Heart failure

Introduction

Heart failure is a syndrome in which the heart is no longer able to ensure sufficient blood flow to meet the body’s needs. It manifests as shortness of breath, fatigue, and edema. This chronic condition affects more than 2% of the adult population, and nearly 10% of people over the age of 80. It is the leading cause of hospitalization after age 65. Although serious, heart failure can now be treated effectively, with a marked improvement in quality of life and life expectancy.

If you develop new shortness of breath, leg swelling, or rapid weight gain, first contact your primary care physician. If they are unavailable, Docadom offers an urgent consultation with a home doctor: call 021 845 45 45 or use our app available on the App Store and Google Play.

Who is at risk?

Heart failure mainly affects people with: a history of myocardial infarction, poorly controlled high blood pressure, coronary artery disease, valvular heart disease (aortic stenosis, mitral regurgitation), cardiomyopathies, arrhythmias (especially atrial fibrillation), diabetes, obesity, sleep apnea, chronic kidney disease, a history of cardiotoxic chemotherapy, or alcohol abuse. The risk increases significantly with age.

Symptoms of heart failure

Symptoms appear gradually and reflect congestion and reduced cardiac output.

Main symptoms

• Dyspnea: shortness of breath on exertion, then at rest in severe forms.

• Orthopnea: difficulty breathing when lying down, forcing the person to sleep with several pillows.

• Paroxysmal nocturnal dyspnea: sudden awakenings with a feeling of choking.

• Bilateral lower limb edema, pitting, worse in the evening.

• Rapid weight gain (water and sodium retention).

• Fatigue, exercise intolerance.

• Cough: dry, nocturnal, sometimes hemoptysis.

• Palpitations, feeling that the heart is racing.

• Digestive symptoms: nausea, loss of appetite, abdominal heaviness (congestive hepatomegaly).

• In advanced forms: confusion, drowsiness, oliguria.

When should you seek urgent care?

An urgent consultation is essential in the following situations:

• Sudden onset or rapid worsening of dyspnea.

• Acute pulmonary edema: severe shortness of breath, pink frothy sputum, distress — call 144 immediately.

• Associated chest pain (suspected myocardial infarction).

• Rapid palpitations that are poorly tolerated.

• Weight gain of more than 2 kg in 2-3 days.

• Massive swelling of the lower limbs.

• Syncope, malaise, hypotension, confusion.

What should you do before calling Docadom? Sit upright to make breathing easier and first contact your primary care physician, who knows your long-term treatment. If they cannot be reached or if you need a home doctor outside office hours, call Docadom at 021 845 45 45 or submit your request directly from our smartphone app (App Store and Google Play). If you have signs of acute pulmonary edema or chest pain, dial 144 without delay.

Causes of heart failure

Heart failure can be due to many underlying cardiac conditions.

Cardiac causes

• Ischemic heart disease and sequelae of myocardial infarction: leading cause.

• Chronic poorly controlled high blood pressure.

• Valvular heart disease: narrowing or regurgitation of the aortic or mitral valve.

• Dilated, hypertrophic, and restrictive cardiomyopathies.

• Chronic arrhythmias, especially atrial fibrillation.

• Congenital heart disease.

• Viral myocarditis, chronic constrictive pericarditis.

Non-cardiac causes

• Diabetes, obesity, sleep apnea.

• Chronic anemia.

• Hyperthyroidism or hypothyroidism.

• Chronic kidney disease.

• Alcohol and toxins (cocaine, amphetamines).

• Cardiotoxic chemotherapy (anthracyclines, trastuzumab).

Factors that can trigger decompensation

Stable heart failure can decompensate in the event of infection (especially pneumonia or flu), recent atrial fibrillation, too much salt in the diet, missed medication, taking NSAIDs, pulmonary embolism, or coronary ischemia.

Diagnosing heart failure

Diagnosis combines the clinical assessment, laboratory tests, and echocardiography.

Diagnostic methods

• Medical history: cardiovascular history, symptoms, risk factors, treatments.

• Clinical examination: cardiac auscultation (gallop rhythm, murmur), lung exam (crackles), search for edema, hepatomegaly, jugular venous distension, hepatojugular reflux.

• NT-proBNP / BNP measurement: key marker. A normal value makes the diagnosis unlikely.

• Electrocardiogram: rarely normal in heart failure.

• Chest X-ray: cardiomegaly, pulmonary vascular congestion.

• Transthoracic echocardiography: central examination that measures the ejection fraction and assesses systolic and diastolic function and the valves.

• Laboratory workup: complete blood count, electrolyte panel, kidney function, liver tests, TSH, ferritin, blood glucose.

• Coronary angiography or cardiac MRI as additional tests.

Alternative diagnoses

• COPD or asthma: chronic dyspnea of respiratory origin.

• Pulmonary embolism: sudden dyspnea.

• Anemia, kidney failure.

• Obesity, physical deconditioning.

• Venous insufficiency, lymphedema (isolated edema).

Treatment of heart failure

Treatment aims to relieve symptoms, slow disease progression, reduce hospitalizations, and improve survival.

Medication treatment

For heart failure with reduced ejection fraction, four groups of medications form the therapeutic foundation:

• ACE inhibitors or ARBs (enalapril, ramipril, valsartan) or ARNI (sacubitril/valsartan).

• Beta-blockers (bisoprolol, metoprolol, carvedilol).

• Mineralocorticoid receptor antagonists (spironolactone, eplerenone).

• SGLT2 inhibitors (dapagliflozin, empagliflozin).

Loop diuretics (furosemide, bumetanide) are used to relieve congestion. Other treatments may be added depending on the situation: ivabradine, digoxin, hydralazine-isosorbide.

Devices and surgery

• Cardiac resynchronization therapy (CRT) in cases of ventricular dyssynchrony.

• Implantable cardioverter-defibrillator (ICD) to prevent sudden death.

• Surgical treatment of valvular heart disease, coronary bypass surgery.

• Mechanical circulatory support or heart transplantation in end-stage cases.

Non-medication measures

• Low-salt diet (< 5 g/day).

• Limit fluid intake (1.5 to 2 L/day) in case of fluid overload.

• Regular physical activity adapted to the patient (cardiac rehabilitation).

• Smoking cessation, limiting alcohol.

• Vaccinations against flu, pneumococcus, and COVID-19.

• Daily self-monitoring: weight, edema, dyspnea.

• Therapeutic education and adherence.

Preventing heart failure

• Strict control of high blood pressure, diabetes, and cholesterol.

• Smoking cessation.

• Maintaining a healthy weight.

• Regular physical activity, at least 150 minutes per week.

• Balanced diet, low in salt and saturated fat.

• Limiting alcohol.

• Screening for and treating sleep apnea.

• Prompt treatment of a known heart attack or heart disease.

Possible complications

Acute pulmonary edema is the most feared acute complication: it requires urgent treatment. Other complications include arrhythmias (atrial fibrillation, ventricular tachycardia), sudden death, thromboembolic events (stroke, pulmonary embolism), kidney failure, cardiac cachexia, depression, and loss of independence. The mortality rate remains high, but modern treatments have clearly improved the prognosis.

When to contact a doctor for heart failure

Heart failure requires regular follow-up. If it worsens:

• First-line: contact your primary care physician or your cardiologist, who knows your treatment and can adjust the doses (especially diuretics).

• If your primary care physician is unavailable (evening, weekend, vacation), Docadom offers an urgent consultation with a home doctor. Call 021 845 45 45 or make your request through our mobile app, available free on the App Store and Google Play.

• If there are signs of severity (acute pulmonary edema, chest pain, syncope), dial 144 immediately.

Conclusion: regular follow-up changes the prognosis

Heart failure is a common chronic condition, whose causes are dominated by coronary artery disease and hypertension. It is characterized by exertional dyspnea followed by dyspnea at rest, swelling of the lower limbs, and chronic fatigue, which can lead to complications such as acute pulmonary edema, sudden death, stroke, or kidney failure. The four pillars of therapy (ACE inhibitors/ARNI, beta-blockers, mineralocorticoid antagonists, SGLT2 inhibitors) have radically changed the prognosis in recent years.

If it worsens, first contact your primary care physician. If they are not available, Docadom provides a home urgent care doctor 7 days a week: call 021 845 45 45 or use our mobile app (App Store, Google Play) to request an urgent consultation.