Heart failure: Important to know

1. What is heart failure?
2. What are the consequences of heart failure?
3. What increases the risk of heart failure?
4. How can heart failure be prevented?
5. How are heart failure, diabetes and obesity related?
6. What are the symptoms of heart failure?
7. How is heart failure diagnosed?
8. How is heart failure treated?

If the left ventricle is primarily affected, doctors speak of left ventricular failure, whereas in the case of the right ventricle it is right ventricular failure. In global heart failure, both ventricles are impaired and can no longer pump enough blood.

If heart failure develops over a longer period of time, it is referred to as chronic heart failure. If it occurs suddenly, for example after a severe heart attack, it is referred to as acute heart failure.

Around 4 million people in Germany have heart failure. The number of sufferers is rising continuously. Women and men are affected about equally often. However, there are differences between the various forms of heart failure.

Heart failure with reduced ejection fraction is more common in men than in women, while the gender ratio is balanced in heart failure with preserved ejection fraction. Age plays a greater role than gender. The risk of developing heart failure increases significantly with age.

Chronic heart failure can worsen acutely. Doctors then speak of decompensation of chronic heart failure. Acute decompensation can be triggered, for example, by infections, certain drugs, concomitant illnesses or non-compliance with treatment recommendations.

In addition, the following damage to various organs may occur as a result of chronic heart failure:

• Thrombosis: Heart failure increases the risk of a blood clot (thrombus) forming in the veins. If the thrombus becomes detached, the result may be an obstruction of a pulmonary vessel (pulmonary embolism). If a blood clot forms in the left ventricle, the result may be a stroke.
• Water retention in the lungs: Failure of the left side of the heart causes blood to back up into the lungs. This congestion and the resulting increase in pressure in the blood vessels of the lungs lead to an accumulation of fluid in the lungs, resulting in pulmonary edema.
• Damage to the liver: Blood can also back up in the vessels of the liver due to the reduced pumping power of the heart, particularly with right heart failure. Blood congestion can lead to liver cirrhosis (scarring of the liver tissue).
• Renal insufficiency: In chronic heart failure, kidney function increasingly deteriorates because the kidneys are no longer supplied with sufficient blood.
• Pericardial effusion: The insufficient pumping power of the heart favors the accumulation of fluid between the skin of the heart and the pericardial sac.
• Heart failure: Heart failure increases the risk of sudden cardiac death.

In many cases, heart failure is the result of another heart disease. Possible causes are:

• Coronary heart disease (CHD): The coronary arteries are responsible for supplying the heart muscle with blood and therefore with oxygen. They are severely narrowed by deposits (plaques) in the event of CHD. As a result, they can no longer transport enough oxygen-rich blood to the heart muscle. This impairs the pumping power of the heart.
• Heart attack: A coronary artery can be completely blocked by a blood clot caused by damage (erosion) or a tear (rupture) in an atherosclerotic plaque. Then part of the heart muscle is no longer supplied with oxygen. If it dies at the affected site, the heart muscle is replaced by scar tissue. This scar tissue cannot contract, so that it results in heart failure.
• High blood pressure (hypertension): Persistently high blood pressure causes the heart muscle to become inelastic. As a result, the left ventricle in particular can no longer fill with enough blood. This causes the heart to lose pumping power.
• Diseases of the heart valves: If one of the heart valves no longer closes properly or is narrowed, the heart’s pumping power is impaired.
• Inflammation of the heart muscle (myocarditis): A viral infection, for example influenza, can lead to chronic inflammation of the heart muscle, which weakens the heart’s pumping power.

In addition, other diseases and lifestyle factors may increase the risk of heart failure. These factors include:

• Congenital heart defects
• Diseases of the heart muscle (cardiomyopathies)
• Cardiac arrhythmia
• Diabetes
• Severe overweight (obesity)
• Elevated blood lipid levels
• Lack of exercise
• Smoking
• Long-term alcohol consumption
• Drug abuse
• Certain medications, for example chemotherapeutic agents, which are used to treat cancer

The most typical and common symptoms of heart failure include:

• Shortness of breath: During exertion, but sometimes also at rest
• Exhaustion/fatigue: Even without considerable exertion
• Swollen ankles/lower legs: Fluid accumulation in the lower part of the body
• Dry cough: Especially at night

In addition, heart failure can also lead to the following symptoms:

• Nocturnal urination
• Dizziness
• Nausea, bloating, abdominal pain, constipation
• Memory disorders (also confusion in older people)
• Loss of appetite and weight loss
• Palpitations

The symptoms of heart failure can be different in women and men. Women with heart failure generally have more severe symptoms than men. They also become exhausted more quickly during exertion and are more likely to develop depression.

The symptoms of heart failure, such as shortness of breath, fatigue and fluid retention, are not specific and can also occur in other diseases. If heart failure is suspected, a physical examination is carried out first. The doctor will examine whether there are any important clinical signs of heart failure in addition to the symptoms mentioned. These include, for example:

• Increased blood pressure in the jugular vein
• A third heart sound
• Rattling noises when listening to the lungs

In addition, the doctor will take the case history at this stage of the diagnosis. For example, important factors include previous illnesses and whether close relatives (grandparents, parents) already have or had a cardiovascular disease. In addition, an electrocardiogram (ECG) is written, in which the spread of the electrical activity of the heart is measured.

If heart failure is suspected after these examinations, a blood test will follow. The B-type natriuretic peptides (BNP) or N-terminal pro-B-type natriuretic peptides (NT-proBNP) are particularly important. If these values are elevated, an echocardiography, i.e., an ultrasound examination of the heart, is performed to classify the pumping function of the heart and thus the heart failure.

Doctors use what is called NYHA classification for the clinical classification of heart failure. It was developed by the New York Heart Association (NYHA).

There are 4 NYHA stages:

• NYHA-I: No limitation of endurance; no heart failure symptoms even during exercise
• NYHA-II: Slight limitation of endurance; no heart failure symptoms at rest and during light exertion, but symptoms during greater exertion
• NYHA-III: Severe limitation of endurance; no heart failure symptoms at rest, but symptoms even during light exertion
• NYHA-IV: Permanent heart failure symptoms, even at rest

Treatment of the cause

The causes of chronic heart failure are often other diseases of the heart, such as coronary heart disease (CHD), a heart attack or cardiac arrhythmia. An important step in the treatment of heart failure is therefore always the treatment of the underlying disease.

Change of lifestyle

Another important aspect of treatment is a change in lifestyle. These aspects include:

• Exercise and sport: Regular exercise, especially endurance training (for example in a cardio sports group)
• Balanced diet: Lots of fruit and vegetables, wholegrain products, “healthy fats” and small amounts of meat, salt and sugar
• Stop smoking: Abstain from smoking
• Avoid or reduce alcohol consumption: It is best to avoid alcohol completely or minimize your alcohol consumption

Therapy with drugs

Various medications are available for the treatment of heart failure. They improve the symptoms of the disease and can reduce the risk of secondary diseases or the progression of heart failure. Various drugs are often combined for therapy.

Which medication is used to treat heart failure depends on

• the form of heart failure (with reduced or preserved ejection fraction)
• the stage (NYHA-I to NYHA-IV)
• other existing diseases, if applicable

Since heart failure is a chronic disease, it is important for the success of the therapy that the prescribed medication is taken permanently.

For people with heart failure with reduced ejection fraction, four prognosis-improving groups of drugs (renin-angiotensin system inhibitors (RASi), beta blockers, SGLT-2 inhibitors and mineralocorticoid receptor antagonists (MRA)) are available. We recommend that you discuss the possible treatment options with your attending physician and draw up an individual treatment plan.

Further therapeutic measures

If lifestyle changes and treatment with drugs are not enough, invasive therapeutic measures are used. The measures vary and depend on the underlying disease that has caused the heart failure.

If the heart failure is due to cardiac arrhythmia, it may be necessary to insert an implantable cardioverter defibrillator (ICD), for example. This is a small device that is placed under the skin and monitors the heart rhythm from there. In the event of a disorder, it emits an electrical impulse, which normalizes the rhythm again.

If the patient has coronary heart disease (CHD) with blocked blood vessels, it may be necessary to apply a vascular bypass so that the blood can circulate freely again.

Advances in the treatment of heart failure have improved the chances of survival for those affected. Nevertheless, heart failure remains a disease that is associated with a high mortality rate.