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Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and oxygen. Basically, the heart can’t keep up with its workload. At first the heart tries to make up for this by:
Enlarging. The heart stretches to contract more strongly and keep up with the demand to pump more blood. Over time this causes the heart to become enlarged.
Developing more muscle mass. The increase in muscle mass occurs because the contracting cells of the heart get bigger. This lets the heart pump more strongly, at least initially.
Pumping faster. This helps increase the heart’s output.
The body also tries to compensate in other ways:
The blood vessels narrow to keep blood pressure up, trying to make up for the heart’s loss of power.
The body diverts blood away from less important tissues and organs (like the kidneys), the heart and brain.
These temporary measures mask the problem of heart failure, but they don’t solve it. Heart failure continues and worsens until these compensating processes no longer work.
Eventually the heart and body just can’t keep up, and the person experiences the fatigue, breathing problems or other symptoms that usually prompt a trip to the doctor.
he body’s compensation mechanisms help explain why some people may not become aware of their condition until years after their heart begins its decline. (It's also a good reason to have a regular checkup with your doctor.)
Heart failure can involve the heart’s left side, right side or both sides. However, it usually affects the left side first.
In order to determine if you have heart failure, your doctor needs to know about your symptoms and medical history. Your doctor will ask you about things such as:
Other health conditions you have, such as diabetes, kidney disease, chest pain (angina), high blood pressure, high cholesterol, coronary artery disease, or other heart problems
If you have a family history of heart disease or sudden death
If you smoke or use tobacco
How much alcohol you drink
If you have had chemotherapy and/or radiation
The medications you take
You will also have a physical exam. Your doctor will look for signs of heart failure and diseases that may have caused your heart muscle to become weak or stiff.
What types of tests are used to diagnose heart failure?
You will have tests to see how bad your heart failure is and what caused it. Common tests include:
Blood tests help us understand how well your kidneys and thyroid are working. We will check your cholesterol and red blood cell levels for high cholesterol and anemia. Anemia means the hemoglobin (HE-mo-globe-in) level in your blood is lower than normal. Hemoglobin is the part of your red blood cells that makes it possible for blood to carry oxygen through the body. Low hemoglobin levels cause you to be tired and have other symptoms that are similar to those of heart failure.
NT-pro**B-type Natriuretic Peptide (BNP) blood test**. BNP is a hormone that is released into the blood by the lower chambers of the heart (ventricles) in people with heart failure. NT-pro BNP is an inactive molecule that is released in the blood with BNP. The level changes based on how severe your heart failure is. Higher levels of NT-pro BNP mean the ventricles are more stressed. Low levels mean your heart failure is stable. If you have shortness of breath, the level of NT-pro BNP in your blood can help your doctor know if it is caused by heart failure. A level of more than 450 pg/mL for patients under age 50 or 900 pg/mL for patients 50 and older could mean you have heart failure.
Cardiac Catheterization. If you are scheduled for a catheterization, your doctor may check your EF during the procedure. A catheterization lets your doctor check your heart from the inside. A long, thin tube called a catheter is inserted into an artery in your arm or leg. The doctor uses a special X-ray machine to guide the catheter to your heart. There are two types of cardiac catheterization — left and right. If you have a left heart catheterization, your doctor may inject dye to record videos of your heart valves, coronary arteries and heart chambers (atria and ventricles). A right heart catheterization does not use dye; it lets your doctor know how well your heart is pumping blood.
Chest x-ray shows the size of your heart and any fluid build-up around your heart and lungs.
Echocardiogram (echo). This is an ultrasound to see how well your heart can pump and relax, to check your heart valves, measure your heart and check blood flow. Images are captured using an ultrasound wand that is moved around on the skin of your chest. An echo is often done with a Doppler test so your doctor can see changes in the pressure inside your heart chambers and in the way your blood flows across your heart valves. This is the most common way to determine your EF.
Ejection fraction (EF). Your EF is a measurement of the blood pumped out of your heart with each beat. Your EF can be measured using an echocardiogram (echo), multigated acquisition (MUGA) scan, nuclear stress test, magnetic resonance imaging (MRI) or during a cardiac catheterization. Ejection fraction is reported as a percentage. A normal EF is between 55% and 70%. Your EF can get better or worse based on how stable your heart failure is and how well your treatment for heart failure is working. It is important for your doctor to know your EF. You should have your EF measured when you are diagnosed with heart failure and as often as your doctor recommends.
Electrocardiogram (EKG or ECG). This test records the electrical activity in your heart by using electrodes that are connected with wires to an electrocardiograph monitor. Electrodes are small sticky patches that are placed on your body. The wires carry information to the monitor, and it creates a graph to show the electrical activity.
Multigated Acquisition Scan (MUGA scan) . This test shows your doctor how well the lower chambers of your heart (ventricles) are pumping blood. A small amount of a radioactive dye is injected into a vein. A special camera (gamma camera) is used to create video of your heart as it beats.
Stress test. This test shows how your heart reacts to stress. You will likely exercise on a treadmill or stationary bike at different levels of difficulty while your heart rate, electrocardiograph and blood pressure are recorded. If you cannot exercise, medication may be used to create the same effect as exercise on your heart (pharmacological stress test).
Other tests may be needed, depending on your condition.
Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and symptoms of heart failure can improve, and the heart sometimes becomes stronger. Treatment may help you live longer and reduce your chance of dying suddenly.
Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, the treatment of heart failure involves a balance of the right medications and, in some cases, use of devices that help the heart beat and contract properly.
Doctors usually treat heart failure with a combination of medications. Depending on your symptoms, you might take one or more medications, including:
Angiotensin-converting enzyme (ACE) inhibitors. These drugs help people with systolic heart failure live longer and feel better. ACE inhibitors are a type of vasodilator, a drug that widens blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart. Examples include enalapril (Vasotec), lisinopril (Zestril) and captopril (Capoten).
Angiotensin II receptor blockers. These drugs, which include losartan (Cozaar) and valsartan (Diovan), have many of the same benefits as ACE inhibitors. They may be an alternative for people who can't tolerate ACE inhibitors.
Beta blockers. This class of drugs not only slows your heart rate and reduces blood pressure but also limits or reverses some of the damage to your heart if you have systolic heart failure. Examples include carvedilol (Coreg), metoprolol (Lopressor) and bisoprolol (Zebeta).
These medicines reduce the risk of some abnormal heart rhythms and lessen your chance of dying unexpectedly. Beta blockers may reduce signs and symptoms of heart failure, improve heart function, and help you live longer.
Diuretics. Often called water pills, diuretics make you urinate more frequently and keep fluid from collecting in your body. Diuretics, such as furosemide (Lasix), also decrease fluid in your lungs so you can breathe more easily.
Because diuretics make your body lose potassium and magnesium, your doctor may also prescribe supplements of these minerals. If you're taking a diuretic, your doctor will likely monitor levels of potassium and magnesium in your blood through regular blood tests.
Aldosterone antagonists. These drugs include spironolactone (Aldactone) and eplerenone (Inspra). These are potassium-sparing diuretics, which also have additional properties that may help people with severe systolic heart failure live longer.
Unlike some other diuretics, spironolactone and eplerenone can raise the level of potassium in your blood to dangerous levels, so talk to your doctor if increased potassium is a concern, and learn if you need to modify your intake of food that's high in potassium.
Inotropes. These are intravenous medications used in people with severe heart failure in the hospital to improve heart pumping function and maintain blood pressure.
Digoxin (Lanoxin). This drug, also referred to as digitalis, increases the strength of your heart muscle contractions. It also tends to slow the heartbeat. Digoxin reduces heart failure symptoms in systolic heart failure. It may be more likely to be given to someone with a heart rhythm problem, such as atrial fibrillation.
You may need to take two or more medications to treat heart failure. Your doctor may prescribe other heart medications as well — such as nitrates for chest pain, a statin to lower cholesterol or blood-thinning medications to help prevent blood clots — along with heart failure medications. Your doctor may need to adjust your doses frequently, especially when you've just started a new medication or when your condition is worsening.
You may be hospitalized if you have a flare-up of heart failure symptoms. While in the hospital, you may receive additional medications to help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen through a mask or small tubes placed in your nose. If you have severe heart failure, you may need to use supplemental oxygen long term.
isosorbide dinitrate Off-label
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