Heart Failure – Causes, Symptoms and Treatment

What is Heart Failure?

Heart failure is a complex clinical syndrome in which the heart is unable to pump a sufficient amount of blood to meet the metabolic demands of the body. This may be due to a weakened pumping function of the heart muscle or to impaired filling of the heart chambers. Heart failure is one of the most prevalent cardiovascular conditions worldwide and is a leading cause of hospitalization, particularly among older adults.

Causes

Heart failure most commonly develops as a consequence of other underlying heart conditions or systemic diseases that place long-term strain on the heart. The most frequent causes include:

• Coronary artery disease (CAD): Narrowing of the coronary arteries reduces blood supply to the heart muscle.
• Myocardial infarction (heart attack): Scarred heart muscle tissue permanently reduces pumping capacity.
• High blood pressure (arterial hypertension): Chronically elevated blood pressure forces the heart to work harder, leading to thickening of the heart wall.
• Heart valve disease: Defective valves disrupt normal blood flow and overload the heart.
• Cardiomyopathies: Primary diseases of the heart muscle, caused by viral infections, alcohol abuse, or genetic factors.
• Cardiac arrhythmias: Persistent rhythm disturbances such as atrial fibrillation can impair cardiac function.
• Diabetes mellitus and obesity: Metabolic disorders significantly increase the risk of developing heart failure.

Symptoms

The symptoms of heart failure result from inadequate blood supply to the body and the backup of fluid into the lungs or venous system:

• Shortness of breath (dyspnea): Initially during exertion, and in advanced stages also at rest or when lying down (orthopnea).
• Fluid retention (edema): Particularly in the legs, ankles, and abdomen.
• Fatigue and reduced exercise tolerance: Rapid exhaustion even with everyday activities.
• Cough and breathlessness: Often caused by fluid accumulation in the lungs (pulmonary edema).
• Rapid or irregular heartbeat: A compensatory response to reduced cardiac output.
• Unexplained weight gain: Due to fluid retention, often occurring rapidly over days.

Classification

Heart failure is graded according to the NYHA classification (New York Heart Association) into four functional classes:

• NYHA Class I: No symptoms during ordinary physical activity.
• NYHA Class II: Symptoms occur with moderate exertion.
• NYHA Class III: Symptoms occur with minimal exertion.
• NYHA Class IV: Symptoms at rest; any physical activity causes discomfort.

Heart failure is also classified by ejection fraction into HFrEF (heart failure with reduced ejection fraction) and HFpEF (heart failure with preserved ejection fraction).

Diagnosis

Diagnosis of heart failure involves a combination of clinical assessment and diagnostic tests:

• Medical history and physical examination: Review of symptoms and auscultation of the heart and lungs.
• ECG (electrocardiogram): Records electrical activity of the heart to detect arrhythmias or previous heart attacks.
• Echocardiography: Ultrasound imaging of the heart to assess pumping function, heart size, and valve performance.
• Blood tests: Elevated levels of BNP and NT-proBNP are specific biomarkers for heart failure.
• Chest X-ray: May reveal an enlarged heart or signs of pulmonary congestion.
• Exercise stress test: Evaluates cardiac function and exercise tolerance.

Treatment

The treatment of heart failure combines pharmacological, non-pharmacological, and interventional approaches aimed at relieving symptoms, improving quality of life, and slowing disease progression.

Pharmacological Treatment

• ACE inhibitors / Angiotensin receptor blockers (ARBs): Reduce cardiac workload and improve survival outcomes.
• Beta-blockers: Lower heart rate and protect the heart muscle from further damage.
• Aldosterone antagonists (e.g., spironolactone): Reduce fluid retention and decrease cardiac stress.
• SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin): Newer agents with proven benefits in heart failure management.
• Diuretics: Promote fluid excretion to relieve edema and breathlessness.

Non-pharmacological Measures

• Regular, tailored physical activity and cardiac rehabilitation
• Low-sodium diet and fluid management
• Daily weight monitoring to detect fluid retention early
• Smoking cessation and reduction of alcohol consumption

Interventional and Surgical Therapy

• ICD implantation (implantable cardioverter-defibrillator): Protects against sudden cardiac death.
• Cardiac resynchronization therapy (CRT): Improves coordination of heart contractions using a specialized pacemaker.
• Heart transplantation: Considered for patients with severe, refractory heart failure as a last resort.

Prognosis and Prevention

The prognosis of heart failure depends on its severity, underlying cause, and adherence to treatment. Early diagnosis and consistent therapy can significantly slow disease progression and improve quality of life. Preventive strategies include maintaining a healthy lifestyle, controlling risk factors such as high blood pressure, diabetes, and elevated cholesterol, and attending regular medical check-ups.

References

1. McDonagh T.A. et al. - 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 2021.
2. World Health Organization (WHO) - Cardiovascular Diseases. www.who.int, 2023.
3. Yancy C.W. et al. - 2013 ACCF/AHA Guideline for the Management of Heart Failure. Journal of the American College of Cardiology, 2013.