Heart failure, also called congestive heart failure, is a life-threatening condition in which the heart can no longer pump enough blood to the rest of the body. The heart becomes enlarged and flabby, and its pumping action becomes weaker. In yesterday’s world, death was usually imminent if a person’s heart started to fail. But, in today’s world, we have the drugs and ability to maintain the heart for several more years. However, the heart will ultimately become so diseased, it will fail completely and stop pumping.
With heart failure, many organs don't receive enough oxygen and nutrients, which damages them and reduces their ability to function properly. Therefore, many of the symptoms a person has are not only heart related, but due to the malfunction of several other vital organs.
The most common causes of heart failure are hypertension (high blood pressure), coronary artery disease (for example, you have had a heart attack), and diabetes.
Heart failure becomes more common with advancing age. You are also at increased risk for developing heart failure if you are overweight, have diabetes, smoke cigarettes, abuse alcohol, or use cocaine.
About 5 million people in the United States have heart failure, and the number is growing. Each year, another 550,000 people are diagnosed for the first time. It contributes to or causes about 300,000 deaths each year.
Symptoms
• Weight gain (due to the retention of fluid)
• Swelling of feet and ankles (due to the heart’s poor pumping action)
• Swelling of the abdomen (due to the back-up of blood from the heart to the liver)
• Pronounced neck veins
• Loss of appetite, indigestion
• Nausea and vomiting
• Shortness of breath with activity, or after lying down for a while
• Difficulty sleeping
• Fatigue, weakness, faintness
• Sensation of feeling the heart beat (palpitations)
• Irregular or rapid pulse
• Decreased alertness or concentration
• Cough (especially noticeable at night)
• Decreased urine production
• Need to urinate at night
Prognosis
As previously stated, the prognosis for people with heart failure is not good. 5 years, on an average, after being diagnosed with heart failure; you will die. However, unlike cancer, this is not a situation that is discussed. Certainly the prognosis of heart failure is more ominous than the prognosis of cancer. So why, then, don’t physicians discuss end of life possibilities with the patient? Cardiologists do not receive the training Oncologists do with death and dying issues. Even the AHA guidelines stipulate that when a patient has less than a year to live, they should be referred to Hospice. This referral is cited despite the fact that Hospice only takes those with 6 months or less to live.
The prognosis is usually given to the patient and family, when there is insufficient time to tie up loose ends: say good-byes, make wills, develop advanced directives, purchase burial plots, etc..
If patients were informed of the possibility they may die (and isn’t this a fact that will happen to all of us mortals?), referrals to Hospice would need to be in relationship to intensive training for Hospice personnel in end stage heart failure.
Issues with end stage heart failure include the following:
• "Heart-failure patients have a lot of pain. NSAIDs for pain are not given, as they may exacerbate heart failure. And, due to the respiratory depression associated with opioids, they aren’t given on a regular schedule, but only for intermittent emergencies.
• Dyspnea or difficulty breathing is always a component of end stage heart failure. The most effective treatment for the anxiety associated with this symptom is either opioids or benzodiazepines (e.g. valium). This doesn’t take the dyspnea away, but it does take some of the edge off the anxiety. However, once again, unless a person is anticipated to die imminently, these medications are rarely used.
• Fatigue is more of a challenge. Certain drugs do relieve the fatigue, by forcing the muscles of a flabby heart to contract more forcefully. This makes oxygenated blood more available at the cellular level, and relieves fatigue. However, in forcing an already diseased and sick heart to work harder, it decreases the amount of time a patient has left to live. As one doctor tells his patients, it may kill you, but it makes you feel better.
• Other problems encountered during end-stage heart failure include sleep-disordered breathing, for which there is some evidence that continuous-positive-airway-pressure (CPAP) treatment is useful.
• Depression. Research has now indicated that depression is an independent factor and inevitably accompanies heart failure. Whether enzymes released from a diseased heart, or the body’s compensatory method, no one knows. However, we do know that little is done to either evaluate or treat the associated depression.
• Most of the other drugs commonly used for congestive heart failure are palliative (i.e. comfort only). However, they are not thought of that way. They do not cure, they only make one feel better, and lessen the symptoms.
Managing heart failure isn't easy, and people who've been diagnosed may not be able to do it alone. Physically, they often can't handle all the tasks they once could. The diet and lifestyle changes, medications and depression may be stressful and difficult. Family members and friends provide a much-needed source of care and support. Our physicians need to be educated; until then, patients and their families need to educate themselves.
http://www.nhlbi.nih.gov/health/dci/Diseases/Hf/HF_Summary.html
National Heart, Lung, and Blood Institute. NIH. HHS
http://www.nlm.nih.gov/medlineplus/news/fullstory_46135.html
Archives of Internal Medicine, Feb 26, 2007
http://www.theheart.org/viewArticle.do?primaryKey=776183&nl_id=tho21mar07
Heart Wire (on line only)
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