What is Left Ventricular Failure?
The heart is made up of three parts: the pericardium (outer layer), myocardium (middle muscle layer), and endocardium (inner layer). Damage to any of these parts can lead to heart failure. A failure of the left ventricle, the chamber that pumps blood to your body, leads to a condition called left ventricular failure. This means it can’t pump enough blood to supply the body’s vital organs adequately.
There are different types of left ventricular failure. This can be classified into heart failure with preserved ejection fraction (HFpEF), where the ejection fraction (the percentage of blood leaving your heart each time it contracts) is over 50%. Alternatively, it could be heart failure with reduced ejection fraction (HFrEF) when the ejection fraction is less than 40%. Then there’s heart failure with a mid-range ejection fraction, where this percentage falls between 41 and 49 percent.
What Causes Left Ventricular Failure?
The most common causes of a condition called left heart failure are coronary artery disease and high blood pressure. High blood pressure can cause the left side of the heart to work harder and become bigger (leading to a condition known as heart failure with preserved ejection fraction), and it can also increase your risk of getting coronary artery disease (which can lead to heart failure with reduced ejection fraction). Other factors that can increase your risk of developing left heart failure include diabetes, smoking, being overweight, being a man, and living a sedentary lifestyle. Many of these causes can be prevented, so it’s extremely important to manage these risk factors to help prevent heart failure.
Risk Factors and Frequency for Left Ventricular Failure
Heart failure is especially common in older people and its rate of occurrence is growing. Roughly 5.7 million people in the United States have been diagnosed with heart failure. This equates to about 10 cases in every 1000 people over the age of 65. Almost half of all heart failure patients have a type called HFrEF, and it is becoming increasingly common. There is another type of heart failure, known as HFpEF, which is more prevalent in women (accounting for 79% of cases compared to 49% in men) and it often affects older individuals.
- Heart failure commonly occurs in older people.
- About 5.7 million people in the U.S. have been diagnosed with heart failure.
- The rate is roughly 10 in every 1000 people over the age of 65.
- About 50% of heart failure patients have a type known as HFrEF, and this is increasing over time.
- The other type, HFpEF, is more frequent in women (79% of cases) compared to men (49% of cases), and mainly affects the older population.
Signs and Symptoms of Left Ventricular Failure
Patients with left heart failure may experience various symptoms. These include feelings of breathlessness, particularly during physical activity, discomfort while trying to sleep lying flat (orthopnea), and nighttime shortness of breath (paroxysmal nocturnal dyspnea). Other symptoms related to excess fluid build-up can also occur, such as swelling in the legs, weight gain, increased size of the abdomen, or pain in the upper right part of the abdomen due to an overloaded liver. Some patients with severe illness might start losing weight, a condition called “cardiac cachexia”.
In a physical examination, the doctor might notice specific signs linked to left heart failure. These may include:
- The presence of crackling sounds (rales) in the lungs, suggesting fluid build-up (pulmonary edema)
- Decreased lung sounds, indicating a potential fluid build-up outside the lungs (pleural effusion)
- An extra heart sound (S3 gallop), suggesting high fluid pressure inside the left heart chamber
- A heart impulse felt to the left on the chest wall, indicating an enlarged heart
- Visible neck veins (jugular venous distention), a sign of high pressure in the right part of the heart
- Increased neck vein pressure when the liver is pressed (positive hepatojugular reflux)
- An increase in abdominal size due to fluid accumulation (ascites)
- Swelling in the scrotum
- Low blood pressure and a fast heart rate, indicating severe heart failure
Testing for Left Ventricular Failure
Heart failure is usually diagnosed based on your symptoms and medical history. But in order to further understand the situation, your doctor may order some additional tests:
* Laboratory tests: One important test measures the level of a hormone called brain natriuretic peptide (BNP) or NT-proBNP. This hormone can help health professionals differentiate between acute heart failure and other causes of shortness of breath. However, this test is not perfect and cannot definitively diagnose acute heart failure. Other tests may measure substances such as troponin T to detect a heart attack, complete blood count to check your overall health, basic metabolic panel to check the function of your vital organs (for instance, a low sodium level could indicate severe heart failure), and liver function tests to check if your liver is damaged due to fluid buildup.
Electrocardiography is another test that can detect changes in the heart, like damage from a heart attack, enlargement of the heart’s main pumping chamber (left ventricular hypertrophy), or heart rhythm problems (arrhythmias). An echocardiogram, which uses sound waves to create pictures of the heart, can help distinguish different types of heart failure by measuring the amount of blood the heart pumps out with each beat (ejection fraction). This test can also gauge the functioning of the heart’s main left chamber (to check for diastolic left ventricular function), detect issues with movement of the heart muscle that may suggest a blockage in a heart artery, and identify diseases of the heart valves and the sac around the heart (pericardial pathologies).
Lastly, if you are experiencing chest pain (anginal symptoms) or worsening heart failure symptoms, your doctor may recommend a test called coronary angiography. This test uses dye and special X-rays to show the insides of your coronary arteries. It can help to see whether a waxy substance called plaque has narrowed or blocked any of your coronary arteries.
Treatment Options for Left Ventricular Failure
Making changes to your lifestyle, such as limiting your salt intake and avoiding alcohol, nicotine, and recreational drugs, can play a crucial role in improving the outcome of heart disease.
Treating the root cause of the heart problem is extremely important. This is because certain types of heart failure, like those caused by alcohol, rapid heart rate or poor blood flow to the heart, can be reversible if the cause is addressed. Managing your blood pressure also helps stop the heart disease from getting worse.
Medication for heart failure often depends on the type of heart failure a person has, which are “Heart Failure with reduced Ejection Fraction” (HFrEF) or “Heart Failure with preserved Ejection Fraction” (HFpEF).
For HFrEF, the main treatment generally involves a combination of two types of drugs: ACE inhibitors or ARBs (both help to relax blood vessels), and beta blockers which slow heart rate. If the patient’s symptoms persist despite taking the maximum dose of these drugs, another type of medication called an angiotensin-receptor neprilysin inhibitor may be used instead. Other potential drugs include hydralazine, nitrates, and a mineralocorticoid receptor antagonist like spironolactone. Sometimes, for certain patients, medications like digoxin and ivabradine may also be used.
For HFpEF, treatment primarily targets the underlying cause or contributing factors. This could mean controlling high blood pressure, restoring blood flow to an area of the heart, and managing irregular heartbeats. A kind of drug known as a mineralocorticoid receptor antagonist could potentially help these patients as well.
Patients with severe symptoms and a low “Ejection Fraction” (a measure of how well your heart is pumping) may be referred for a device implant such as an ICD (a device that can monitor heart rhythm and deliver an electrical shock if needed) or a CRT (a device that helps both sides of the heart beat together). For advanced cases where the heart is not able to pump sufficient blood, other options include implanted devices that assist the heart, medications that continuously increase the force or speed of heartbeats, or even a heart transplant as a last resort.
What else can Left Ventricular Failure be?
When a patient experiences difficulty breathing upon physical exertion, it’s crucial for doctors to consider a wide range of possible causes. A patient already diagnosed with left heart failure might also have another disease contributing to these symptoms. A few other conditions should be investigated, especially if the patient’s symptoms don’t typically align with heart failure. These can include:
- Other heart-related issues such as primary pulmonary hypertension
- Lung conditions such as chronic obstructive pulmonary disease and interstitial lung disease
- Conditions unrelated to the heart or lungs, like anemia
Swelling in the lower legs, or edema, is usually not due to heart failure. Doctors should first check for other possible reasons for such swelling, which may include the following:
- Vein problems (venous insufficiency)
- Liver disease (cirrhosis)
- Kidney-related issues (nephrotic syndrome)
- Blockage of fluid flow in the body (lymphedema)
- Blood clots in the veins (thrombosis)
What to expect with Left Ventricular Failure
In 2008, death rates for heart failure were roughly 18.2 in every 100,000 men, and 15.8 in every 100,000 women, according to the “Morbidity and Mortality: 2012 Chart Book on Cardiovascular, Lung and Blood Diseases”. It’s known that patients with a type of heart failure called HFpEF typically have a lower death rate compared to those with a type called HFrEF.
There are several factors that can make heart failure outcomes worse. These include: being male, getting older, having a low ejection fraction (which means your heart isn’t pumping blood as well as it should), being assessed as having a high severity of heart failure symptoms according to a scale called the NYHA functional class, having low levels of red blood cells (hematocrit) and sodium, high levels of a hormone called brain natriuretic peptide, low maximum oxygen uptake during exercise, having a certain type of heart rhythm (wide QRS), kidney failure, low blood pressure, fast heart rate, and having an excess amount of fluid in your body despite trying medical treatment.
Possible Complications When Diagnosed with Left Ventricular Failure
Left heart failure can be complicated with a number of serious conditions. If the body is overwhelmed with too much fluid, it can cause difficulty breathing and a condition known as anasarca, where there is extreme fluid buildup in the body. Other complications might include irregular heart rhythms, either too fast or two slow, known as tachyarrhythmias or bradyarrhythmias. This can escalate to a state called cardiogenic shock: the heart can’t pump enough blood, leading to death.
Moreover, several conditions that lead to sudden death are common in patients with heart failure. These may include a sudden blockage in a lung artery (pulmonary embolism), an abrupt reduction of blood flow to the heart (acute coronary syndrome), strokes (cerebrovascular accidents), and physical rupture of the heart muscle.
To decrease the risk of sudden death, treatments start as soon as they are needed. They can range from implanted devices that control heart rhythms to medications that have been found to reduce deaths in left heart failure patients.
Common Complications:
- Respiratory distress due to fluid overload
- Anasarca – overall swelling of the body
- Tachyarrhythmias – too fast heart rhythms
- Bradyarrhythmias – too slow heart rhythms
- Cardiogenic shock – heart can’t pump enough blood, leading to death
- Pulmonary embolism – sudden blockage in a lung artery
- Acute coronary syndrome – abrupt reduction of blood flow to the heart
- Cerebrovascular accidents – strokes
- Rupture of the heart muscle
Potential Treatments:
- Implantable cardioverter-defibrillators
- Medications to reduce mortality
Preventing Left Ventricular Failure
It’s important for individuals to stick with lifestyle changes and prescribed medications to avoid being hospitalized for worsening heart failure and to maintain a good quality of life. Many factors that cause heart failure, such as high blood pressure and irregular heart rhythms, can be controlled by patients themselves. Therefore, education about the disease and its management is a key component in a team-based strategy to reduce the risk of death and health complications from heart failure.
