1. An epidemic can reflect increased incidence, increased survival
leading to increased prevalence or both factors combined. Delineating the respective
responsibility of each of these factors is essential to understand the determinants of the
HF epidemic.

Progress in the primary prevention of HF would lead to decreasing incidence of the

disease while improvement in medical care would result in improved survival, in turn
increasing the prevalence of HF. Both incidence and survival in turn play a major role in
the genesis of the burden of hospitalization among patients living with HF.

SIGNS AND SYMPTOMS

People with Heart Why It Happens

Failure May
Experience...

Shortness of breath ...breathlessness during activity (most commonly), at
(also called rest, or while sleeping, which may come on suddenly
dyspnea) and wake you up. You often have difficulty breathing
while lying flat and may need to prop up the upper
body and head on two pillows. You often complain of
waking up tired or feeling anxious and restless.
Blood "backs up" in the pulmonary veins
(the vessels that return blood from the
lungs to the heart) because the heart
can't keep up with the supply. This
causes fluid to leak into the lungs.

Persistent coughing ...coughing that produces white or pink blood-tinged Fluid builds up in the lungs (see above).
or wheezing mucus.

Buildup of excess ...swelling in the feet, ankles, legs or abdomen or As blood flow out of the heart slows,
fluid in body weight gain. You may find that your shoes feel tight. blood returning to the heart through the
tissues (edema) veins backs up, causing fluid to build up
in the tissues. The kidneys are less able
to dispose of sodium and water, also
causing fluid retention in the tissues.
Tiredness, fatigue ...a tired feeling all the time and difficulty with
everyday activities, such as shopping, climbing stairs,
carrying groceries or walking.
The heart can't pump enough blood to
meet the needs of body tissues. The
body diverts blood away from less vital
organs, particularly muscles in the
limbs, and sends it to the heart and
brain.

Lack of appetite, ...a feeling of being full or sick to your stomach. The digestive system receives less
nausea blood, causing problems with digestion.

Confusion, ...memory loss and feelings of disorientation. A Changing levels of certain substances in
impaired thinking caregiver or relative may notice this first. the blood, such as sodium, can cause
confusion.

Increased heart ...heart palpitations, which feel like your heart is To "make up for" the loss in pumping
rate racing or throbbing. capacity, the heart beats faster.

DIAGNOSIS
Symptoms that are relatively specific to CHF (e.g. orthopnoea, paroxysmal nocturnal
dyspnoea or ankle oedema) occur in more advanced disease and do not help early
diagnosis.

Exertional dyspnoea is usually present and may be slowly progressive. A dry, irritating
cough (especially at night), dizziness or palpitations can also suggest CHF.

Examination should include assessment of vital signs, cardiac auscultation (murmurs, S3

gallop) and checking for signs of fluid retention (e.g. raised jugular venous pressure,
peripheral oedema, basal inspiratory crepitations).

Physical examination is often normal, and clinical diagnosis of CHF can be unreliable,
especially in older people and people who are obese or have concomitant pulmonary
disease. Clinical assessment cant rule out a diagnosis of CHF. People with a low LV
ejection fraction (LVEF) may be asymptomatic. Absence of clinical signs of fluid overload
(e.g. clear lung fields) or a normal chest X-ray do not rule out the possibility of CHF.

CLASIFICATION OF HEART FAILURE

Doctors usually classify patients' heart failure according to the severity of their
symptoms. The table below describes the most commonly used classification system, the
New York Heart Association (NYHA) Functional Classification . It places patients in one of
four categories based on how much they are limited during physical activity.
Clas Patient Symptoms
s

I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation,
dyspnea (shortness of breath).

II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue,
palpitation, dyspnea (shortness of breath).

III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue,
palpitation, or dyspnea.

IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any
physical activity is undertaken, discomfort increases.

Clas Objective Assessment

s
A No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical
activity.
B Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during
ordinary activity. Comfortable at rest.
C Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to
symptoms, even during less-than-ordinary activity. Comfortable only at rest.
D Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even
while at rest.
 TREATMENT
The goals of treatment for all stages of heart failure include:

Treating the conditions underlying cause, such as coronary heart disease, high
blood pressure, or diabetes
Reducing symptoms
Stopping the heart failure from getting worse
Increasing your lifespan and improving your quality of life

Treatment plan may include:

Lifestyle changes
Medications
Devices and Surgical Procedures
Ongoing Care

o Physical Changes to Report

o Your Healthcare Team

o For Caregivers

Medicines

ACE inhibitors lower blood pressure and reduce strain on your heart. They also
may reduce the risk of a future heart attack.

Aldosterone antagonists trigger the body to remove excess sodium through

urine. This lowers the volume of blood that the heart must pump.

Angiotensin receptor blockers relax your blood vessels and lower blood pressure
to decrease your hearts workload.

Beta blockers slow your heart rate and lower your blood pressure to decrease
your hearts workload.

Digoxin makes the heart beat stronger and pump more blood.

Diuretics (fluid pills) help reduce fluid buildup in your lungs and swelling in your
feet and ankles.

Isosorbide dinitrate/hydralazine hydrochloride helps relax your blood vessels so

your heart doesnt work as hard to pump blood. Studies have shown that this medicine
can reduce the risk of death in blacks. More studies are needed to find out whether this
medicine will benefit other racial groups.
PREVENTION
The fact that treatment is not always effective in prolonging life means that prevention
of heart failure should be prioritized by policy-makers. This is particularly important for
groups at high risk of developing this condition. Many people have existing illnesses that
place them at risk of heart failure. Healthcare professionals treating such patients
should adopt a broad approach that includes encouraging positive lifestyle changes that
reduce the risk of heart failure and prescribing preventive therapies as appropriate.
Medications that control blood pressure, heart rhythm and cholesterol levels are
effective in preventing heart failure in the large number of people who have conditions
such as high blood pressure, coronary heart disease, kidney disease and diabetes.
Pacemakers and heart valve replacement can also prevent heart failure in the small
number of people who have particular heart rhythm or valve disorders. The range of
illnesses that predispose patients to heart failure is extremely wide. Healthcare
professionals across all clinical disciplines should be educated to identify patients with
illnesses that increase the risk of heart failure and prescribe preventive medications.
This will ensure that as many people as possible benefit from available therapies.

Patients receiving long-term preventive therapies need to be assessed regularly at the

cost of healthcare providers. In addition those with chronic conditions, such as coronary
artery disease or Chagas disease, should be evaluated periodically and monitored for
changes to the heart. Patients with breast cancer are another group who would benefit
from such monitoring. Several existing and new cancer treatments are toxic to the
heart, and it is important for healthcare professionals to be aware of the need to assess
and manage the associated risks.

Bacterial infections that cause heart disease have been largely eliminated in
economically
developed countries, owing to the use of antibiotics. In other regions, bacteria and
tropical parasites cause a substantial proportion of heart failure cases, many of which
could be prevented if appropriate therapies were used. The potential benefits of policy
initiatives aimed at eliminating infectious diseases therefore extend to preventing heart
failure in many parts of the world.

PROGNOSIS
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