Heart Failure

Heart Failure

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What is heart failure?

Heart failure happens when the heart fails to function properly and does not pump blood throughout the body as efficiently as it should. This can be an effect of certain conditions such as narrowed arteries (CAD) or high blood pressure.

What are the types of heart failure?

The heart has four chambers. The two upper chambers are the right atrium and left atrium (plural “atria”); the two lower chambers are the right and left ventricles. Blood comes in from the body through the right atrium and into the right ventricle; from there it flows to the lungs, where it picks up oxygen. Then the blood comes back through the left atrium and into the left ventricle, which pumps the oxygenated blood out to the entire body. During times of increased physical activity (such as climbing the stairs), the body requires more oxygen. When a person has heart failure, the heart cannot adjust to this increased demand.

There are two main types of heart failure. They are defined based on whether the “ejection fraction” (which indicates how well the left ventricle is able to pump) is reduced or preserved:

  • In “heart failure with reduced ejection fraction” (HFrEF, also called “systolic heart failure”), the heart is too weak. When the heart pumps, it doesn’t squeeze normally.
  • In “heart failure with preserved ejection fraction” (HFpEF, also called “diastolic heart failure”), the heart is too stiff. When the heart pumps, it doesn’t relax and refill with blood normally.
Systolic, Normal and Diastolic Function
What causes heart failure?

Heart failure is usually an effect of other prior conditions that have damaged or weakened the heart. It may also be an effect of the heart stiffening as we age.

Some common underlying conditions that may contribute to heart failure are:

  • Coronary artery disease (CAD)
    This is the blockage or narrowing of the arteries, reducing blood flow. This leads to the heart muscle being deprived of oxygen and its function weakened. Sometimes, as a result of a heart attack, there is permanent damage to the heart muscle which impairs heart function.
  • Hypertension
    High blood pressure means your heart has to work harder to pump blood throughout the body. The extra stress on the heart may stiffen or weaken the heart muscle, reducing its efficiency.
  • Heart valve disease
    The valves of the heart ensure that blood flows in the right direction. A damaged valve may require the heart to work harder and cause extra stress. The valve can become narrowed (“stenosed”), which interferes with blood flow through the valve and increases pressure in the heart. The valve can also become leaky, causing blood to flow backward (“regurgitation”).
  • Cardiomyopathy
    Changes in the heart muscle tissue may lead to the inability of the heart muscle to pump or relax normally, but the cause is not high blood pressure or coronary heart disease. Cardiomyopathy can be related to different medical conditions or can be genetic.
  • Arrhythmias (abnormal heart rhythm)
    Arrhythmias are when your heart beats inconsistently, either too fast, or too slow. This may lead to the weakening of the heart muscle and ineffective pumping of the blood.
What are the symptoms and signs of heart failure?

As the amount of blood pumped by the heart decreases, a variety of symptoms can develop, including:

  • Shortness of breath, which might require you to cut back on your normal activities or sleep with several pillows to elevate your head
  • Feeling tired or fatigued quickly
  • Weakness, particularly of the legs when exercising
  • Lightheadedness or dizziness
  • A fast heart rate, even while resting
  • Swelling in the lower legs and feet (oedema) or in the abdomen (ascites)
  • Poor appetite and unintentional weight loss (in severe heart failure)
When should I see a doctor?

It is important to seek medical treatment immediately if you experience chest pain, difficulty breathing, fainting, fast or irregular heartbeat (arrhythmia) or cough up white or pink blood-tinged phlegm.

How is heart failure diagnosed?

Heart failure is diagnosed based upon your medical history, a physical exam, and a series of tests. These tests can tell your doctor how well your heart is working and can help determine the cause of your heart failure. Tests may include:

  • Electrocardiogram (ECG) – An ECG measures the electrical activity of your heart. An ECG may detect the causes of heart failure, such as an abnormal heart rhythm or a heart attack.
  • A blood test known as brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) – BNP is a hormone produced by the heart. When a person has heart failure, the BNP or NT-proBNP level is higher than normal.
  • Chest X-ray – A chest X-ray shows the size and shape of the heart and the large blood vessels in the chest. It also can show if there is fluid collected in the lungs, which may occur in people with heart failure.
  • Echocardiography – An echocardiogram uses ultrasound to assess the size and function of the heart’s chambers and the structure and function of the heart valves, and how well the left ventricle pumps (the “ejection fraction”). A Follow-up echocardiogram is important to monitor your heart function over time.
  • Exercise testing – An exercise test (also called a “stress test”) determines how well your heart performs during exercise. Your ECG, blood pressure and heart rate are monitored while walking on a treadmill machine. It can detect signs of lack of blood supply to your heart caused by blockages in the coronary arteries.
  • Coronary angiography – Coronary angiography looks at the coronary arteries to detect blockages. During the test, the cardiologist inserts a thin tube (catheter) through a large blood vessel in your wrist or groin and advances it into the heart. A contrast dye is injected into the catheter to view the arteries and the under live X-ray.
  •  Other imaging tests – Computed tomography (CT), magnetic resonance imaging (MRI), and nuclear myocardial perfusion imaging are all imaging tests.
    These specialised imaging tests help the cardiologist to assess the heart function and cause of the heart failure.
Can heart failure get better?

Whether your condition gets better ultimately depends on its causes. Certain conditions that cause heart failure cannot be reversed. However, you can take steps to improve your symptoms of heart failure to help you live longer. This can be done through proper treatment and making healthy lifestyle changes to reduce your risk factors. Some of these heart-healthy lifestyle changes are:

  • Stop smoking
  • Adequate management of diabetes and high blood pressure
  • Adequate physical exercise
  • Eating healthily
  • Maintaining a healthy weight
  • Reducing and managing stress
Senior Citizen being assisted by young people
How is heart failure treated?

In most people, heart failure is a chronic (long term) condition. While there are effective treatments that can help with symptoms and slow the progress of heart failure, in most cases it is a chronic condition that requires life-long treatment.

Essential treatment usually includes a combination of changes in your lifestyle, diet and medications. Medications are often used to treat heart failure symptoms; some medications have even been proven to prolong life.

Lifestyle and dietary changes:

  • Cut down on salt and water – Try not to add salt at the table or when you cook. Also, avoid processed foods. The best choices for food are fresh or fresh frozen foods, and foods you prepare yourself. Your cardiologist might also tell you to limit the amount of fluids you drink.
  • Lose weight, if you are overweight – If you are overweight, your heart has to work extra hard to keep up with your body’s needs.
  • Stop smoking – Smoking worsens heart failure and increases the chance that you will have a heart attack or die.
  • Limit alcohol – limit to 1-2 drinks a day.
  • Be physically active – Activities such as walking or cycling on most days of the week can help reduce your symptoms. But do not exercise if you are having symptoms. Ask your cardiologist what activities are safe for you.

Heart failure medications:

Most people with heart failure take 3 or more medications.

  • Diuretic – A diuretic (also called a “water pill”) helps your body get rid of the excess fluid. The dose of diuretic requires careful monitoring and adjustment by your cardiologist.
  • ACE inhibitor, ARNI, or ARB – Angiotensin-converting enzyme inhibitor (“ACE inhibitor”), angiotensin receptor-neprilysin inhibitor (“ARNI”), and angiotensin II receptor blocker (called “ARB”) medicines all widen blood vessels and lowers blood pressure, making it easier for your heart to pump. They also directly improve heart function.
  • Beta blocker – A beta blocker can slow your heart rate and lower your blood pressure. These medicines also protect the heart from the adverse effects of certain hormones that are increased when a person has heart failure. This medication can help prolong life.

Other medications may be prescribed on top of the above medications, and also to treat the underlying cause of the heart failure e.g. blood pressure medications and medications for coronary artery disease.

Further treatment may include:

  • Coronary angioplasty and stenting
    Narrowing of the arteries can be treated with a coronary angioplasty to increase the heart’s blood supply, which is an effective non-surgical alternative to a coronary artery bypass surgery.
  • Heart surgery
    Surgery is sometimes recommended for people with heart failure and extensive coronary artery disease or severe disease of the heart valves. This might include heart valve surgery or coronary artery bypass graft (CABG) surgery or both. CABG is a procedure to bypass narrowed or blocked coronary arteries and restore blood flow to the heart muscle.
  • Implantable cardiac devices
    If you have a very weak heart which predisposes you to an abnormal and potentially fatal heart rhythm, your cardiologist might recommend a device that shocks the heart and returns it to a normal rhythm. The device is called an implantable cardioverter-defibrillator (ICD). It is implanted under the skin in your upper chest.In some situations, the walls of the left ventricle contract out of sync, making the heart work less efficiently. A special type of pacemaker, called “cardiac resynchronization therapy” (CRT) or biventricular pacing, can treat this problem.
  • Cardiac transplant
    Heart transplantation, if available, can be helpful for some people with severe heart failure that has not responded to other treatments.
How to care for yourself

Being diagnosed with heart failure can be frightening and stressful. There are some things you can do to manage your condition:

  • Be sure to take your medicines as instructed. Do not skip doses when you feel better.
  • Tell your cardiologist if your medicines cause side effects or other problems, so that necessary adjustments can be made.
  • Pay attention to how you feel, and look for signs that your heart failure is getting worse.

Call for emergency help – Call 995 (ambulance) if you have any of the following:

  1. Severe shortness of breath
  2. Chest discomfort or pain that lasts more than 15 minutes and does not get better with rest. If you have nitroglycerin (GTN), please take it as directed.
  3. Fainting

Call your cardiologist for an early appointment if you develop any of the following, which can be signs of worsening heart failure:

  • Increasing or new shortness of breath
  • New or worsened cough, especially if you are coughing up frothy or bloody material
  • An increase in leg or ankle swelling
  • Weight gain of 1 kg in one day or 2 kg in one week
  • A fast or irregular heartbeat
Summary

It is possible to live a normal life with heart failure. First, early detection is key. From there, working with your cardiologist to help understand your heart failure and properly manage your condition will help you live longer and feel better.

How can we help you?

We offer consultation for a comprehensive range of cardiac diagnostic tests and treatment plans.

Dr Joshua Loh

Senior Consultant Interventional Cardiologist

Medical Director at Capital Heart Centre, Dr Joshua Loh has more than 15 years of experience in the field of cardiology.

He is experienced in the treatment of complex coronary and interventional procedures.

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