DEFINITION OF HEART FAILURE

Heart failure is defined as pathophysiologic state in which cardiac function is

unable to maintain an adequate circulation for the metabolic needs of the
tissue of the body. It may be acute or chronic. The term of congestive heart
failure (CHF) is used for the chronic form of heart failure in which the patient
has evidence of congestion of peripheral circulation and of lungs. CHF is a
end-result of serious heart disease.

CAUSES AND SOLUTION

1. THYROTOXICOSIS
Also known as hyperthyroidism. It is a condition that occurs due to excessive
production of thyroid hormone by thyroid gland. The thyroid gland is a small,
butterfly-shaped gland located at the front of our neck. It produces
tetraiodothyronine (T4) and triiodothyronine (T3), which are two primary
hormones that control our body metabolism. Hyperthyroidism can accelerate
our body's metabolism significantly, causing sudden weight loss, a rapid or
irregular heartbeat, sweating, and nervousness or irritability.
Untreated hyperthyroidism can lead to serious complications, mainly related
to the heart. Thyrotoxicosis-induced heart failure is one of the most grave
complications of uncontrolled hyperthyroidism. It is high output type of heart
failure, which is the cardiac output is high, but still inadequate to maintain
metabolic demand of body. This condition lead to increase mechanical load
on the heart results in increased myocardial demand, resulting in myocardial
failure. The most recognizable features of hyperthyroidism are those that
result from the effects of triiodothyronine (T3) on the heart and
cardiovascular system. About 6% of thyrotoxic individuals develop symptoms
of heart failure, but less than 1% develop dilated -cardiomyopathy with
impaired left ventricular systolic function. Heart failure resulting from
thyrotoxicosis is due to an increased levels of thyroxine released from the
thyroid gland stimulate the heart to beat more quickly and more strongly.
Initially this may produce a fast heart rate which is called a tachycardia.
Prolonged stimulation of the heart with thyroxine may cause an
incoordination of the conduction of electrical impulses within the heart and
atrial fibrillation may ensue. This is where the impulses arising in the right
atrium, rather than be conducted normally into the ventricles, form a short
circuit within atria and rapidly go round in circles causing incoordinated atrial

contraction and loss of regular stimulation of the ventricle with an irregular

heartbeat. Pulmonary artery hypertension in thyrotoxicosis is gaining
awareness as a cause of isolated right-sided heart failure. In both cases,
older individuals are more likely to be affected.
The first essential solution that should be carried out in hyperthyroid patients
with HF is to correct the hyperthyroidism. The decision whether to use drugs,
radioactive iodine therapy, or thyroid surgery, depends on the nature of the
thyroid problem. University of Missouri-Kansas City School of Medicine,
Department of Medicine, Section of Cardiology, present three cases of CHF
due to systolic left ventricular dysfunction secondary to hyperthyroidism,
which showed considerable improvement in the left ventricular function once
the hyperthyroidism was treated. Initial treatment for hyperthyroidism
usually is antithyroid medicine or radioactive iodine therapy. No special diet
must be followed by patients with thyroid disease. However, some
expectorants, radiographic contrast dyes, seaweed tablets, and health food
supplements contain excess amounts of iodide and should be avoided
because the iodide interferes with or complicates the management of
antithyroid and radioactive iodine therapies. Simple example of food contain
rich amount of iodide is seafood. Exercise tolerance often is not significantly
affected in otherwise healthy patients with mild to moderate
hyperthyroidism. For these patients, no reduction in physical activity is
necessary. For patients who are elderly or have cardiopulmonary
comorbidities or severe hyperthyroidism, a decrease in activity is prudent
until hyperthyroidism is medically controlled. In severe thyrotoxicosis, betablocker therapy often greatly improves exercise tolerance until thyroid
hormones levels are reduced by other therapies. For patients with sustained
forms of hyperthyroidism, such as Graves' disease or toxic nodular goiter,
anti-thyroid medications are often used. The goal with this form of drug
therapy is to prevent the thyroid from producing hormones. Two common
drugs in this category are methimazole and propylthiouracil (PTU), both of
which actually interfere with the thyroid gland's ability to make its hormones.
Anti-thyroid drugs can have side effects such as rash, itching, or fever, but
these are uncommon.

Radioactive iodine is the most widely-recommended permanent treatment of

hyperthyroidism. This treatment takes advantage of the fact that thyroid
cells are the only cells in the body which have the ability to absorb iodine. In
fact, thyroid hormones are experts at doing just that. By giving a radioactive
form of iodine, the thyroid cells which absorb it will be damaged or killed.
Because iodine is not absorbed by any other cells in the body, there is very
little radiation exposure (or side effects) for the rest of the body. The only
common side effect of radioactive iodine treatment is underactivity of the
thyroid gland. The problem here is that the amount of radioactive iodine
given kills too many of the thyroid cells so that the remaining thyroid does
not produce enough hormone, a condition called hypothyroidism. There is no
evidence that radioactive iodine treatment of hyperthyroidism causes cancer
of the thyroid gland or other parts of the body, or that it interferes with a
woman's chances of becoming pregnant and delivering a healthy baby in the
future.
Another permanent cure for hyperthyroidism is to surgically remove all or
part. Surgery is not used as frequently as the other treatments for this
disease. The biggest reason for this is that the most common forms of
hyperthyroidism are a result of overproduction from the entire gland (Graves'
disease) and the methods described above work quite well in the vast
majority of cases. Although there are some Graves' disease patients who will
need to have surgical removal of their thyroid (cannot tolerate medicines for
one reason or another, or who refuse radioactive iodine), other causes of
hyperthyroidism are better suited for surgical treatment earlier in the
disease. This assessment of the mechanisms that may lead to HF in patients
with thyroid dysfunction confirms the link between thyroid hormone and
cardiovascular function. This, in turn, reinforces the importance of early
detection and effective treatment of cardiac abnormalities in patients
affected by thyroid disorders. Close cooperation between endocrinologists

and cardiologists to identify the best treatment options is essential if we are

to improve the prognosis of severe cardiac involvement in patients with overt
and subclinical thyroid dysfunction.

2. ANEMIA
Anemia is a medical condition in which the red blood cell count or
hemoglobin is less than normal. For men, anemia is typically defined as
hemoglobin level of less than 13.5 gram/100 ml and in women as
hemoglobin of less than 12.0 gram/100 ml. There are many forms of anemia,
each with its own cause. Anemia can be temporary or long term, and it can
range from mild to severe.
Signs and symptoms of anemia vary depending on the cause of anemia, but
may include fatigue, pale skin, fast or irregular heartbeat, shortness of
breath, chest pain, dizziness, cognitive problems, cold hands and feet and
headache. This is all due to lack in oxygen carrying item which is hemoglobin
in blood.
The anemia itself can worsen cardiac function, both because it causes
cardiac stress through tachycardia and increased stroke volume, and
because it can cause a reduced renal blood flow and fluid retention, adding
further stress to the heart. Long-standing anemia of any cause can cause left
ventricular hypertrophy (LVH), which can lead to cardiac cell death through
apoptosis and worsen the CHF. Therefore, a vicious circle is set up where in
CHF causes anemia, and the anemia causes more CHF and both damage the
kidneys worsening the anemia and the CHF further. We have termed this
vicious circle the Cardio Renal Anemia (CRA) Syndrome. Patients with CHF
who are anemic are often resistant to all CHF medications resulting in being
hospitalized repeatedly. Many studies also demonstrate that these patients
die more rapidly than their non-anemic counterparts do.
According to World Health Organization (WHO), anaemia is the worlds
second leading cause of disability and thus one of the most serious global
public health problems. The WHO estimated that about 40% of the world's
population (more than 2 billion individuals) suffers from anaemia. The groups
with the highest prevalence are: pregnant women and the elderly, about
50%; infants and children of 1-2 years, 48%; school children, 40%; non
pregnant women, 35%; adolescents, 30-55%; and preschool children, 25%.
In order to prevent anemia, it is important to eat a balanced healthy diet rich
in iron. Women ages 19 to 50 should be consuming 18 milligrams of iron per
day, and if theyre pregnant, 27 milligrams, while men at this age only need
8 milligrams. There are two types of iron, heme iron from animal sources and
non-heme iron from plant sources. From animal sources, organ meats like
liver and giblets are some of the best sources of heme iron, with the added

bonus of other minerals, vitamins, and protein. While from plant sources,
beans of all varieties are a wonderful source of iron, offering up anywhere
from 3 to 7 mg per cup. For example, one half cup of soybeans contains over
4 mg of iron, plus they're an excellent source of important minerals like
copper, which helps keep our blood vessels and immune systems healthy,
and manganese, an essential nutrient involved in many chemical processes
in the body. In addition, soybeans are high in protein and fiber as well as
many vitamins and amino acids. One way to improve the absorption of iron
from food is to increase the intake of vitamin C. This enhances the absorption
of non-haem iron if the two nutrients are consumed within an hour of each
other.
Treating this anaemia with iron alone had no effect. In prevention and
treatment of anaemia, vitamin A, folic acid, vitamin B12, and vitamin C also
must be included in diet. Vitamin A deficiency (VAD) also can cause anaemia.
VAD may be quite common in developing countries where intake of animal
products is low, and especially during seasons when there is less intakes of
vegetables. It has been estimated that 90% of adults in China were vitamin A
deficient. There is a lack of information the prevalence of deficiency in other
Asian countries. High vitamin A foods include sweet potatoes, carrots, dark
leafy greens, winter squashes, lettuce, dried apricots, cantaloupe, bell
peppers, fish, liver, and tropical fruits. The current daily value for Vitamin A is
5000 international units (IU).
Severe folic acid or vitamin B12 deficiencies can cause anaemia, but it is not
clear to what extent the global prevalence of anaemia is influenced by such
deficiencies. Folic acid has long been included in iron supplements for
pregnant women on the assumption that this will treat folic acid deficiency
anaemia. Good sources of folic acid include broccoli, brussels sprouts, liver,
spinach, asparagus, peas, chickpeas, fortified breakfast cereals. Adults need 0.2mg
of folic acid a day. However, in pregnant women, it is recommended to take a

0.4mg (400 micrograms) folic acid supplement daily. As with folic acid
deficiency, a severe deficit of vitamin B12 results in megaloblastic anaemia.
There are, however, limited data on the global prevalence of vitamin B12
deficiency. This vitamin, also called cobalamin, is found only in animal
products. No forms of cobalamin found in plants or bacteria are biologically
active in humans. Therefore, a low intake of animal products is certainly a
risk for vitamin B12 deficiency. Good sources of vitamin B12 include meat,
salmon, cod, milk, cheese, eggs and some fortified breakfast cereals. An
adult need approximately 0.0015mg a day of vitamin B12.

3. PULMONARY VASCULAR DISEASE.

Not only heart is involved in chronic heart failure but also lung, kidney,
peripheral and respiratory muscles, chemo-ergoreceptors, neuro-hormonal
mechanisms, mitochondria, all play a major role in determining the complex
clinical syndrome of chronic heart failure. The complex nature of interactions
between the respiratory (pulmonary) and cardiovascular systems is
becoming increasingly appreciated. Blood travels from the heart, to the
lungs, and back to the heart. This process continually refills the blood with
oxygen, and lets carbon dioxide be exhaled. Pulmonary heart disease, also
known as cor pulmonale is the enlargement and failure of the right ventricle
of the heart as a response to increased vascular resistance (such as from
pulmonic stenosis) or high blood pressure in the lung. Right-sided ventricular
disease caused by a primary abnormality of the left side of the heart or
congenital heart disease is not considered cor pulmonale, but cor pulmonale
can develop secondary to a wide variety of cardiopulmonary disease
processes. Cor pulmonale also known as right-sided heart failure because it
occurs within the right ventricle of your heart. Its causes the right ventricle
to enlarge and pump blood less effectively than it should. The ventricle is
then pushed to its limit and ultimately fails. This condition is often prevented
when the high pressure of blood going to the lungs is controlled. However,
untreated pulmonary hypertension can eventually lead to cor pulmonale
along with other related, life-threatening complications. The symptoms of cor
pulmonale may not be noticeable at first because theyre similar to the
feelings after a hard workout. They include shortness of breath, tiredness, an
increased heart rate and lightheadedness. Over time, these symptoms will
worsen and flare up even during periods of rest. There are few reliable
figures for prevalence of cor pulmonale in the population at large, as the
condition is difficult to diagnose reliably on the basis of clinical symptoms
and signs alone. Its most common cause in the developed world is chronic
obstructive pulmonary disease (COPD), due largely to tobacco smoking.
Prevalence of cor pulmonale in COPD has been reported from 20-91%, but it
does not affect all sufferers of COPD

REFERENCES:
1. Textbook of pathology, seventh edition 2015, Ivan Damanov, Jaypee
Brothers medical publishers, page 399.
2. Systemic Pathology, Prof Ali Al Hendawi, 2011, page 15.

3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4730167/ J Extra Corpor Technol.

2015

4. http://www.ncbi.nlm.nih.gov/pubmed/15593047 J Nephrol. 2004 Nov-Dec;17

5. http://circ.ahajournals.org/content/113/20/2454#T1 Yi-Da Tang and Stuart D.
Katz, May 23, 2006

6. http://www.everydayhealth.com/pictures/foods-high-in-iron/#08

Last Updated:

08/25/14

7. http://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-B.aspx

Page last

reviewed: 18/02/2015

8. http://www.endocrineweb.com/conditions/hyperthyroidism/hyperthyroidismcomplications Updated on: 05/27/14

9. http://www.ncbi.nlm.nih.gov/pubmed/18752767 Curr Heart Fail Rep. 2008 Sep;5
10. http://www.thyroid.ca/e6a.php J. Malcolm O. Arnold,Cardiologist, Victoria Hospital, London, reviewed
2000

11. http://www.eje-online.org/content/167/5/609.full Eur J Endocrinol November 1, 2012

12. http://emedicine.medscape.com/article/121865-treatment#d14 Updated: Jul 13, 2016
13. http://www.endocrineweb.com/conditions/hyperthyroidism/hyperthyroidismoveractivity-thyroid-glandUpdated on: 04/26/16
14. http://emedicine.medscape.com/article/154062-overview
15.
http://patient.info/doctor/cor-pulmonale