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Heart failureAs Heart failure is the inability of the heart to pump the required amount of blood as needed by the body.

The common German translation "cardiac insufficiency" only inaccurately captures the term, because not only a pathologically reduced pump function (systolic heart failure or cardiac insufficiency), but also a disturbed filling of the heart (diastolic heart failure with normal or even increased pump function) can lead to heart failure. Acute severe heart failure is occasionally referred to as Heart failure is the term used for cleaning and surface disinfection, although there is no generally accepted definition of this term, which is frequently used, especially in coroner's reports. Critics object that heart failure is probably also named as the most frequent cause of death because the heart has ultimately failed in every naturally deceased person and the disease actually leading to death has often not been determined.

Heart failure can occur in two different forms, the chronic and the acute form. Chronic heart failure develops over a longer period of time, while acute heart failure, z.B. due to a heart attack, suddenly occurs. Heart failure can affect only the left heart (left heart failure), the right heart only (right heart failure) or both halves of the heart (global heart failure) affect. It can occur as a result of many different diseases of the heart and also other organs, and usually indicates an already serious stage of disease with shortened life expectancy if the cause cannot be treated.

Table of Contents

Epidemiology

Heart failure is one of the most common internal medicine conditions, with an estimated more than 10 million. Affected persons in Europe. Another nearly 10 million. People already have heart muscle weakness without symptoms. Heart failure is one of the most common occasions for consultation in a general medical practice [1] .

Prevalence and incidence of heart failure are age-dependent. Between the ages of 45 and 55, less than 1 percent of the population suffers from heart failure; 65- to 75-year-olds suffer from heart failure at a rate of 2-5 percent, and over 80-year-olds suffer from heart failure at a rate of almost 10 percent. Men are about 1.5 times more likely to be affected than women of the same age. With increasing age, the proportion of diastolic heart failure increases to more than 30 percent, and in women to more than 40 percent. In Germany's cause-of-death statistics published by the Federal Statistical Office in 2006, heart failure ranks third, ahead of cancers such as breast, lung or colon cancer. In women, heart failure even moves up to second place among the most common causes of death, accounting for 7.4% [2] .

Pathophysiology and etiology

The right heart receives blood from the body via the superior and inferior vena cava and pumps it through the pulmonary artery (pulmonary artery) into the lungs (cf. pulmonary circulation). Oxygen-rich blood flows from there through the pulmonary veins to the left heart, from where it flows through the aorta (aorta) pumped into the body.

Heart failure leads to a lack of oxygen supply to the body and its organs, furthermore, in front of the right and left heart there can be a buildup of blood in the body veins or the pulmonary veins. Depending on the side of the heart affected, the condition is referred to as right, left or global insufficiency.

The heart function is comparable to the operation of a bellows pump. As with any pump, dysfunction can only be caused by 2 principles: 1. by reduced work output as a result of a reduction in blood uptake or output, and 2. due to malfunction of the pump valves. In terms of the heart, this means that heart failure u. a. can occur when

– the efficiency of the heart muscle tie is reduced, – one of the heart valves is narrowed (valve stenosis) or leaking (valvular insufficiency) is z.B. Pulmonary valve insufficiency – the heart muscle is too stiff to be in the filling phase (diastole) the required amount of blood is taken up, – the pulse is too slow due to cardiac arrhythmia (bradycardia) or too fast (tachycardia) is, – the heart is damaged by pericardial effusion (pericardial effusion) or a rind (pericarditis constrictiva) is constricted too much, – the resistance in the pulmonary arteries (pulmonary hypertension) or the body arteries (arterial hypertension) is too large for the heart, or – the body's blood requirements can no longer be met even by an actually healthy heart, for example in the case of high fever or severe anemia.

80-90 percent of those affected by heart failure have a functional disorder of the heart muscle, almost two-thirds of them in the form of cardiac insufficiency. The most common cause of heart failure in Western countries is a circulatory disorder of the heart (coronary heart disease or CHD) in 54-70 percent of patients, accompanied by hypertension in 35-52 percent. In 9-20 percent, high blood prere (hypertension) is the sole cause of heart failure.

Symptoms

The main symptom of left-sided heart failure is shortness of breath (dyspnea) At first with physical exertion (exertional dyspnea), In the advanced stage also at rest (resting dyspnea). The shortness of breath often worsens after lying down, which in severe cases can lead to threatening nocturnal attacks of shortness of breath and coughing (cardiac asthma). Eventually, cardiac pulmonary edema ("water in the lungs") with severe shortness of breath and leakage of fluid into the alveoli can occur (alveoli)) come, recognizable by "bubbling" side noises during breathing and frothy sputum.

A common symptom in advanced heart failure is nocturnal respiratory disturbances, often in the form of Cheyne-Stokes respiration, which is characterized by periodic waxing and waning of respiration.

Heart failure leads to fluid retention ("water retention") in the body, in the lungs in left heart failure and mainly in the legs in right heart failure (leg edema) and abdominal (ascites).

The most severe form of heart failure is cardiogenic shock, which usually presents with severe shortness of breath, clouding of consciousness, cold sweats, weak and rapid pulse, and cool hands and feet.

Diagnostics

Heart failure is diagnosed when typical symptoms (s. o.) and corresponding objective findings coincide.

Physical examination

Already during the physical examination, some clinical signs may indicate heart failure. These include jugular venous congestion, rales over the lungs, cardiac enlargement (cardiomegaly), a 3. heart tone, lower leg edema, enlargement of the liver (hepatomegaly), Pleural effusions, nocturia and an acceleration of the pulse.

Ultrasound diagnostics

The most important examination procedure in heart failure is ultrasound examination of the heart (echocardiography). It allows rapid and risk-free assessment of myocardial function, heart valves, and pericardium. On the one hand, the suspected diagnosis of heart failure can be confirmed or ruled out. On the other hand, significant causes already identified.

X-ray examinations

The X-ray of the chest forms u. a. the heart and lungs. In milder forms of heart failure, it usually shows normal findings; in advanced cases, cardiac enlargement and dilatation of the pulmonary veins ("pulmonary congestion") are visible.

In order to determine or exclude coronary artery disease as the cause of heart failure, a cardiac catheterization with coronary angiography is often performed. The prere conditions in and around the heart can be measured directly, and possibly. Constrictions of the coronary vessels can be assessed.

Laboratory diagnostics

Usually blood tests are only needed to detect specific causes and complications of heart failure (such as diabetes mellitus, renal insufficiency or electrolyte disturbances) and possible side effects of therapy.

Since the beginning of 21. The normal range in the early twentieth century is related to the determination of plasma concentrations of the brain natriuretic peptide (BNP resp. NTproBNP) is a test that can also be helpful in the diagnosis of heart failure in everyday routine. Depending on the extent of heart failure, values are moderately to severely elevated, whereas low normal BNP or NTproBNP levels in an untreated patient largely exclude heart failure. The normal range depends on age. Gender dependent. Women have somewhat higher values for reasons that have not yet been clearly explained. Basically, the BNP increases with age in both sexes. Newborns also have significantly elevated values (Mir et al. Pediatrics 2003 Oct;112, 896-99). In childhood and puberty, other normal ranges also apply (Mir et al. Pediatr Cardiol. 2006 Jan-Feb;27(1):73-7). Measurement of BNP for differential diagnosis and monitoring of heart failure has now been incorporated into the guidelines of the German Society of Cardiology and Pediatric Cardiology.

Therapy

Whenever possible, the cause of heart failure should be eliminated first:

– Elevated blood prere should be lowered, – Surgical valve replacement must be considered in case of a relevant valvular defect, – Patients with coronary artery disease often benefit from balloon dilatation or bypass surgery.

Non-drug therapy consists of extensive physical rest in NYHA stage IV, whereas dosed physical endurance training is useful in stable patients in all other stages. Increased body weight should be reduced, as well as the daily intake of common salt.

In the drug therapy of heart failure, a distinction is made between drugs with a definite prognostic indication and those with a symptomatic indication.

– A confirmed prognostic indication means that the long-term administration of the drug has been shown in several studies to have a clear life-prolonging effect. In chronic heart failure, these include – ACE inhibitors in all stages, – AT1 antagonists: blockers of the angiotensin II receptor (subtype 1); in case of intolerance to ACE inhibitors, – the beta-blockersBisoprolol, carvedilol, metoprolol and nebivolol generally from NYHA II, – aldosterone antagonists from NYHA stage III onward.

– Calcium sensitizers (z.B. Levosimendan). – renin antagonists (z.B. aliskiren).

– diuretics if there are signs of overhydration of the body, – digitalis glycosides in patients with atrial fibrillation, a marked decrease in performance or frequent hospitalizations for heart failure, and – antiarrhythmics in symptomatic cardiac arrhythmias.

Many patients with severe heart failure and intraventricular conduction disturbances (ECG diagnostics) benefit from resynchronization of the ventricles by means of biventricular pacemaker stimulation.

If the patient suffers from acute (decompensated) heart failure, z. B. after myocardial infarction, the administration of negative inotropic drugs is rarely indicated, especially beta-blockers. After lengthy discussions, however, their life-prolonging effect in the treatment of chronic compensated heart failure is considered to be ared.

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