Definition and symptoms of heart failure

About the heart

The heart is a hollow organ, located in the thorax, between the lungs and resting on

the diaphragm. Its function is to propel blood to all the organs of the body.

It pumps nearly 5 liters of blood per minute, and it will beat about 3 billion times during

of a life. This organ is divided into 4 cavities:

• 2 upper cavities, the right and left atria separated by the inter septum

ear.

• 2 lower chambers, the right and left ventricles separated by the septum

interventricular.

The atria communicate with the ventricles via the atrioventricular orifices. THE

right heart is composed of a right atrium and a right ventricle communicating by

the tricuspid orifice. The left heart consists of an atrium and a ventricle

left communicating through the mitral orifice.

The heart rate is enabled thanks to 3 main phases:

• A relaxation phase called diastole allowing the filling of the cavities

cardiac through blood;

• A phase of contraction called systole which is characterized by an increase in the

intracavitary pressure;

• A phase of blood ejection into the circulatory network.

What is heart failure?

Heart failure is the inability of the heart to keep blood flowing

sufficient to satisfy the needs of the different organs of the body. It's about a

alteration of the “pump function” of the heart which results in lowered blood flow,

low blood pressures, fluid accumulation with high blood pressures

upstream.

Heart failure may predominantly involve:

• the left heart, we then speak of left heart failure

• the right heart, we then speak of right heart failure

This condition can occur suddenly, which defines acute insufficiency (at the end

endocarditis, mitral insufficiency due to cord rupture or infarction of the

myocardium), or involve a slowly evolving process, this is heart failure

chronic.

Two main types of dysfunction are distinguished:

• Heart failure with systolic dysfunction corresponding to a reduction in

contractile capacity of the heart and therefore of blood ejection.

• Heart failure with diastolic dysfunction resulting in abnormalities of

relaxation of the ventricles which alters their filling which will be slowed or

incomplete.

To know ! Preload represents end-diastolic blood volume (at the end of diastole)

of the ventricle intended to be ejected during systole. Afterload is the force opposing

ejection of blood from the ventricle; the left heart pumps against blood pressure

systemic while the right heart pumps against pulmonary arterial pressure

Heart failure can be caused by:

1. An obstacle to the ejection of blood from the ventricle. We are talking about an increase in

afterload which will rather result in hypertrophy of the ventricle. By

example, during aortic stenosis or during cardiomyopathy

hypertensive.

Concerning the right heart, pulmonary arterial hypertension is a cause

significant right heart failure due to increased afterload. It is

a serious vascular disease, characterized by an increase in resistance

pulmonary arteries.

2. An increase in the volume of blood in the ventricle at the time of ejection

corresponding to the increase in preload. This mainly leads to a

dilatation of the ventricle. For example, in case of mitral regurgitation (reflux of blood

in the left atrium), aortic insufficiency (reflux of blood into the ventricle

left), or tricuspid insufficiency (backflow of blood into the right ventricle)

concerning the right heart.

3. Damage to muscle fibers and the ability of the myocardium to contract.

This damage most often results in dilatation of the ventricle. Notably,

at the level of the left and right heart during a myocardial infarction: after an infarction

of the myocardium, certain areas of the heart have become ineffective and contract poorly

and during cardiomyopathy of the left or right ventricle.

4. Difficulties filling the ventricles as in cardiomyopathy

hypertrophic.

Myocardial dilation is frequently associated with a reduction in contractile capacity

(systolic dysfunction) while hypertrophy is classically linked to difficulty in

relaxation and/or filling of the ventricles (diastolic dysfunction). This is the

mostly a continuum with coexistence of hypertrophy and dilatation

corresponding to myocardial remodeling. This remodeling corresponds to one of the

adaptive and compensatory phenomena implemented by the myocardium; phenomenon which

term will be exceeded and will become deleterious for the functioning of the heart.

Symptoms of heart failure

In case of left heart failure:

Upstream of the left ventricle, an increase in pressure in the left atrium then in

the pulmonary capillaries produce a passage of liquid (from the blood) towards the alveoli

pulmonary problems leading to sudden breathing difficulties such as dyspnea (shortness of breath)

with the appearance of foamy and pink sputum concretizing the picture of acute edema

of the lung.

Several stages of dyspnea exist according to the NYHA (New York Heart) classification.

Association) :

1. Stage I: dyspnea for significant unusual efforts, no discomfort in life

current

2. Stage II: dyspnea for major efforts in everyday life

3. Stage III: dyspnea for modest efforts in everyday life

4. Stage IV: permanent dyspnea at rest

Patients may also have difficulty sleeping while lying down because dyspnea

is accentuated. We then speak of orthopnea, rated by the number of pillows used by the patient.

to raise yourself into a semi-sitting position, thus reducing venous return and therefore the

preload.

Signs of cardiac asthma may appear corresponding to a slowing of

respiratory rate (or bradypnea) predominantly expiratory.

Downstream of the left ventricle, the reduction in blood flow (i.e. the deficit in irrigation of the

different organs) causes asthenia (or great fatigue), hypotension,

kidney failure (with oliguria: decrease in urine volume) or even

cognitive function disorders.

In case of right heart failure

In case of right heart failure, clinical manifestations are due to:

1. Venous stasis (stagnation of blood in the veins) which presents with

Edema of the lower limbs, ascites (accumulation of fluid in the abdomen),

hepatomegaly and hepatalgia (heaviness felt in the liver), turgor

jugular (swelling of the jugular vein), renal stasis, and effusions

pleural (presence of fluid between the layers of the pleura).

2. Low flow which results in exercise intolerance and dyspnea.

Diagnosis and treatment of heart failure

What diagnosis?

After examining the patient's clinical signs, the doctor may prescribe a set

explorations, the main ones of which are the following:

1. The electrocardiogram (ECG) can highlight rhythm disturbances

or conduction, signs of left ventricular hypertrophy or even

after-effects of heart attack;

2. Chest x-ray can reveal cardiomegaly

(increase in heart size), signs of pulmonary stasis (alveolar edema)

or even pleural effusions;

3. Echocardiography makes it possible in particular to assess systolic function with the

key parameter of left ventricular ejection fraction (LVEF); a

Systolic dysfunction will appear for LVEF values < 45%. Function

diastolic is investigated by measuring in particular the filling pressures of the

ventricles;

4. Biological examination: We mainly measure the level of natriuretic factor of

type B or BNP. BNP is a peptide synthesized by ventricular myocytes

cardiac during elevation of left ventricular pressures and stretching

cardiomyocytes. Its elevation in the blood is a marker of insufficiency

cardiac A BNP less than 100 pg/mL makes it possible to eliminate with great

probability of diagnosis of heart failure. On the other hand, this diagnosis is very

probable when BNP is greater than 400 pg/mL.

What treatment?

The first steps to take after the diagnosis of heart failure are

hygienic-dietary:

1. Avoid any self-medication, particularly non-inflammatory anti-inflammatories

steroids;

2. Reduce salt consumption;

3. Limit the consumption of foods rich in salt (cold meats, cheeses, bread,

preserves, etc.) and certain medications (effervescent forms, etc.);

4. Adopt a Mediterranean diet by balancing the calorie balance;

5. Eliminate alcohol consumption;

6. Reduce cardiovascular risk factors (balancing diabetes, controlling

dyslipidemia, high blood pressure, smoking cessation, etc.)

7. Control your weight;

8. Practice physical activity adapted to your possibilities and preferences, in

agreement with your doctor;

9. Get vaccinated: the flu vaccine every year and the pneumococcal vaccine

every 5 years because respiratory infections are triggering factors for

cardiac decompensation.

The treatment of heart failure is based on treating its cause and

factors favoring decompensation.

Treatments for heart failure aim to facilitate the work of the heart, by

reducing the volume of blood to be ejected at each systole (preload) or the resistance to

ejection (afterload). Enzyme-converting enzyme inhibitors (ACEI), Sartans

(angiotensin II receptor inhibitor) or even diuretics are the main

treatments for heart failure.

ACE inhibitors are prescribed as first-line treatment in all patients with

systolic dysfunction. They improve survival, symptoms and reduce

hospitalizations. In the event of poor tolerance to IEC, which may manifest itself in particular by

a dry cough, Sartans represent a therapeutic alternative.

Diuretics are mainly prescribed for symptomatic purposes to reduce

dyspnea or edema, particularly in cases of cardiac decompensation.

Aldosterone receptor antagonists have demonstrated their effectiveness in reducing

mortality in post-infarction complicated by heart failure with dysfunction

left systolic or in moderate to severe heart failure patients, in addition to

standard treatments with ACE inhibitor and β-blocker.

Heart transplantation is indicated in young subjects (‹ 65 years old) presenting

severe heart failure with left ventricular dysfunction refractory to

drug treatments. The major problem with this alternative remains the lack of

grafts available.

Several medical devices can support the heart using electrical impulses

to maintain a regular beat and improve heart function. It's the case

pacemakers, automatic defibrillators, assistive devices

circulatory systems and more recently the artificial heart still under study.

Published on December 22, 2015. Updated by Charline D., Doctor of Pharmacy, August 2

2021.

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