Heart failure: causes, symptoms and treatment
Heart failure is the condition in which the heart is unable to pump sufficient blood to all organs and parts of the body. The condition is also called heart failure, although this term would be better suited to indicate the stages of heart failure characterised by excess fluid accumulation and/or impairment of the function of other organs caused by the heart’s malfunction
Such insufficiency is a very common condition, affecting more than 5% of people over the age of 70.
In most cases, it is a chronic condition that must be followed and treated throughout life.
What are the causes of heart failure?
Heart failure can be caused by several causes, the most common of which are:
- high blood pressure (hypertension), especially if left untreated: this increases the work of the heart, which over time can become enlarged (i.e. develop hypertrophy), and fatigued;
- coronary artery disease (disease of the arteries that carry arterial blood to the heart muscle), especially if it has resulted in one or more heart attacks, which have impaired the heart’s ability to contract;
- diseases of the heart muscle (myocardiopathies or cardiomyopathies), most often of unknown origin, less frequently they may be the consequence of the intake of substances toxic to the heart (e.g. excessive alcoholic beverages or certain drugs used in cancer therapy), or viral infections (myocarditis); there are also forms with inherited characteristics (familial myocardiopathies)
- diseases of the heart valves (valvulopathies) and malformations of the heart present from birth (congenital heart diseases), which cause an increase in the work of the heart and/or an alteration (excess or deficiency) of the flow in the pulmonary vessels.
What are the disorders caused by heart failure?
The main complaints (symptoms) caused by heart failure are:
- tiredness (asthenia), easy fatigability, reduced ability to perform physical exertion and, in more advanced forms, even lighter activities (e.g. dressing);
- shortness of breath and breathlessness (dyspnoea) during exertion (intense, medium or light, depending on the degree of the disease), or even at rest; characteristic of heart failure is the difficulty in breathing while lying down, which improves in a sitting position or makes it necessary to use 2 or more pillows to sleep;
- swelling (oedema) due to the accumulation of fluid in the soft tissues of the legs; it may be noticeable (shoes feel tight, socks leave a mark), but can sometimes be recognised only by observing that pressing with the fingers around the ankle or on the front of the leg leaves a mark; it manifests itself mainly in the evening
- the sensation of abdominal engorgement (sometimes with pain in the mouth of the stomach or on the right side, appearing during physical activity or after even non-abundant meals) due to digestive difficulties as a result of reduced blood supply to the digestive system and accumulation of fluid in the liver;
- the sensation of palpitations, accelerated heartbeat (tachycardia) or slowed heartbeat (bradycardia) or otherwise irregular heartbeat (arrhythmia);
- dizziness or vertigo, generally of no concern if of short duration or associated with the change from lying down or sitting to standing; to be reported promptly to the doctor if independent of the change of position and associated with acceleration, slowing or irregularity of the heartbeat.
How is heart failure treated?
Heart failure is in most cases a chronic condition; therefore it deserves lifelong follow-up and treatment.
Only in some cases (e.g. surgery for a valvular disease that has not yet resulted in irreversible damage to the heart muscle) is it possible to recover definitively.
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The aim of treatment is to prolong life and improve the quality of life of the patient with heart failure.
The treatment of heart failure is based on drugs and some non-pharmacological treatments, the most important of which are certain cardiac surgeries and, recently, the application of electrical devices such as defibrillators and pace-makers.
An integral part of the therapeutic programme is the adoption of an appropriate lifestyle, both in terms of general cardiovascular prevention measures, and with respect to certain specific rules (reducing salt intake, limiting water and fluid intake in general), which in the subject with heart failure take on particular value.
Drugs for heart failure
The pharmacological therapies available today have allowed a substantial improvement in the natural history of heart failure patients.
There are drugs that can treat some of the most disabling symptoms of heart failure (this is the case with diuretics with respect to fluid retention) and others that can counteract, slow down or even reverse the underlying mechanisms of heart failure.
Most patients with heart failure take several drugs; although it can be difficult and inconvenient to take so many different drugs, the aim is to maintain the compensatory condition (and thus the patient’s well-being) for as long as possible and to use as many drugs as possible that are able to ‘cure’ heart failure, preserving the heart from worsening or even improving its performance.
The classes of drugs most commonly used in the treatment of heart failure are listed below.
Obviously, not all patients need to take all the drugs listed here
Diuretics: they eliminate the fluid overload that occurs as a result of heart failure. The dose of the diuretic may vary according to the needs of the patient, who should, under certain circumstances, be able to ‘self-manage’ this drug (e.g. increase in dosage in the event of weight gain of more than 1.5-2 kg from one day to the next, a sign of increasing water retention). The most common side effects are lower blood pressure, cramps and reduced blood potassium levels.
Digitalis: increases the heart’s ability to contract and reduces the frequency of beats. It is helpful in improving symptoms in patients with more advanced heart failure. Digitalis levels in the blood should be checked periodically to avoid overdosing, which can cause excessive slowing of the heart rate, rhythm disturbances and nausea.
ACE-inhibitors: they act as vasodilators, lowering blood pressure and thus reducing the work of the heart; they also counteract some of the mechanisms of progression of heart failure, thus exerting a ‘curative’ effect. In addition to acting on some of the symptoms of heart failure, these drugs are able to prolong the lives of patients suffering from heart failure and/or heart failure, thus improving their prognosis. They are also used in the treatment of high blood pressure and after myocardial infarction. The most frequent side effects are coughing, excessive lowering of blood pressure values, and, much more rarely, increased blood potassium levels and worsening of kidney function indices. To prevent these problems, one usually starts with low doses, then gradually increases them, and periodically checks laboratory tests.
Angiotensin II receptor inhibitors: they act with a mechanism similar to that of ACE inhibitors, although coughing is less frequent among the side effects.
Beta-blockers: they act by reducing heart rate, blood pressure and ultimately the work of the heart, thus allowing the heart muscle to gradually replenish its energy reserves. Beta-blockers can reverse the tendency of the failing heart to dilate and contract less and less. In addition to improving the pumping function of the heart, these drugs can also prolong life. They are also used for high blood pressure, angina (chest pain due to reduced blood flow to the heart muscle) and heart attack. In patients with heart failure, their use requires a great deal of caution at the start of treatment: in order to start and bring this therapy up to the appropriate doses, one must start with very low doses that are gradually increased. Indeed, at the beginning, precisely because beta-blockers reduce the work of the heart, patients may feel more tired and, in some cases, decompensation may worsen. The most frequent side effects are linked precisely to these effects on the heart and their ability to worsen asthma in predisposed individuals.
Antialdosteronics: these drugs are diuretics that are scarcely effective as such, but compared to the others have the peculiarity of hindering potassium loss, one of the most dreaded side effects of diuretics used to combat water retention. Recently, spironolactone, the progenitor of this pharmacological class, has been shown to prolong the life of patients with advanced heart failure.
ARNI – Sacubitril/valsartan: ARNI (neprilysin and angiotensin receptor antagonists) are the new class of drugs used in the innovative therapeutic treatment of heart failure. The combination of the two active ingredients of Sacubitril and valsartan activates a hormonal mechanism that makes it possible, for the first time, to enhance the effects of the natriuretic peptide system (increasing sodium elimination through the urine) and simultaneously maintain the inhibition of the renin-angiotensin system (regulating blood pressure).
Innovative therapy with Sacubitril/valsartan has been shown to reduce mortality from cardiovascular causes by 20 per cent compared to reference therapy, leading in younger patients with chronic heart failure with reduced ejection fraction, to a prolongation of survival by one and a half years, with peaks of up to 2 years.
SGLT2 inhibitors: these are a new class of hypoglycaemic drugs capable of reducing the most disabling symptoms of cardiovascular disease. They act on blood glucose reduction by causing an increase in urinary glucose excretion such that it would also influence the reduction of blood pressure (on average 4 mmHg), secondary to the reduction of sodium and circulating volume, providing significant cardiovascular benefits.
Clinical studies have shown that the SGLT2 inhibitors that have been approved for the treatment of type 2 diabetes mellitus and have shown significant results on cardiovascular risk reduction were Empagliflozin, Canagliflozin and Dapagliflozin.
Many other drugs can be used by patients with heart failure, depending also on the presence of other diseases or specific indications.
This is the case with some antiarrhythmics, anticoagulants (especially in the case of coexisting atrial fibrillation), antiplatelet agents, statins (drugs that can reduce plasma cholesterol levels), nitroderivatives and calcium channel blockers, vitamins, iron and recently erythropoietin, which are used to combat anaemia, which can worsen the symptoms of heart failure patients.
Can heart failure be treated with medication alone?
Most patients with heart failure can be treated with medication alone.
Over the last two or three years, however, in certain specific conditions to be identified and discussed with the family doctor, cardiologist and heart surgeon, the usefulness of interventional procedures (implantation of a biventricular pacemaker or defibrillator) or cardiac surgery (correction of mitral insufficiency, plastic surgery or ventricular remodelling) has become established, which do not replace but supplement medical therapy.
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