This insufficiency is a very common condition, affecting more than 5% of people over 70 years old.
In most cases, it is a chronic condition that must be monitored and treated throughout life.
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What are the causes of heart failure?
Heart failure can be caused by several causes, the most common being:
- high blood pressure (hypertension), especially if not treated: this increases the work of the heart, which over time can increase in size (that is, develop hypertrophy) and fatigue;
- coronary artery disease (disease of the arteries that carry arterial blood to the heart muscle), especially if it has resulted in one or more heart attacks, which have impaired the heart’s ability to contract;
- diseases of the heart muscle (myocardiopathies or cardiomyopathies), most often of unknown origin, less often they can be a consequence of ingesting substances toxic to the heart (for example, excessive alcoholic beverages or certain drugs used in cancer therapy) or viral infections (myocarditis); there are also forms with hereditary characteristics (familial cardiomyopathies)
- diseases of the heart valves (valvulopathies) and malformations of the heart present from birth (congenital heart defects), which cause an increase in the work of the heart and/or alteration (excess or deficiency) of the flow in the pulmonary vessels.
What are the disorders caused by heart failure?
The main complaints (symptoms) caused by heart failure are:
- tiredness (asthenia), easy fatigability, reduced capacity for physical exertion and, in more advanced forms, even lighter activities (eg, getting dressed);
- shortness of breath and shortness of breath (dyspnea) during exertion (intense, medium or mild, depending on the degree of the disease), or even at rest; characteristic of heart failure is difficulty breathing in the lying position, which improves in the sitting position or makes it necessary to use 2 or more pillows to sleep;
- swelling (edema) due to accumulation of fluid in the soft tissues of the legs; can be noticeable (shoes feel tight, socks leave a mark), but can sometimes be recognized just by noticing that pressing with fingers around the ankle or front of the leg leaves a mark; manifests itself mainly at night
- the feeling of abdominal bloating (sometimes with pain in the pit of the stomach or on the right side, appearing during physical activity or even after light meals) due to digestive difficulties as a result of reduced blood supply to the digestive system and fluid buildup in the liver;
- the feeling of palpitations, fast heartbeat (tachycardia) or slow heartbeat (bradycardia) or irregular heartbeat (arrhythmia);
- dizziness or vertigo, usually unconcerned if short-lived or associated with moving from lying down or sitting to standing; to be communicated immediately to the doctor if regardless of the change in position and associated with acceleration, slowness or irregular heartbeats.
How is heart failure treated?
Heart failure is, in most cases, a chronic condition; therefore, it deserves follow-up and treatment throughout life.
Only in some cases (for example, surgery for a valvular disease that has not yet resulted in irreversible damage to the heart muscle) is it possible to recover permanently.
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The aim of treatment is to prolong life and improve the quality of life of patients with heart failure.
The treatment of heart failure is based on medication and some non-pharmacological treatments, the most important being some heart surgeries and, recently, the application of electrical devices such as defibrillators and pacemakers.
The adoption of an appropriate lifestyle is an integral part of the therapeutic program, both in terms of general cardiovascular prevention measures and in respect of some specific rules (reduction in salt intake, limitation of water intake and water intake in general), which in the subject with heart failure it assumes a particular value.
Heart failure medications
The pharmacological therapies available today have allowed a substantial improvement in the natural history of patients with heart failure.
There are drugs that can treat some of the most disabling symptoms of heart failure (this is the case with diuretics in relation to fluid retention) and others that can counteract, delay or even reverse the underlying mechanisms of heart failure.
Most patients with heart failure take multiple medications; although it can be difficult and inconvenient to take so many different medications, the aim is to maintain the compensatory condition (and therefore the patient’s well-being) for as long as possible and to use as many medications as possible that are capable of ‘curing’ heart failure, preventing the heart from getting worse or even improving its performance.
The drug classes most commonly used in the treatment of heart failure are listed below.
Obviously, not all patients need to take all of the medications listed here.
Diuretics: they eliminate the fluid overload that occurs as a result of heart failure. The dose of the diuretic may vary according to the needs of the patient, who must, under certain circumstances, be able to ‘self-manage’ this medication (for example, increasing the dose in case of weight gain of more than 1.5-2 kg overnight, a sign of increased water retention). The most common side effects are lower blood pressure, cramps and reduced levels of potassium in the blood.
Digital: increases the heart’s ability to contract and slows down the heartbeat. It is useful for improving symptoms in patients with more advanced heart failure. Blood levels of digitalis should be checked periodically to avoid overdose, which can cause excessive heart rate slowdown, rhythm disturbances and nausea.
ACE inhibitors: they act as vasodilators, lowering blood pressure and thus reducing the work of the heart; they also counteract some of the progression mechanisms of heart failure, thus exerting a ‘curative’ effect. In addition to acting on some of the symptoms of heart failure, these drugs are able to prolong the lives of patients with heart failure and/or heart failure, thus improving their prognosis. They are also used in the treatment of high blood pressure and after myocardial infarction. The most frequent side effects are coughing, excessive lowering of blood pressure values and, much more rarely, increased levels of potassium in the blood and worsening of kidney function indices. To avoid these problems, you usually start with low doses, then gradually increase them, and periodically check laboratory tests.
Angiotensin II receptor inhibitors: they act with a mechanism similar to that of ACE inhibitors, although coughing is less frequent among the side effects.
beta blockers: they work by reducing heart rate, blood pressure and ultimately the work of the heart, thus allowing the heart muscle to gradually replenish its energy stores. Beta-blockers can reverse the failing heart’s tendency to dilate and contract less and less. In addition to improving the pumping function of the heart, these drugs can also prolong life. They are also used for high blood pressure, angina (chest pain due to reduced blood flow to the heart muscle) and heart attack. In patients with heart failure, its use requires great caution at the beginning of treatment: to initiate and adapt this therapy to adequate doses, one must start with very low doses and gradually increase them. In fact, at the beginning, precisely because beta-blockers reduce the work of the heart, patients may feel more tired and, in some cases, the decompensation may become worse. The most frequent side effects are linked precisely to these effects on the heart and its ability to worsen asthma in predisposed individuals.
Antialdosterones: these drugs are ineffective diuretics as such, but compared to the others they have the particularity of preventing the loss of potassium, one of the most feared side effects of diuretics used to combat water retention. Recently, spironolactone, the progenitor of this pharmacological class, has been shown to prolong the lives of patients with advanced heart failure.
ARNI – Sacubitril/valsartan: ARNI (neprilysin and angiotensin receptor antagonists) are the new class of drugs used in the innovative therapeutic treatment of heart failure. The association of the two active principles Sacubitril and valsartan activates a hormonal mechanism that allows, for the first time, to potentiate the effects of the natriuretic peptide system (increasing the elimination of sodium in the urine) and simultaneously maintain the inhibition of renin -Angiotensin system (regulator of blood pressure).
Breakthrough therapy with Sacubitril/valsartan has been shown to reduce mortality from cardiovascular causes by 20 percent compared to reference therapy, leading in younger patients with chronic heart failure with reduced ejection fraction, to a one-year survival extension and medium, with peaks of up to 2 years.
SGLT2 inhibitors: it is a new class of hypoglycemic drugs capable of reducing the most disabling symptoms of cardiovascular disease. They act to reduce blood glucose by causing an increase in the urinary excretion of glucose in a way that would also influence the reduction of blood pressure (on average 4 mmHg), secondary to the reduction of sodium and circulating volume, providing important cardiovascular benefits.
Clinical studies have shown that SGLT2 inhibitors that have been approved for the treatment of type 2 diabetes mellitus and have shown significant results in reducing cardiovascular risk are Empagliflozin, Canagliflozin and Dapagliflozin.
Many other drugs can be used by patients with heart failure, also depending on the presence of other diseases or specific indications.
This is the case with some antiarrhythmics, anticoagulants (mainly in the case of coexisting atrial fibrillation), antiplatelet agents, statins (drugs that can reduce plasma cholesterol levels), nitroderivatives and calcium channel blockers, vitamins, iron and recently erythropoietin, which are used to combat anemia, which can worsen symptoms in patients with heart failure.
Can heart failure be treated with medication alone?
Most patients with heart failure can be treated with medication alone.
In the last two or three years, however, in certain specific conditions to be identified and discussed with the family doctor, cardiologist and cardiac surgeon, the usefulness of interventional procedures (implantation of a pacemaker or biventricular defibrillator) or cardiac surgery (correction of heart failure, plastic surgery or ventricular remodeling), which do not replace, but complement medical therapy.
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