About 200,000 of all Dutch people have heart failure. This is a very large number and it is estimated that this number will only increase significantly in the coming years. This is due to poorer lifestyles and the increasing aging population. People who suffer from heart failure can have serious difficulties in daily life. What exactly is heart failure and how can it develop? Is heart failure hereditary or is it possible for everyone to develop it? Furthermore, there are a number of options for investigating heart failure. Also, it is very important to know what the treatment methods are and whether it can be cured forever.

What is heart failure?

Heart failure is the condition in which the heart and circulation fail to supply all tissues with sufficient blood and nutrients. More simply, heart failure is the condition in which the heart fails to pump the entire amount of blood supplied. So the heart fails in its task. This is due to irreparable damage to the heart, which can cause all kinds of unpleasant physical consequences. These symptoms are related to the parts of the heart that no longer function properly.With a pump that is not working properly, moisture accumulates in front of the pump and too little moisture comes out. This is also the case with the heart, except that the fluid is blood. Causes of heart failure can almost always be found on the left side of the heart, because this part is the most sensitive. This is where the largest amount of muscle tissue is located, so damage to it has the most striking consequences.

Backward failure

When the left side of the heart becomes full of blood, the heart looks for a way out to get rid of the blood somewhere. The result is overfilling of the pulmonary circulation. This is called Backward failure because it goes back to the lungs. The blood vessels of the small circulatory system will then become overcrowded. This causes blood fluid to leak from the small blood vessels of the lungs. The accumulation of fluid causes someone with heart failure to become short of breath and develop a tickly cough. Patients may also become short of breath when lying flat, causing them to sleep higher on pillows and sometimes even while sitting in a chair. Excess fluid is then mainly moved to the lower parts of the lungs and the patient can then breathe better with the higher parts of the lungs, the upper lobes. The fluid from the blood also accumulates in the alveoli. This is called pulmonary edema. This creates fluid behind the lungs. This sometimes produces a soft bubbling noise in breathing.

Forward failure

The aorta will also not be sufficiently filled with blood. This is called Forward failure. The result is a deterioration of the blood flow to organs, including:

The kidneys

Due to the reduced blood flow in the kidneys, the RAAS system will be stimulated (renin-angiotensin-aldosterone system). Through a few difficult feedback loops, aldosterone will be produced by the adrenal gland. This hormone ensures reabsorption of sodium and water. This will cause the blood volume to increase, causing blood pressure to increase.

The skin

Due to reduced blood flow, the skin becomes pale-gray in color and feels cold.

The brain

Too little blood in the brain can cause fatigue, confusion and unconsciousness.

The main complaints of heart failure

• A feeling of tiredness
• Shortness of breath
• Swollen legs and ankles
• Bloating and loss of appetite, due to fluid retention
• Weight gain due to retained fluid
• Needing to urinate more often at night
• Irritating cough
• Insomnia
• Forgetfulness because the brain receives less oxygen
• Cold hands and feet due to poor blood circulation

The body therefore receives too little oxygen-rich blood. For example, patients become short of breath and tired when exercising such as climbing stairs or shopping . After all, muscles need oxygen to do their work properly. It is also typical of heart failure that people often have to get up at night to urinate or that they feel short of breath when they bend over.If the left side of the heart fails, the right side of the heart will also pump blood less well. This causes fluid accumulation in the general circulation. A different distribution of the amount of fluid in the body then occurs. First it becomes clear that the walking and sitting patient has fluid in the ankles. In patients who are lying down, it can often be seen that there is a lot of fluid under the skin of the upper legs. There is also too much blood in the veins around all kinds of abdominal organs, causing patients to experience feelings of oppression (a feeling of pressure) in the stomach area. In extreme cases, fluid can also escape into the pleural space around the lungs (hydrothorax) and into the free abdominal space (ascites).

Causes of heart failure

The medical term for heart failure is congestive heart failure. There are various causes that can cause damage to the heart (decompensation): mainly heart attacks, but also certain diseases. These causes can reduce the pumping function of the heart. The pumping function of the heart also decreases due to overload of the heart or irreparable damage to the heart muscle, such as during trauma.The pumping function of the heart is influenced by:

• The heart rate
• The contractility of the heart muscle
• The preload (this is the state of stretching of the heart muscle fibers just before the contraction of the heart starts)
• The afterload (this is the tension in the heart muscle that must be developed during contraction in order to pump out the blood)

If the heart muscle is diseased or damaged, these four factors become out of balance and therefore the pump function decreases. The body tries to compensate for this by means of an increased release of adrenaline (causes accelerated pulse and vasoconstriction and therefore higher blood pressure) and by thickening the heart muscle. But if this does not help either, decompensation occurs. Insufficient pumping of blood leads to fluid accumulation in front of or in the heart. The body also has to deal with a shortage of oxygen, which manifests itself in shortness of breath and fatigue quickly. You usually don’t get heart failure overnight. It is a gradual process, it ‘creeps’ in, as it were. Below are the main causes.

Coronary artery disorders

The biggest cause is the occurrence of one or more heart attacks due to coronary artery narrowing. The coronary arteries may be narrowed by atherosclerosis (hardening of the arteries) or spasms. Complaints can also arise from a partial or total blockage of a coronary artery due to a blood clot (thrombosis or embolism).There is no clear cause for the development of coronary heart disease. The most important factors that play a role are smoking, obesity, diabetes, high blood pressure, increased cholesterol levels in the blood and lack of exercise. 80% of all heart failure occurs as a result of coronary artery narrowing. A heart attack damages the heart muscle, causing some of its pumping power to be lost. Whether you can develop heart failure depends on the size of the infarction. This can sometimes take a while, and heart failure does not always have to occur with a small heart attack. Due to improved medical technology, more and more people are surviving a heart attack. This causes the number of patients with heart failure to increase.

High bloodpressure

In nine out of ten cases, no clear physical cause can be identified for high blood pressure. Occasionally high blood pressure is the result of a disease of the kidneys or adrenal glands. It has been shown that certain lifestyle and eating habits can have a detrimental effect on blood pressure. For example, people who smoke or are overweight are more likely to develop high blood pressure. Factors such as little exercise, excessive alcohol consumption and a lot of stress also have an unfavorable influence on this.In principle, anyone can develop high blood pressure, although it appears to be more common in certain families than others. Hereditary predisposition and/or factors in the family certainly play a role. High blood pressure can occur at any age, but as people get older, the risk increases. Up to the age of 55, high blood pressure is more common in men than in women. Above that age, women are in the majority.High blood pressure is usually not noticeable. If blood pressure is too high for a long time, this can have (sometimes serious) consequences for your health. High blood pressure can cause damage to the blood vessel walls. Fats and cholesterol easily deposit on this surface (arteriosclerosis or atherosclerosis). This allows the blood vessels to slowly narrow. Resistance in the blood vessels increases, causing the heart to work harder to pump blood. This can lead to a thickened heart muscle or ultimately to heart failure, which means that the heart can pump less blood.If a cholesterol level in the blood is too high (hypercholesterolemia ), this increases the risk of cardiovascular disease. It is therefore important that the cholesterol level goes down.Cholesterol is a fatty substance that the body needs as a building material for body cells and hormones. Without cholesterol the body cannot function properly. However, too much of it is harmful. Most cholesterol is made by the body itself in the liver, a small part is absorbed directly from the diet. Normally the body makes just enough cholesterol to function properly. Like fats, cholesterol does not dissolve well in the blood. Small balls of cholesterol are therefore surrounded by a layer of protein. In this way it is transported by the blood. The two main protein-cholesterol particles are:

• LDL: transports cholesterol to different parts of the body. Along the way, cholesterol can easily settle in the walls of arteries and cause narrowing. LDL cholesterol is therefore also called bad cholesterol.
• HDL: transports excess cholesterol to the liver. The liver then ensures that the cholesterol enters the intestines and is then excreted through the feces. HDL cholesterol is therefore also called good cholesterol.

Cardiac arrhythmias

If the heart beats too slowly or too fast for a long time, heart failure can also develop. A blockage in the conduction of stimuli can cause a rhythm that is too slow (bradycardia), causing the heart to pump too little blood. If the heart pumps rapidly and irregularly, which is called atrial fibrillation, this will also be harmful to the heart. Atrial fibrillation is often caused by a heart that is larger than normal, i.e. more or less stretched. As a result, the heart pumps out less blood than normal. Long-term cardiac arrhythmias can result in reduced muscle function and therefore reduced pump function.

Heart valve abnormalities

The heart has to work extra hard to allow enough blood to pass through the valves if heart valves are narrowed or no longer close properly. The heart muscle compensates for this by becoming thicker. The ventricle stretches and widens. The heart becomes overloaded, so the heart will lose pumping power. The heart muscle also becomes wider, because blood remains in the heart because the heart valve does not close properly. This also causes the heart to lose pumping power.

Cardiomyopathy

Disease of the heart muscle, cardiomyopathy, has only been known since the 1950s. It can be caused by alcohol, sarcoidosis (a disease in which inflammation can occur spontaneously) or, for example, hemochromatosis (where too much iron is absorbed from food). In cardiomyopathy, the heart muscle cells have an abnormal structure and function, which can cause the wall of the heart to be too weak or too thick and stiff. Sometimes the heart rhythm is also disturbed, causing the heartbeat to be irregular. In all cases, these conditions lead to the heart being less able to pump properly.

Combination

In some people, multiple causes may play a role. For example, someone may have suffered a heart attack, but at the same time also have a heart valve problem or heart rhythm disorder.

The diagnose

Chest X-ray

A chest photo is also called a chest photo. Every patient must have an x-ray taken. Patients should stand with their torso bare against a slab and breathe deeply and hold their breath. In the photo you can see the contours of the heart and see whether the heart is too large, whether the blood vessels of the lungs are overcrowded and whether there is fluid in the lungs.

Blood tests

Patients also often need to have blood tests done. This allows one to deduce which organs are not functioning properly due to heart failure. Nowadays it can also be determined that certain substances are formed to an increased extent in the heart muscle in the event of heart failure. Blood tests are also done during the treatment of heart failure, for example to monitor kidney function and the salt content of the body, so that it can be determined whether the dosage of the medicines is correct or whether the body tolerates the medicines well.

ECG or electrocardiogram

An electrocardiogram is also called an ECG. An ECG device measures the currents that the heart itself generates and creates a graph. The current is transmitted to the measuring equipment via stickers on the torso. This creates a pattern on the paper in which you can see when the blood flows through the chambers and atria and is pumped out. The cardiologist can deduce from this, for example, that someone has had a heart attack, or that there is a shortage of oxygen in the heart muscle or a thickening of the heart muscle. The abnormality itself can be determined by looking at the ECG, but more research is often required to identify the cause. The actual examination is painless and only takes five minutes.

Tracer exercise research

A small safe amount of radioactive substance (isotopes) is injected into the blood in a vein in the arm or hand. By measuring radioactivity you can see how blood flows through the heart. One can thus make images of the heart. The healthy parts of the heart absorb more of the substance and therefore emit more radiation than the damaged parts. First, an ECG is made of the heart and an IV is placed in the arm or hand. This is followed by the exercise test. At the moment of maximum effort, the isotope (the radioactive substance) is injected into the infusion. After this exercise test, the patient must lie on an examination table and a large camera will rotate around the table. This camera records the radiation from the heart and creates a three-dimensional map of it. This shows the different areas with different degrees of radiation activity. Later in the day, or after a few days, these photos are taken again, only this time at rest. These two series of images are compared and it can be determined exactly which part of the heart receives too little blood during exercise and whether there has ever been a heart attack.

Echocardiogram

Echocardiography is a test in which the structures of a beating heart are imaged using ultrasonic vibrations (sound waves with very high frequencies). This imaging is possible because the heart reflects the sound waves.There are two types of echocardiograms. One is via the chest (external) and the other via the esophagus. With the external cardiogram, a kind of microphone is placed on the chest when the patient lies on the left side or on the back. The resulting images give an impression of the size of the heart chambers, the pump function, the thickness of the heart muscle and the functioning of the heart valves. In this way, both leaking and narrowed heart valves can be detected. This examination takes twenty minutes to half an hour.The examination through the esophagus is only performed if other examinations provide insufficient information. Because the esophagus is closer to the heart , the ultrasound is made from this location. Before inserting the tube with the ultrasound crystal, the throat is anesthetized with a spray. This makes the throat insensitive and makes swallowing more difficult. This ultrasound works in the same way as the ultrasound through the chest.

Exercise research

An exercise test, also called an exercise tolerance test, determines the heart function and the response of the heart to physical exertion. During such an examination, the patient walks on a treadmill or rides an exercise bike while breathing through a special device. This keeps track of how much oxygen is absorbed and how much carbon dioxide is exhaled. The activity is measured by means of an ECG. If a narrowing of one of the coronary arteries causes a local oxygen deficiency in the heart muscle during exercise, this can usually be seen on the ECG. An ECG is also made for the exercise test. Furthermore, the patient’s heart rate and blood pressure are measured during the examination. The entire investigation takes about half an hour.

Cardiac catheterization

During a cardiac catheterization, a tube is passed from the groin (the elbow crease), the neck or via an artery in the wrist to the heart. Once in position, the blood pressure in different parts of the heart and arteries can be measured via this catheter. The amount of blood that the heart pumps out per minute can also be measured. A dye (contrast agent) can also be injected so that the blood flow in the coronary arteries can be monitored so that any blockages or narrowings can be detected. This is visualized by X-rays. If the catheter has been inserted in the groin, you should only get up after a few hours, because cardiac catheterization can cause nausea.

Influence of lifestyle on heart failure

Education

It is very important that patients receive a lot of professional information about the condition itself and the importance of the treatments. Self-care is a very important part when it comes to successful treatment of heart failure. This is good for maintaining optimal physical condition, avoiding behaviors that could adversely affect the disease and noticing early symptoms of deterioration. That is why active involvement of the heart failure patient is a prerequisite. It is also important that family and caregivers are involved in the information. Important aspects are: repeating the information and implementing the rules of life. In addition to verbal information, the patient also receives information on paper. A special site has also been set up for patients and families: www.heartfailurematters.org

Food and drink

It is very important what you eat, but also how you eat and when you eat. In some heart failure patients there is congestion in the liver and fluid accumulation in the abdomen. Too much strain on the heart results in a heart that functions poorly. Sometimes the pressure in the heart cavities and vascular system increases, resulting in fluid accumulation in body tissues. This can give you the feeling that you are constantly full. It is then better to eat small, easily digestible portions several times a day, instead of three regular meals. It is also important to eat a varied diet. It is important to eat from each of the following four groups every day:

• Bread, potatoes, rice, pasta, legumes
• Vegetables and fruit
• Semi-skimmed or skimmed milk and milk products
• Halvarine, margarine and other spreads for bread with less than 17g saturated fat per 100g, oil

It is very important that someone with heart failure greatly reduces their salt intake. Salt contains sodium and this retains moisture. The salt that your body naturally needs is already in the food you normally eat. When you eat a varied diet, any salt you add is unnecessary and therefore too much. It is important that you eat a sufficiently varied diet so that you get the most important vitamins, proteins and minerals. The human body consists largely (70%) of water. This is refreshed daily. You take in fluid when you eat and drink, while at the same time you lose fluid through urine, perspiration and water vapor in your exhalation.In the body, fluid is distributed through the circulatory system, with the heart as the main worker. Major fluctuations in daily fluid intake place a great deal of strain on the heart. In heart failure, the heart pump is not always able to cope with this large increase; there is too little reserve pump power. It is therefore advisable for people with heart failure to consume approximately the same amount of fluid per day to avoid large fluctuations. Usually about 2 liters is recommended.Sometimes the heart is so weak that fluid restriction is necessary. This means that a patient is usually not allowed to ingest more than 1.5 liters of fluid. The fluid you ingest through products such as yogurt and soup must be included. Fluid restriction, together with the water tablets, ensures that there is less fluid in the bloodstream than normal. This is better than when there is too much fluid in the bloodstream, because you then get fluid in the lungs, for example, which can cause shortness of breath.

Movement

Especially if you have heart failure, it is very important to exercise well and often. If a heart failure patient does not move much, the muscles, lungs, heart and blood vessels no longer become accustomed to working. When they do have to go to work, they have difficulty doing so. This is clearly noticeable by the patient: he or she quickly gets out of breath and gets tired quickly. Because this hardly promotes motivation to start exercising again, it is very important for the team guiding the patient to continue to encourage the patient. When there is enough exercise, the muscles, heart, lungs and blood vessels are used to working. This makes the patient feel fitter and has more energy. It also keeps his heart and blood vessels in good condition, so that the chance of relapse or deterioration is smaller. Finally, exercise has a blood pressure-lowering effect, which reduces the risk of cardiovascular disease and therefore the risk of stroke.It is important that every heart failure patient exercises in the way that is right for him or her. A moderate to reasonable effort is different for one person than for another. The point is that the heart and blood vessels are immediately put to work properly. The patient and his supervisor will therefore have to find out for themselves what level of exercise has the desired effect for that patient. There are four rules of thumb.The patient is comfortable with the level of exertion if :

• This one has to breathe quite a bit
• It makes the heart beat faster

What should not be the case is the following :

• That the patient becomes so out of breath that he or she is no longer able to speak during the effort
• That the patient needs a long time to recover

The amount of exercise must be built up gradually. This can be introduced into the daily routine: taking the stairs instead of the elevator, running errands by bike instead of by car.

Weight and obesity

It is always wise to keep a close eye on your body weight. Being overweight means overloading the heart. When someone with heart failure gains more than 2 kg in weight in a few days, while still eating normally, the body is probably retaining fluid.Excess weight that is not due to fluid retention is also an extra burden on the heart. The more overweight, the higher the risk of cardiovascular disease. This is partly because obesity increases the cholesterol level in the blood. In addition, it increases the risk of an incorrect ratio between good and bad cholesterol. A lot of cholesterol can cause plaques to form in the arteries. Damage to the inside of your blood vessel walls is constantly being repaired. Over time, fatty substances stick to places with small, unrepaired damage, especially in the arteries. These are plaques. Because they narrow the blood vessels, the blood cannot flow through them as well. As a result, the heart has to pump harder to get blood to the desired places. The risk of heart failure is therefore increased here. It is therefore very important that your patients are adherent to therapy, so that they can maintain their condition. The picture shows what plaque actually means.The body needs energy. That energy is obtained from food. The supply and consumption must be in balance. Those who eat too much and/or exercise too little become fatter. The surplus of energy is stored in the body in the form of fat. If you move more, the motor runs faster, so more energy is used. More exercise is therefore very important if someone wants to improve his or her weight. In addition, exercise keeps the heart and blood vessels in good condition. The three most important changes you need to make if you are overweight are:

• Change in eating habits
• Move more
• Ensure that no eating problems arise (such as eating large portions quickly in a short period of time without others noticing, then fasting again, using laxatives, pinching your finger)

Smoking and alcohol

It is of course better for everyone’s health not to smoke and not to use drugs. Smoking is the most important risk factor for a (possible subsequent) heart attack. Nicotine and carbon monoxide contained in tobacco smoke are the main causes. Nicotine attacks the blood vessel walls, which promotes the development of narrowing in the blood vessels. Carbon monoxide binds to the red blood cells and is almost impossible to let go. As a result, the blood cells can transport less or even no oxygen. This causes the body, but also the heart, to lack oxygen. Blood clots can also form that can break loose. When these get stuck somewhere in the blood vessel and cut off the blood supply, an infarction occurs. Three facts are known about smokers in connection with cardiovascular disease:

• Smokers are twice as likely to have a heart attack than non-smokers.
• Smokers are much more likely to suffer a stroke than non-smokers.
• Smokers are more likely to suffer from narrowing of the arteries in the legs (window legs) than non-smokers. Then one has pain in the legs when walking a short distance.

Quitting smoking is therefore always very useful. It also turns out that passive smoking is very bad. Since the ban on smoking in public spaces, the number of heart attacks caused by smoking has decreased.Scientific research also shows that there are fewer heart attacks among moderate drinkers than among non-drinkers; they die less often from a heart attack than those who do not drink. Explanations for this are : beneficial effects on blood, cholesterol levels and blood clotting. However, drinking more than three glasses of alcohol per day increases blood pressure. This can take more serious forms; heart and blood vessels will suffer. Because alcohol can also have a negative effect on muscles in our body, the heart muscle can also be damaged. Excessive alcohol consumption has a lot to do with the muscles. Alcohol dilates the blood vessels, so the heart has to make a greater effort to pump enough blood. The vasodilation reduces blood circulation in the muscles. This causes the quality of the muscles to deteriorate and muscle damage can occur. Furthermore, alcohol forms extra lactic acid. Lactic acid causes people to suffer from tired and stiff muscles for a long time. This results in severe muscle pain and cramps, especially in the calves.