HEART FAILURE

HEART FAILURE is a pathological condition in which cardiac output does not meet the needs of the body due to a reduction in the pumping function of the heart. The cause may be overload of the heart with an increased volume of blood or (and) pressure (with heart defects, hypertension, pulmonary heart, etc.), as well as a decrease in the contractile function of the myocardium with a decrease in its mass (myocardial infarction, postinfarction cardiosclerosis , cardiac aneurysm , ), Degenerative changes (with amyloidosis, hemochromatosis, etc.), myocarditis, cardiomyopathy, myocardial dystrophy of various etiologies.

In clinical practice, distinguish between acute and chronic, left ventricular and right ventricular failure, as well as three stages of circulatory failure. Stage I is characterized by shortness of breath, tachycardia, fatigue only with physical exertion. In the II stage there are clinical signs of stagnation in organs and tissues, accompanied by reversible impairments of their function. This stage is divided into HA (signs of stagnation are not clearly expressed and are determined mainly only in small or only in a large circle of blood circulation) and IIB (significant hemodynamic disorders are detected in both circles of the circulation, accompanied by edema of organs and tissues). In the III stage irreversible morphological changes of organs due to their prolonged hypoxia, protein dystrophy, the development of sclerosis in them (hemosiderosis of the lungs, cirrhosis of the liver , etc.) are added to the signs characteristic of stage IIB. There is also a preclinical stage of heart failure, the recognition of which is possible only under conditions of stress tests using special instrumental methods.

The pathogenesis of heart failure depends on its causes. In most cases, the reduction of myocardial contractility, which is almost always caused by a violation of energy supply of cardiac contractions as a result of insufficient formation and a decrease in the effectiveness of ATP in the cardiac muscle, is of major importance. This is facilitated by a reduction in the delivery of oxygen to the heart muscle (hypoxemia in patients with respiratory failure, anemia , decreased blood flow in the myocardium), increased use (with hypertension of the myocardium caused by cardiac overload, thyrotoxicosis, etc.), incomplete its utilization by the heart muscle because of Lack of certain enzymes (for example, diabetes mellitus, avitaminosis B, etc.). Significant pathogenetic importance is also the violation of the function of cell membranes (in all forms of myocardial dystrophy), leading to a change in the flux of cations (sodium, potassium, calcium) through the membrane in the phases of systole and diastole and thus to a decrease in the force of cardiac contraction.

With insufficient left ventricle of the heart, the increase in venous pressure and fluid retention occur in a small circle, and in case of right ventricular failure, in a large circle of blood circulation, accompanied by an increase in the liver, acrocyanosis, edema on the legs, and severe degrees of right ventricular failure with ascites, hydropericardium, hydrothorax. With the appearance of edema, the resistance to blood flow in the tissues and, accordingly, the load on the heart is further increased, contributing to the progression of heart failure: In left ventricular heart failure, congestion in the veins of the small circulation circle is accompanied by a reflex increase in the tone of the pulmonary arterioles, which prevents the development of edema, but increases the pressure in the pulmonary trunk And the right ventricle of the heart, causing its overload, which eventually leads to right ventricular failure.

Clinical manifestations are diverse and determined by the nature of the heart disease, the degree of severity of myocardial contractility and intracardiac hemodynamics, the primary involvement in the pathological process of the left or right heart, as well as the duration of the disease. By the speed of development, acute heart failure occurs almost suddenly or within a few hours, and chronic, developing within a few weeks, months, years.

Acute left ventricular failure is most often manifested by cardiac asthma and pulmonary edema in patients with acute myocardial infarction, after physical congestion in patients with certain heart defects, myxoma of the left atrium, sometimes can be triggered by hypertensive crisis or paroxysm of arrhythmia. With thromboembolism of pulmonary arteries, as well as with interventricular septal rupture, acute right ventricular failure develops; With myocarditis, poisoning with cardiotropic poisons - usually right and left ventricular at the same time.

Chronic heart failure in the early stages of development is manifested mainly by symptoms of a decrease in cardiac output: rapid fatigue, muscle weakness, lack of air, chilliness. With physical exertion, shortness of breath , palpitations are observed. As the progression of heart failure begins to prevail complaints that reflect the development of stagnation in the organs (stage II of circulatory failure). With left ventricular failure, shortness of breath appears at the forefront with less physical exertion, and then arising and at rest, especially with the horizontal position of the body, because of which patients prefer to sit or stand - orthopnea. At night there are attacks of suffocation - cardiac asthma ; Physical stress can lead to the development of pulmonary edema. With the progression of right ventricular failure, patients complain of a decrease in diuresis, the appearance of edema on the feet and legs at the end of the day. Then edema becomes permanent, common, but more pronounced in low-lying areas of the body - hypostatic swelling. The stomach is enlarged due to flatulence, stagnant increase in the liver, and later - ascites. Possible nausea and decreased appetite (congestive gastritis). With mitral stenosis often appear coughing , hemoptysis.

When examining a patient , symptoms that indicate the cause of heart failure (signs of heart disease, pulmonary heart, arterial hypertension , etc.) are often revealed. Of the symptoms of left ventricular failure, orthopnea is most important, the expansion of the boundaries of relative cardiac dullness to the left with a weakened and diffused apical impulse (a sign of dilatation of the left ventricle); Tachycardia in combination with pendulum rhythm; Deaf I tone (or its weakening) in the presence of an accent tone II of the heart over the pulmonary trunk; Rhythm of canter, presence of wet (stagnant) wheezing in the lower parts of the lungs. The main signs of right ventricular failure include swelling of the cervical veins, which does not disappear on inspiration; Acrocyanosis; The presence of edema; Expansion of the heart's borders to the right (a sign of dilatation of the right auricle); The appearance of systolic murmur over the xiphoid process; Enlargement of the liver, the edge of which, when palpated, is determined without difficulty in the absence of ascites; Presence of hydrothorax. Simultaneously, all signs are rarely found. In terminal stages of heart failure, patients are usually depleted, lethargic, adynamic; Cyanosis is combined with pallor and jaundice of the skin. The liver as a result of the development of cirrhotic changes becomes very dense and does not decrease in size with the use of diuretics. Often ascites is observed. When a blood test is often revealed violations of its coagulability. In the urine, protein is almost always found.

The diagnosis of heart failure in patients with heart disease is not difficult and is determined by the characteristic clinical features without the use of additional research methods. The latter (especially echocardiography) are needed to determine the preclinical stage of heart failure. For the purpose of early diagnosis of heart failure, it is also expedient to evaluate the tolerance to physical activity for patients. Complaints about the appearance of dyspnoea and palpitations with insignificant physical exertion (climbing the stairs to the 2nd 3rd floor), inadequate changes in cardiac output during stress tests (on a veloergometer) indicate the presence of latent heart failure. Differential diagnosis is often carried out with respiratory failure, in which dyspnea usually has an expiratory character (difficulty and prolonged exhalation) and does not increase in the horizontal position of the body; Cyanosis is diffuse, i.e. Characteristic of pulmonary insufficiency. According to the anamnesis and the patient's examination data, the presence of bronchopulmonary pathology is revealed. In patients with chronic lung diseases, a combination of cardiac and pulmonary insufficiency is possible in the case of pulmonary heart development and decompensation.

Treatment . In acute heart failure, urgent therapy is performed according to clinical manifestations and causes. Treatment begins at the site of recognition of acute heart failure and is continued in the hospital. In most cases, intravenous injection of diuretics, cardiac glycosides, the use of peripheral vasodilators are indicated, if possible, oxygen inhalations are used.

Treatment of chronic heart failure is mainly performed on an outpatient basis, includes, in addition to the treatment of the underlying disease (eg, coronary heart disease), physical activity and psychoemotional stress, exercise therapy, the use of protein and vitamin-rich diets with restriction of table salt to 3 to 4 g in Day (sometimes up to 1-2 grams per day) and fluids (up to 800-1200 ml per day), the medicinal effect on the pathogenetic links of heart failure. The main pathogenetic means of treatment of chronic heart failure, developed against the background of ciliary tachyarrhythmia, are cardiac glycosides. Parenterally administered strophantan, korglikon, digoxin . For oral administration appoint digoxin , Celanide , etc. A dose of cardiac glycosides is selected by a doctor. The average medical worker helps to monitor the effectiveness of the selected dose (on the dynamics of dyspnea, swelling, tolerance to the patient's workload, etc.) and its safety.

In the presence of peripheral edema, hydrothorax, ascites used diuretics - lasix (furosemide), ureitis, hypothiazide , etc. sometimes in combination with aldosterone antagonists (veroshpiron with hyperaldosteronism) and potassium preparations (potassium chloride, etc. with hypokalemia). For long-term use, potassium-sparing diuretics (triamterene, triampur) are used. These funds are appointed by the doctor; The average paramedic helps control their action by measuring the diuresis and body weight of the patient in the dynamics. In the process of treatment diuretics periodically need to examine the blood levels of potassium, sodium, uric acid and acid-base balance.

In most cases, it is advisable to prescribe drugs that improve hemodynamics as a result of peripheral vasodilator action (vasodilators). First of all, angiotensin-converting enzyme inhibitors (capoten, enalapril , culapril, etc.) are used, acting on both arterial and venous vessels. Less commonly used nitrates - nitroglycerin , nitrosorbide (mainly reduce the tone of the veins), apressin, phentolamine (expand the arterioles), sodium nitroprusside, prazozin (act on the tone of arterioles and venules). When they are used, lowering blood pressure, the appearance or strengthening of tachycardia, the development of edema, resistant to the action of diuretics are possible. Assigns the vasodilators and controls the effect of their action only by the doctor.

The prognosis depends on the nature of the heart disease, as well as on the severity of heart failure (in acute form) and the stage of circulatory failure (in chronic form). With a timely and complete elimination of the causes of heart failure (for example, by surgical treatment of heart disease), the outlook is favorable. Rational complex therapy And dispensary observation of a patient with chronic heart failure increases the load tolerance and deletes the lethal outcome. With irreversible changes in internal organs, the prognosis is unfavorable.

Prevention in patients with heart failure is aimed at combating the exacerbation and progression of the underlying disease, preventing its complications, and ensuring proper physical activity through the correct employment of the patient.