Heart Failure

The real cause of heart failure lies in the heart muscle. It is due to changes which make it unable to carry on the proper circulation of the blood. These changes may follow valvular disease, disturbances of the heart rate as in atrial fibrillation, or diseases of the blood vessels associated with high blood pressure.

Left Ventricular Failure. This is liable to occur as a result of the increased work which the left ventricle has to do in cases of arteriosclerosis with high blood pressure, in diseases of the aortic valve, and disease of the blood vessels of the heart muscle. In left-sided failure the chief effects are upon the lungs, such as attacks of paroxysmal breath-lessness or `cardiac asthma', often associated with copious frothy or blood-stained sputum. Left ventricular failure may be sudden in onset, and death may occur rapidly in severe cases.

Right Ventricular Failure

Right-sided heart failure is usually more gradual and occurs especially in mitral stenosis, which leads to congestion of the lungs, and in chronic lung diseases. These conditions cause extra work for the right ventricle, which, as it begins to fail leads to congestive heart failure. Congestion is apparent in several ways - in distension of the veins of the neck, in the enlarged tender liver associated with loss of appetite and nausea, in impairment of the kidney function, with scanty urine, and in dropsy, with swelling of the ankles.

Symptoms

The onset may be gradual or sudden and is shown by certain symptoms which appear on exertion. These symptoms occur as the result of less and less effort until some or all of them are present during rest.

Treatment

Both types of failure may disappear with treatment; the cause, however, remains, and the failure will recur later.

Rest

The most important question is that of rest. In cases of slight heart failure with shortness of breath, palpitation and fatigue on moderate exertion, partial rest is usually sufficient. In moderate failure with slight dropsy of the legs and a fast pulse at rest, the patient should remain in bed for at least three weeks. In severe heart failure with shortness of breath and palpitation on slight exertion with a considerable degree of dropsy of the legs, and with attacks of cardiac asthma, rest in bed is required for at least six weeks.

In all cases when a patient has had a long period of rest in bed, it should be followed by a period of partial rest (lifting to a couch or wheel chair for 15 to 30 minutes, with only a very gradual return to moderate activity). Climbing stairs should be avoided for several weeks.

Mode of Life

When some degree of activity has been resumed, it is important to live within the limits of the heart's strength, and the chief object of treatment is to prevent the recurrence of heart failure. The usual habits should not be too much restricted since the patient may become introspective and depressed. Every patient with early heart failure should be in bed for at least nine hours each night, and allow at least an hour for the midday meal. He should have one quiet day a week. With more severe degrees of impairment he should be in bed for 10 to 12 hours each night, resting for one or two hours after the midday meal, and should stay in bed for one day each week.

Excitement, worry, and all forms of emotional strain and exhausting activity should be avoided.

Exercise

Unnecessary tasks must be avoided, together with undue exertion. On the other hand, it is wise to take a moderate amount of exercise (walking on level ground, or a leisurely game of golf), short of producing symptoms, and always allowing for some reserve of strength. Sudden effort should be avoided, such as walking up hills or against a strong wind.

Massage

Massage is often useful for those who have not the opportunity for ordinary exercise, while simple passive movements of the limbs and light massage are beneficial in the early stages. In cases with dropsy, massage is often followed by an increased output of urine and a reduction in the amount of fluid in the limbs. It may be given for half an hour two or three times a week.

Diet

Moderation and temperance should be the chief rules of diet. Since most cases of heart disease are chronic, severe dietary restrictions are as unwise as excesses. Elderly patients with chronic heart disease are often improperly nourished, either because of dietary fads or because of unwise advice.

Fluids

In general the daily intake of fluids should be somewhat restricted. The meals should be as dry as the patient will take them, a sufficient amount of fluid (3 to 4 pints a day) being taken between meals, and consisting of weak tea, milk, fruit juices, aerated waters, barley water, or plain water.

Treatment by Drugs

Digitalis. The most striking benefit from digitalis is seen in atrial fibrillation with its irregular heart rhythm, but it is also quite effective in congestive failure with regular heart rhythm. The appropriate dose varies between 0-3 and 1 millilitre of the tincture, or 1 to 3 tablets (0-25 milligramme each) of digoxin (Lanoxin), in 24 hours.

Among the indications of overdosage are headache, which is followed in definite sequence by loss of appetite, nausea, vomiting and diarrhoea, and occasionally by mental confusion, usually associated with 'coupling' of the pulse beats.

It should be noted, however, that vomiting is not uncommon in heart failure quite apart from overdosage with digitalis, but usually the occurrence of the above symptoms is an indication to stop the drug for a few days and, when it is resumed, to give a smaller dose. The pulse rate should also be carefully recorded daily in digitalis intoxication and the drug withheld when the pulse rate falls below 60 per minute.

The secret of success with digitalis is to be found in the use of the drug in short intermittent courses of a few days' duration. It should be taken regularly day by day until the first appearance of headache or nausea is noted. It is then stopped for two or three days and a further course begun.

A convenient rule is to omit all digitalis on two days, say Saturday and Sunday, of each week. All persons who are taking digitalis should be examined by a doctor at regular intervals.

Circulatory Stimulants

Carminatives and stimulants such as sal volatile (aromatic spirit of ammonia, ½ to 1 teaspoonful in cold water); Hoffman's Anodyne (compound spirit of ether), or spirit of chloroform (10 to 15 drops) may give relief for gastric flatulence and its associated shortness of breath.

Aminophylline (Cardophylin) 100 milligrammes, nikethamide (Coramine), or leptazol (Cardiazol) 100 milligrammes by mouth or by injection are valuable in acute heart failure because of their stimulating action.

Oxygen

This may be needed in acute heart failure, especially with blueness of the lips and cheeks and marked shortness of breath, and in cases due to pneumonia. It should be given continuously through a nasal cannulae, by a disposable plastic mask, Ventimask, or by the Edinburgh mask.

Diuretics:

Treatment of Dropsy

If, in congestive failure the response to restriction of fluid intake, rest and digitalis is not sufficiently quick or adequate, diuretics, or kidney stimulants, are required to assist the removal of fluid from the water-logged tissues by way of the kidneys.

Diuretics such as such as Saluric, Hydro-saluric K, Hydrenox, Esidrex, Navidrex, etc., have the advantage of being in tablet form, to be taken by the mouth. One to three tablets are taken early in the day, in divided doses, on two to five days in each week. Chlorthali-done (Hygroton) has a longer-acting effect and two or three doses a week will provide complete therapeutic control of oedema in most cases.

Frusemide (Lasix) is a powerful diuretic which can be given by injection or in tablet form. Spironolactone (Aldactone) may be used in resistant cases.

The older mercurial diuretics, such as injection of mersalyl B.P., or mersalyl with theophylline are still used at times.

Diuretics are advisedly given first thing in the morning to avoid disturbances of sleep the following night. A profuse secretion of urine usually begins within two hours, and continues for 24 to 48 hours; as much as 10 to 20 pints of urine may be passed.

It is important to restrict the daily intake of fluid to 12 litres (2 pints). It is wise to weigh the patient at weekly intervals, as a steady reduction of weight shows the efficacy of the treatment. A rest period of several weeks is generally advisable after six injections of mercurial diuretics.

This treatment must only be given under medical supervision, and may give rise to symptoms of mercurial poisoning if carried to excess, with inflammation of the mouth and bowel.

Sedatives:

Treatment of restlessness and sleeplessness.

If the patient is excitable, sedatives may be prescribed, e.g. pheno-barbitone and valerian (Euvalerol B Elixir), or a tranquilliser such as Equanil. No sedatives should be given except on a doctor's advice.

In heart failure, sleep is often impossible without sedatives; 300 to 600 milligrammes of chloral hydrate may be given in water by mouth, and the dose repeated in two to four hours if necessary.

Whisky is a good soporific for the elderly, especially if the patient is accustomed to it; as an alternative, paraldehyde (1 to 2 tea-spoonfuls) may be given with chipped ice or brandy.

Sedatives:

Treatment of Cardiac Asthma

For attacks of breathlessness at night the patient should sit upright in bed, supported by high pillows or a bed rest, and should be given a draught of sal volatile in water. More severe attacks require the injection (by a doctor) of 15 milligrammes of morphine and 0.5 mg of atropine, or injection of amino-phylline intravenously.

The injection of a diuretic such as fru-semide (Lasix) has a rapid effect.

Blood-letting (Venesection)

This is occasionally used in heart failure due to high blood pressure with congestion of the lungs, and in cases with distended neck veins and an enlarged liver. It is performed by removing 300 to 600 millilitres of blood from one of the veins in front of the elbow.

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