Descripción general de la insuficiencia cardíaca congestiva (CHF)

Síntomas, causas, diagnóstico, tratamiento y afrontamiento

La insuficiencia cardíaca congestiva (CHF) es el término utilizado para describir lo que sucede cuando el corazón no puede bombear suficiente sangre para satisfacer las necesidades del cuerpo. (No debe confundirse con un paro cardíaco en el que el corazón deja de latir por completo). La ICC es simplemente el funcionamiento inadecuado del músculo cardíaco. La afección puede ser aguda, lo que significa que ocurre rápidamente o crónica, lo que significa que ocurre a largo plazo.

Los síntomas de la ICC pueden incluir fatiga, hinchazón de las piernas y falta de aire (especialmente con el ejercicio). La CHF se puede diagnosticar en función de una revisión de sus síntomas, análisis de sangre, una ecografía cardíaca y radiografías. El tratamiento puede variar según la causa subyacente y puede incluir dieta, ejercicio, medicamentos antihipertensivos , anticoagulantes y medicamentos como Entrestodiseñados específicamente para tratar la insuficiencia cardíaca.

Los casos graves pueden requerir un dispositivo cardíaco implantable para mejorar la fuerza o el ritmo del corazón. En el peor de los casos, puede ser necesario un trasplante de corazón.

Síntomas

Los síntomas de la ICC pueden variar según la ubicación del daño cardíaco, que se describe ampliamente como insuficiencia cardíaca izquierda, insuficiencia cardíaca derecha o insuficiencia biventricular.

Falla del lado izquierdo

El lado izquierdo del corazón es responsable de recibir sangre enriquecida con oxígeno de los pulmones y bombearla al resto del cuerpo.

Si el corazón está fallando en el lado izquierdo (denominado insuficiencia cardíaca ventricular izquierda), retrocederá a los pulmones, privando al resto del cuerpo del oxígeno que necesita.

La insuficiencia cardíaca del lado izquierdo es causada por una disfunción sistólica , que es cuando el corazón no bombea sangre como debería, o una disfunción diastólica , en la que el corazón no se llena de sangre como debería.

Los síntomas característicos de la insuficiencia cardíaca izquierda incluyen:

  • Fatiga
  • Mareo
  • Falta de aliento, especialmente cuando está acostado o durante el esfuerzo.
  • Pirateo en seco o sibilancias
  • Ruidos y crujidos en los pulmones.
  • Abnormal “galloping” heart sounds (gallop rhythm)
  • Nighttime breathlessness (paroxysmal nocturnal dyspnea)
  • Cool skin temperature
  • Bluish skin tones due to the lack of oxygen (cyanosis)
  • Confusion

Right-Sided Failure

The right side of the heart is responsible for receiving oxygen-poor blood from the body and pumping it to the lungs to be oxygenated.

If the right side of the heart is failing (known as right ventricular heart failure), the heart cannot fill with enough blood, causing the blood to back up into the veins.

Right-sided heart failure is often caused by pulmonary heart disease (cor pulmonale) in which the enlargement or failure of the right ventricle leads to circulatory congestion in the lungs as well as the rest of the body.

Los síntomas característicos de la insuficiencia cardíaca derecha incluyen:

  • Fatiga
  • Debilidad
  • Falta de aliento, particularmente con ejercicio
  • Acumulación de líquido, generalmente en la parte inferior de las piernas (edema periférico) o en la parte baja de la espalda (edema sacro)
  • Una vena yugular distendida en el cuello.
  • Frecuencia cardíaca rápida ( taquicardia )
  • Dolor o presión en el pecho
  • Mareo
  • Tos crónica
  • Micción nocturna frecuente (nicturia)
  • La acumulación de líquido del abdomen ( ascitis )
  • Un hígado agrandado
  • Náusea
  • Pérdida de apetito

Falla Biventricular

La insuficiencia cardíaca biventricular implica la falla de los ventrículos izquierdo y derecho del corazón. Es el tipo más comúnmente visto en la práctica clínica y se manifestará con síntomas característicos de la insuficiencia cardíaca izquierda y derecha.

Una de las características comunes de la insuficiencia cardíaca biventricular es el derrame pleural , la acumulación de líquido entre el pulmón y la pared torácica.

Si bien el derrame pleural puede ocurrir con insuficiencia cardíaca derecha y, en menor medida, con insuficiencia cardíaca izquierda, es mucho más característico cuando ambas partes están involucradas. Los síntomas del derrame pleural incluyen:

  • Dolor agudo en el pecho
  • Falta de aliento, particularmente con actividad
  • Tos seca crónica
  • Fiebre
  • Dificultad para respirar cuando está acostado
  • Dificultad para respirar profundamente
  • Hipo persistente

Complicaciones

La ICC es una complicación potencial de muchas enfermedades y trastornos diferentes. Sin embargo, el desarrollo de CHF puede provocar complicaciones adicionales, aumentando el riesgo de enfermedad, incapacidad y muerte. Las complicaciones características de la ICC incluyen:

  • Tromboembolismo venoso , que es un coágulo de sangre que se forma cuando la sangre comienza a acumularse en una vena. Si el coágulo se desprende y viaja al pulmón, puede causar una embolia pulmonar . Si se rompe y se aloja en el cerebro, puede causar un derrame cerebral.
  • La insuficiencia renal , que puede ocurrir cuando la circulación sanguínea reducida permite que los productos de desecho se acumulen en el cuerpo. Si es grave, puede requerirse diálisis o un trasplante de riñón.
  • Daño hepático. Esto ocurre comúnmente con insuficiencia cardíaca avanzada del lado derecho cuando el corazón no puede suministrar al hígado la sangre que necesita para funcionar, lo que lleva a hipertensión portal (presión arterial alta en el hígado), cirrosis e insuficiencia hepática.
  • Daño pulmonar , incluyendo empiema (acumulación de pus), neumotórax (colapso pulmonar) y fibrosis pulmonar (cicatrización pulmonar), que es una complicación común del derrame pleural.
  • Daño a la válvula cardíaca , que puede ocurrir a medida que su corazón trabaja más para bombear sangre, lo que hace que las válvulas se agranden de manera anormal. La inflamación prolongada y el daño cardíaco pueden provocar arritmia severa, paro cardíaco y muerte súbita.

Causas

Las causas de CHF incluyen enfermedad de la arteria coronaria, presión arterial alta, enfermedad de la válvula cardíaca, infección, consumo excesivo de alcohol o un ataque cardíaco previo.

La insuficiencia cardíaca congestiva (a menudo denominada simplemente insuficiencia cardíaca) afecta a alrededor de 6 millones de estadounidenses y es la principal causa de hospitalización en personas mayores de 65 años. Más de 650,000 casos nuevos son diagnosticados cada año.

La palabra “congestivo” se refiere a la acumulación de líquido en las venas y tejidos de los pulmones y otras partes del cuerpo. Es esta congestión la que desencadena muchos de los síntomas característicos de la ICC.

La CHF es causada por cualquier cantidad de afecciones que dañan el músculo cardíaco en sí, lo que se conoce como cardiomiopatía . Las causas comunes incluyen:

  • Enfermedad de la arteria coronaria (CAD), en la cual las arterias que suministran sangre y oxígeno al corazón se estrechan u obstruyen
  • Infarto de miocardio (IM), también conocido como ataque cardíaco, en el que se bloquea una arteria coronaria, que mata de hambre y mata los tejidos del músculo cardíaco
  • Heart overload (including high-output heart failure), in which the heart is overworked by conditions such as hypertension, kidney disease, diabetes, heart valve disease, a congenital heart defect, Paget’s disease, cirrhosis, or multiple myeloma
  • Infections, which includes viral infections such as German measles (rubella) or coxsackie B virus. Another cause is systemic viral infections, such as HIV, which can cause progressive damage to the heart muscle. Non-viral illnesses like Chagas disease can also cause heart failure.
  • Long-term alcohol or substance abuse, including methamphetamine or cocaine abuse
  • Cancer chemotherapy drugs like daunorubicin, cyclophosphamide, and trastuzumab
  • Amiloidosis , una condición en la cual las proteínas amiloides seacumulan en el músculo cardíaco, a menudo en asociación con trastornos inflamatorios crónicos como lupus, artritis reumatoide y enfermedad inflamatoria intestinal (EII)
  • La apnea obstructiva del sueño , una forma de apnea del sueño considerada un factor de riesgo independiente para CHF cuando se acompaña de obesidad, hipertensión o diabetes
  • Exposición tóxica al plomo o al cobalto

Insuficiencia cardíaca descompensada aguda

La insuficiencia cardíaca crónica es la etapa en la cual la condición cardíaca es estable. La insuficiencia cardíaca crónica a veces puede progresar a insuficiencia cardíaca descompensada aguda (ADHF) en la que los síntomas empeoran y aumentan el riesgo de insuficiencia respiratoria.

ADHF si a menudo se desencadena por un evento instigador como:

  • Ataque al corazón
  • Neumonía
  • Hipertensión no controlada o que empeora
  • Hipertiroidismo (glándula tiroides hiperactiva)
  • Anemia severa
  • Arritmia (ritmo cardíaco anormal)

Diagnóstico

Si se sospecha insuficiencia cardíaca congestiva, su médico realizará el diagnóstico basándose en una revisión de sus síntomas, un examen físico, análisis de sangre, pruebas de imágenes y otros diagnósticos diseñados para medir la función cardíaca. La falla se clasificará por orden de gravedad para dirigir el curso de tratamiento apropiado.

Examen físico

Después de una revisión de sus síntomas e historial médico, su médico realizará un examen físico para identificar los síntomas indicativos de CHF. Esto incluirá, entre otras cosas, una revisión de su:

  • Presión sanguínea
  • Ritmo cardiaco
  • Sonidos cardíacos (para verificar ritmos anormales)
  • Sonidos pulmonares (para evaluar la congestión, estertores o derrames)
  • Extremidades inferiores (para detectar signos de edema)
  • Jugular vein in your neck (to check whether it is bulging or distended)

Laboratory Tests

There are a number of blood tests used to diagnose CHF, some of which can identify the underlying cause of the dysfunction. These may include a complete blood count (to check for anemia), a C-reactive protein (to detect signs of infection), and liver function, kidney function, or thyroid function tests (to establish whether other organ systems are involved and why).

Arguably the most important test is the B-type natriuretic peptide (BNP) test which detects a specific hormone secreted by the heart in response to changes in blood pressure. When the heart is stressed and works harder to pump blood, the concentration of BNP in the blood will begin to rise.

The BNP test is one of the cornerstone diagnostics of heart failure. However, increases in BNP values do not necessarily correspond to the severity of the condition.

In most labs, a BNP of less than 100 picograms per milliliter (pg/mL) can definitively rule out CHF in 98 percent of cases.

High BNP levels are far less conclusive, although levels above 900 pg/mL in adults over 50 years old can accurately diagnose CHF in around 90 percent of cases.

Imaging Tests

The primary imaging tool for diagnosing CHF is an echocardiogram. An echocardiogram is a form of ultrasound that uses reflected sound waves to create real-time images of the beating heart. The echocardiogram is used to determine two diagnostic values:

  • Stroke volume (SV): the amount of blood exiting the heart with each beat
  • End-diastolic volume (EDV): the amount of blood entering the heart as it relaxes

The comparison of the SV to the EDV can then be used to calculate the ejection fraction (EF), the value of which describes the pumping efficiency of the heart.

Normally, the ejection fraction should be between 55 percent and 70 percent. Heart failure can typically be diagnosed when the EF drops below 40 percent.

Another form of imaging, known as angiography, is used to evaluate the vascular structure of the heart. If coronary artery disease is suspected, a narrow catheter would be inserted into a coronary artery to inject contrast dyes for visualization on an X-ray. Angiography is extremely useful in pinpointing blockages that may be damaging the heart muscle.

A chest X-ray on its own can help identify cardiomegaly (enlargement of the heart) and evidence of vascular enlargement in the heart. A chest X-ray and ultrasound can also be used to help diagnose pleural effusion.

Other Tests

In addition to the BNP and echocardiogram, other tests can be used to either support the diagnosis or characterize the cause of the dysfunction. These include:

  • Electrocardiogram (ECG), used to measure the electrical activity of the heart
  • Cardiac stress test, which measures your heart function when placed under stress (usually while running on a treadmill or pedaling a stationary cycle)

CHF Classification

If congestive heart disease is definitively diagnosed, your cardiologist would classify the failure based on a review of your physical exam, lab findings, and imaging test. The aim of the classification is to direct the appropriate course treatment.

There are several classification systems a doctor may rely upon, including the functional classification system issued by the New York Heart Association (NYHA) or the CHF staging system issued by the American College of Cardiology (ACC) and the American Heart Association (AHA).

The NYHA functional classification is broken down into four classes based on both your physical capacity for activity and the appearance of symptoms.

  • Class I: no limitation in any activities and no symptoms from ordinary activities
  • Class II: mild limitation of activity and no symptoms with mild exertion
  • Class III: marked limitation of activity and symptoms at all times except rest
  • Class IV: discomfort and symptoms at rest and with activity

The ACC/AHA staging system provides greater insight as to what medical interventions should be implemented at which stages.

  • Stage A: the “pre-heart failure” stage in which there is no functional or structural heart disorder but a distinct risk of one in the future
  • Stage B: a structural heart disorder but with no symptoms at rest or activity
  • Stage C: stable heart failure that can be managed with medical treatment
  • Stage D: advanced heart failure in need of hospitalization, a heart transplant, or palliative care

The ACC/AHA system is especially useful—each stage corresponds to specific medical recommendations and interventions.

Treatment

The treatment of congestive heart failure is focused on reducing symptoms and preventing the progression of the disease. It also requires treatment for the underlying cause of the failure, whether it be an infection, a heart disorder, or a chronic inflammatory disease.

The treatment will be largely directed by the staging of the CHF and may involve lifestyle changes, medications, implanted devices, and heart surgery.

Lifestyle Changes

One of the first steps in managing CHF is making changes in your life to improve your diet and physical fitness and to correct the bad habits that contribute to your illness. Depending on the stage of the CHF, the interventions may be relatively easy to implement or may require a serious adjustment of your lifestyle.

Reduce Sodium Intake

This not only includes the salt you add to food, but also the types of food that are high in sodium. The less salt in your diet, the less fluid retention there will be. Most doctors recommend no more than 2,000 milligrams per day from all sources.

Limit Fluid Intake

This can vary depending on the severity of your condition, but generally speaking, you would limit your fluids to no more than 2 liters (8.5 cups) per day.

Achieve and Maintain a Healthy Weight

If you are overweight, you may need to work with a nutritionist to first determine your ideal weight and daily calorie intake, and then to design a safe and sustainable low-sodium diet.

Stop Smoking

There is no safe amount of smoking. Smoking contributes to the development of atherosclerosis (hardening of the arteries), making your heart work much harder than it normally would have to.

Exercise Regularly

You need to find an exercise plan you can sustain and build upon to get stronger. Try starting with no less than 30 minutes of exercise three times per week, incorporating cardio and strength training. Working with a personal trainer can help ensure the appropriate workout routine, which is one that neither overtaxes you nor leaves you unchallenged.

Reduce Alcohol Intake

While an occasional drink may not do you any harm, moderate alcohol intake can sometimes complicate left-sided heart failure, particularly in people with alcohol-induced cardiomyopathy. Speak to your doctor about the appropriate limits based on the nature and severity of your CHF.

Medications

There are a number of medications commonly prescribed to improve the function of your heart. These include:

  • diuretics (water pills) to reduce the amount of fluid in your body and, in turn, your blood pressure
  • angiotensin-converting enzyme (ACE) inhibitors which block an enzyme that regulates blood pressure and salt concentrations in your body
  • angiotensin receptor blockers (ARBs) that reduce blood pressure by relaxing blood vessels and improving blood flow
  • Entresto (sacubitril/valsartan), which is a combination drug used in place of ARBs and ACE inhibitors in people with a reduced EF (generally under 40 percent)
  • Apresoline (hydralazine) and isosorbide dinitrate, which are sometimes prescribed in combination for people who can’t tolerate ARBs and ACE inhibitors
  • Lanoxin (digoxin), which is sometimes prescribed for people with severe heart failure but is largely avoided due to the high degree of toxicity
  • Vasopressin receptor antagonists like Vaprisol (conivaptan) which may be used for people with ADHF who develop abnormally low sodium levels (hyponatremia)
  • beta blockers, which continue to be an integral component in treating CHF

Drugs to Avoid

There a number of drugs that you may need to avoid if you have heart failure, which may either undermine therapy or contribute to cardiac congestion.

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) like Voltaren (diclofenac), Advil (ibuprofen), or Aleve (naproxen) can precipitate fluid retention. Use Tylenol (acetaminophen) instead.
  • Certain anti-arrhythmia drugs (particularly sodium channel-blocking drugs) may increase heart rhythm problems in people with CHF.
  • Calcium channel blockers can also induce arrhythmia, particularly in people with left-sided systolic failure.
  • Salt substitutes typically contain potassium which promotes arrhythmia.
  • Antacids often contain high quantities of sodium and are best avoided.
  • Decongestants like pseudoephedrine can raise blood pressure and should only be used under the direction of your doctor.

Since other drugs (including ketamine, salbutamol, tamsulosin, and thiazolidinediones) can affect heart function, it is important to advise your doctor about any drugs you are taking, including supplements and herbal remedies.

Implantable Devices

Heart failure is described when the EF is 40 percent or less. This means that 40 percent or less of the blood in your left ventricle leaves the heart with each heartbeat.

If your EF falls below 35 percent or you experience severe arrhythmia as a result of CHF, your doctor may recommend an implantable device to reduce the risk of illness or death. Different approaches are used for different conditions.

  • Automatic implantable cardioverter defibrillators (AICDs), similar to pacemakers, are used to correct arrhythmias as they occur.
  • Cardiac resynchronization therapy (CRT) involves the synchronization of the right and left ventricles so that they work more effectively.
  • Cardiac contractility modulation (CCM), approved in Europe but not in the United States, is used to strengthen the contraction of the left ventricle with synchronized bursts of electrical stimulation.

The implants are typically inserted beneath the skin of the upper left chest. Before the surgery, medication will be given to make you sleepy and comfortable.

The implantation of a device does not require open-heart surgery, and most people go can home within 24 hours.

Surgery

Surgery may be indicated to repair the underlying or contributing causes of heart failure. This may include repairing or replacing leaky heart valves or performing a coronary artery bypass graft (CABG) to redirect the blood flow around one or more blocked arteries.

If a heart attack has occurred, surgery is often needed to repair the bulging and thinning of the left ventricular, known as a ventricular aneurysm.

Some surgeries are minimally invasive—accessing the heart through a blood vessel or through the chest without opening the ribcage—while others are open-heart.

If the risk of death is high and a donor heart is not available, open surgery may be used to implant a ventricular assist device (VAD) into the chest. The VAD mechanically pumps blood from the left ventricle to the aorta and is powered by an external battery worn over the shoulder. It is a short-term solution used by doctors when waiting for a donor heart.

heart transplant is typically indicated with the EF has dropped below 20 percent and/or the risk of death within one year is high. Around 3,500 heart transplants are performed around the world each year, more than half of which are performed in the United States.

People who successfully undergo heart transplant surgery can expect to live an additional 15 years on average.

Coping

Being diagnosed with congestive heart failure doesn’t mean that you’re going to die or that your heart will suddenly stop. It simply means that your heart is failing to work as well as it is supposed to.

While there is no cure for CHF, there are steps you can take to maintain or improve your heart function.

Weigh Yourself Daily

Changes in your weight may be a sign that your condition is worsening. Start by knowing your “dry weight” (your weight when there no extra fluids in our body) and keep a daily record. Call your doctor if your weight is either 4 pounds more or 4 pounds less than your dry weight in the span of a week.

Take Your Medications Daily

You need to maintain a steady concentration of medications in your bloodstream to sustain the desired effect. Some drugs used to treat CHF have a short drug half-life (including Entresto with a half-life of 10 hours) and must be taken as prescribed without missing any doses. To avoid missed doses, try programming alarm reminders on your cell phone.

Keep Your Doctor Appointments

People who remain under consistent medical care invariably do better than those who don’t. Making and keeping your appointments allows your doctor to intervene before a medical problem become serious or irreversible.

Check Food Labels

Sodium is hidden in many foods that we eat. Learn how to read product labels and to choose foods low in salt, including lean meats, poultry, fish, fruit, vegetables, eggs, low-fat dairy, rice, pasta, and dry or fresh beans. Avoid canned or packaged foods, and be aware that “reduced-sodium” products may still contain more than you need.

Find Alternative Seasonings

Instead of salt or sodium-rich condiments, season your food with fresh herbs, dried spices, lemon juice, or flavored vinegar.

Plan Ahead When Eating Out

Check the menu online in advance of your reservation, and call ahead to discuss your dietary requirements so that you make the right choices.

Get Help Kicking Bad Habits

Quitting “cold turkey” with cigarettes or alcohol is rarely effective. Speak with your doctor about smoking cessation aids (many of which are fully covered by the Affordable Care Act). If you have a drinking problem, ask your doctor about support groups or alcohol treatment programs.

Try to Relax

Don’t treat your stress with alcohol or sleeping pills. Instead, explore methods of stress relief, including exercise, yoga, or meditation. If you are unable to cope, ask your doctor for a referral to a therapist who can either help you one-on-one or enlist you in group therapy.

Bone Marrow Transplantation at | 832-533-3765 | [email protected] | Website

I am Dr. Christopher Loynes and I specialize in Bone Marrow Transplantation, Hematologic Neoplasms, and Leukemia. I graduated from the American University of Beirut, Beirut. I work at New York Bone Marrow Transplantation
Hospital and Hematologic Neoplasms. I am also the Faculty of Medicine at the American University of New York.