Heart failure

Diagnosis

A doctor diagnoses heart failure through a physical checkup and symptoms assessment. The doctor will be checking for hypertension, coronary artery diseases, and diabetes which are the risk factors for heart failure.

After completing the body checkup, the doctor might perform some of the following tests:

• Blood tests: show factors that raise the risk for heart disease.
• Chest X-ray: shows abnormalities in the lungs and heart.
• Electrocardiogram (ECG or EKG): This device helps record the electrical signals of the heart, the timing and the length of the heartbeats in a quick manner without causing any pain.
• Echocardiogram: This is a non-invasive procedure which creates pictures that show the heart’s size as well as its structure and movement through sound waves to create the pictures and to measure the ejection fraction.
• Stress test: A patient is required to run on a treadmill or stationary bicycle while having the cardiac activity recorded.
  Alternatively, an IV drug might also be given to increase the exercising effect on the heart, or a patient is recommended to wear a mask to assess the effectiveness of the exchange of oxygen and carbon dioxide in the heart and lungs.
• Cardiac computerized tomography (CT) scan: is done by lying down inside a scanning machine with an X-ray tube inside the machine rotating around you to collect images of the heart and chest. Contrast materials may also be used for further analysis.
• Magnetic resonance imaging (MRI): requires you to go inside a long machine and lie down on a table inside there. The machine will create pictures of the heart by radio waves, and a contrast agent might also be used to support the pictures’ analysis.
• Coronary angiogram: A doctor starts this procedure by inserting a catheter into a blood vessel, usually in the groin, before guiding to the heart arteries. The doctor will detect cardiac blockages by looking at pictures of the arteries shown on an X-ray. Contrast may also be injected through the catheter for further analysis.
• Myocardial biopsy: In this test, a tiny piece of heart muscle is removed to look for any abnormalities of the muscle that can cause heart failure. The removal of the muscle is done by inserting a small and flexible cord into a vein in the area of the neck or groin.

A doctor diagnoses and assesses heart failure to find the best treatment plan for each patient using the following two systems:

New York Heart Association classification

Heart failure is classified into four categories under this classification, as follows:

• Class I heart failure: which is asymptomatic.
• Class II heart failure: symptoms occur only when doing hard activities, including difficulty breathing and loss of energy.
• Class III heart failure: Any normal activity causes heart failure symptoms to appear.
• Class IV heart failure: This is the most severe type of heart failure where you might suffer from symptoms like difficulty breathing even while resting.

American College of Cardiology/ American Heart Association classification

This classification system is useful for both slowing down and preventing heart failure, as well as determining its risk factors to be able to make a treatment plan in a fast and effective manner.

This system uses the English letters from A to D. It is based on the stages of the disease with a category for people who are at risk of developing heart failure.

• Stage A: This is an asymptomatic stage, but a patient might already have several contributing factors for heart failure.
• Stage B: Patients in this stage already have heart disease but still have no signs or symptoms of heart failure.
• Stage C: The heart disease and heart failure’s signs or symptoms are detectable in this stage.
• Stage D: Heart failure in this process has pretty much progressed and specialized treatments are needed.

Both classification systems are mostly used together with assessment of the score and health conditions to make the most effective treatment plan.

Treatment

Chronic diseases like heart failure require long-term treatment to put their signs and symptoms under control or improve them.

Treatment can make the heart stronger as the underlying cause is taken care of. This includes fixing a heart valve and regulating an abnormal heartbeat or heart contraction.

The treatment approaches include medications and use of equipment, which in some cases can cure heart failure.

Medications

Medications are a common method for heart failure. The best medications will be chosen based on each patient’s symptoms, including:

• Angiotensin-converting enzyme (ACE) inhibitors: These drugs include enalapril, lisinopril and captopril, which relax the blood vessels to lower blood pressure, regulate blood flow and lower cardiac stress.
• Angiotensin II receptor blockers: used for those who do not respond well to the side effects of ACE inhibitors, such as losartan, valsartan and candesartan.
• Beta blockers: They include carvedilol, metoprolol and bisoprolol. The drugs are used to slow the heart rate and control blood pressure. They may put symptoms of heart failure under control and improve the cardiac function.
• Diuretics: prevent fluid buildups in your body, including the lungs to treat shortness of breath, by triggering more frequent urinations. They include furosemide (Lasix). Blood tests are required to monitor potassium and magnesium levels as these minerals are lost from the body through frequent urinations.
• Aldosterone antagonists: These are diuretics that can lower the chance of death among those with severe systolic heart failure.
  The antagonists include spironolactone and eplerenone. These drugs can increase the potassium level in your body, which in certain cases might make the potassium level in the body dangerously high. Patients are required to consult with their doctor first about the potassium level concern and food adjustment to control the intake of potassium.
• Positive inotropes: This type of drugs regulates the blood pumping activity of the heart as well as blood pressure. A doctor might give the medications intravenously to hospitalized patients with severe heart failure. However, certain patients who have used the positive inotropes for a long period of time might suffer from fatal side effects, therefore close medical care is needed.
• Digoxin (Lanoxin), or digitalis: This drug helps the heart muscle contract more firmly. It tends to slow the heartbeat. Digoxin is used for alleviating symptoms of systolic heart failure. It may be given to people with certain heart arrhythmia diseases, such as atrial fibrillation.
• Hydralazine and isosorbide dinitrate: They are used to relax blood vessels. A doctor mostly prescribes the drugs together for those with severe heart failure or have not responded well to ACE inhibitors or beta blockers.
• Vericiguat: This is a new type of medicine called oral soluble guanylate cyclase (sGC) stimulator for chronic heart failure.
• Other medications: Heart failure might have certain symptoms that require other medications to be treated. They include nitrates which alleviate chest pain and statins which reduce the cholesterol level in the blood.

If the symptoms of heart failure are getting severe or suddenly emerging, you might be required to adjust medication doses or even be admitted to the hospital to control symptoms and regulate the blood pumping. In case of severe heart failure, a long-term use of oxygen supplement might be required.

Surgery or other procedures

Certain severe causes of heart failure can be treated by implanting cardiac devices inside the body which includes:

• Coronary bypass surgery: in which the surgeon will create a new channel for blocked arteries for improving blood flow to heart muscle. The new pathway is created by removing a normal blood vessel of the leg, arm or chest and connecting it to lower and upper areas of the arterial blockage and is recommended for those with severe arterial blockage that leads to heart failure.
• Heart valve repair or replacement: In this process, a faulty valve is fixed or replaced to treat heart failure through certain kinds of cardiac surgery, including open-heart surgery, a minimally invasive surgery or cardiac catheterization. An impaired valve might be treated by reconnecting valve flaps, removing excess valve tissue to allow the leaflets to normally close, or tightening or replacing the ring of a valve.
• Implantable cardioverter-defibrillators (ICDs): This device is used to prevent complications of heart failure. It is like a pacemaker. It is implanted under the skin in the chest with wires leading through veins and into the heart to monitor the cardiac beating. The device can detect if the heart is beating abnormally or has stopped beating. If such an incident occurs, the ICD will pace or give shocks to the heart to restore regular beats.
• Cardiac resynchronization therapy (CRT) or biventricular pacing: If you have heart failure and your lower heart chambers (ventricles) do not beat in sync, CRT may likely be recommended for you. The device will send electrical signals to the chambers to regulate their contractions and resynchronize how they pump blood in the area out of the heart.
• Ventricular assist devices (VADs): This mechanical circulatory support device is generally implanted in one or both ventricles of the heart so that the lower chambers or ventricles can more effectively pump blood out of the heart to organs around the body. VADs are mostly recommended to heart failure patients who are scheduled to receive a heart transplant or as a permanent alternative to those who cannot receive a heart transplant.
• Heart transplant: In this surgery, the surgeon will replace your current heart with another one received from a donor and is recommended for those with advanced heart failure.

However, a heart transplant can cause dangerous risks and that is why careful consideration of safety needs to be made before receiving this kind of surgery.