Patient information

About Heart Failure

The heart is a vital organ made up of muscle, blood vessels, heart valves and nerves. The main function of the heart is to receive utilized deoxygenated blood, pump it into the lung to be oxygenated or “refreshed”, then, receive this oxygenated blood from the lung and to pump it around the body, supplying it with oxygen and nutrients needed for energy and growth.

Heart failure occurs when the heart is no longer able to relax to receive blood (“stiff heart”) or to pump blood through the body effectively (“weak heart”).

This can cause accumulation of fluid in various parts of the body, such as the lungs, abdomen or lower limbs. Reduced blood flow can also result in dysfunction in vital organs such as the kidneys, liver or brain.
Heart failure is one of the leading causes of recurrent hospitalisation and reduced life expectancy in the world. Quality of life is also reduced in a heart failure patient. However, these can be greatly improved with appropriate management.

Causes of heart failure

Some conditions may cause the heart to become too weak or too stiff to pump blood efficiently. Some common causes include:

• Coronary artery disease and its unstable variant- heart attack
• Cardiomyopathy (disease of the heart muscles)
• Uncontrolled chronic high blood pressure
• Heart valve disease
• Excessive alcohol use and
• Drug abuse

Diagnosing heart failure

Diagnosis of heart failure is made by your doctor based on the following:

• Assessing for risk factors of heart failure
• Assessing for symptoms of heart failure
• Physical examination
• Tests including blood, radiological and cardiology tests

Risk factors of heart failure include:

• Blocked coronary arteries or heart attacks
• High blood pressure
• High cholesterol
• Diabetes mellitus
• Cigarette smoking
• Heavy alcohol consumption
• Obesity
• Sleep apnea
• Family history of heart failure
• Congenital heart defects
• Heart valve disease

A person with heart failure may present with one or more of the following symptoms:

• Shortness of breath on exertion or at rest
• Difficulty in breathing when lying flat
• Waking up breathless at night with dry hacking cough
• Persistent coughing or wheezing
• Swollen ankles, legs or abdomen
• Sudden weight gain
• Tiredness and giddiness
• Loss of appetite or nausea
• Palpitation

The following tests may be performed for the diagnosis of heart failure:

1.  Blood tests
   Blood tests may be taken to assess your blood, kidney, liver and thyroid function for causes and complications of heart failure. NT-proBNP is a specific test performed when the diagnosis of heart failure is uncertain.
2.  Chest Radiograph (X-ray)
   Chest X-rays can reveal fluid build-up in the lungs or if the heart is enlarged. Other abnormalities of the lungs or chest detected on chest X-rays may also account for your symptoms.
3.  Electrocardiogram (ECG)
   An ECG detects the electrical activity of the heart and can distinguish if the heart is enlarged or damaged from a previous heart attack. It can also detect an abnormal heart rhythm.
4.  Echocardiogram
   An echocardiogram is an ultrasound study of the heart. It assesses how well the heart relaxes and pumps and also identify any structural abnormalities of the heart (e.g. heart valve problems, abnormally thick heart muscles, enlarged heart chambers). The echocardiogram cannot tell if there are any blockages in the coronary arteries, but this can be inferred from any abnormal heart contractions.
5.  Stress test
   A stress test is performed to assess for the presence of significant blockages in the coronary arteries. This may be in the form of a simple treadmill ECG test, or involve additional imaging with echocardiogram or by injection of a radionuclide into the vein. If you are unable to run on a treadmill, you may instead receive an injection of a medication that will increase your heart rate and contractility of your heart during the test.
6.  Cardiac Computed Tomography (CT)
   A cardiac CT scan is a non-invasive way of assessing for blockages in the coronary arteries. Iodinated dye is injected into the vein and the patient will be put through a donut shaped X-ray tube for a detailed scan of the heart.
7.  Cardiac Magnetic Resonance Imaging (MRI)
   The cardiac MRI may be useful in assessing for specific conditions that may result in heart failure and to assess for the amount of scarring in a patient with heart failure.
8.  Coronary Angiogram
   The coronary angiogram is the gold standard for diagnosing blockages in the coronary arteries. In this procedure, a catheter is inserted through an artery in the arm or the groin to reach the coronary arteries. Iodinated dye is then injected into the coronary arteries, making them visible on X-rays. If significant blockages are detected, you may then be recommended to undergo ballooning and stenting of the blood vessels, or for more extensive blockages, bypass graft operation.

Treatment of heart failure

Treatment of cause of heart failure
Treating the underlying cause of heart failure is important in regaining heart function. Such treatments include stenting or coronary bypass operations for blocked arteries, repair or replacement of damaged heart valves, stopping alcohol consumption.

Lifestyle changes
Living with heart failure will involve lifestyle modification. This is a pivotal, yet often overlooked, aspect of heart failure treatment. Useful lifestyle changes that can help reduce the risk of your condition deteriorating include:

• Low salt diet
• Appropriate fluid management
• Stop smoking
• Reduction in or stop alcohol consumption
• Weight loss for obese patients
• Regular physical activity and exercise.

Medications
Several types of medication have been proven to improve survival, reduce hospitalisation, and improve symptoms and quality of life of heart failure patients. They may also result in improved function of the heart over time. You may be prescribed with more than one of these medications.

Heart failure is now understood to be a condition that does not involve the heart alone. It also involves the entire body’s organ systems. Two of the systems most closely linked to heart failure are the kidneys and the neurohormonal (nerves and hormones) system. Heart failure medication is prescribed to target these systems to achieve a new balance, leading to improved symptoms and overall outcomes.

You may be prescribed with heart failure medication belonging to the various drug classes below:

• Beta-blockers
• Angiotensin Converting Enzyme Inhibitors (ACE-I) & Angiotensin II Receptor Blockers (ARB)
• Angiotensin receptor-neprilysin inhibitor (ARNI)
• Aldosterone antagonists
• Diuretics
• Vasodilators
• Digoxin
• Ivabradine

At each clinic visit, your doctor may alter the dosage of your heart failure medication, or add on another medication, depending on how you have tolerated your medications since the previous visit. This is because the highest tolerated dosages of heart failure medication is believed to be most beneficial to the patients.

It is important that you take these medications regularly. It will be helpful if you understand the reasons for taking the medicines, know the dose and desired effects of the medicines. While side effects are uncommon, you should inform your doctor, heart failure nurse or pharmacist should you develop any side effects, or suspect that your symptoms may be caused by your heart failure medication.

Immunization
Do receive your immunization against influenza and pneumococcal disease according to your doctor’s advice. This will help prevent or reduce the severity of these conditions.

Devices
Patients with moderate to severely weak heart function are prone to developing abnormal heart rhythms, and are at increased risk of sudden cardiac arrest. The Implantable Cardioverter Defibrillator (ICD), a pacemaker-like device, is implanted to detect abnormal heart rhythms. When an abnormal heart rhythm is detected, the ICD delivers an electric shock to restore normal heart rhythm. It is important to note that the ICD’s function is to deliver the life-saving shock when such life-threatening abnormal rhythm occurs. It does not lead to improved heart function nor relieve the heart failure symptoms.

In a subgroup of patients, a similar device (the Cardiac Resynchronisation Therapy Defibrillator or CRTD) with an additional lead may be implanted. This device has resulted in improved heart function in up to two-thirds of our patients.

Advanced heart failure treatment
In spite of optimal medication, heart function in some patients may continue to deteriorate, leading to debilitating symptoms affecting their quality of life. In suitable patients, advanced options such as artificial heart pumps (known as Ventricular Assist Devices) and heart transplants may be discussed by your attending cardiologist.

Palliation and End of life care
In some patients, the above therapy may still not be adequate and their heart failure condition worsens. The aim of therapy will then focus on symptom relief and improving quality of life. This is done by a specialist team trained specifically for this. The medical team may broach the topic of end of life care with these patients and discuss the option of hospice care.

Your doctor can make a referral to a palliative care service. Seek advice from your doctor on the type of palliative care services most suitable for you or your loved ones.

A comprehensive list of in-patient and out-patient hospice services available in Singapore is listed here: https://singaporehospice.org.sg/services/

Government subsidy is available through means-testing. Medisave can also be used for palliative care services. Please seek advice from your healthcare provider. If there are any financial concerns, ask to speak to a social worker.

Some useful websites with information on heart failure:

A. The Heartbeat Trust Click Here

B. UK National Health Service Click Here

C. Keep It Pumping Click Here