Russian Journal of Cardiology »» N 5 2008
Shevchenko O.P. Shevchenko A.O.
Heart failure is the most important clinical syndrome characterized by steady progression, which leads to disability and significantly worsens the quality of life of an increasing number of patients. An increase in the incidence of heart failure occurs against the background of increasingly notable advances in the treatment of patients with heart diseases and, primarily, coronary heart disease .
In the future, such a trend will probably not only not disappear, but, rather, will become even more relevant. Advances in the treatment of acute myocardial infarction and a decrease in sudden deaths inevitably lead to an increase in the number of patients with heart muscle defects who subsequently develop heart failure.
Currently, the number of patients with heart failure due to coronary heart disease far exceeds the number of cases with a different cause of its development. The mortality rate of patients with a pronounced degree of heart failure reaches 40% per year, while the average life expectancy with the appearance of clinical signs of circulatory failure is about 5 years .
Neurohumoral activity and progression of heart failure
The sympathetic nervous system and renin-angiotensin activity are the most important factors affecting blood circulation in the development of heart failure. Already in the early stages of hemodynamic impairment, activation of neurohumoral systems can compensate for a decrease in blood flow. The increased activity of the sympathetic nervous system leads to an increase in contractility of cardiomyocytes and an increase in the tension forces acting on the wall of the left ventricle in both systole and diastole, which leads to the development of hypertrophy of cardiomyocytes .
If the amount of damage to the heart muscle is small, the degree of myocardial hypertrophy and expansion of the cavities of the heart can be moderately pronounced. Against the background of a significant loss of mass of the functioning myocardium, cardiomyocyte hypertrophy is no longer sufficient, and the cavity of the left ventricle begins to expand, which leads to an increase in the tensile force acting on the wall of the left ventricle and a further increase in the size of its cavity, contributing to the progression of the pathological process.
An increase in the activity of the renin-angiotensin-aldosterone system (RAAS) also contributes to the development of hypertrophy and fibrosis of cardiomyocytes. If at the short-term stage activation of the neurohumoral system allows to increase the perfusion of organs and compensate for circulatory failure, then after a certain period of time the “energy-consuming” mechanism that intensifies the work of the heart muscle becomes the most important mechanism for the progression of heart failure.
Since the end of the 80s of the past century, the progression of heart failure and the accompanying neurohumoral activity began to be considered as the most important problem in cardiology. The use of two groups of drugs — ACE inhibitors (ACE inhibitors) and beta-blockers — significantly changed the concept of the pathogenesis of heart failure progression in medical therapy of patients with circulatory failure .
In large-scale studies with long-term follow-up, including more than 200 patients, ACE inhibitors have been shown to reduce the risk of death from myocardial infarction, cerebral stroke and progression of heart failure in patients with heart failure syndrome, decreased left ventricular ejection fraction, coronary or peripheral arteriosclerosis, or diabetes mellitus.
ACE inhibitors in the treatment of heart failure
ACE inhibitors are drugs that simultaneously suppress the pressure regulation systems of blood pressure and activate vasodepressor processes. Possessing the properties of neurohumoral modulators, these drugs inhibit the formation of vasoconstrictor substances such as angiotensin II, aldosterone, as well as norepinephrine, arginine-vasopressin, endothelin-1. At the same time, the level of vasodilators of bradykinin, nitric oxide, endothelial hyperpolarization factor, prostaglandins E2 and I2 increases.
In addition to blocking the conversion of inactive angiotensin-I to highly active angiotensin II, ACE inhibitors inhibit the secretion of aldosterone and vasopressin. Another effect of ACE inhibitors, also directly related to the inactivation of this enzyme, is associated with the prevention of degradation of bradykinin, which causes relaxation of vascular smooth muscle and promotes the release of endothelial relaxation factor – nitric oxide NO.
Adrenergic (sympathetic) and renin-angiotensin systems are closely related. For example, renin release is regulated by beta-1-adrenergic receptors, and angiotensin II promotes the release of norepinephrine into the synaptic cleft. Thus, the impact on one of these systems in patients with heart failure allows you to influence the other.
Symptomatic vasodilators that improve hemodynamics in patients with heart failure, such as hydrolazine, increase blood noradrenaline levels. In contrast, ACE inhibitors lower blood levels of norepinephrine, suggesting suppression of sympathetic activity. Decreased plasma levels of norepinephrine with ACE inhibitors may be due to a weakening of angiotensin II-dependent release of norepinephrine.
Gilbert EM et al. in a controlled double-blind crossover study, lysinopril was prescribed to patients with heart failure at a dose of 5–20 mg for 12 weeks. As the results of the study showed, lisinopril significantly reduced the activity of the sympathetic nervous system. During treatment with lisinopril, noradrenaline levels in the right atrium decreased from 695 ± 300 to 287 ± 72 pg/ml, and the average heart rate decreased from 83 ± 5 to 75 ± 3 beats/min .
The result of ACE inhibitors is a pronounced decrease in total peripheral vascular resistance with a slight increase in stroke and cardiac output without a significant change in heart rate. ACE inhibitors increase cardiac output and stroke volume [8, 9].
The positive hemodynamic effects of ACE inhibitors help to improve the contractile function of the left ventricular myocardium and reduce the clinical manifestations of heart failure. When compared with other vasodilators, ACE inhibitors cause a uniform (balanced) systemic arterial and venous vasodilation, reduce the retention of salt and water in the body, reducing the synthesis of aldosterone .
ACE inhibitors are indicated as first-line agents in patients with reduced contractile function of the left ventricle (left ventricular ejection fraction lt; 40–45%) in patients with and without symptoms of heart failure, in the absence of contraindications .
In patients with heart failure, ACE inhibitors reduce mortality, hospitalization and reduce the progression of heart failure. The effectiveness of ACE inhibitors in heart failure does not depend on the presence of diabetes mellitus, racial and gender differences [12, 13]. So, in the CONSENSUS I study (the first of the studies to evaluate the effect of ACE inhibitors on mortality in patients with heart failure), enalapril showed a 40% decrease in mortality in patients with heart failure IV of functional class .
The SOLVD study showed that ACE inhibitors are effective not only in patients with severe heart failure, but also in patients with an asymptomatic decrease in left ventricular myocardial contractile function (NYHA 0). In the SOLVD study, patients with heart failure II-III FC were observed, on average, for 3,5 years. The mortality rate in the placebo group was 39,7%, in the group of patients receiving ACE inhibitors – 35,2% .
Analysis of the research results showed that out of a thousand treated patients, the use of ACE inhibitors prevents 45 deaths, or in order to save one life, ACE inhibitors should be prescribed to 22 patients for 3,5 years. The results of large-scale studies with long-term follow-up showed that with the intake of ACE inhibitors, the hospitalization rate of patients with CHF decreases.
In the VHeFT II (Vasodilator Heart Failure Trial II) study, the efficacy of ACE inhibitors of enalapril was compared with the efficacy of combination therapy with hydralazine and isosorbide dinitrate in male CHF patients. Against the background of ACE inhibitors, a significant decrease in mortality was observed after 2 years of observation (18% versus 25%). A reduction in mortality was achieved by reducing the frequency of sudden death, especially in patients with less severe symptoms of heart failure (I-II FC) .
Thus, the results of clinical studies indicate that ACE inhibitors in patients with heart failure increase life expectancy, slow the progression of heart failure and improve quality of life.
The main effect of ACE inhibitors is associated with their ability to inhibit the activity of the angiotensin-converting enzyme (kinase II) and, thus, have an effect on the activity of RAAS. ACE inhibition results in suppression of the effects of angiotensin II.
Fig. Adverse effects exerted by angiotensin II [17, 18].
Diastolic heart failure
The positive effect of ACE inhibitors has also been demonstrated in patients with heart failure with diastolic dysfunction of the left ventricle. The beneficial effect of ACE inhibitors in these patients may be associated with an effect on myocardial remodeling and a decrease in myocardial mass, reverse development of fibrosis, and increased elasticity of the left ventricular wall.
Heart failure life prognosis
In this article, we learn what heart failure is. let’s talk about its prevalence among different categories of patients, discuss the prognosis and mortality from heart failure.
Heart failure is understood as the inability of the heart to pump blood, which is necessary to ensure the functioning of organs and tissues, i.e., to fulfill its main pumping function.
In Russia, there has been an increase in the number of patients with heart diseases and, accordingly, with chronic heart failure. According to epidemiological forecasts in the next 20 years, the number of patients with chronic heart failure will increase. This is due to:
- Change in demographic situation (increase in the number of elderly people)
- Decrease in mortality from cardiovascular diseases (heart attacks and strokes)
- Improving survival in chronic heart failure itself
According to epidemiological studies, the prevalence of chronic heart failure among the general population ranges from 1 to 3%. This indicator increases significantly with age, in elderly patients the prevalence of chronic heart failure is about 15%, and in people over 80 years old it reaches 20%, and is diagnosed in about 70% of cases of patients aged 90 years.
The incidence of chronic heart failure among men is higher than among women. For people with a preserved ejection fraction of the left ventricle, a predominance of elderly people and women is characteristic.
The annual incidence of heart failure is 0.2-0.3% in people aged 50-59 years and increases by about 10 times by 80-89 years. As a rule, the average age for the development of clinical manifestations is 75 years.
One of the main questions that worries all patients with an already diagnosed disease sounds like this – heart failure life prognosis. It can only be answered by appealing data from multicenter clinical trials. Firstly, chronic heart failure refers to a disabling, economically costly pathological condition requiring frequent repeated hospitalizations throughout the year. The quality of life of patients is greatly affected, even more than with severe arthritis and strokes.
- Mortality from heart failure remains high, it exceeds that for many malignant neoplasms (breast, prostate, colon cancer).
- Five-year mortality from chronic heart failure (according to the Framingham study) was 62% for men and 42% for women.
- The annual survival after the start of decompensation is 30-40%, while the survival of patients is higher with the preserved ejection fraction of the left ventricle (we will discuss how to determine it below).
The cost of treating chronic heart failure averages 1-2% of the total cost of health services per year.
Heart failure treatment. Heart failure life expectancy
Treatment of heart failure begins with the correct diagnosis of the causes of the disease and the appointment of an effective course of treatment. Contact the Medisan Medical Center immediately as soon as the first hints of health problems occur. Remember that the timely assistance of specialists will help to avoid serious complications in the future.
The treatment of heart failure is not only a limitation of salt intake and taking your favorite heart drops, as some say, but a whole series of individual prescriptions. After all, the causes of the deterioration of the heart muscle can be heart and vascular diseases, such as coronary heart disease, heart defects, arterial hypertension, lung diseases, etc. And our experts only on the basis of examining the entire body and identifying the causes of the pathology prescribe the optimal course of treatment.
Our heart is like a powerful pump that provides normal blood circulation. And if the work of the heart is broken, then the failure is reflected in the work of the whole organism.
Signs of heart failure:
- the occurrence of edema (first shins and feet, and then hips, abdominal cavity);
- an increase in the size of the liver;
- heart palpitations both during physical work and at rest;
- paroxysmal cough and lack of air while lying down;
- decreased physical activity and loss of strength.
The appearance of any of these signs is an occasion to contact the Medisan Medical Center for a comprehensive examination and, as a rule, further treatment of heart failure.
The main methods of treating heart failure include carrying out general therapeutic measures, drug treatment, the use of mechanical means and, in extreme cases, surgical intervention.
– elimination of symptoms characteristic of the disease;
– protection of organs affected by the disease (kidneys, liver, lungs, blood vessels, brain);
– change in the patient’s lifestyle;
– increase the patient’s life expectancy.
General recommendations for the treatment of heart failure: monitor symptoms, body weight and sound the alarm when it suddenly increases, vaccinate against flu and pneumococcal infection, show social activity and live a full life, avoiding stressful situations. It is also necessary to follow a diet, control the intake of salt and liquid, give up alcohol and smoking, not be afraid of vigorous physical exertion, sleep at least 8-9 hours a day. Rest is recommended only in acute heart failure and in exacerbation of chronic heart failure.
It remains to be noted that in our medical center for the treatment of heart failure we use the most modern therapeutic approaches and medications that are aimed not only at eliminating the symptoms, but also at preventing the onset and progression of heart failure.
Check your health status at the Medisan medical center today, make an appointment with a specialist, or call (495) 649-85-86.
Reviewed by Nicholas. “A year ago, I passed a session on the method of removing subconscious barriers in the center of V.A. Tsygankova. After this session, I did not drink all year, I felt good. Now I’ve come again to go through the same session. “
Review by Tamara. “I was very bad, and I could not solve my problem with drinks on my own. I came to see Vladimir Anatolyevich Tsygankov and in one session I felt much better. My soul became calm, my mood improved, there was no craving for alcohol. I can live without alcohol myself and feel the joy of being able to manage my life. ”
Reviewed by Paul. “Put protection against alcohol six months ago. He got well-being, began to lose weight, and everything was working out in the family. I decided to put up another year’s defense. ”
Reviewed by Stepan Timofeevich. “I drank almost every day for many years. Then he decided to put protection against alcohol and not need it anymore. But in order to protect against alcohol, it was necessary not to drink for seven days, and I could not drink even for one day. “Stopalkogol-Elite” helped me. I began to drink a decoction of this phytosborder and after a few days I noticed that the craving for alcohol decreased noticeably, my health became better.
Reviewed by Alexey. “I would like to thank Vladimir Anatolyevich Tsygankov for helping me stop my drunkenness three years ago. God give you health and long life, dear Vladimir Anatolyevich! “Stopalkogl-Elite” and restoring phyto-harvests helped me. ”
Reviewed by Tatyana. “The method of removing subconscious barriers is wonderful. Life has radically changed for the better, the psychological state has improved, the craving for alcohol has completely disappeared. ”
Reviewed by Michael. “I remember with gratitude how easy and comfortable the session was with the secure coding method. Thank you for returning to normal! I haven’t been drinking for 9 months. In three months I’ll come to you to extend the protection against alcohol for another year. ”
Review by Alexander Ivanovich. “I drank for over 20 years. Could not stop. The draft was too strong. But 5 years ago, I was still able to stop drinking for good. The phyto collections “Stopalkogol-Elit” and “Restoring” helped me. Restorative fees were especially useful: the liver was restored, the kidneys were restored. Even the doctors were surprised. Now I don’t go to them and do not take pills. I’ve been living soberly for 5 years. Many thanks to the center of Vladimir Tsygankov! ”
Recall of Faith. “I join the good reviews of Vladimir Anatolyevich Tsygankov. I drank a lot and a lot. She had a heart attack two years ago. It was then that I came to Vladimir Anatolyevich Tsygankov and he gave me protection against alcoholism. Then he taught me how to manage my thoughts and feelings, taught me how to cope with stress and fears. I go to the temple, and instead of alcohol I drink fragrant, tasty and healthy medicinal herbs. I live a new, happy life. ”
Review by Stanislav Mikhailovich. “When I first went through the session using the method of removing subconscious barriers, I did not last long without alcohol – after 9 months I started drinking again, although the protection against alcohol was for 1 year. Friends persuaded them to drink, they said that nothing bad would happen, the period of non-use was coming to an end.
By stupidity, I obeyed from a drink. and the binges returned again. I signed up again to the center of Vladimir Tsygankov for a session using the method of removing subconscious barriers. I was given protection from alcohol, first for 6 months, then for 1 year. I don’t drink it for a year and a half and I feel great. The second time I’m not making a mistake, no one can persuade me to drink. I do not want and do not want this. And so I’ll extend the protection against alcohol again. ”
Detonic – a unique medicine that helps fight hypertension at all stages of its development.
The complex effect of plant components of the drug Detonic on the walls of blood vessels and the autonomic nervous system contribute to a rapid decrease in blood pressure. In addition, this drug prevents the development of atherosclerosis, thanks to the unique components that are involved in the synthesis of lecithin, an amino acid that regulates cholesterol metabolism and prevents the formation of atherosclerotic plaques.
Detonic not addictive and withdrawal syndrome, since all components of the product are natural.
Detailed information about Detonic is located on the manufacturer’s page.