Ishwarya Sivakumar

St Angelas and St Bonaventures Sixth form

Heart failure

Heart Failure
Figure 1

Definition and Epidemiology

Heart failure develops as an outcome of
cardiac disease. It can be described as an
abnormality of cardiac structure or function
causing inadequate systemic perfusion so
the delivery of oxygen does not meet the
requirements of the metabolizing tissues.
Around 68,000 people in the UK are
diagnosed with heart failure each year.1

Causes
Coronary heart disease (CHD) is the most common cause of heart failure with about
23,000 people aged less than 75 dying in the UK each year due to CHD.15 In coronary
heart disease the arteries that supply the cardiac muscle with oxygen becomes blocked
or severely narrowed by the process of atherosclerosis leading to myocardial
infarction. CHD weakens the heart overtime and leads to heart failure. Another
common cause of heart failure is hypertension.2 Since hypertension increases
afterload, there is a rise in preload as more blood stays in the heart after it pumps. The
heart will have to work harder to pump blood around the body. To cope with this, the
cardiac muscle becomes harder and stiffer which makes the heart inefficient at doing
its job. Usually there is an excessively high preload in heart failure.8, 9
Cardiomyopathy is the term used to define any disease of the cardiac muscle that
affects the hearts ability to pump blood with an adequate force.10 There are three
types of cardiomyopathies. In congested cardiomyopathy, the left ventricle becomes
dilated and weak. Initially, the chambers of the heart respond to this situation by
stretching to hold more blood for systemic perfusion. However, this only temporarily
strengthens the hearts contraction.11 Eventually, the cardiac muscle weakens and is
unable to pump blood with the force required. In hypertrophic cardiomyopathy the
walls of the ventricles become hypertrophied, the affected cardiac muscle may
become stiff. Consequently the ventricles may not fill as effortlessly as normal, so less
blood is pumped to the body. Restrictive cardiomyopathy inhibits the heart from
sufficiently filling with blood before contracting due to a loss of elasticity. This leads
to heart failure.
The types of arrhythmia that can lead to heart failure include bradycardia and
tachycardia. Bradycardia is when the heart beats at an abnormally slow rate resulting
in a low cardiac output that can consequently lead to heart failure.13 Tachycardia is
when the heart rhythm is too fast or irregular. The heart rate ranges from 100 beats per
minute to 400 beats per minute. The heart will not be able to pump oxygenated blood
sufficiently at such high rates.14

Ishwarya Sivakumar
St Angelas and St Bonaventures Sixth form
Heart failure
Other factors such as alcohol intake, smoking, valve regurgitation, valve stenosis and
genes can also increase the chances of heart failure.
Signs and symptoms
Many symptoms of heart failure are linked to the
congestion that develops due to the transudation of
plasma into alveolar spaces (pulmonary edema).
This occurs as a result of the redistribution of blood,
which causes an increase in venous blood pressure
in the lungs.2 The plasma reduces oxygen
movement through the lungs and leads to dyspnea.
Other symptoms occur due to insufficient systemic
perfusion so not enough oxygenated blood reaches
the metabolizing tissues.4 Some of the main
symptoms of heart failure can be seen in figure 2.

Figure 2

If right-sided heart failure occurs, the right ventricle

loses its ability to pump causing blood congestion in
the systemic circulation. The congestion affects the
liver, gastrointestinal tract, limbs and lungs causing
fatigue, fluid build-up in the feet, ankles, legs and
abdomen, liver enlargement, weight gain and dyspnea.
In left-sided heart failure, people experience systolic failure, diastolic failure or both.
In systolic heart failure, the heart muscles are unable to contract normally, so not is
blood is pumped out of the body. Diastolic heart failure is when the left ventricle
cannot fill well. This is because the left ventricle loses the ability to rest properly in
between heartbeats.26 Some of the symptoms of left-sided heart failure include fluid
congestion in the lungs, dyspnea and fatigue. Orthopnea is also said to occur as the
heart condition progresses.
Heart failure is classified into four classes according to the New York Heart
Association (NYHA). Descriptions of these four classes would be that35: Class 1
means that there will be no restrictions in the physical activity of the heart failure
patient. Class 2 means that there will be a slight restriction to the physical activity of
the patients, even normal physical activity causes the patient to experience symptoms
of heart failure. Class 3 means that there will be a considerable restriction to the
physical activity of the patient and they may only find themselves comfortable when
they are resting. Class 4 means that the patient will experience symptoms of heart
failure even when they are not taking part in any physical activity. Moreover, their
symptoms may increase if they do not rest.
Diagnostic tests are used to reveal whether a person suffers from heart failure. Some
of the various tests used to diagnose heart failure are explained below.32 A B-type
natriuretic peptide (BNP) blood test can be carried out. When heart failure progresses,
the heart secretes BNP due to the changes in pressure. BNP levels are higher in heart
failure patients. This highlights that a BNP blood test will reveal whether a person
suffers from heart failure. A chest x-ray can be carried out to check for fluid
2

Ishwarya Sivakumar
St Angelas and St Bonaventures Sixth form
Heart failure
congestion in the lungs and heart and to see whether the heart is enlarged. An
electrocardiogram can be used to determine the hearts ejection fraction and also
check if there is any abnormality in the electrical activity of the heart. An
echocardiogram uses ultrasound waves to check blood flow across the valves by the
Doppler effect. A stress test is when the pumping of the heart is increased by physical
activities or medication to determine whether there are blocked arteries. Other tests
include cardiac catheterization and CT coronary angiogram to check if the person has
coronary heart disease, which can lead to heart failure.
Prognosis
The prognosis of heart failure is dependent on the health of the patient. However,
heart failure prognosis is generally poor with nearly 50% of patients dying within 5
years of being diagnosed.16 Smoking and alcohol intake tend to contribute to early
demise in people with heart failure. Some studies have revealed that there are heart
failure patients who dont even live up to their life expectancy28: Despite the
prediction that 50% of heart failure patients live for 5 years after diagnosis, studies in
Scotland showed that the five-year survival rate only applied to 25% of the
population. Furthermore, an American study showed that 54% of heart failure patients
died within three days even though they were expected to live for six more months.
Treatment
Figure 3

There is no cure for heart failure. However,

there are many treatments that exist to
improve the symptoms and/or prognosis of
heart failure. The body produces a very
powerful peptide hormone called angiotensin
II, which causes vasoconstriction, and a
subsequent raised blood pressure. Therefore,
most heart failure patients are prescribed an
angiotensin-converting enzyme (ACE)
inhibitor.1 They work by slowing down the
activity of the ACE leading to a decline in
the production of angiotensin II. As a result, vasodilation occurs which in turn, lowers
blood pressure. This makes it easier for the cardiac muscle to pump blood, as there is
an improvement in the oxygen supply/demand ratio. ACE inhibition induces progress
in the function of the failing heart by predominantly decreasing the demand for
oxygen by reductions in afterload and preload.6, 7
Diuretics work by increasing the volume of urine. Diuretics that are commonly used
to treat heart failure include loop diuretics and thiazide diuretics. Different diuretics
are said to work at different parts of the kidney tubules; this gives rise to the benefit of
being able to use a combination of different diuretics to get the best treatment.
Diuretics alleviate symptoms of fluid congestion and lower high blood pressure by
eliminating excess sodium and water. The blood pressure reducing effect is increased
due to the dilating effect of diuretics on the blood vessels.19 These events reduce the
demand of oxygen-rich blood pumped from the heart allowing it to work less hard.
3

Ishwarya Sivakumar
St Angelas and St Bonaventures Sixth form
Heart failure
Beta-blockers cause the heart to beat with less force by slowing it down and reducing
afterload. This prevents arrhythmias from developing and therefore improves the
prognosis of heart failure.20 Digoxin is also a drug used to improve the symptoms of
heart failure. Digoxin blocks the sodium-potassium ATPase enzyme subsequently
rising the amount of calcium and potassium in heart cells.21 This makes the heart
muscle contract more forcefully.22 Consequently, systemic perfusion is more efficient.
If medication isnt working, surgery may be considered. Coronary angioplasty or
coronary artery bypass may be used if the persons heart failure is caused by coronary
heart disease.24 Valve replacements may be considered if valve regurgitation or
stenosis is the root cause of heart failure. A cardiac defibrillator can be surgically
implanted in the chest to treat arrhythmia and lessen some of the symptoms of heart
failure. Despite the advancement in medical and surgical treatments for heart failure,
patients continue to move to end-stage failure.23 During this stage, when all other
treatments have failed, heart transplantation is used as a last resort given that there is
chance of long-term transplantation success.
Possible future direction
Figure 4

Human pluripotent stem cells (human embryonic stem

cells or reprogrammed somatic cells) have the ability to
generate cardiomyocytes to replace the dead cells and
restore cardiac function.25 Figure 4 shows how embryonic
stem cells an be derived and examples of the various types
of cells it can differentiate into. Cardiomyocytes are heart
muscle cells that contract to pump blood out of the
ventricles. Researchers have shown that cardiomyocytes
derived from human embryonic stem cells can be used to
restore cardiac function in non-human primate hearts.
They
showed that the intra-cardial transfer of one billion human
embryonic stem cells remuscularized a significant amounts of the infarcted monkey
heart.17 This suggests that human pluripotent stem cells have a future as potential
treatment for heart failure in humans. However, more research has to be done on
whether a similar remuscularization of the human heart is likely. Moreover, the use of
stem cells can cause controversy. Examples of the issues that would arise from stem
cells are that: The long-term effects of using stem cells are still not known. Stem cells
involve the usage and destruction of a potential life but using reprogramed somatic
cells may not be so controversial but people dont know if adult stem cells are as
effective as embryonic stem cells.
Bibliography
1. www.patient.co.uk/health/heart-failure-leaflet Accessed on 01/08/14
2. www.almostadoctor.co.uk/content/systems/-cardiovascular-sytem/heart-failure
Accessed on 01/08/14
3. www.nytimes.com/health/guides/disease/right-sided-heartfailure/overview.html Accessed on 01/08/14

Ishwarya Sivakumar
St Angelas and St Bonaventures Sixth form
Heart failure
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Accessed on 01/08/14
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01/08/14 - Figure 1
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Accessed on 01/08/14
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Accessed on 02/08/14
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02/08/14
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Accessed on 02/08/14
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03/08/14
29. http://body-disease.com/congestive-heart-failure/ Accessed on 03/08/14 Figure 2
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Ishwarya Sivakumar
St Angelas and St Bonaventures Sixth form
Heart failure
30. http://www.euroclinix.net/ace-inhibitors.html Accessed on 03/08/14 - Figure 3
31. http://trussty-jasmine.blogspot.fr/2012/03/stem-cells-forcardiac.html#axzz39eCC0Vba Accessed on 03/08/14 Figure 4
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Accessed on 03/08/14
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