Heart Failure

Heart failure (HF) is a clinical syndrome characterised by symptoms of shortness of breath, effort intolerance and fluid retention. These symptoms are caused by abnormalities in heart function. It is also commonly called 'congestive cardiac failure' or 'congestive heart failure'.

Common causes of heart failure include

• Coronary artery disease
• Acute myocardial infarction ('heart attack')
• Hypertension
• Diabetes mellitus
• Heart valve disorders
• Electrical rhythm disturbances in the heart
• Cardiomyopathies (heart muscle disease)
• Alcohol and other substance abuse
• Congenital heart conditions

Heart failure is a serious, chronic condition which can result in persistent symptoms affecting quality of life, recurrent hospital admissions for disease exacerbation, as well as premature death.

• Shortness of breath (on exertion or during rest)
• Decreasing effort tolerance
• Difficulty in breathing when lying flat
• Waking up breathless at night
• Chronic fatigue
• Swelling of ankles/ legs/ abdomen
• Unexplained fainting spells

Heart failure is a clinical syndrome diagnosed through integrating various medical data and information, including:

• Patient symptoms
  • Typical symptoms of shortness of breath on exertion, inability to sleep lying flat, worsening fatigue etc
• Clinical examination
  • Signs of fluid retention (leg swelling, abdominal swelling, fluid sound in lungs)
  • Detect possible underlying cause of heart failure (heart murmur, irregular pulse)
  • Cardiac pumping function (assessment of peripheral perfusion)
• Blood tests
  • Red blood cell counts, kidney/ liver function, thyroid hormone level
  • NT-proBNP: hormone produced by the heart, which is markedly elevated in heart failure
• Electrocardiogram ('ECG')
  • Electrical tracing of the heart, looking for heart rhythm abnormalities, as well as signs of underlying structural heart abnormalities
• Chest radiograph
  • X-ray examination, looking for abnormal heart enlargement/ abnormal fluid collection in the lungs
• Specialised cardiac imaging
  • Echocardiogram: Ultrasound examination which allows doctors to look for abnormalities of the heart structure, as well as to assess heart function
  • Cardiovascular magnetic resonance imaging ('Cardiac MRI'): Specialised scan looking specifically at the heart muscles, to look for underlying heart muscle abnormalities
• Invasive investigations
  • Coronary angiogram: look for blockages in the heart blood vessels from atherosclerotic plaques
  • Right heart study: assess pressures in the heart chambers, as well as the pumping function of the heart
• Endomyocardial biopsy: sampling of heart muscle tissue to look for heart muscle disease

Acute decompensation

When a patient is admitted to the hospital for severe shortness of breath and fluid retention, the treatment will be targeted at reversing the episode of decompensation and getting the patient back to his/ her baseline functioning.

Treatment of acute decompensation may include:

• Oxygen supplementation if necessary
• Medications to remove excess fluid ('diuretics')
• Adjustment of home heart failure therapy
• Education/ counseling to prevent repeat episodes of decompensation
• Medications to improve heart pumping function ('inotropes') in severe cases

Chronic management

Heart failure is a chronic condition that requires long term treatment and follow up. The Heart Failure Programme at NUHCS provides a multi-disciplinary approach to the chronic management of heart failure, which will include:

Lifestyle modifications

• Smoking/ alcohol cessation
• Fluid and salt restriction
• Regular monitoring of body weight/ blood pressure
• Exercise as recommended by the heart failure team
• Cardiac rehabilitation programme enrollment

Medical therapy

• Control of risk factors (high blood pressure, diabetes mellitus)
• Starting on medications which has been shown to reduce mortality and improve symptoms in heart failure patients

Procedures

• Restore blood flow to the heart muscles via coronary angioplasty ('stenting') or coronary artery bypass graft surgery
• Repair/ replacement of dysfunctional heart valves
• Implantable electronic devices (defibrillators/ pacemakers) in patients who qualify

Advanced heart failure management

• Evaluation for patients with persistent symptoms for consideration of mechanical circulatory support ('mechanical heart pumps') or heart transplantation

Suitable patients will be followed up in the specialised Heart Failure Clinic, a multi-disciplinary clinic aimed at providing holistic management of heart failure, to improve the long-term outcome for our patients.