note by dr Claudio Italiano
Are you hungry for air, you are dyspnoic, if you take a few steps or try to climb a flight of stairs, you have trouble and you have to stop? In recent times have you noticed that the legs have swollen and the shoes can no longer get into the feet, rather you had to buy comfortable shoes? Do you have to sleep at night in a sitting position or with two pillows? Do you feel the thuds of your heart and a weight on your chest? You probably have a heart failure. Talk to your doctor, right away!
With the apologies to our cardiologist friends for the simple topics that we will report in this article, we will try to explain to the general public the problem of a heart that breaks down and, therefore, becomes insufficient (heart failure). The heart is a pump and, therefore, like all pumps, including that of the autoclave, it requires energy and strength to push liquids into a circuit, in our case the blood (cardiac output) into the blood vessels..
Patient in condition of severe pulmonary edema due to decompensation, agitated,
oligo-anuric, which was subsequently subjected to intubation and mechanical
assisted ventilation, obligatory orthopnea
Hence the problem of its decompensation, especially in patients with diabetes (see
diabetes and heart), where the energy deriving from glucose catabolism is
altered: our organism is a complex machine that, as such, requires energy that
derives from the chemical combustion of glucose and oxygen. The fuel and the
comburent are transported in circulation in the blood. The blood, in turn, is
pushed into the blood vessels from the heart, a pump like many others, subjected
to the laws of mechanics, only this is not constituted by a pinwheel, but by a
contracting muscle, the myocardium.
If the heart fails to pump enough blood to our organs, then they will receive less oxygen and less nourishment than is necessary for them, with negative physiopathological consequences for the organism, until they reach a generalized state of general malaise. Muscles can weaken, resulting in asthenia and fatigue. A major pathophysiological problem arises from the lack of pressure in the bloodstream, so that the kidneys, receiving a reduced blood flow, will end up filtering less.
Even in case of reduced pressure (for example less than 80-90 mmHg for the maximum) they cease to function (cf. acute renal failure) and to implement mechanisms of "compensation", with fluid retention for activation of the renin system -angiotensina-aldosterone. The retention of liquids and salts with a lower filtrate will result. The excess liquid will tend to accumulate in the periphery (declining edema) and in the lungs ((see pleural effusion pulmonary edema) and in the abdomen (ascitic fluid) The patient will be weak, until having to breathe in a sitting position, with dangling feet from the bed, will have wheezing difficulty (lack of breath even for small efforts, eg going to the toilet for the needs), because the blood is not "sucked" adequately from the pulmonary circuit by the insufficient heart, with small deficiency circulation, increase in pulmonary pressure and fluid exudation in the alveoli (wet lung, congestive auscultation) It is clear that these pathophysiological changes occur gradually and so the subject realizes in time that his heart is decompensated, ie that the pump cardiac has become insufficient and turns to the doctor of trust who, auscultating him and, comparing his signs, often exchanges it for a bronchitic (sic!)
 A real patient in a condition of severe pulmonary edema due to heart failure, agitated, oligo-anuric, which was subsequently subjected to intubation and mechanical assisted ventilation, obligatory orthopnea |
The subject with heart failure will notice a series of strange symptoms:
- if he climbs the stairs, he pants, he must stop;
- sometimes at night, once in bed, he feels the throat that tightens him and
lacks the air: cardiac asthma (dyspnoea)
- in the chest can feel the heart that "dances", "rolls", "skips" (arrhythmias).
- in the morning, looking at herself in the mirror, she sees her legs less
swollen, because during the night she has been in clinostatism, that is, relaxed
and the return of blood to the heart has been favored, so the legs and ankles
have been deflated;
- after a few hours, being raised, the pretibial regions resume the fluids and
an edema develops and the "sign of the fovea" appears, that is if the doctor, or
ourselves, crush the ankle edema with a finger, ie the pasty swelling that has
been created, it forms a sinking, in short, like a hole, see the photo.
- the patient will always be hungry for air and will tend, especially at night,
to assume the orthopedic position, ie to breathe seated, to allow the lung a
better ventilation and a lower venous return to the heart.
I remember the case of a patient, a person close to me, that the night, in
winter, fortunately in my Milazzo, in Sicily where the winters are mild, he got up
every night from the bed, around 3 o'clock, for asthma from first decubitus, to go to
the countryside in his properties, where he lit a fire for the cold and, in
order to "take air", assumed the sitting orthopedic position to allow his heart
a lower blood supply: it was an old bronchopath and smoker, now in the stage of
right heart failure. Obviously, because it was a close friend of my friend, the
treating physicians called the undersigned to talk to him to try and get it
back. Everything useless.
Heart failure is a common disease. Although it can occur at any age, the
problems usually get worse over many years and for this reason the
heart failure appears predominantly in older people.
The heart failure can be caused by numerous diseases and therefore the
treatment may be different depending on the cause. The heart muscle may have
weakened (due to arterial hypertension, obstruction of the coronary arteries or
other diseases) or may have become "stiffer" (due to advanced age or arterial
hypertension); the valves of the heart may have shrunk or no longer be "sealed";
the heart may have a disease present from birth but later manifested itself.
There are also other causes, for example arrhythmias.
 Fovea sign: by imprinting the finger on the anterior edematous surface of the tibia, it remains a hollow due to the soft pasty edema from the differential with the condition of hard edema of the mixedema |
You can see in the picture a patient with severe heart failure, in obligatory orthopedic decubitus: breathe with his feet dangling out of bed and sitting
 Patient with severe heart failure, in obligatory orthopedic decubitus: breathe with his feet dangling out of bed and sitting |
- Excess water and salt should be avoided, ie you should drink little (eg 750 cc maximum per day) and use little salt or not at all during cooking and food preparation, avoiding too salty foods. In fact, salt attracts water and water causes the implementation of the circle and, therefore, more work for the already weakened heart. In addition, overweight should be avoided because an insufficient heart can supply a limited number of liters of blood per minute (heart rate) and, therefore, not be able to support a weighted body. Moreover, the fact of weighing regularly allows to assess whether or not there has been fluid retention; in fact, a sudden increase in weight must be related to the retention of sodium and water.
-The cardiopath must abolish the smoke: this is the most useful thing you can do for your health!
-A physical therapy is ideal and recommended: every day you need to do a modic exercise; it is also good to walk for half an hour. It is important not to overdo and overdo it. Another information for cardiopaths is to perform influenza vaccination (influenza) every year.
The heart is a muscle that pumps blood through the body. The heart is divided into two parts: right and left. Each part has two chambers: the atrium and the ventricle, separated by valves that allow blood to flow only in one direction. The right atrium receives oxygen-poor blood from the venous circle. It slides it into the right ventricle, which pumps it into the lungs, to oxygenate it. From the lungs, oxygen-enriched blood passes through the left atrium into the left ventricle (small circulation). From here it is pumped into the aorta artery and then to the organs and tissues, to which it supplies oxygen. Finally, the blood, through the veins, is returned to the right atrium and the cycle begins again. (large circle). At rest, the heart beats between 60 and 80 times and pumps about 5 liters of blood per minute. During exercise, the heart can pump up to 25 liters per minute.
 Radiology of the thorax of a person with heart failure, where the heart is huge and, among other things, the massive left-over has ended up collapsing an entire lung. |
Radiology of the thorax of a decompensated subject, where the heart is enormous
and, among other things, the imposing left-over pouring has ended up collapsing
an entire lung.
In heart failure, the heart muscle is weakened. The most common cause is
coronary heart disease and myocardial infarction (one or more) that causes the
replacement of heart muscle tissue with scar tissue. Almost always this happens
in the left ventricle. The heart muscle expands, the valves do not hold any more
and the pump action becomes more and more difficult. It decreases the amount of
blood that goes to the tissues through the aorta and increases the amount that
stagnates in the lungs because the function of aspiration as well as the thrust
of the heart is lost. This is the reason for breathing difficulties. The kidney
that filters behind the "push" of the heart becomes insufficient. Therefore, the
kidneys retain mineral salts and water and the result is an excess of fluid in
the body, which further strains the circle, first the left side of the heart
that has to work harder and then the right of the heart. When the right side
starts to have some problems, the pressure increases in the veins and the
liquids accumulate in the legs and ankles. In severe cases even in the abdomen,
resulting in a sense of swelling and loss of appetite. At this point the
appropriate therapy is imposed. So taking the medications prescribed by the
doctor or undergoing specific surgical procedures is absolutely possible to live
well and calm.
 Patient with severe edema of the lower limbs of middle degree: notice the succulent feet. |
At the visit it is necessary:
- first, Pay close attention to your patient's signs and perform the
following procedures:
-
frequent measurement of the pulse and blood pressure. Pulse measurement reveals
the existence of possible abnormal rhythms (arrhythmias). On the contrary there
can be very low frequency!
- Auscultation
The auscultation of the sounds produced by the heart and the lungs allows the
doctor to verify the regularity of the heartbeat, the functionality of the heart
valves (puffs) and if there is an accumulation of fluid in the lungs.
- Palpation
It allows the doctor to determine the accumulation of fluid in the tissues, for
example in the legs, delimi the cardiac aia, that is the area of the heart.
- Electrocardiogram (ECG)
The electrocardiogram identifies arrhythmias and can provide information on any
"damage" suffered by the heart muscle.
- Radiography of the thorax
Reveal if the heart is enlarged (old and good "telecuore" in the absence of
echocardiography), and to what extent. This investigation also highlights the
presence of fluid in the lungs, signs of stasis.
-Echocardiogram
This is the most important investigation for the diagnosis of heart failure.
Allows to determine the ejection fraction, ie the F.E. which must always be> 70%
in the healthy subject. It also allows the study of the functioning heart and
the status of the valves and to quantize other parameters. These include, for
example, nuclear magnetic resonance or cardiac catheterization.
The blood tests allow, first of all, to define the presence of some risk factors
for heart failure such as high cholesterol or blood sugar. In addition, some
specific tests can highlight the so-called cardiac markers, which indicate if
the person suffers from the disease in progress.
Some of these tests require a laboratory analysis, others can be performed as a
rapid test, with determination of the result even in the clinic.
The NT-proBNP protein (see Monitoring of decompensation with BNP) is, from this
point of view, very useful for the rapid diagnosis of heart failure. High
NT-proBNP levels show an anomaly that needs to be further investigated. Instead,
normal values virtually exclude dysfunction. The NT-proBNP is a particularly
sensitive index, which allows the detection of the disease even in the initial
stages in which the symptomatology is mild. It could therefore also be used to
analyze a high number of patients at risk, such as diabetics or hypertensives.
The choice of cure in decompensation
- ACE inhibitors
ACE inhibitors counteract the negative effects of some substances called
neuro-hormones, on the heart and blood vessels. In addition, they have a
relaxing effect on the arteries. This means that the heart must exert less force
to pump blood into the body.
ACE inhibitors increase survival and reduce hospital admissions and usually
improve quality of life. They are initially prescribed in low doses, otherwise
they would cause a rapid lowering of the pressure, which could be dangerous. The
initial dose, in most patients, is subsequently increased. Prior to prescribing
an ACE inhibitor, blood tests should be performed to establish renal function.
ACE inhibitors may cause dry cough, which in some patients leads to
discontinuation of therapy. In this case we can resort to the sartans (ARB,
angiotensin receptor blockers), which have similar effects.
- Beta-blockers are indicated in association with ACE inhibitors, even in
mild forms. They act on other neuro-hormones and further improve survival and
reduce hospitalization. Beta-blockers slow the heartbeat and improve the
function of the heart muscle. They are initially prescribed in low doses, which
can then be adjusted, increasing them gradually.
- Aldrosterone inhibitors (potassium canrenoate species) are used in
heart failure due to infarction or advanced forms. They facilitate heart rhythm
control, improve survival and reduce hospitalizations.
-Sartani: have a mechanism of action similar to ACE inhibitors and are
used as an alternative, in the case of intolerance to the latter. They improve
survival and reduce hospital admissions.
-The diuretics: promote the elimination of water and mineral salts through the
kidney, in the urine. They help alleviate some symptoms, such as swollen ankles
or shortness of breath, which are common in heart failure.
- Digital, also known as digoxin, is very useful in patients who have a rapid and irregular heart rhythm (atrial fibrillation). Atrial fibrillation can lead to heart failure. Digoxin is no longer used as much as it once was. May cause loss of appetite and nausea, vomiting, redness, palpitations and collapses.
- Cardiac resynchronization therapy (much simpler to remember as CRT) is a treatment of heart failure that involves the use of an implantable device. This sends electrical impulses of minimum intensity to the heart chambers to restore the correct synchronism in the interventricular contraction (between right ventricle and left ventricle) and, if necessary, in the atrioventricular (AV). This improves the heart's ability to pump blood and oxygen to the rest of the body. Simple treatment systems (biventricular pacemakers) provide only cardiac resynchronization therapy. The CRT, associated with a complete therapeutic program, has been shown to improve the quality of life, reducing symptoms of heart failure, increasing exercise tolerance and allowing to many patients to start doing various usual activities again. This treatment can not replace drug therapy and it is recommended to anyone who decides to undergo CRT to continue taking medication prescribed by the doctor.