Heart Failure (Heart Failure audit)
Whether due to congenital heart muscle abnormalities (‘cardiomyopathies’), inflammation of the heart (‘myocarditis’) or damage associated with problems arising from coronary artery or valve disease, the pumping chambers of the heart may increase in size and their pump power reduce (‘heart failure with reduced ejection fraction’ or HFrEF). This may be associated with fatigue and breathlessness and may be associated with dangerous heart rhythm abnormalities and a reduced survival rate. The ejection fraction is a measure of the pumping capability of the heart. Symptoms might also occur in patients with thickened heart muscle which may become stiff. Although the pump power may be retained, the wall of the pump does not relax well, the cavity of the main heart chamber can reduce in size and this leads to back pressure on the blood vessels in the lungs. The syndrome of heart failure can be exactly the same but this combination is referred to as ‘heart failure with preserved ejection fraction’ or HFpEF.
In the past, symptoms of heart failure could only be improved by the use of diuretics (‘water tablets’) and in some people by the use of digoxin, but over the last two decades new treatments have had an impact on reducing the rate of deterioration of heart muscle problems, have made the patients less prone to dangerous heart rhythm abnormalities and have helped improve symptoms and quality of life. These ‘disease-modifying treatments’ include beta blockers, ACE-inhibitors (ACE-Is), angiotensin receptor blockers (ARBs) and mineralocorticoid receptor antagonists (MRAs).
In some patients with specific characteristics related to a combination of their symptoms, their pump power and the shapes seen on their electrocardiograms (ECGs), the power of the pump may be improved by special pacemaker devices (cardiac resynchronisation therapy or CRT). These devices may also be able to monitor the patient’s heart rhythm and provide special pacing techniques or shock treatment should any life-threatening rhythms occur. Other devices provide these functions but without the resynchronisation function – so called implantable cardioverter defibrillators (ICDs). Most of the research for improved outcomes has been on patients with HFrEF. Ongoing research is looking to see whether new treatments other than that aimed at the causative mechanism might improve outcomes for patients with HFpEF.
Shenaka Singarayer, National Heart Failure Audit Project Coordinator