Heart failure
The content of the article:
- Acute heart failure
- Chronic heart failure
- Causes of heart failure
- Kinds
- Stages
-
Signs of heart failure
- Gas exchange disorder
- Edema
- Stagnant changes in internal organs
- Signs of acute heart failure
- Signs of chronic heart failure
- Diagnostics
- Heart failure treatment
- Prevention
Heart failure is a pathological condition that develops as a result of a sudden or long-term weakening of the contractile activity of the myocardium and is accompanied by stagnation in the large or pulmonary circulation.
Heart failure is not an independent disease, but develops as a complication of pathologies of the heart and blood vessels (arterial hypertension, cardiomyopathy, ischemic heart disease, congenital or acquired heart defects).
Heart failure picture
Acute heart failure
Acute heart failure most often develops as a complication of severe forms of arrhythmia (paroxysmal tachycardia, ventricular fibrillation), acute myocarditis or myocardial infarction. The ability of the myocardium to effectively contract is sharply reduced, which leads to a drop in the minute volume, and a much smaller volume of blood enters the arterial system than normal.
Acute heart failure may be due to a decrease in the pumping function of the right ventricle, left ventricle, or left atrium. Acute left ventricular failure develops as a complication of myocardial infarction, aortic defect, hypertensive crisis. A decrease in the contractile activity of the left ventricular myocardium leads to an increase in pressure in the veins, capillaries and arterioles of the lungs, an increase in the permeability of their walls. This causes blood plasma to sweat and the development of pulmonary edema.
In terms of clinical manifestations, acute heart failure is similar to acute vascular insufficiency, therefore it is sometimes called acute collapse.
Chronic heart failure
Chronic heart failure develops gradually due to compensatory mechanisms. It starts with an increase in the heart rate and an increase in their strength, arterioles and capillaries expand, which facilitates the emptying of the chambers and improves tissue perfusion. With the progression of the underlying disease and the depletion of compensatory mechanisms, the volume of cardiac output decreases steadily. The ventricles cannot empty completely and become overflowing with blood during diastole. The heart muscle seeks to push the blood accumulated in the ventricles into the arterial system and ensure a sufficient level of blood circulation, compensatory myocardial hypertrophy is formed. However, over time, the myocardium weakens. Dystrophic and sclerotic processes associated with a lack of blood supply and oxygen supply occur in it,nutrients and energy. The stage of decompensation begins. At this stage, the body uses neurohumoral mechanisms to maintain hemodynamics. Maintaining a stable level of blood pressure with a significantly reduced cardiac output is ensured by activating the mechanisms of the sympathetic-adrenal system. In this case, a spasm of the renal vessels (vasoconstriction) occurs and renal ischemia develops, which is accompanied by a decrease in their excretory function and a delay in interstitial fluid. Increases the secretion of the pituitary gland of antidiuretic hormone, which increases water retention in the body. Due to this, the volume of circulating blood increases, the pressure in the veins and capillaries increases, and the perspiration of fluid into the interstitial space increases. At this stage, the body uses neurohumoral mechanisms to maintain hemodynamics. Maintaining a stable level of blood pressure with a significantly reduced cardiac output is ensured by activating the mechanisms of the sympathetic-adrenal system. In this case, a spasm of the renal vessels (vasoconstriction) occurs and renal ischemia develops, which is accompanied by a decrease in their excretory function and a delay in interstitial fluid. Increases the secretion of the pituitary gland of antidiuretic hormone, which increases water retention in the body. Due to this, the volume of circulating blood increases, the pressure in the veins and capillaries increases, and the perspiration of fluid into the interstitial space increases. At this stage, the body uses neurohumoral mechanisms to maintain hemodynamics. Maintaining a stable level of blood pressure with a significantly reduced cardiac output is ensured by activating the mechanisms of the sympathetic-adrenal system. In this case, a spasm of the renal vessels (vasoconstriction) occurs and renal ischemia develops, which is accompanied by a decrease in their excretory function and a delay in interstitial fluid. Increases the secretion of the pituitary gland of antidiuretic hormone, which increases water retention in the body. Due to this, the volume of circulating blood increases, the pressure in the veins and capillaries increases, and the perspiration of fluid into the interstitial space increases. Maintaining a stable level of blood pressure with a significantly reduced cardiac output is ensured by activating the mechanisms of the sympathetic-adrenal system. In this case, a spasm of the renal vessels (vasoconstriction) occurs and renal ischemia develops, which is accompanied by a decrease in their excretory function and a delay in interstitial fluid. Increases the secretion of the pituitary gland of antidiuretic hormone, which increases water retention in the body. Due to this, the volume of circulating blood increases, the pressure in the veins and capillaries increases, and the perspiration of fluid into the interstitial space increases. Maintaining a stable level of blood pressure with a significantly reduced cardiac output is ensured by activating the mechanisms of the sympathetic-adrenal system. In this case, a spasm of the renal vessels (vasoconstriction) occurs and renal ischemia develops, which is accompanied by a decrease in their excretory function and a delay in interstitial fluid. Increases the secretion of the pituitary gland of antidiuretic hormone, which increases water retention in the body. Due to this, the volume of circulating blood increases, the pressure in the veins and capillaries increases, and the perspiration of fluid into the interstitial space increases.which is accompanied by a decrease in their excretory function and a delay in interstitial fluid. Increases the secretion of the pituitary gland of antidiuretic hormone, which increases water retention in the body. Due to this, the volume of circulating blood increases, the pressure in the veins and capillaries increases, and the perspiration of fluid into the interstitial space increases.which is accompanied by a decrease in their excretory function and retention of interstitial fluid. Increases the secretion of the pituitary gland of antidiuretic hormone, which increases water retention in the body. Due to this, the volume of circulating blood increases, the pressure in the veins and capillaries increases, and the perspiration of fluid into the interstitial space increases.
Chronic heart failure according to different authors is observed in 0.5–2% of the population. With age, the incidence increases, after 75 years, pathology occurs in 10% of people.
Heart failure is a serious medical and social problem, as it is accompanied by high rates of disability and mortality.
Causes of heart failure
The main reasons for the development of heart failure are:
- ischemic heart disease and myocardial infarction;
- dilated cardiomyopathy;
- rheumatic heart disease.
In elderly patients, the causes of heart failure are often type II diabetes mellitus and arterial hypertension.
Type 2 diabetes can lead to heart failure
There are a number of factors that can reduce the compensatory mechanisms of the myocardium and provoke the development of heart failure. These include:
- pulmonary embolism (PE);
- severe arrhythmia;
- psycho-emotional or physical stress;
- progressive ischemic heart disease;
- hypertensive crises;
- acute and chronic renal failure;
- severe anemia;
- pneumonia;
- severe ARVI;
- hyperthyroidism;
- long-term use of certain medications (adrenaline, ephedrine, corticosteroids, estrogens, nonsteroidal anti-inflammatory drugs);
- infective endocarditis;
- rheumatism;
- myocarditis;
- a sharp increase in the volume of circulating blood with an incorrect calculation of the volume of intravenously administered fluid;
- alcoholism;
- fast and significant weight gain.
Eliminating risk factors can prevent the development of heart failure or slow down its progression.
Kinds
Heart failure is acute and chronic. Symptoms of acute heart failure appear and progress very quickly, from a few minutes to a few days. Chronic forms slowly over several years.
Acute heart failure can develop in one of two types:
- left atrial or left ventricular failure (left type);
- right ventricular failure (right type).
Stages
In accordance with the Vasilenko-Strazhesko classification, the following stages are distinguished in the development of chronic heart failure:
I. Stage of initial manifestations. At rest, the patient has no hemodynamic disturbances. With physical exertion, excessive fatigue, tachycardia, shortness of breath occur.
II. The stage of pronounced changes. Signs of long-standing hemodynamic disturbances and circulatory insufficiency are well expressed at rest. Stagnation in the small and large circles of blood circulation becomes the cause of a sharp decrease in working capacity. During this stage, two periods are distinguished:
- IIA - moderately pronounced hemodynamic disturbances in one of the parts of the heart, working capacity is sharply reduced, even ordinary loads lead to severe shortness of breath. The main symptoms are: hard breathing, slight enlargement of the liver, edema of the lower extremities, cyanosis.
- IIB - pronounced hemodynamic disturbances both in the large and in the pulmonary circulation, the ability to work is completely lost. The main clinical signs: severe edema, ascites, cyanosis, dyspnea at rest.
III. Stage of dystrophic changes (terminal or final). A persistent circulatory failure is formed, leading to serious metabolic disorders and irreversible disorders of the morphological structure of internal organs (kidneys, lungs, liver), exhaustion.
Signs of heart failure
Severe heart failure is accompanied by:
- disorder of gas exchange;
- swelling;
- stagnant changes in internal organs.
Gas exchange disorder
Slowing down the velocity of blood flow in the microvasculature doubles oxygen uptake by tissues. As a result, the difference between the oxygen saturation of arterial and venous blood increases, which contributes to the development of acidosis. Under-oxidized metabolites accumulate in the blood, activating the basal metabolic rate. As a result, a vicious circle is formed, the body needs more oxygen, and the circulatory system cannot provide these needs. Gas metabolism disorder leads to symptoms of heart failure such as shortness of breath and cyanosis.
For severe heart failure, shortness of breath and cyanosis occurs
With stagnation of blood in the pulmonary system and deterioration of its oxygenation (oxygen saturation), central cyanosis occurs. Increased utilization of oxygen in the tissues of the body and a slowdown in blood flow cause peripheral cyanosis (acrocyanosis).
Edema
The development of edema against the background of heart failure is caused by:
- slowing down blood flow and increasing capillary pressure, which enhances the extravasation of plasma into the interstitial space;
- violation of water-salt metabolism, leading to a delay in the body of sodium and water;
- a protein metabolism disorder that violates the osmotic pressure of plasma;
- decrease in liver inactivation of antidiuretic hormone and aldosterone.
In the initial stage of heart failure, edema is latent in nature and is manifested by a pathological increase in body weight, a decrease in urine output. Later they become visible. First, the lower extremities or the sacral region (in bedridden patients) swell. Subsequently, fluid accumulates in the body cavities, which leads to the development of hydropericardium, hydrothorax and / or ascites. This condition is called abdominal dropsy.
Heart failure is almost always accompanied by edema
Stagnant changes in internal organs
Violations of hemodynamics in the pulmonary circulation lead to the development of congestion in the lungs. Against this background, the mobility of the pulmonary edges is limited, the respiratory excursion of the chest decreases, and the rigidity of the lungs is formed. Patients develop hemoptysis, cardiogenic pneumosclerosis, and congestive bronchitis develop.
Congestion in the systemic circulation begins with an increase in the size of the liver (hepatomegaly). Subsequently, the death of hepatocytes occurs with their replacement by connective tissue, i.e., cardiac fibrosis of the liver is formed.
In chronic heart failure, the cavities of the atria and ventricles gradually expand, which leads to relative insufficiency of the atrioventricular valves. Clinically, this is manifested by the expansion of the borders of the heart, tachycardia, swelling of the cervical veins.
Signs of congestive gastritis are loss of appetite, nausea, vomiting, flatulence, a tendency to constipation, and weight loss.
With long-term chronic heart failure, patients develop cardiac cachexia - an extreme degree of exhaustion.
Congestion in the kidneys causes the development of the following symptoms of heart failure:
- hematuria (blood in the urine);
- proteinuria (protein in the urine);
- cylindruria (cylinders in urine);
- an increase in the relative density of urine;
- oliguria (decrease in the amount of urine discharge);
Heart failure has a pronounced negative effect on the function of the central nervous system. This leads to the development of:
- depressive conditions;
- increased fatigue;
- sleep disorders;
- decrease in physical and mental performance;
- increased irritability.
The clinical manifestations of heart failure are also determined by its type.
Signs of acute heart failure
Acute heart failure may be due to a decrease in the pumping function of the right ventricle, left ventricle, or left atrium.
Acute left ventricular failure develops as a complication of myocardial infarction, aortic defect, hypertensive crisis. A decrease in the contractile activity of the left ventricular myocardium leads to an increase in pressure in the veins, capillaries and arterioles of the lungs, an increase in the permeability of their walls. This causes blood plasma to sweat and the development of pulmonary edema.
Clinically, acute left ventricular failure is manifested by symptoms of cardiac asthma or alveolar pulmonary edema.
The development of an attack of cardiac asthma usually occurs at night. The patient wakes up in fear from a sharp suffocation. Trying to alleviate his condition, he takes a forced posture: sitting, with his legs down (orthopnea position). On examination, the following signs attract attention:
- pallor of the skin;
- acrocyanosis;
- cold sweat;
- severe shortness of breath;
- in the lungs, hard breathing with occasional moist wheezing;
- low blood pressure;
- muffled heart sounds;
- the appearance of a gallop rhythm;
- expansion of the boundaries of the heart to the left;
- pulse is arrhythmic, frequent, weak filling.
To alleviate the condition in acute heart failure, patients take the orthopnea position
With a further increase in stagnation in the pulmonary circulation, alveolar pulmonary edema develops. Its symptoms:
- severe suffocation;
- cough with pink frothy sputum (due to blood);
- bubbling breath with a mass of moist wheezing (a symptom of a "boiling samovar");
- cyanosis of the face;
- cold sweat;
- swelling of the neck veins;
- a sharp decrease in blood pressure;
- arrhythmic, threadlike pulse.
If the patient is not provided with urgent medical care, then against the background of an increase in heart and respiratory failure, death will occur.
With mitral stenosis, acute left atrial insufficiency is formed. Clinically, this condition manifests itself in the same way as acute left ventricular heart failure.
Acute right ventricular failure usually results from thromboembolism of the pulmonary artery (PE) or its large branches. The patient develops stagnation in the systemic circulation, which is manifested by:
- pain in the right hypochondrium;
- edema of the lower extremities;
- swelling and throbbing of the veins of the neck;
- pressure or pain in the heart;
- cyanosis;
- shortness of breath;
- expansion of the boundaries of the heart to the right;
- increased central venous pressure;
- a sharp decrease in blood pressure;
- a threadlike pulse (frequent, weak filling).
Signs of chronic heart failure
Chronic heart failure develops in the right and left atrial, right and left ventricular type.
Chronic left ventricular failure is formed as a complication of ischemic heart disease, arterial hypertension, mitral valve insufficiency, aortic disease and is associated with stagnation of blood in the pulmonary circulation. It is characterized by gas and vascular changes in the lungs. Clinically manifested:
- increased fatigue;
- dry cough (rarely with hemoptysis);
- heart attacks;
- cyanosis;
- attacks of suffocation, which more often occur at night;
- shortness of breath.
In chronic left atrial insufficiency in patients with mitral valve stenosis, congestion in the pulmonary circulation system is even more pronounced. The initial signs of heart failure in this case are cough with hemoptysis, severe shortness of breath and cyanosis. Gradually, sclerotic processes begin in the vessels of the small circle and in the lungs. This leads to the creation of an additional obstacle to blood flow in the small circle and further increases the pressure in the pulmonary artery basin. As a result, the load on the right ventricle also increases, causing the gradual formation of its insufficiency.
Chronic left ventricular failure may present with a dry cough, sometimes with hemoptysis
Chronic right ventricular failure usually accompanies pulmonary emphysema, pneumosclerosis, mitral heart defects and is characterized by the appearance of signs of blood stagnation in the systemic circulation. Patients complain of shortness of breath during exercise, an increase and distension of the abdomen, a decrease in the amount of urine separated, the appearance of edema of the lower extremities, heaviness and pain in the right hypochondrium. The examination reveals:
- cyanosis of the skin and mucous membranes;
- swelling of peripheral and cervical veins;
- hepatomegaly (enlarged liver);
- ascites.
Failure of only one part of the heart cannot remain isolated for a long time. In the future, it necessarily turns into general chronic heart failure with the development of venous stasis both in the small and in the large circle of blood circulation.
Diagnostics
Heart failure, as mentioned above, is a complication of a number of diseases of the cardiovascular system. Therefore, in patients with these diseases, it is necessary to carry out diagnostic measures to detect heart failure at the earliest stages, even before the appearance of obvious clinical signs.
When collecting an anamnesis, special attention should be paid to the following factors:
- the presence of complaints of dyspnea and fatigue;
- indication of the presence of arterial hypertension, ischemic heart disease, rheumatism, cardiomyopathy.
Specific signs of heart failure are:
- expansion of the boundaries of the heart;
- the appearance of a III heart sound;
- rapid low-amplitude pulse;
- swelling;
- ascites.
If heart failure is suspected, a number of laboratory tests are performed, including biochemical and clinical blood tests, determination of the gas and electrolyte composition of the blood, the characteristics of the metabolism of proteins and carbohydrates.
It is possible to identify arrhythmias, ischemia (insufficient blood supply) of the myocardium and its hypertrophy by specific changes in the electrocardiogram. Various ECG-based stress tests are also used. These include the treadmill test ("treadmill") and bicycle ergometry (using an exercise bike). These tests assess the reserve capacity of the heart.
One of the methods for diagnosing heart failure is an electrocardiogram
To assess the pumping function of the heart, to identify a possible cause of the development of heart failure, ultrasound echocardiography allows.
Magnetic resonance imaging is indicated for the diagnosis of acquired or congenital defects, coronary heart disease and a number of other diseases.
Chest x-rays in patients with heart failure show cardiomegaly (enlarged heart shadow) and pulmonary congestion.
To determine the volumetric capacity of the ventricles and assess the strength of their contractions, radioisotope ventriculography is performed.
In the later stages of chronic heart failure, ultrasound is performed to assess the condition of the pancreas, spleen, liver, kidneys, and to detect free fluid in the abdominal cavity (ascites).
Heart failure treatment
In heart failure, therapy is primarily aimed at the underlying disease (myocarditis, rheumatism, hypertension, coronary heart disease). Indications for surgery can be adhesive pericarditis, cardiac aneurysm, heart defects.
Strict bed rest and emotional rest are prescribed only for patients with acute and severe chronic heart failure. In all other cases, physical activity is recommended that does not cause deterioration in well-being.
Properly organized dietary nutrition plays an important role in the treatment of heart failure. Dishes should be digestible. The diet should include fresh fruits and vegetables as a source of vitamins and minerals. The amount of table salt is limited to 1-2 g per day, and fluid intake to 500-600 ml.
The diet of patients with heart failure should include fresh vegetables and fruits.
Pharmacotherapy, which includes the following groups of drugs, can improve the quality of life and prolong it:
- cardiac glycosides - enhance the contractile and pumping function of the myocardium, stimulate diuresis, increase the level of exercise tolerance;
- ACE inhibitors (angiotensin-converting enzyme) and vasodilators - reduce vascular tone, expand the lumen of blood vessels, thereby reducing vascular resistance and increasing cardiac output;
- nitrates - dilate the coronary arteries, increase the output of the heart and improve the filling of the ventricles with blood;
- diuretics - remove excess fluid from the body, thereby reducing swelling;
- β-blockers - increase cardiac output, improve filling of the heart chambers with blood, slow down the heart rate;
- anticoagulants - reduce the risk of blood clots in blood vessels and, accordingly, thromboembolic complications;
- agents that improve metabolic processes in the heart muscle (potassium preparations, vitamins).
With the development of cardiac asthma or pulmonary edema (acute left ventricular failure), the patient needs emergency hospitalization. Prescribe drugs that increase cardiac output, diuretics, nitrates. Oxygen therapy is mandatory.
Removal of fluid from body cavities (abdominal, pleural, pericardium) is carried out by puncture.
Prevention
Prevention of the formation and progression of heart failure consists in the prevention, early detection and active treatment of cardiovascular diseases causing its development.
YouTube video related to the article:
Elena Minkina Doctor anesthesiologist-resuscitator About the author
Education: graduated from the Tashkent State Medical Institute, specializing in general medicine in 1991. Repeatedly passed refresher courses.
Work experience: anesthesiologist-resuscitator of the city maternity complex, resuscitator of the hemodialysis department.
The information is generalized and provided for informational purposes only. At the first sign of illness, see your doctor. Self-medication is hazardous to health!
