Heart Failure Clinic

Heart is a four chambered structure with two top chambers (atria) and two bottom chambers (ventricles). Right side of the heart receives de-oxygenated blood from different parts of the body and it is delivered to the lungs, whilst the left side of the heart receives oxygenated blood from the lungs which in turn is delivered to various body organs by effective pumping of blood from the left ventricle. This process is repeated with every single heartbeat. Heart, therefore, functions as a pump and maintains proper circulation of blood throughout the body.
Heart failure or congestive cardiac failure results from sub optimal functioning of the heart. This may often be due to weak heart muscle. It is referred to as systolic heart failure when the ventricles of the heart do not contract properly during each heartbeat, so blood is not adequately pumped out of the heart or diastolic heart failure when the ventricles do not fill up with blood enough when the heart rests in between each heartbeat (often due to increased stiffness of heart muscle). Heart failure may affect only the right ventricle (right-sided heart failure) or the left ventricle (left-sided heart failure), or both.

Heart failure could be due to various reasons. Most common cause of heart failure is a previous heart attack which has resulted in weakening of the heart muscle. Some of the other causes of heart failure include heart valve disease, high blood pressure, disease of the heart muscle (cardiomyopathy), drugs or chemicals (alcohol, cocaine or some drugs used in cancer treatment), heart rhythm abnormalities (cardiac arrhythmias) or other medical conditions, such as thyroid disease, anaemia, etc.

Patients with heart failure may or may not experience symptoms. The common symptoms include:

• Shortness of breath, usually more on exertion
• Difficulty in lying flat (referred to as orthopnea)
• Waking up in the night experiencing breathlessness or swollen ankles or legs (excessive fluid retention)
• Depending on the underlying cause of heart failure they may also experience chest pains, palpitations, excessive tiredness, dizziness and loss of appetite

After initial consultation and examination the following investigations are recommended:

• Electrocardiogram (ECG-a way of recording electrical activity of heart by attaching a series of electrodes to the chest wall) is performed
• Echocardiogram (ultrasound scan of the heart) is the most definitive way to diagnose heart failure
• Chest X-ray
• Blood Tests (to assess thyroid function, kidney function, to rule out anaemia etc) and urine tests
• Based on the results of these initial investigations further tests (cardiac MRI scan, coronary angiogram etc) may be recommended

Ejection fraction (EF- fraction of blood pumped out of the heart) is calculated doing echocardiogram. EF is often used to grade severity of systolic heart failure. EF for a normal heart is over 50%. However, in patients with diastolic heart failure, EF may sometimes be normal.
Severity of heart failure is also assessed based on the symptoms experienced by the patient.

• Class 1 (Very Mild): Ordinary physical activity does not cause breathlessness, fatigue (extreme tiredness), or palpitations
• Class 2 (Mild): Comfortable at rest. However, ordinary physical activity such as walking causes some symptoms
• Class 3 (Moderate): Although comfortable at rest, slight physical activity, such as dressing causes breathlessness or fatigue
• Class 4 (Severe): Unable to carry out any physical activity without developing breathlessness, fatigue, or palpitations. Symptoms are often present even at rest.

Following the diagnosis of heart failure and its cause, patients are started on medication to improve their symptoms and at the same time attempts are made to treat the underlying cause as well (patients with severe narrowing of the heart arteries are recommended further treatment either by angioplasty or bypass surgery, similarly patients with severe heart valve disease are recommended valve surgery, etc).The commonly used medications in treatment of heart failure are as below:

• Angiotensin-Converting Enzyme (ACE) Inhibitors prevent a build-up of fluid by interfering with the enzyme angiotensin (a body chemical) which is involved in regulating body fluid.ACE inhibitors also have a protective effect on the heart, and may slow down the progression of heart failure.Ramipril, Lisinopril, Perindopril and Enalapril are some of the commonly used ACE inhibitors.
  Angiotensin-II Receptor Antagonists work in a similar way to ACE inhibitors.One may be used instead of an ACE inhibitor if patient has problems or side-effects (such as a persistent cough) on taking an ACE inhibitor Candesartan, Telmisartan, Losartan and olmisartan are some of the commonly used angiotensin-II receptor antagonists
• Beta-Blockers have a protective effect on the heart.A low dose is started at first, and then increased every few weeks until a regular dose is reached. Occasionally, beta-blockers cause an initial worsening of symptoms before symptoms improve.Bisoprolol, Carvedilol and Metoprolol are some of the commonly used beta-blockers.Research studies have shown that ACE inhibitors and beta-blockers not only help to ease symptoms, but can improve the outlook and extend life expectancy for people with heart failure.
• Diuretics work on the kidneys and help loose extra fluid.Furosemide, Toresemide and Bumetanide are some of the commonly used diuretics.
• Aldosterone antagonists also prevent the fluid build-up.Research has shown that they reduce number of hospitalisations and extend patient life expectancy.Spironolactone and Eplerenone are two drugs that belong to this group.
• Digoxin is sometimes used in patients with heart failure in addition to above mentioned medications.It works by improving heart muscle contractility.
• Ivabradin, Trimetazidine and omega-3-acid ethyl esters are some of the others drugs used in treatment of patients with heart failure.
• Patients are advised lifestyle changes including salt restricted diet, daily weight monitoring, regular blood pressure monitoring, diabetes control (in case of diabetic patients) and regular exercise, etc.

After initial treatment with medications some select group of patients (who have severe left ventricular dysfunction) are advised cardiac device therapy in addition to the above medications.

Over the last decade there have been several advances in the management of patients with heart failure. It is now well known that patients with heart failure are susceptible to heart rhythm problems. Some of these heart rhythm abnormalities can result in dangerously fast heart rates causing sudden cardiac death.

Patients with advanced heart failure who are at risk of heart rhythm abnormalities would benefit from implantation of Implantable Cardioverter Defibrillator (ICD) device (similar to a pacemaker) which would detect and treat dangerous fast heart rhythms.

Select group of patients with concomitant heart failure and delayed electrical conduction in the ventricles would benefit from implantation of a special type of pacemaker called biventricular pacemaker or also known as Cardiac Resynchronisation Therapy Pacemaker (CRTP).

A device with both ICD and CRT capabilities is called a combo device or Cardiac Resynchronization Therapy Defibrillator (CRTD).

Large clinical studies have shown that both ICD and CRT devices improve longevity in heart failure patients. CRT devices in addition also confer improved quality of life and reduce number of hospitalisations due to heart failure.

Cardiac devices were approved for implantation following large randomised control trails which have shown that these devices can safely be implanted with substantial beneficial effects. These devices are approved for use by both American and European health authorities. Cardiac devices are implanted in cardiac cath lab. These devices are implanted under local anaesthesia (which means that the patient would be conscious during the procedure). The device is placed under the skin and subcutaneous fat near the left shoulder and is connected to the pacing leads (wires which are introduced into the heart via a vein under the left collar bone). Patient would be allowed to walk and mobilise two to three hours after the procedure and total length of hospital stay following the procedure is around two days.

Patients with heart failure and recurrent anginal symptoms have been shown to benefit from use of Enhanced External Counter Pulsation (ECP) Therapy. This is a non-invasive method where in external pneumatic cuffs placed around the legs are inflated and deflated in synchronization with heart beat. This in turn improves blood supply to the organs and reduces work load on the heart. However ECP therapy is not an alternative to cardiac device therapies.

All of the above treatments are now available at Kokilaben Dhirubhai Ambani Hospital and a dedicated heart failure clinic has been established. Heart Failure Clinic is a one stop clinic where a thorough assessment of patients with a presumed diagnosis of heart failure is made, further investigations carried out, following which suitable above mentioned therapies are offered.