Overview of cardiovascular disease
This is a condition in which structural or functional diseases of the heart cause a decrease in cardiac output, which is unable to meet the needs of the body.
The main symptoms are dyspnea, cough, weakness, oliguria, and abdominal distension.
Any disease that causes structural or functional damage to the heart can cause the disease.
Treatment is mainly pharmacologic, interventional, or surgical
Definition
Congestive heart failure is a clinical syndrome in which myocardial systolic or (and) diastolic dysfunction in the presence of normal venous return results in cardiac output that is either absolutely or relatively lower than the metabolic needs of systemic tissues, also known as heart failure.
It can lead to stasis in the pulmonary and/or body circulation, and inadequate blood perfusion to organs and tissues manifested as dyspnea, limitation of physical activity and fluid retention.
Classification
Classification by cause
Left heart failure: caused by left ventricular compensatory insufficiency, characterized by pulmonary circulation stasis.
Right heart failure: caused by compensatory insufficiency of the right ventricle, characterized by blood stasis in the circulation.
Total heart failure: left heart failure followed by an increase in pulmonary artery pressure, which increases the load on the right heart, followed by right heart failure.
Classification according to the course of the disease
Acute heart failure: acute onset and/or exacerbation of heart failure.
Chronic heart failure: signs and symptoms of heart failure appear gradually on the basis of existing chronic heart disease.
Classification by heart function
Heart failure with reduced ejection fraction (HFrEF): left ventricular ejection fraction <40%, with predominantly systolic dysfunction.
Heart failure with intermediate range ejection fraction (HFmrEF): left ventricular ejection fraction between 40% and 49%, with mild systolic dysfunction predominantly accompanied by diastolic insufficiency.
Heart failure with preserved ejection fraction (HFpEF): left ventricular ejection fraction ≥50% with predominantly diastolic cardiac dysfunction.
Incidence
The prevalence of congestive heart failure in adults in China was 0.9% in 2003, and the number of heart failure patients increases rapidly with age, with the prevalence rising to more than 10% in people over 70 years old [1].
In 2019, the results of China’s Heart Failure Epidemiologic Survey showed that the prevalence of heart failure among residents aged ≥35 years in China was 1.3%, or approximately 13.7 million cases of heart failure.
The prevalence of heart failure in China has increased by 44% over the past 15 years, with more than 9 million additional cases of heart failure.
Causes
Causes
Myocardial damage
Primary Myocardial Damage
Primary myocardial damage is mostly caused by coronary arteries, heart structure, or myocardial cells themselves, including the following conditions.
Coronary artery disease such as myocardial infarction, chronic myocardial ischemia due to coronary atherosclerotic heart disease.
Inflammatory lesions and immune myocardial damage such as myocarditis and dilated cardiomyopathy.
Hereditary diseases such as familial dilated cardiomyopathy, hypertrophic cardiomyopathy, myocardial densification insufficiency, etc.
Secondary myocardial damage
Metabolic diseases such as diabetes mellitus, hyperthyroidism, etc.
Systemic infiltrative diseases such as myocardial amyloidosis
Connective tissue diseases such as systemic lupus erythematosus, rheumatoid arthritis, etc.
Myocardial toxic drug damage such as chemotherapeutic drugs, etc.
Excessive heart burden
Excessive pressure burden
Also known as afterload, it is the resistance that the heart needs to resist to eject blood into blood vessels throughout the body.
Causes include hypertension, pulmonary hypertension, aortic stenosis, etc.
Volume overload
Also known as preload, this is the pressure generated by the heart as it receives the inflow of blood.
Causes include heart valve closure insufficiency, congenital cardiovascular disease (right heart and arteriovenous shunt), chronic anemia, and hyperthyroidism.
Ventricular preload insufficiency
The pressure exerted on the walls of the ventricles before blood flows into the ventricles.
Etiologies include mitral stenosis, cardiac tamponade, restrictive pericardial disease, constrictive pericarditis, etc.
Predisposing factors
Common triggers of congestive heart failure are listed below:
Infection.
Cardiac arrhythmias.
Increased blood volume: e.g., excessive sodium intake, excessive and rapid intravenous fluid administration.
Excessive physical exertion or emotional stress.
Inappropriate treatment, such as inappropriately discontinuing diuretics or antihypertensive drugs.
Exacerbation of pre-existing cardiac lesions or complication of other diseases.
Pathogenesis
Damage to the structure or function of the heart leads to a decrease in cardiac output, which activates the renin-angiotensin-aldosterone system and the sympathetic nervous system, causing sodium retention and peripheral vasoconstriction, which exerts a compensatory effect in the early stages, and results in stasis in the pulmonary circulation or the circulation in the late stages.
Over-activated neurohumoral factors promote dilatation and hypertrophy of ventricular structures, leading to further deterioration of cardiac function.
Symptoms
Chronic Heart Failure Symptoms
Left heart failure
Dyspnea of varying degrees: shortness of breath after activity, inability to breathe when lying down, sudden awakening from sleep due to breath-holding.
Pulmonary stasis: coughing, coughing up sputum, hemoptysis, pink foamy sputum, etc.
Inadequate organ perfusion: weakness, fatigue, deterioration of physical strength, dizziness, panic, oliguria, etc.
Right heart failure
Body circulation stasis: abdominal distension, lack of appetite, nausea, vomiting.
Total heart failure
Because the blood output of the right heart is reduced in right heart failure, symptoms of pulmonary stasis such as dyspnea are reduced, and symptoms of physical circulation stasis such as abdominal distension, lack of appetite, nausea, and vomiting are predominant.
Acute heart failure symptoms
The main manifestation is sudden dyspnea, and the respiratory rate often reaches 30 to 50 breaths/minute.
The patient usually needs to be forced to sit, and will be accompanied by symptoms such as grayish color, cyanosis, profuse sweating, irritability and even shock.
Coughing is frequent, and pink frothy sputum may be present during the attack.
Complications
Lower extremity deep vein thrombosis
Manifested by the formation of sudden swelling of one side of the limb, localized pain, aggravated when walking.
Pulmonary embolism
Sudden chest pain, hemoptysis, purple skin and mucous membrane, fainting and even shock.
Bronchopneumonia
Manifested by fever, chills, cough, sputum, chest pain, shortness of breath.
Consultation
Department of Medicine
Cardiovascular Medicine
If you have a structural or functional heart disease and have recently developed symptoms such as dyspnea, cough, hemoptysis, abdominal distension, lack of appetite, nausea, vomiting, and edema of both lower limbs, you need to go to the Department of Cardiovascular Medicine in a timely manner.
Emergency Department
Patients with sudden onset of severe dyspnea, forced sitting, ashen face, purple skin and mucous membranes, profuse sweating, irritability, and coughing up pink foamy sputum are advised to go to the Emergency Department or call 120 emergency immediately.
Cardiovascular surgery
Patients who are in the refractory end-stage heart failure stage after optimized treatment in cardiovascular medicine and recommended for heart transplantation need to go to cardiovascular surgery for evaluation of surgical indication and waiting for a donor.
Preparation
Preparing for your visit: registering, preparing your documents, frequently asked questions
Tips for your visit
Maintain an empty stomach in case blood tests are needed.
Be accompanied by a family member, preferably in a wheelchair, to avoid straining yourself to walk around.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Are there any physical discomforts such as dyspnea, cough, sputum, hemoptysis, abdominal distension, lack of appetite, nausea, vomiting, edema of both lower limbs, etc.?
When did the symptoms appear and how long did they last?
Are there any relieving or aggravating factors for the symptoms?
Medical history checklist
Any previous history of cardiovascular disease such as coronary heart disease, hypertension, heart valve disease, congenital heart disease, cardiomyopathy, arrhythmia, etc.?
Any history of endocrine disease such as diabetes mellitus, hyperthyroidism, etc.?
Any history of connective tissue diseases such as systemic lupus erythematosus or scleroderma?
Any family history of cardiovascular disease?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Laboratory tests: brain natriuretic peptide, troponin, blood routine, urine routine, liver and kidney function, blood glucose, blood lipid, electrolytes, thyroid function, etc.
Imaging and other auxiliary tests: electrocardiogram, echocardiogram, X-ray chest radiograph, cardiac magnetic resonance, cardiopulmonary exercise test, etc.
Medication list
Medications used in the last 3 months, if available in boxes or packages, bring with you to the doctor’s office
Diuretics: furosemide, hydrochlorothiazide, aminopterin
Angiotensin converting enzyme inhibitors: captopril, enalapril, benazepril
Angiotensin II receptor antagonists: chlorosartan, valsartan, irbesartan
Beta-blockers: propranolol, nadolol
Aldosterone receptor antagonists: spironolactone, eplerenone
Beta-blockers: propranolol, metoprolol, atenolol
Cardiotonic drugs: digoxin, milrinone
Nitrates: sodium nitroprusside, nitroglycerin
Antiplatelet agents: aspirin, clopidogrel
Diagnosis
Diagnosis is based on
Medical history
There may be a history of cardiovascular diseases such as coronary artery disease, hypertension, heart valve disease, congenital heart disease, cardiomyopathy, arrhythmia, and family history.
There may be history of endocrine diseases such as diabetes mellitus, hyperthyroidism, etc.; history of connective tissue diseases such as systemic lupus erythematosus and scleroderma.
Clinical symptoms
Symptoms
Left heart failure may be characterized by dyspnea, cough, sputum, hemoptysis, pink foamy sputum, malaise, fatigue, decreased exercise tolerance, dizziness, panic attacks, and oliguria.
Right heart failure may be characterized by abdominal distension, lack of appetite, nausea and vomiting.
Physical signs
Left heart failure
Wet rales can be heard from the base of the lungs to the whole lungs, with more rales on the side of the sagging side in the lateral position.
In addition to the inherent signs of the underlying cardiac disease, cardiac palpation suggests cardiac enlargement, and cardiac auscultation reveals a regurgitant murmur of relative mitral insufficiency, a hyperactive second heart sound in the area of the pulmonary valve, a pathologic third heart sound, and a prancing horse rhythm.
Right heart failure
Symmetrical depressed edema of both lower extremities and pleural effusion are seen.
Jugular vein pulsation is enhanced, filled, and aneurysmal, and hepatic jugular venous reflux sign is positive.
Hepatic stasis is enlarged with tenderness.
In addition to the inherent signs of underlying cardiac disease, a regurgitant murmur of relative tricuspid valve insufficiency is audible on cardiac auscultation.
Laboratory Tests
Brain natriuretic peptide
Diagnose congestive heart failure and determine treatment and prognosis.
A normal level of brain natriuretic peptide in a treated patient can essentially rule out the diagnosis of congestive heart failure, while a high level of brain natriuretic peptide in a treated patient suggests that treatment has been ineffective and the prognosis is poor.
Troponin
The presence of myocardial injury.
Troponin may be slightly elevated in patients with severe heart failure or decompensated heart failure, or sepsis, while significant elevation of troponin suggests myocardial infarction.
Routine examination
Understand the patient’s blood glucose, blood lipid, liver and kidney function, electrolytes, inflammation and other conditions.
Routine examination includes blood routine, liver and kidney function, blood glucose, blood lipid, electrolyte and other items, which is helpful to guide the clinical treatment.
Electrocardiogram
Check whether the patient has any cardiac arrhythmia.
Congestive heart failure has no specific electrocardiographic manifestations, but can determine abnormalities such as myocardial ischemia, previous myocardial infarction, conduction block and arrhythmia.
Be careful not to perform ECG on an empty stomach, immediately after strenuous exercise, during stress, or while talking to avoid hypoglycemia or accelerated heart rate, which may affect the ECG results.
Imaging
Echocardiography
To clarify the presence of structural and functional abnormalities of the heart.
Evaluate more accurately the changes in the size of each heart chamber and the structure and function of the valves, assess the heart function and determine the cause of the disease, it is the most important imaging test for diagnosing congestive heart failure.
Fasting is not required; try to eliminate nervousness to avoid rapid heartbeat affecting the image display; lie on the left side during the examination.
Chest X-ray
To screen for lung disease and to check the size of the heart.
Chest X-ray in patients with congestive heart failure shows lung bruising and heart enlargement. The size and shape of the heart shadow provide important reference information for the etiologic diagnosis of heart failure, and the degree of heart enlargement indirectly reflects the functional status of the heart.
Cardiac magnetic resonance examination
Accurately evaluates ventricular volume and wall motion.
Cardiac magnetic resonance can provide diagnostic basis for myocardial infarction, myocarditis, pericarditis, cardiomyopathy, infiltrative disease, and help to diagnose the etiology of congestive heart failure.
Cardiopulmonary Exercise Test
To assess the cardiac function and exercise capacity of patients with congestive heart failure.
Important indexes include maximum oxygen consumption and anaerobic threshold, the lower the value of indexes, the worse the cardiac function, which helps to judge the prognosis of patients with congestive heart failure.
Invasive hemodynamic tests
Measurement of the pressure in various parts of the heart and the oxygen content of the blood.
It is suitable for patients with severe congestive heart failure to dynamically monitor blood volume, peripheral vascular resistance, total cardiac output and other indicators to better guide volume management.
Staging and grading
Staging
Congestive heart failure staging is used to assess the stage of progression of the disease so as to adopt the appropriate treatment plan.
Stage A (preclinical heart failure stage): Risk factors for heart failure are present, but there are no structural or functional abnormalities of the heart, and no signs and/or symptoms of heart failure.
Stage B (preclinical heart failure stage): there are no symptoms and/or signs of heart failure, but structural changes in the heart have occurred, such as left ventricular hypertrophy, asymptomatic valvular heart disease, and a history of previous myocardial infarction.
Stage C (Clinical Heart Failure Stage): Structural changes of the heart are already present, with previous or current symptoms and/or signs of heart failure.
Stage D (refractory end-stage heart failure stage): the patient is still symptomatic at rest despite strict optimization of medical treatment, often with cardiogenic cachexia, requiring repeated long-term hospitalization.
Grading
The severity of congestive heart failure is usually graded using the New York Heart Association (NYHA) method of grading cardiac function:
Grade I: daily activities are not limited, and general activities do not cause symptoms of heart failure such as fatigue and dyspnea.
Grade Ⅱ: physical activity is mildly limited, no conscious symptoms at rest, and heart failure symptoms can appear under general activities.
Grade III: physical activity is obviously limited, below the usual general activities that cause heart failure symptoms.
Grade IV: unable to engage in any physical activity, heart failure symptoms exist even at rest.
Differential Diagnosis
Bronchial asthma
Similarities: both can have cough and dyspnea.
Differences: The disease has a history of allergy in adolescents, typical rales can be heard in both lungs during the attack, plasma natriuretic peptide level is normal, and the symptoms can be relieved rapidly after bronchodilator drug treatment.
Pericardial effusion, constrictive pericarditis
Similarities: both may present with dyspnea, palpitations, lower extremity edema, jugular venous distension, and hepatomegaly.
Differences: In this disease, the radial artery pulsation is weakened or disappears during inspiration (odd pulse), and the jugular vein filling is more obvious during inspiration (Kussmaul’s sign), which can be quickly differentiated by echocardiography.
Cirrhosis abdominal effusion with lower extremity edema
Similarities: both may present with lower extremity edema, abdominal distension, and dyspnea.
Differences: Spider nevus, liver palms, abdominal wall varicose veins, splenomegaly can be seen in this case, which can be quickly differentiated by abdominal ultrasound combined with history of liver disease.
Treatment
Aim of treatment: to prevent and delay the development of congestive heart failure; to alleviate clinical symptoms and improve the quality of life; to improve the long-term prognosis and reduce the mortality rate and hospitalization rate.
Principles of treatment: Adopt comprehensive therapeutic measures, including early management of underlying diseases such as hypertension, coronary artery disease and diabetes mellitus, regulation of the compensatory mechanism of congestive heart failure, antagonizing the over-activation of neurohumoral factors, and preventing or delaying ventricular remodeling.
General treatment
Maintain semi-recumbent or seated position to reduce venous return.
Administer oxygen and keep the airway open.
Open venous access.
Cardiac monitoring.
Intake and output management: Record daily fluid intake, including fluids and diet, and urine output.
Medication
Diuretics
Commonly used drugs include furosemide and torasemide.
Improve symptoms of congestive heart failure by controlling fluid retention.
Prolonged use of diuretics is prone to electrolyte disorders, especially hypokalemia or hyperkalemia can lead to serious consequences and should be monitored.
Renin-angiotensin-aldosterone system (RAAS) drugs
Angiotensin converting enzyme inhibitors (ACEI)
Commonly used drugs include captopril, enalapril, ramipril.
They can dilate blood vessels and improve hemodynamics; reduce the adverse effects of neurohumoral compensatory mechanisms and improve ventricular remodeling.
Side effects of ACEI include hyperkalemia, renal impairment, cough, angioneurotic edema, etc. Inability to tolerate the drug can be converted to ARB, attention to the monitoring of renal function and potassium during the use of the drug, and after regular review, life-long use of the drug is recommended.
Angiotensin receptor antagonist (ARB)
Commonly used drugs include chlorosartan, valsartan, irbesartan.
They can dilate blood vessels and improve hemodynamics; reduce the adverse effects of neurohumoral compensatory mechanisms and improve ventricular remodeling.
Precautions: Side effects of ARB include hyperkalemia, renal function impairment, etc. Pay attention to monitoring renal function and blood potassium during the medication period, and review regularly afterwards, and lifelong medication is recommended.
Angiotensin receptor enkephalinase inhibitor (ARNI)
Commonly used drugs are sacubitril valsartan.
It dilates blood vessels and improves hemodynamics; reduces the adverse effects of neurohumoral compensatory mechanisms and improves ventricular remodeling.
Side effects of ARNI include hypotension, hyperkalemia, renal function impairment, angioneurotic edema, etc. Attention is paid to the monitoring of blood pressure, renal function, blood potassium during the use of the drug, and regular review afterward, and lifelong use of the drug is recommended.
Aldosterone receptor antagonists
Commonly used drugs include spironolactone and eplerenone.
The drugs work by blocking the aldosterone effect, inhibiting sympathetic activation and ventricular remodeling.
Adverse effects such as male breast development, impotence, and female menstrual irregularities can occur with long-term use.
Beta-receptor antagonists
Commonly used drugs include metoprolol, bisoprolol, carvedilol.
They can inhibit the adverse effects of sympathetic activation on congestive heart failure compensation, reduce symptoms, and improve prognosis.
Abrupt discontinuation of this drug can lead to worsening of the condition and should be avoided. It is contraindicated in patients with bronchospastic disease, severe bradycardia, severe atrioventricular block, severe peripheral vascular disease, and severe acute heart failure.
Sodium-glucose cotransporter protein 2 (SGLT2) inhibitors
Commonly used drugs include dagliflozin and empagliflozin.
May reduce the risk of cardiovascular death and hospitalization in heart failure patients with reduced ejection fraction.
Viliciclovir
Used primarily in adult patients with symptomatic chronic heart failure with reduced ejection fraction who have recently lost heart failure stabilized on intravenous therapy, it may reduce the risk of hospitalization for heart failure or the need for emergency intravenous diuretic therapy.
Watch for the occurrence of adverse effects such as drowsiness, malaise, and gastrointestinal reactions.
Positive Inotropic Drugs
Commonly used drugs include digoxin and deacetyl furfurazone.
They enhance myocardial contractility, inhibit the cardiac conduction system, reduce symptoms, and improve exercise tolerance.
Myocardial ischemia, hypoxia, low blood potassium, low blood magnesium, renal insufficiency and other conditions are prone to digitalis toxicity, manifested as cardiac arrhythmia, nausea, vomiting, blurred vision, yellow-green vision and so on.
Vasodilators
Commonly used drugs include sodium nitroprusside, nitrate.
The effect of the drug is to dilate the peripheral blood vessels, reduce the amount of return blood, reduce symptoms.
Blood pressure should be closely monitored to avoid hypotension.
Interventional therapy
Cardiac resynchronization therapy (CRT)
Improve atrial, interventricular and intraventricular systolic synchronization, increase cardiac output, improve symptoms and prognosis.
It is suitable for patients with sinus rhythm, NYHA cardiac function class III-IV, left ventricular ejection fraction ≤35%, and complete left bundle branch block who continue to have symptoms of congestive heart failure despite optimized drug therapy.
Precautions: avoid lifting heavy objects or strenuous exercise on the upper limb of the implanted triple-chamber pacemaker; try to stay away from welding machines, high-voltage wires, and power substation equipment.
Implantable cardioverter defibrillator (ICD)
Prevent sudden cardiac death caused by malignant arrhythmia.
It is suitable for patients with left ventricular ejection fraction ≤35%, who have had cardiac arrest, ventricular fibrillation, and hemodynamic instability.
Avoid lifting heavy objects or strenuous exercise on the upper limb on the side of the implanted ICD; do not place cell phones close to the ICD; and try to stay away from welding machines, high-voltage power lines, and substation equipment.
Left Ventricular Assist Device (LVAD)
Provides hemodynamic support to assist the heart’s pumping function.
Indicated for short-term transitional therapy and adjunctive therapy for acute heart failure after a serious cardiac event or in preparation for heart transplantation.
The implantation of LVAD carries the risk of complications such as infection, bleeding, and thrombosis, and postoperative management of relevant laboratory and hemodynamic parameters should be noted.
Intra-aortic balloon counterpulsation (IABP)
IABP is a method to increase intra-aortic diastolic pressure, increase coronary blood supply and improve cardiac function with a mechanical assisted circulation device.
It is indicated for patients with congestive heart failure who have failed medical therapy.
Surgery
Heart transplantation
Indications are patients with end-stage heart failure.
Contraindications are the combination of serious diseases of the brain, lungs, liver and other important organs other than the heart, which will easily increase the complications of surgery.
Postoperative complications include infection, bleeding, acute renal failure, and immune rejection. Long-term postoperative immunosuppression is required to reduce the risk of immune rejection.
Prognosis
Cure
As the disease progresses, symptoms gradually worsen, activities and life are significantly affected, with poor prognosis and high mortality.
Timely treatment can effectively alleviate clinical symptoms, delay the development of heart failure, reduce the rate of re-hospitalization and mortality, and improve the prognosis.
Hazards
Congestive heart failure is the end-stage manifestation of cardiovascular disease and the most important cause of death, and may be complicated with acute pulmonary edema, pulmonary embolism, malignant arrhythmia, cardiogenic shock and other critical diseases, which will pose a great threat to the patient’s life.
Congestive heart failure is incurable, with recurrent symptoms, significant limitations in mobility, and the need for multiple hospital admissions, reducing quality of life.
Daily
Daily Management
Dietary management
Regular diet and attention to nutrition.
Limit water and sodium intake.
Promote a diet high in protein, low in animal fat and high in vitamins.
Life management
Acute or unstable patients should restrict physical activities and take bed rest.
According to the severity of the disease, appropriate activities to improve exercise endurance.
Quit smoking and drinking.
Reduce mental stress, maintain psychological balance, and avoid great joy and sorrow.
Disease monitoring
Monitor blood pressure and heart rate daily to control the risk factors of congestive heart failure.
Record daily water intake and urine output, and monitor body weight daily to guard against sodium retention. Seek prompt medical attention and adjust medication regimen when oliguria and significant weight changes are detected.
Raise awareness of congestive heart failure and seek prompt medical attention when symptoms such as dyspnea, cough, sputum, hemoptysis, fatigue, oliguria, abdominal distension, nausea and vomiting occur.
Prevention
Prevent the risk factors of congestive heart failure and change the bad lifestyle, including low-salt and low-fat diet, weight reduction, quitting smoking and drinking, keeping a happy mood and doing appropriate physical activities.
Actively treat underlying diseases that trigger congestive heart failure, such as hypertension, coronary artery disease, heart valve disease, hyperthyroidism, etc., to slow down the progression of the disease and prevent the aggravation or occurrence of congestive heart failure.
Patients with a history of heart disease or congestive heart failure should avoid triggers such as exposure to cold, overwork, strenuous exercise, excessive fluid intake, alcohol consumption, and taking cardiotoxic drugs.
Regular medical checkups should be conducted and the disease should be actively treated.
Strictly follow the doctor’s instructions for anti-heart failure treatment, take medication regularly, and review regularly.