Shortness of breath in heart failure

Dyspnea in heart failure or cardiac dyspnea is one of the leading symptoms of impaired filling or emptying of the heart, imbalance of vasoconstriction and vasodilation of neurohormonal systems. In most cases, we are talking about chronic inspiratory dyspnea: patients complain of periodic recurrent difficulty breathing, often against a background of general weakness, tachycardia, edema. The pathology is complex, requiring constant treatment and monitoring cardiologist.

Causes of the shortness of breath in heart failure

Dyspnea in heart failure can occur due to past or ongoing pathological processes that increase the load on the heart and blood vessels. Thus, the most common direct causes are as follows:

• suffered myocardial infarction;
• obesity;
• physical adaptation disorder, hypodynamia;
• coronary heart disease;
• high blood pressure;
• various myocardial pathologies (both inflammatory and non-inflammatory in nature);
• heart defects;
• lung diseases;
• alcohol abuse, drug use.

Sometimes, against the background of a sharp increase in physical activity, it becomes difficult for the heart to provide all the oxygen needs of the body, so dyspnea can develop even in compensated patients with heart failure. Pathologies that increase the likelihood of this symptom:

• infectious processes;
• renal disorders, renal failure;
• anemia;
• arrhythmias;
• Thyroid disorders (hyperthyroidism).

With competent treatment of these diseases, dyspnea in heart failure can become less pronounced.

Other disorders - such as diabetes - can worsen symptoms and increase attacks of breathlessness.

Often problems with breathing occur if the patient violates the therapy regimen, adjusts the intake of drugs at their own discretion, engages in self-medication.

Risk factors

The presence of any of the following factors determines the appearance of dyspnea in heart failure. If two or more factors are combined, the prognosis is significantly worsened, the risk of chronic pathology increases.

Among the most significant risk factors:

• high blood pressure;
• ischemic heart disease;
• a history of myocardial infarction;
• heart rhythm disorders;
• diabetes;
• congenital cardiac anomalies, heart defects;
• frequent viral infections;
• chronic renal failure;
• Heavy smoking, chronic alcoholism, drug addiction.

Pathogenesis

Rhythmic heartbeats provide continuous circulation of vascular blood flow, oxygen and nutrients to all tissues and organs, removal of excess fluid and the final products of metabolism. This process is carried out in two phases:

1. Systole (myocardial contraction).
2. Diastole (myocardial relaxation).

Depending on the disturbance of one or another functional phase, systolic or diastolic heart failure develops.

In systolic heart failure, dyspnea is caused by myocardial weakness and a deficit in blood ejection from the heart chambers. The most common underlying cause is ischemic heart disease and dilated cardiomyopathy.

In diastolic insufficiency, the elastic capacity of the myocardium suffers, as a result of which the atria receive a smaller volume of blood. The primary cause of such pathology is considered to be high blood pressure, pericarditis with stenosis, hypertrophic cardiomyopathy.

The right side of the heart transports blood to the lungs and oxygenates the blood flow. Delivery of oxygen and nutrients to the tissues is carried out by the left side of the heart, so dyspnea is most often explained by left ventricular failure. Right ventricular failure is mainly manifested by the occurrence of systemic edema.

Epidemiology

An estimated 64.3 million people worldwide are living with heart failure. [1], [2] The number of heart failure patients has increased significantly over the past few decades due to the high prevalence of triggering factors - such as obesity and diabetes mellitus - as well as an increase in the elderly population.

According to statistical information, the probability of dyspnea in heart failure percentage increases with age. In the United States, the pathology affects 10 out of a thousand elderly people over 65 years of age. At the same time, the total number of elderly and senile patients is about six million. In European countries, the number of patients is estimated at about 10%.

The prevalence of heart failure is increasing from 4.5% in the population over 50 years of age to 10% in the population over 70 years of age. [3] In recent years, dyspnea in heart failure has become more common in older patients: for example, the average age of patients has increased from 64 years (25 years ago) to 70 years (10 years ago). More than 65% of patients suffering from heart failure and dyspnea are over 60 years of age.

Men have a slightly higher incidence than women. Mortality increases with age, although mortality in the general population has generally decreased over the past decade, which is attributed to increasing advances in the treatment of cardiovascular disease.

Symptoms

With the formation of left ventricular insufficiency, the left ventricle weakens and the load on it increases. In this situation, there are two possible developments:

• the left ventricle contracts, but not enough, which negatively affects its ability to pump blood;
• the left ventricle loses the ability to qualitative relaxation, which is associated with myocardial overstrain, as a result of which the blood supply to the heart is insufficient.

Against the background of fluid accumulation in the lung area, a person's breathing gradually becomes difficult.

Swelling, dyspnea in heart failure most often occur with increasing over several days or weeks, less often the symptoms develop suddenly. The most common symptomatology is characterized by the following signs:

• Difficulty breathing, a feeling of shortness of breath (especially during physical activity), which is caused by fluid accumulation in the lungs.
• Nocturnal insomnia associated with frequent awakenings due to a feeling of shortness of breath, as well as dry cough without relief. Dyspnea and coughing in heart failure may increase when lying down, which requires additional pillows (often patients are forced to sleep half-sitting, which is not conducive to a normal full sleep).
• Swelling of the feet, ankles, the entire lower extremities, hands, lumbar area, with a tendency to increase in the afternoon, or against the background of prolonged stay "on your feet" or sitting.
• Fluid accumulation in the abdominal cavity (manifested visually by abdominal enlargement), which may be accompanied by nausea, pain, changes in appetite, increased shortness of breath. Characteristically, due to fluid accumulation, weight increases even with loss of appetite and significant restriction of diet.
• Severe and constant fatigue, which is due to insufficient oxygenation of the blood and tissues.
• Regular dizziness, loss of concentration, which is due to insufficient oxygen supply to the brain tissues.
• Heart palpitations.

If such symptoms occur, you should definitely visit your doctor:

• sudden weight gain;
• a dramatic increase in abdominal volume;
• swelling of the legs and abdomen;
• unexplained constant fatigue;
• worsening of dyspnea after exertion, during night rest, lying down;
• the onset of an unreasonable cough, especially at night;
• pinkish or bloody sputum;
• Unusually low urine volume during the day and increased urination at night;
• dizziness;
• nausea.

Urgent medical attention is required if detected:

• fainting spell;
• frequent or prolonged shortness of breath, in which it becomes difficult not only to breathe but also to speak;
• pain behind the sternum that can't be controlled with nitroglycerin;
• A sudden tachycardia that doesn't go away, as well as a feeling of irregular heart rhythm.

Dyspnea in chronic heart failure usually develops gradually, against the background of increased fatigue, decreased physical activity, the appearance of edema (including ascites). As for other pathological manifestations, they may differ, depending on which ventricle is overloaded:

• in left ventricular failure dyspnea occurs more often at night or after exercise; the patient is forced to take a sitting position to improve blood flow from the pulmonary vessels;
• in right ventricular failure dyspnea is accompanied by increased heart rate, decreased blood pressure, edema, bloating of neck veins.
• Patients with chronic heart failure often have cyanosis - blueing of the lips, fingertips, which is associated with a deficit of oxygen in the blood.

Diagnostics of the shortness of breath in heart failure

Diagnosis of dyspnea in heart failure is carried out along with the study of medical history, assessment of symptomatology and the results of laboratory and instrumental studies.

Recommended Laboratory Tests:

• general blood test (inflammatory changes may be absent, sometimes moderate anemia is detected);
• COE (increased if dyspnea and heart failure directly caused by rheumatic lesions or infectious processes - for example, endocarditis);
• general urinalysis (allows you to identify complications from the kidneys, exclude the renal nature of fluid accumulation in the body, detect proteinuria, often accompanying chronic heart failure);
• blood test for total protein and protein fractions (may be lower due to redistribution of fluid due to edema);
• blood sugar analysis (necessary to rule out the presence of diabetes mellitus);
• indicators cholesterol, high-density and low-density lipoproteins (examined to assess the likelihood of developing atherosclerosis, coronary heart disease, hypertension);
• potassium and sodium in the blood (especially important if the patient is taking diuretics or has severe edema).

Additional instrumental diagnostics is prescribed depending on the specific indications and is determined individually:

• Chest X-ray (helps to determine the size and position of the heart, detect changes in the lungs);
• electrocardiography (detects arrhythmias, cardiac dysfunction);
• echocardiography (allows you to assess the work of all parts of the heart, valve system, determine the size and thickness of the myocardium, trace the quality of the ejection fraction and the percentage of blood volume that enters the aorta during cardiac contraction);
• stress tests (help assess heart function under conditions of high physical activity);
• Coronarography (is an X-ray diagnostic test with injection of contrast agent into the coronary vessels).

Another important laboratory test to detect heart failure is the determination of NT-proBNP - brain natriuretic hormone - a protein substance formed in the left ventricle. The study is performed by electrochemiluminescent immunoassay (ECLIA).

Differential diagnosis

Dyspnea at rest in heart failure appears when a person is in a relaxed state (not physically active), sleeping or resting. In addition, the problem can occur during and after physical activity, accompanied by various additional manifestations. Thus, cardiovascular dyspnea is characterized by:

• palpitations;
• skin lividity;
• cold and swollen extremities;
• shortness of breath, nighttime choking episodes.

Pulmonary dyspnea is characterized by chest pain, weakness, fever, cough, asthmatic attacks. In general, pulmonary breathing problems are more often manifested on exhalation (dyspnea in heart failure implies difficulty in inhalation), but in general, the symptomatology depends on the specific causes and pathological conditions (infectious-inflammatory, oncological, obstructive, etc.).

Dyspnea of central neurogenic origin is manifested by abrupt rapid-surface breathing and occurs due to any stressful situation.

Hormone-induced shortness of breath is the result of adrenaline release into the bloodstream, which can accompany states of intense fear, anxiety, and worry.

In order to accurately determine the root cause of respiratory distress, to distinguish one disease from another, a thorough auscultation, chest percussion, external examination, study complaints and anamnesis, evaluate the indicators of laboratory and instrumental studies. Depending on what pathology is suspected, spirometric and cardiologic tests are performed. If necessary, additional consultation with a psychiatrist, neurologist, nephrologist, endocrinologist, infectious disease specialist, etc. Is additionally prescribed.

Treatment of the shortness of breath in heart failure

To relieve the symptom of dyspnea in heart failure, therapy of the underlying disease is prescribed. A comprehensive approach consists of such measures:

• drug therapy;
• normalization of body weight;
• nutritional correction (reducing the amount of salt and animal fats consumed);
• Exclusion of bad habits, counteracting stress and psycho-emotional overload;
• sufficient physical activity, physical therapy, breathing exercises.

As part of drug therapy, such groups of drugs are used:

• diuretics;
• cardiac glycosides;
• vasodilators (nitrates);
• calcium channel blockers;
• β-blockers, etc.

In case of a complex course of heart failure and dyspnea turning into suffocation, surgical intervention may be prescribed.

Diuretics are the primary means of stimulating the excretion of salts and excess fluid in the process of urinary excretion. Thanks to the action of diuretics, the volume of circulating blood is reduced, high blood pressure is normalized, and heart function is facilitated.

A special therapeutic role in shortness of breath associated with heart failure is played by foxglove preparations, or cardiac glycosides. These drugs have been used for centuries and have proven their effectiveness in improving metabolic processes in the myocardium, increasing the strength of heart contractions. After taking cardiac glycosides, the blood supply to internal organs and tissues is significantly facilitated.

Nitrates are also actively used - vasodilators that affect the lumen of peripheral arteries. As a result, blood vessels dilate, blood flow is facilitated, cardiac function improves. In addition to nitrates (Nitroglycerin), the category of vasodilators also includes calcium channel blockers and angiotensin-converting enzyme blockers.

Surgical intervention may be considered if dyspnea in heart failure is caused by abnormalities of the valve system.

Aerosols for shortness of breath in heart failure are less commonly used than in respiratory shortness of breath (e.g. Due to bronchial asthma or pneumonia). However, some aerosol preparations are still used - for example, the oromucosal spray Izoket, with the active ingredient isosorbide dinitrate. Isoket promotes relaxation of vascular smooth muscle, which leads to their dilation and reduction of venous return to the heart. As a result, the final ventricular diastolic pressure, preload and systemic vascular resistance are reduced, which generally facilitates heart function. The drug belongs to the category of organic nitrates. It can be used for dyspnea caused by angina, myocardial infarction, acute left ventricular heart failure. The spray is injected into the oral cavity from 1 to 3 times with an interval of 30 seconds. The drug is not used in cardiogenic shock, severe drop in blood pressure, constrictive pericarditis and hypertrophic obstructive cardiomyopathy, and in cardiac tamponade. The most frequent side effect: so-called nitrate headache, which goes away on its own and does not require withdrawal of the medicine.

Other nitrate aerosol preparations include Iso-Mic sublingual spray, Nitro-Mic spray, and Nitromint.

Dyspnea in heart failure in the elderly requires particularly careful diagnosis and thoughtful treatment due to age-related characteristics and a large number of chronic diseases.

Drugs for dyspnea of heart failure in the elderly

Drugs to relieve dyspnea in heart failure in elderly patients are selected as carefully as possible, because in the process of therapy may occur drug interactions associated with the use of other drugs for other chronic diseases. In addition, with age, the risk of side effects increases - in particular, an increase in blood pressure.

To reduce the risks of adverse effects from medications, treatment is prescribed with these recommendations in mind:

• start a course of medications by determining the minimum effective dosage;
• constantly monitor the patient's condition, monitor possible adverse reactions to therapy.

Standard Usage:

• β-adrenoblockers are drugs that block adrenoreceptors located in the heart muscle, which leads to increased adaptation to hypoxia, normalization of rhythm and blood pressure. It should be taken into account that β-adrenoblockers provoke the so-called withdrawal syndrome when abruptly stopping their use, so they should be canceled gradually, step by step. Elderly patients suffering from dyspnea against the background of chronic heart failure, most often take Bisoprolol, Metoprolol, Carvedilol. These drugs reduce the intensity and frequency of heart contractions, normalize blood pressure and heart rhythm. Among the possible side effects of these drugs, the most common are dizziness, nausea, dry mouth.
• Angiotensin-converting enzyme inhibitors are designed to block the activity of the enzyme that affects the formation of angiotensin II. This substance has a strong vasoconstrictor activity, so it can provoke the development of dyspnea and aggravates the load on the heart. Taking ACE inhibitors allows you to improve the adaptation of the cardiovascular system to the effects of physical and psycho-emotional factors. Among the most common drugs of this group: Captopril, Enalapril, Fosinopril, etc. Possible side effects: skin rashes, dry cough, diarrhea, headache.
• Angiotensin II receptor antagonists can block the receptor network sensitive to angiotensin II, which provokes an increase in vascular tone and blood pressure. These drugs are used as part of complex therapy: most often prescribed Losartan, Valsartan and others. The most common side effects are hypotension, headache.
• Aldosterone antagonists - potassium-saving diuretics (spironolactone, Eplerenone) relatively quickly eliminate dyspnea caused by tissue edema. These drugs do not cause potassium deficiency and are suitable for prolonged use.
• Diuretics (Furosemide, Hydrochlorothiazide, Torasemide) quickly eliminate edema, contributing to the elimination of dyspnea and preventing the development of pulmonary stasis. Contraindications to the use of diuretics: acute renal or hepatic failure, glomerulonephritis with acute course, gout, decompensation of aortic or mitral stenosis, low blood pressure, acute myocardial infarction.
• Vasodilators - vasodilators (Nitroglycerin).
• Cardiac glycosides (Strophanthin, Digoxin).

As for bronchodilators, their use in cardiac patients is not only inappropriate, but sometimes dangerous. For example, Eufylline in dyspnea of heart failure can aggravate the symptomatology, as it has a stimulating effect on contractile activity, increases heart rate, increases coronary blood flow and further increases myocardial oxygen demand. Eufylline is contraindicated in low blood pressure, paroxysmal tachycardia, extrasystoles, myocardial infarction with arrhythmias, obstructive hypertrophic cardiomyopathy. However, in some cases - for example, in the combined treatment of left ventricular failure with bronchospasm - the use of the drug is justified.

Folk remedies for shortness of breath in heart failure

Heart failure requires constant treatment and monitoring by a cardiologist. You can treat the problem with folk remedies only after consulting a doctor, or to relieve the main symptom of shortness of breath, if it is not possible to quickly seek medical help.

Dyspnea in heart failure can be relieved by drinking an infusion of fennel seeds, a mixture of honey and grated horseradish.

• Pour 10 g of fennel seeds 200 ml of boiling water, cover with a lid, insist until cool, filter. Take one sip on average 4 times a day.
• Mix 1 spoonful of honey and 1 spoonful of grated horseradish. Take on an empty stomach 1 hour before meals, drinking water. It is optimal to carry out such treatment in courses of 4-6 weeks: in this case, the mixture is consumed in the morning 1 hour before breakfast.

In addition, you can use phytotherapy with marsh wheatgrass, hawthorn and motherwort, dill.

• Pour 10 g of wheatgrass plant 200 ml of boiling water, insist under a lid until cool, filtered. Use 100 ml three times a day after meals.
• Chop dill or its seeds, brewed in the amount of 1 tbsp. In 300 ml of boiling water, insist. This volume of infusion should be drunk in equal portions during the day.
• Take 6 tbsp. Of motherwort herb and the same amount of hawthorn berries, pour 1.5 liters of boiling water. The container is warmly wrapped (you can pour in a thermos, in this case, you do not need to wrap) and leave for 24 hours for infusion. Then the liquid is strained through gauze and take 200 ml in the morning, afternoon and evening. Additionally, you can drink tea from rose hips.

Vitamins for heart failure and shortness of breath

Vitamins and minerals are important for the normal functioning of the entire organism, in particular the respiratory and cardiovascular systems. Therefore, it is necessary to know and understand which substances the body lacks and to perform timely prevention.

• Vitamin D lowers the risk of cardiac dyspnea attacks, supports heart function, and is involved in regulating blood pressure.
• B-group vitamins (_B6, _B12, folic acid) reduce the concentration of homocysteine in the blood (a factor in increasing blood pressure), prevent the development of anemia.
• Ascorbic acid helps strengthen vascular walls, prevents the development of atherosclerosis.
• Tocopherol (vitamin E) maintains normal blood pressure, prevents the development of myocardial infarction, coronary heart disease, atherosclerosis.
• Vitamin K stabilizes blood clotting processes, prevents the deposition of calcium on the walls of blood vessels.

It is advisable to regularly monitor the levels of vitamins and minerals in the blood to take timely action and prevent the development of pathologic deficiency states.

With regard to minerals, in shortness of breath associated with heart failure, special attention should be paid to such of them:

• Magnesium (prevents increased thrombosis, maintains stability of blood pressure);
• Potassium (controls myocardial contraction, prevents arrhythmias);
• Calcium (takes part in ensuring normal myocardial function, formation of blood cells).

Additionally, it is recommended to take omega 3 fatty acids. In general, multivitamin preparations should be prescribed by a doctor after diagnosing the vitamin and mineral composition of the blood.

Complications and consequences

In heart failure, the heart loses the ability to provide the body with the necessary amount of oxygen, a state of hypoxia occurs. General fatigue and shortness of breath are symptoms of all stages of this pathology. If you do not take measures at the first stage of the development of the disease, then in the future the problem will move to the next, deeper and more dangerous state. Specialists distinguish such stages of development of heart failure:

1. Dyspnea and unmotivated fatigue appear, heart rate increases with exertion. This condition is often mistaken for the usual result of physical exertion.
2. (There are two sub-stages, A and B). A: Dyspnea and palpitations begin to bother even at rest. Swelling appears, liver enlargement is detected. B: Health deteriorates, ascites develops, dyspnea accompanied by pulmonary wheezing. Cyanosis is noted. The development of renal failure is possible.
3. The patient's condition is severe, symptoms of emaciation are noted, cardiogenic pneumosclerosis and liver cirrhosis develop.

Dyspnea in heart failure in the acute form is dangerous because of the high probability of the development of suffocation. In addition, the acute course can gradually transform into a chronic form, as a result of which may develop:

• arrhythmias;
• pulmonary edema;
• myocardial infarction;
• thromboembolism cerebral vessels or pulmonary artery;
• sudden death.

Prevention

The risk of developing heart failure can be reduced by simple preventive measures. If the pathology is already present, secondary prevention is used to prevent dyspnea attacks.

You can minimize the risks of cardiac problems by following these recommendations:

• Moderate physical activity. To support the cardiovascular system, it is recommended to walk at least half an hour or at least 3 kilometers every day. Instead of walking, you can swim, run, dance, or perform daily half-hour gymnastics. It is important to increase the load gradually, which helps to increase the adaptation of the cardiovascular apparatus, training of the muscular corset, stabilization of blood circulation and reducing the risk of increased thrombosis.
• Weight control. The weight limit is calculated by dividing the weight in kg by the height in m (squared). The resulting value is the so-called body mass index, which should normally be between 18.5 and 25 kg/m². According to information from the World Health Organization, exceeding this indicator for every 5 units increases the risk of heart failure by an order of magnitude. Overweight contributes to the formation of myocardial fatty degeneration, hypoxia and increased thrombosis.
• Dietary correction. Reducing the share of sweets, animal fats and fried foods in the diet, calorie control, sufficient consumption of greens, vegetables, berries and fruits will help to maintain cardiovascular health. Salt and sugar intake should be minimized: this step alone can significantly reduce the risks of hypertension, obesity and atherosclerosis.
• Adequate intake of vitamins and minerals. The main "cardiac" trace elements are potassium and magnesium: they are responsible for normal myocardial trophism, vascular elasticity and the rhythm of contractile activity.
• Exclusion of bad habits. Nicotine, alcohol, drug addiction disrupt the normal operation of the blood coagulation system, contribute to high blood pressure, increase the load on the heart, thereby causing increased heart rate, arrhythmia, hypoxia and, as a consequence, shortness of breath.
• Regular and adequate rest. Without sufficient rest, the body sinks into a state of stress and energy deficit. Myocardium in such conditions works with increased load and wear out faster. The most common factors in the development of hypertension are sleep deprivation and fatigue. Experts recommend sleeping at least 8 hours a day, and in the process of work regularly take small breaks.

Secondary preventive measures are aimed at preventing recurrent episodes of dyspnea in heart failure:

• Taking medications prescribed by a doctor;
• strict adherence to all medical recommendations;
• regular exercise (LFK), after prior coordination of the load with the attending physician;
• Compliance with diet (for most patients with dyspnea in heart failure is suitable therapeutic table №10);
• complete exclusion of smoking and alcoholic beverages;
• regular doctor's appointments.

Seeing a cardiologist once a year is recommended for everyone over the age of 40, regardless of how they feel. Patients with diagnosed heart failure should consult a cardiologist every six months. This is necessary not only to prevent the development of attacks, but also to correct drug therapy or lifestyle (as indicated).

Forecast

In order to determine the prognosis of patients with dyspnea in heart failure, it is necessary to simultaneously take into account the influence of numerous factors that can directly or indirectly affect the development of complications and patient survival. The presence or absence of dyspnea alone cannot predetermine the outcome of the pathology, so it is important to take into account the possible involvement of other factors and symptoms.

Among the major prognostically significant factors are:

• The origin (etiology) of heart failure;
• intensity of manifestations, symptomatology, presence of decompensation, tolerance to loads;
• heart size, ejection fraction;
• hormonal activity;
• hemodynamic quality, left ventricular status and function;
• the presence of rhythm disturbances;
• the treatment used and the body's response to it.

No less significant factor is also the qualification and experience of the attending physician, completeness (comprehensiveness) of therapeutic measures.

It is important to realize that dyspnea in heart failure is not just a symptom, but a combined manifestation accompanying disorders of the heart, blood vessels, kidneys, sympathetic nervous system, renin-angiotensin system, hormonal apparatus, metabolic processes. Therefore, it is very difficult to adequately predict the outcome of the disease.