In heart failure the heart is no longer able to supply the body, via the blood vessels with blood on a permanent basis. The reduced pumping function means that the organs are no longer optimally supplied with blood and oxygen.
It is a complex heart condition that can run an acute or chronic course. Chronic heart failure usually develops insidiously, whereas acute heart failure occurs within a short time and can be a medical emergency.
In overview: Heart failure comprises different forms, causes and stages. It can affect the left ventricle, the right side or both ventricles. The symptoms and treatment vary according to the severity and cause. Particularly in older people, heart failure in old age is a common and serious clinical picture that deserves particular attention within Geriatrics and Medicine for the Elderly.
Physicians divide heart failure into different forms based on various characteristics:
- acute or chronic
- left or right heart failure
- systolic or diastolic heart failure
- by symptoms into different degrees of severity
If cardiac weakness begins suddenly within a few hours or days, acute cardiac weakness is present.
Anatomy of the human heart © bilderzwerg | AdobeStock
Cardiac weakness is chronic when the disease develops over months or even years.
The body can compensate for the reduced performance of the heart in chronic cardiac weakness up to a certain degree. Thus the heart muscle can thicken in order to develop a higher pumping capacity. An increased heart rate can also compensate for heart failure.
Patients with compensated heart failure frequently have symptoms only under heavy physical strain. In contrast, in decompensated cardiac weakness symptoms already occur at rest or with little physical strain.
If the left half of the heart is responsible for the cardiac weakness, left heart failure is present. Then the blood backs up in the pulmonary circulation.
In right heart failure the right half of the heart is affected by the disorder. This leads to a backup of blood in the systemic circulation.
Global heart failure shows the symptoms of both forms.
If there is a reduced pumping function of the heart muscle, systolic heart failure (heart muscle weakness) is present. If, on the other hand, the heart does not fill sufficiently despite a normal pumping capacity, this is referred to as diastolic heart failure.
The New York Heart Association (NYHA) has developed criteria for classifying cardiac weakness into stages / degrees of severity:
- In stage I there are no symptoms with normal physical strain
- In stage II there are mild symptoms (shortness of breath and weakness) with normal physical strain as well as reduced performance
- In stage III there is a considerable reduction in performance with ordinary physical strain
- In stage IV there is already shortness of breath at rest
The causes of heart failure are varied. Frequently there is a pre-existing heart disease at the root, which can permanently impair the function of the heart muscle.
The most common cause is coronary heart disease (CHD). It is often the cause of a heart attack, in which the heart no longer receives sufficient oxygen because of narrowed coronary vessels.
High blood pressure is likewise a central risk factor. Here the heart has to perform at a higher level, which the body cannot manage in the long term and which can lead to heart failure over time.
Other causes can also be the following diseases:
Lifestyle factors such as smoking, lack of exercise or being overweight are additional factors that can worsen this disease. Atrial fibrillation in old age is also a frequent trigger or amplifier of heart failure in older patients. In addition, concomitant illnesses such as diabetes in old age can increase the risk of heart failure and negatively influence its course. Likewise, an existing frailty syndrome can considerably worsen the course of the disease.
The symptoms of heart failure depend on the form of the heart failure and on the stage of the disease.
Typical symptoms of left heart failure are:
- Coughing and shortness of breath as well as
- Accumulations of water in the lungs (edema) or pulmonary edema
In right heart failure, edema typically occurs in the tissues, especially the legs and in the abdomen.
Shortness of breath is also possible. In the advanced stage, symptoms such as severe shortness of breath already occur at rest. Exercise tolerance is reduced; frequent nocturnal urination is likewise a typical symptom.
The first signs of heart failure are often non-specific and are therefore recognized late. Among the first symptoms are rapid exhaustion and shortness of breath on exertion. In older women and men these complaints can be confused with a general frailty syndrome or immobility in old age, which makes the diagnosis more difficult.
In the advanced stage, severe symptoms already occur at rest. Severe heart failure can be life-threatening.
Classification follows the New York Heart Association (NYHA) into four stages, which describe the degree of restriction of performance capacity.
The diagnosis of heart failure is made in several steps. Besides the medical history, the physical examination is an important component.
Further diagnostic measures include:
In echocardiography (which shows the function of the ventricle), a distinction is made between systolic heart failure and diastolic insufficiency, or also between heart failure with reduced ejection fraction and heart failure with preserved ejection fraction.
An X-ray image frequently also provides clues, e.g. to water retention in the lungs or an enlarged heart.
In geriatric patients, an additional geriatric assessment is advisable in order to capture the overall functional status and possible concomitant illnesses such as sarcopenia or malnutrition in old age.
A female doctor performs a resting ECG. An ECG records the heart’s impulses and shows pathological changes © Gennadiy Poznyakov / Fotolia
Heart muscle weakness is not curable. The treatment of heart failure aims to alleviate the symptoms, avoid complications and improve quality of life.
The treatment of heart failure is individual and depends on the cause and the severity of the cardiac weakness.
Depending on the underlying disease, certain medications are frequently used:
- ACE inhibitors lower blood pressure
- Beta-blockers prevent cardiac arrhythmias
- Diuretics promote the excretion of water and
- Digitalis preparations improve the pumping power of the heart
For drug therapy, the consistent intake of the prescribed medications by patients is important. Particularly in older people with several pre-existing conditions, the topic of polypharmacy in old age must be taken into account – too high a number of medications taken at the same time can cause interactions and jeopardise the success of treatment. In such cases, targeted deprescribing can be useful.
In patients with life-threatening cardiac arrhythmias, an implantable cardioverter-defibrillator (ICD) can be used. A biventricular pacemaker can also help to compensate for the cardiac weakness.
If the condition continues to worsen despite drug and invasive heart failure therapy, a heart transplant may become necessary. In older patients for whom a transplant is not an option, palliative care in old age and an advance directive drawn up early play an important role in further care planning.
The course of heart failure varies and depends heavily on the time of diagnosis and consistent treatment.
In early stages the disease can often be kept stable. In compensated heart failure, symptoms usually occur only under exertion. Without adequate treatment, however, the disease can worsen. A possible consequence of heart failure is severe restrictions in performance capacity as well as organ damage. Older patients are particularly at risk of subsequently developing depression in old age or suffering pneumonia in old age. In order to prevent falls and further consequential damage, accompanying fall prevention as well as early geriatric early rehabilitation is advisable.
Life expectancy in heart failure depends on many factors, including cause, severity and treatment success.
Specialists for heart failure are specialists in cardiology (heart diseases). For further diagnosis or specific treatment of cardiac weakness, it may be necessary to call in further specialists, such as:
- Radiologists
- Vascular and cardiac surgeons as well as
- Transplant physicians
- Specialist clinics for heart failure are usually clinics for cardiology
What are typical symptoms of heart failure?
Among the most common complaints are shortness of breath, coughing, reduced performance capacity and water retention. These symptoms can vary according to the stage.
How is heart failure diagnosed?
The diagnosis of heart failure is made through medical history, physical examination, ECG, imaging and laboratory values.
What treatment options are there?
The treatment of heart failure comprises drug therapy, technical support systems and, in severe cases, a heart transplant.
What is the life expectancy with heart failure?
Life expectancy in heart failure is individual and depends on the course, treatment and concomitant illnesses.
