Heart Failure: Many Causes, Many Solutions

The elderly population increases and with it, cases of heart failure, which is compromising the ability of the heart to pump blood to meet the metabolic needs of the organism. Although not save children and young people, primarily affects people age 65 or older, who account for more than 80% of all hospitalizations for this condition. The high prevalence in this age group is because, in general, heart failure is a disease per se. It is the consequence of various diseases that affect not only the heart - such as a stroke - but also other organs - such as metabolic diseases, infectious and autoimmune diseases - and that may affect the individual throughout life. Furthermore, advances in diagnosis and treatment increased the survival of patients with diseases that result in heart failure - in particular acute myocardial infarction, because about 50% of cases of acute heart failure.

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A survey of the Unified Health System shows that heart failure was the leading cause of hospitalization in Brazil in 2009, with 300 000 patients. In the United States, are recorded annually about 500 000 new cases, and spending on the disease reach $ 40 billion / year according to the American College of Cardiology. The World Health Organization (WHO) considers the disease a public health problem.

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Data for mortality are scarce and unreliable, as is usually the cause of death notifies the disease that resulted in heart failure. At the beginning of the last decade, a study sponsored by the British Heart Foundation found that about 40% of patients died within a year after the initial diagnosis of heart failure worse prognosis than breast cancer, prostate and bladder.

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Attention to risks

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The vast majority of deaths occur mainly in acute manifestation of the disease, when the heart becomes unable to perform effectively his duties by factors such as acute myocardial infarction or a severe arrhythmia. Factors unconnected with heart problems - such as severe brain injury, extensive hemorrhage or high voltage electric shock - can also lead to acute heart failure.

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Have a chronic heart failure is progressive. Often, only its bearer realizes something is wrong when obvious symptoms such as increased fatigue, cough, shortness of breath, abdominal pain, pleural effusion and enlarged liver. The chronic form may also have acute manifestations. In moderate and advanced stages of the chronic form, the heart may already be dilated and rounded, rather than its traditional elliptical.

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Detect and treat the cause of heart failure is the key to the evolution of the disease is controlled. At the beginning of the last decade, guidelines of the American College of Cardiology (ACC) and American Heart Association (AHA) have strengthened the recommendation for a focused approach to diagnosis and treatment of risk factors of heart failure. These include hypertension, obesity, diabetes, anemia, congenital factors, alcohol abuse and drugs and diseases of the heart and coronary artery disease, valvular heart disease, cardiomyopathy, rheumatic diseases. The chagasic chronic problem that affects approximately 30% of individuals who contracted Chagas disease, risk factor is prevalent in Brazil, where there are about 5 million people infected, according to World Health Organization

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The creation of specific protocols and multidisciplinary teams to monitor and follow up of patients with risk factors trend is still embryonic in Brazil, although it is already adopted in top institutions and have great potential for dissemination. Until now been hospitalized patients are monitored and, if necessary, to achieve the contacted test and control procedures. "The focus of these protocols is to integrate the activities of the multidisciplinary team to optimize the use of drugs recommended by national and international guidelines and educate the patient about the disease to improve treatment adherence and thus improve survival and quality of life and reduce the chances of readmission, "says Dr. Marcia Makdisse, Center Manager of the Cardiology Hospital Albert Einstein.

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Clinical efficacy

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In recent years, technological development has added a large arsenal of possibilities for additional clinical, laboratory and graphic methods necessary for the diagnosis of heart failure. Imaging studies such as Doppler echocardiography, two-dimensional echocardiography and scintigraphy increased the degree of accuracy in detecting the disease stage.

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When the failure is diagnosed in its early stages, clinical treatment with medication is effective in most cases. In the 90s, the traditional therapy with diuretics and vasodilators was reinforced by the arrival on the market of beta-blockers, which reduce the rush of adrenaline, reducing the pace and strength of heart contractions.

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"Beta blockers have brought a change in the therapeutic concept of heart failure and are responsible for a significant drop in readmission rates and mortality," says Dr. Fernando Bacal, a cardiologist and coordinator of the Einstein Center for Heart Failure. When the failure is caused by heart disease such as coronary artery disease or valvular disease (heart valves) may be indicated for the clinical treatment is now complemented by the usual surgical procedures such as coronary artery bypass and valve repair or replacement, which have shown great promise in reversing the disease.

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High-tech devices

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When there is no adequate response to medical treatment, characterizing refractory heart failure as may be necessary for more complex behaviors. The technology has become an important ally, particularly in the last five years, with the development of devices such as biventricular pacing, which may benefit certain cases of heart failure of moderate to severe. Unlike conventional pacemakers, which stimulates only the functioning right ventricle, biventricular device, also known as resynchronization or multisite, optimizes the functioning of the heart, resynchronizing the contraction and relaxation of both ventricles. It is indicated for patients who have delayed activation of the right ventricle to the left - abnormalities recorded in at least 30% of patients with heart failure.

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It is made subcutaneous implantation of the device in the pectoral region, with a technique very similar to that used in the placement of a conventional pacemaker. Resynchronization therapy reduces symptoms, hospitalizations and mortality. However, not all patients are eligible for therapy, which can only be determined after conducting specific tests, such as tissue Doppler.

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Artificial ventricles

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Also in the last five years has increased the importance and use of circulatory assist devices called for more severe cases. Best known for artificial ventricles (or "artificial heart"), are the functions that should be performed by the heart.

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In Brazil, centers of excellence in cardiology have been using the devices in two specific indications, pending the completion of the transplant and to keep the patient alive until the body recovers its pumping capacity. In both situations, it is a temporary measure and should generally be taken with the patient in the intensive care unit.

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There are various types and categories of circulatory assist devices. "Indication will depend on the therapeutic approach of each patient, but among the most widely used are the intra-aortic balloons, which serve to increase the flow of blood reaches the coronary arteries. This is a catheter with a balloon at its end and whose operation is controlled by a monitor computer coupled to the patient's heart. The balloon inflates and deflates in synchrony with the phases of contraction and relaxation of the heart, "explains Dr. Fabio Jatene, surgeon, cardiologist and professor of medicine at the University of Sao Paulo.

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Despite the benefits that the artificial ventricles can bring to the reduction of mortality in patients with severe heart failure, the high cost of the devices makes them an alternative therapy rarely used outside of major urban centers.

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There are also definitive artificial ventricles, which are devices implanted in the patient's own body. Worldwide, however, is a feature still not adopted. In Brazil, there is no record of patients living with these devices.

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A new heart

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When chronic heart failure reaches the terminal stage, transplantation becomes the only option to ensure the survival of the patient. Since it began to be made in the early '70s, the procedure has undergone several enhancements aimed at increasing its effectiveness and safety. More recently, changes in suture technique of the transplanted organ brought great improvement in the control of possible arrhythmias after the procedure.

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The rejection factor that initially generated high mortality rate and almost led to the abandonment of transplantation, is now a phase overcome. New antirejection drugs with fewer side effects, increased the eligibility of patients to the procedure and increased the survival rate of transplant, with a success rate exceeding 85% in the first year.

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Still, there is a technique widely used. In past years, were carried out not more than 5000 transplants worldwide. In Brazil there were 200 procedures, 77 of which the State of Sao Paulo. "Brazil has a well structured program of transplants, but donors are still missing and techniques developed to allow conservation of organ for longer," says Dr. Enio Buffolo, surgeon and professor at the Federal University of Sao Paulo (UNIFESP). Today, the maximum storage time for a heart is removed after four hours.

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Back to life

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Most feared consequence of acute heart failure, cardiogenic shock is the sudden inability of the heart to pump blood, causing a sharp drop in blood pressure and inadequate irrigation of tissues. Between 5% to 10% of cases of acute myocardial infarction may progress to cardiogenic shock. 20 years, the rate of mortality in these cases was 80%. Today, that number dropped to 40%, mainly due to the advancement of diagnostic and treatment, allowing flexibility in the detection of disease and early treatment.

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Even with high-end features, the Swan-Ganz catheter, used since the 70s, is still the best indication that aids in the diagnosis and provides subsidies for the proper treatment of cardiogenic shock. Introduced by central vein reaches the heart structures and provides lots of information about the patient's condition.

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"Identifying the cause of cardiogenic shock is crucial to determine the behavior," explains Dr. Elias Knobel, a cardiologist and founder of the Intensive Care Unit of the Albert Einstein Hospital. In cases of acute myocardial infarction, measures such as catheterization and percutaneous procedures desobstruem that the artery should be performed as early as possible.

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Less common causes such as acute myocarditis, viral often require hospitalization in intensive care units. Unique to ICU care for patients with heart disease offer advanced monitoring systems, and mechanical circulatory support devices that enable minimally invasive treatment techniques.

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Whatever the cause, however, the flexibility in attendance is essential. The faster, the smaller the chance of irreversible damage to heart muscle.

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Depression also causes

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Although undervalued, psychosomatic illnesses, especially depression, are also entering the list of causes of heart disease with the potential to evolve into acute heart failure. Rare, Takotsubo syndrome, or broken heart syndrome, heart disease is one of the most closely linked to emotional factors.

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It is a disease co adrenergic infarction, or caused by high discharge adrenaline. In most cases, this discharge is triggered by factors such as a news item or event which strongly affects the person. The syndrome is characterized by simulating an acute myocardial infarction and affects mostly women between 45 and 55 years. If progress to cardiogenic shock, has a mortality rate near 50%.

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Speed ??is essential to reverse the situation. The differential diagnosis is made by catheterization (to exclude the possibility of having the arterial blockages that cause heart attacks) and dosage levels of adrenaline. "In patients with Takotsubo syndrome, adrenaline levels are up to 25 times higher than those of acute myocardial infarction," explains Dr. Helio Korkes, a cardiologist at Albert Einstein Hospital and PhD in Cardiology by UNIFESP (Federal University of Sao Paulo .)

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In Takotsubo syndrome, tests such as echocardiography showed heart-shaped jug. Treatment is primarily with hemodynamic support measures, such as catheterization. After the critical phase, between five and ten days, the disease is fully reversible without sequelae. Their recurrence rate, however, is considered high - 10%. Hence the importance of treatment of psychosomatic factors, since the vast majority of patients affected by the syndrome showed signs of depression at the time of the episode. The prescription anti-anxiety medications can help to considerably reduce this recurrence.

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Cardiac rehabilitation

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In recent years, has been gaining momentum cardiac rehabilitation through physical activity. It is a concept radically opposed to thinking in force until 20 years ago when it was believed that patients with heart failure should stay away from any kind of effort.

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Early clinical trials demonstrating the benefits of exercise in patients with heart failure were conducted by MJ Sullivan and colleagues in 1988. Today, the Brazilian Society of Cardiology indicates cardiac rehabilitation as part of treatment for patients with heart failure.

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"Some studies show a close relationship between cardiac rehabilitation and reduction in hospitalization rates and mortality," says Dr. Luciana Janot de Mattos, a cardiologist at the Rehabilitation Center of the Albert Einstein Hospital. The aerobic physical activity (walking and cycling) and weight exercises promote a series of changes not only beneficial for the heart, but throughout the circulatory system and muscle.

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The activity must be performed after conducting thorough assessment of the patient's condition and should preferably be carried out under supervision and / or guidance of skilled professionals in the area.

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Of exercise rehabilitation for the improvement of traditional techniques, diagnostic tools of last generation of new treatment technologies, also in heart failure medicine following your journey for life. With his progress, helps to increase the longevity, which, in turn, increases the incidence of many diseases. But this is the same medicine, with its innovations, deals with these new challenges and contribute so that patients can overcome them and for people to live more and better.

Source: http://heart.ezinemark.com/heart-failure-many-causes-many-solutions-7d3682736ed0.html

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