In our country usually use the classification proposed V. X. Vasilenko, N. D. Strazhesko and G. F. Lang in 1935. There are 3 stages of circulatory failure (NK):
♦ NC I - initial (hidden, latent). Signs of heart failure: shortness of breath, fatigue, palpitations appear only during exercise.
♦ HK II A - signs of heart failure are moderately expressed. Congestion mainly in one circle of blood circulation. Moderate swelling of the legs.
♦ NK IIB - pronounced signs of heart failure, deep hemodynamic disturbances, pronounced congestion in the small and large circles of blood circulation. Massive edema, up to anasarca.
♦ NC III - final (dystrophic, cachexic): extremely pronounced hemodynamic disturbances, irreversible changes in organs and tissues.
In recent years, they have increasingly begun to use the functional classification of heart failure proposed by the New York Heart Association (NYHA), in which 4 functional classes (FC) are distinguished:
♦ FC I - latent HF: patients with heart disease, but without limitation of physical activity (asymptomatic left ventricular dysfunction).
♦ FC II - slight limitation of physical activity, symptoms of heart failure appear with normal daily exercise.
♦ FC III - severe limitation of physical activity, symptoms of heart failure with minimal physical activity.
♦ FC IV - symptoms of heart failure at rest, semi-bed or bed rest.

It is easy to see that there is a certain correspondence between the domestic NK classification and the NYHA classification. The difference is that the NYHA classification is based only on the assessment of clinical signs of performance (the presence or absence of peripheral edema and, moreover, the reversibility of changes in organs and tissues is not taken into account). Therefore, FC may decrease as a result of treatment. According to the domestic classification, the stage of NK cannot decrease, even if shortness of breath and edema disappear during treatment.
The NYHA classification is fully consistent with the classification of angina pectoris of the Canadian Society of Cardiology (only the symptoms are different: with CH - shortness of breath and fatigue, and with angina pectoris - pain in the chest). Classes I and II include a fairly wide range of physical activity, and in the presence of class III HF, activity is sharply limited (walking within 200-500 m, climbing stairs no more than 1-2 flights). There have been proposals to subdivide class II into 2 subclasses: II s - mild CH; Fri - moderate CH. In addition, it was proposed to indicate in each class whether the patient is receiving treatment or not. Finally, in scientific studies, objective signs of NC are used in terms of the level of maximum oxygen consumption during physical activity during spiroveloergometry (“metabolic classification of HF”), Cohn (1995) for an objective assessment of the degree of myocardial damage and the state of systolic function of the left ventricle proposed using the value ejection fractions (EF): A - EF > 45%; B - EF from 35 to 45%; C - FI from 25 to 35%; D - FV< 25 %.

In 2001, the American Heart Association (AHA) and the American College of Cardiology (ACC) proposed to additionally consider the stage of heart failure.. Stage A - Patients at high risk of heart failure but without organic heart disease and without any symptoms or signs of heart failure. Stage B - Patients who have structural heart disease but no symptoms or signs of heart failure. Stage C - patients with structural heart disease and symptoms of heart failure. Stage D - patients with severe structural heart disease and severe symptoms of heart failure, even at rest.

To more accurately determine the physical performance and FC of patients with heart failure, you can use 6 minute test- measurement of the distance that the patient can walk in 6 minutes. When passing a distance of less than 150 m - severe heart failure (FC IV), 150-300 m - moderate heart failure (FC III), 300-425 m - light heart failure (FC II), more than 425 m - latent heart failure (FC I). During the test, it is necessary that the patient tries to walk as quickly as possible, so that he is forced to stop to rest.
Clinical signs of heart failure: shortness of breath and increased fatigue during exercise can be observed in many patients or even in healthy people with detraining. Therefore, it is very important to identify signs of organic heart disease and impaired systolic or diastolic function of the heart.

The classification of clinical forms and variations of chronic heart failure is necessary to distinguish between the severity of the patient's condition, and the characteristics of the course of the pathology.

Such a distinction should simplify the diagnostic procedure and the choice of treatment tactics.

In domestic clinical practice, the classification of CHF according to Vasilenko-Strazhesko and the functional classification of the New York Heart Association are used.

The classification was adopted in 1935 and is used to this day with some clarifications and additions. Based on the clinical manifestations of the disease during CHF, three stages are distinguished:

I. Latent circulatory failure without concomitant hemodynamic disorders. Symptoms of hypoxia appear with unusual or prolonged physical exertion. Possible shortness of breath, severe fatigue,. There are two periods A and B.
Stage Ia is a preclinical variant of the course, in which cardiac dysfunctions have almost no effect on the patient's well-being. An instrumental examination reveals an increase in the ejection fraction during physical exertion. At stage 1b (hidden CHF), circulatory failure manifests itself during exercise and resolves at rest.
II. In one or both circles of blood circulation, congestion is expressed that does not pass at rest. Period A (stage 2a, clinically expressed CHF) is characterized by symptoms of blood stagnation in one of the circles of blood circulation.

The patient manifests acrocyanosis, peripheral edema, dry cough and others, depending on the location of the lesion. In period B (stage IIb, severe), the entire circulatory system is involved in pathological changes.
III. The final stage of the development of the disease with signs of insufficiency of both ventricles. Against the background of venous stasis in both circles of blood circulation, severe hypoxia of organs and tissues is manifested. Multiple organ failure develops, severe swelling, including ascites, hydrothorax.
Stage 3a is treatable, with adequate complex therapy for CHF, it is possible to partially restore the functions of the affected organs, stabilize blood circulation and partially eliminate congestion. Stage IIIb is characterized by irreversible changes in metabolism in the affected tissues, accompanied by structural and functional disorders.

The introduction of additional gradations is partly due to the development and implementation of new methods of treatment, which significantly increase the chances of patients to improve the quality of life.

The use of modern drugs and aggressive methods of treatment quite often eliminates the symptoms of CHF corresponding to stage 2b to the preclinical state.

New York (FC 1, 2, 3, 4)

The functional classification is based on exercise tolerance as an indicator of the severity of circulatory insufficiency. Determination of the patient's physical abilities is possible on the basis of a thorough history taking and extremely simple tests. On this basis, four functional classes are distinguished:

I FC. Daily physical activity does not cause manifestations of dizziness, shortness of breath and other signs of myocardial dysfunction. occur against the background of unusual or prolonged physical exertion.
II FC. Physical activity is partially limited. Everyday stress causes discomfort in the heart area or anginal pain, tachycardia attacks, weakness, shortness of breath. At rest, the state of health is normalized, the patient feels comfortable.
III FC. Significant limitation of physical activity. The patient does not experience discomfort at rest, but everyday physical activity becomes unbearable. Weakness, pain in the heart, shortness of breath, tachycardia attacks are caused by loads less than usual.
IV FC. Discomfort occurs with minimal physical exertion. or others may appear at rest without apparent prerequisites.

See the table of correspondence between the classifications of CHF according to NIHA (NYHA) and N.D. Strazhesko:

Functional classification is convenient for assessing the dynamics of the patient's condition during treatment. Since the gradations of severity according to a functional basis and according to Vasilenko-Strazhesko are based on different criteria and do not exactly correlate with each other, the stage and class for both systems are indicated when diagnosing.

Your attention to the video about the classification of chronic heart failure:

The classification of which is presented in this article is the decrease in the functionality of the heart. This process is provoked by a pathological lesion of the muscle, as well as an imbalance of systems that affect the functioning of the cardiovascular system.

Disease classification

What degrees of damage are noted by cardiologists in CHF? The classification of the disease was approved at the All-Union Congress of Physicians in 1935. It is based on functional and morphological principles for assessing the dynamics of clinical manifestations of the disease. It was compiled by cardiologists N. D. Strazhesko and V. Kh. Vasilenko with the participation of G. F. Lang. Subsequently, it was supplemented by scientists N. M. Mukharlyamov and L. I. Olbinskaya.

So how is CHF subdivided? The classification involves 4 stages:

NK 1 - represents the initial stage. Signs of CHF 1 degree are manifested in shortness of breath, asthenia, tachycardia only during physical exertion.
HK 2A - signs are moderate. Congestion is noted in one circle of blood circulation. Swelling of the legs is not intense.
NK 2B - signs of the disease are pronounced, gross hemodynamic disturbances are noted, congestion in the pulmonary and systemic circulation is clearly manifested. Edema is massive.
NK 3 - dystrophic stage. Extremely gross hemodynamic disturbances, irreversible processes in tissues and organs are noted.

Despite the fact that the classification of chronic heart failure by N. D. Strazhesko and V. Kh. Vasilenko is quite convenient for determining biventricular (total) chronic pathology, it cannot be used to assess the degree of development of right ventricular failure, which is characterized by an isolated character.

The classification of chronic heart failure, proposed by the New York Heart Association (NYHA) in 1964, is based on the principle of the prevalence of the process and hemodynamic disturbances in the systemic and pulmonary circulation.

What gradation did American scientists give to such a disease as CHF? Classification (functional classes) suggests the degree of tolerance of the patient to physical activity.

It is customary to subdivide four classes:

CHF 1 degree - the patient is physically active. Ordinary loads do not cause such manifestations as shortness of breath, tachycardia, angio pain, nausea.
CHF 2 degree - limitation of physical activity is moderate. The patient is comfortable at rest, but under load he becomes ill. He experiences asthenia, tachycardia, dyspnea, and angio pain.
CHF 3 degrees - limitation of physical activity is pronounced. The patient experiences comfort only in a state of rest. Minor physical activity leads to lightheadedness, weakness, shortness of breath and rapid heartbeat.
CHF 4 degrees - any slight physical activity causes instant discomfort. Symptoms of heart failure and angina pectoris can also be detected at rest.

The NYHA classification of CHF is simple and convenient. It is recommended for use by the International and European Society of Cardiology.

Causes of pathology

CHF (classification is given in this article) can be caused by the following pathological processes:

damage to the heart muscle;
ischemia (impaired blood flow);
myocardial infarction, suggesting the death of the heart muscle due to circulatory disorders;
ischemia without myocardial infarction;
high blood pressure;
the presence of cardiomyopathy;
changes in muscle structure due to the negative effects of certain drugs (for example, drugs used in oncology, as well as for the treatment of cardiac arrhythmia);
the presence of endocrine pathologies;
diabetes;
dysfunction of the adrenal glands;
obesity;
exhaustion;
lack of certain vitamins and minerals in the body;
the presence of infiltrative pathologies;
amyloidosis;
sarcoidosis;
HIV infection;
the presence of renal failure;
atrial fibrillation;
heart block;
the presence of congenital heart defects;
dry constrictive or adhesive pericarditis;
smoking;
the use of alcoholic beverages.

Symptoms

Preclinical chronic sleep has mild symptoms. Slow blood circulation provokes moderate oxygen starvation of all organs and tissues.

As the disease progresses, the following symptoms appear:

shortness of breath on exertion;
asthenia;
insomnia;
tachycardia.

Inadequate oxygen supply to the fingers and toes causes them to turn grayish-bluish. In medicine, this condition is called "cyanosis". A low level of cardiac output causes a decrease in the volume of blood that enters the arterial bed, as well as stagnation in the venous bed. This causes swelling. The legs are the first to suffer. Pain in the right hypochondrium is also noted, which are provoked by overflow of blood in the veins of the liver.

With CHF (the stages are presented above), which proceeds in severe form, all of the above signs become more intense. Cyanosis and shortness of breath begin to disturb a person even in the absence of physical activity. The patient is forced to spend the whole day in a sitting position, as the dyspnea becomes more intense when lying down.

Hemodynamic disturbances cause swelling that covers the entire lower region of the body. Fluid accumulates in the peritoneum and pleura.

Diagnostic methods

How is the diagnosis made? CHF is determined on the basis of an examination by a cardiologist and additional methods of examination.

The following methods apply:

Evaluation of the state of the heart based on data obtained by using an electrocardiogram in various combinations: ECG monitoring during the day and a treadmill test.
The level of contractility and the size of the various parts of the heart, as well as the volume of blood ejected by it into the aorta, can be established using an echocardiogram.
Perhaps the implementation of cardiac catheterization. This manipulation involves the introduction of a thin tube through a vein or artery directly into the cavity of the heart. This procedure makes it possible to measure the pressure in the chambers of the heart and identify the area of blockage of the lumen of the vessels.

Medical treatment

How is CHF treated?

The main means of drug therapy are:

Angiotensin-converting enzyme (ACE) inhibitors, which make it possible to significantly slow down the progress of pathology. They serve to protect the heart, blood vessels and kidneys, and also control blood pressure.
Angiotensin receptor antagonists. They constitute a group of agents that provide a complete set of the necessary enzymes. The drugs are used for the most part with intolerance to ACE inhibitors. For example, when you have a cough.
Beta blockers. These drugs block beta-adrenergic receptors in the heart, blood vessels and lungs, help control pressure and correct hemodynamic disorders. In pathology, beta-blockers are used as an adjunct to ACE inhibitors.
Aldosterone receptor antagonists. They are mild diuretic agents that help retain potassium in the body. They are used for severe heart failure (3 and 4 functional classes), and are also prescribed for patients who have had a myocardial infarction.
Diuretic drugs that help remove excess salts and fluids from the body. They are used by all patients who have fluid retention.
Plant-based cardiac glycosides. These drugs increase the strength of the heart muscle. In small doses, their use is justified in the presence of atrial fibrillation (contraction of certain sections of the atria with a very high frequency). Only a part of these impulses reaches the ventricles.
Ethyl esters of polyunsaturated fatty acids affect the metabolism and the level of blood clotting. They help to increase the life of the patient, reduce the risk of myocardial infarction and cerebral hemorrhage.

Additional medications

Treatment of CHF is carried out by additional means:

Statins. These are drugs that help reduce proatherogenic lipids in the liver - fats that can be deposited in the walls of blood vessels and narrow their lumen, leading to circulatory disorders. Typically, funds are used in the presence of ischemia (impaired circulation through the heart arteries).
Indirect anticoagulants. Means disrupt the synthesis of blood clots in the liver. They are used for atrial fibrillation or for the prevention of thromboembolism (blockage of blood clots in blood vessels).

Auxiliary medications

Such drugs are used in special clinical situations that complicate the course of a pathology such as chronic insufficiency.

Nitrates. They are used in the complex course of the disease.
Salts of nitric acid. They promote vasodilation and improve blood circulation. They are used for pathological conditions such as angina pectoris (pressing pain behind the sternum due to circulatory disorders in the heart arteries).
calcium antagonists. They serve as an obstacle to the penetration of calcium into the cells of the heart. They are used for persistent angina pectoris, persistent high blood pressure, pulmonary hypertension, and severe valvular insufficiency.
Antiarrhythmic drugs. Used for arrhythmias.
Disaggregants. Means prevent blood clotting by disrupting the process of gluing platelets. Typically, drugs are used as a secondary prophylactic for myocardial infarction.
Non-glycoside inotropic stimulants that increase the strength of the heart.

Electrophysiological treatments

Such therapies include:

Implantation. It involves the installation of pacemakers, contributing to the artificial adjustment of the heart rhythm. The devices create an electrical impulse and transmit it to the heart muscle.
Cardiac resynchronization therapy. It also involves the installation of pacemakers.

Mechanical and surgical methods of therapy

These include:

Coronary artery bypass grafting, which involves ensuring the flow of blood from the aorta to the vessels by creating additional paths.
Mammary coronary artery bypass surgery involves the creation of pathways that promote blood flow from the thoracic artery, located inside, to the heart vessels. Typically, such an operation is indicated for a deep atherosclerotic process in the heart vessels, in which cholesterol is deposited on their walls.
Surgical repair of heart valves is performed when there is significant stenosis, narrowing, or an inability to prevent backflow of blood.
Wrapping the heart with an elastic mesh-based scaffold is used in the presence of dilated cardiomyopathy. This method of treatment helps to slow down the increase in the size of the heart, helps to optimize the patient's condition, and also increases the level of effectiveness of drug treatment. Further studies are required to confirm the effectiveness of this method.
Heart transplant. The operation is used in the presence of chronic insufficiency, not amenable to drug treatment.

Associated problems with a heart transplant

A number of related problems during transplantation of a donor organ include:

Insufficient number of donor hearts.
Rejection of a donor heart.
Damage to the vascular system of a transplanted heart.
The use of devices for blood circulation of an auxiliary nature for blood circulation, as well as artificial heart ventricles. These devices are introduced into the body through the surface of the skin and operate on batteries that are attached to the patient's belt. Artificial ventricles pump blood from the left ventricle into the aorta. The volume is 6 liters per minute, which unloads the left ventricle and restores its contractility. It should be noted that the price of devices is high. They provoke complications of an infectious nature, and also contribute to the formation of blood clots.

Complications and consequences

CHF, the stages of which are described in this article, can lead to a number of complications.

These should include:

sudden death from cardiac arrest;
failure of the heart rhythm and its conduction;
an increase in the size of the heart;
thrombus formation;
provoking liver failure;
the appearance of cardiac cachexia;
weight loss of a person;
thinning of the skin and the appearance of ulcers;
loss of appetite;
violation of the process of absorption of fats;
increased metabolism due to an increase in the frequency of the muscles responsible for breathing.

Diet food

CHF is a disease in which adherence to a strict diet is essential. The diet involves limiting the intake of table salt to 3 g per day, and liquids to 1-2 liters per day. Consumed products should contain a sufficient amount of calories, protein, vitamins and be easily digestible.

It is advised to regularly weigh yourself, since an increase in a person's weight by 2 kg in 3 days is evidence of fluid retention in the body. In this case, there is a threat of a violation of the mechanisms of decompensation, which causes a deterioration in the patient's well-being.

Physical activity

It is recommended not to completely abandon physical activity. Their volume is calculated on an individual basis, depending on the degree of development of CHF (the classification describes each). For example, in the presence of myocarditis, the volume of loads should be small.

Preference is given to dynamic loads. Shows running, walking, swimming, cycling.

It is not advised to stay in the highlands. Also, the body of a sick person is adversely affected by heat and moisture.

Psychological rehabilitation of patients

Psychological rehabilitation involves the provision of medical supervision and the creation of special schools for patients with chronic insufficiency.

The purpose of the organizations is to help patients and their families. Relatives and the patient himself receive information about the disease and diet.

For the patient, types of physical activity corresponding to his condition are selected, useful recommendations are given regarding the medication regimen, skills are instilled in assessing the symptoms of the disease and timely seeking medical help when the condition worsens.

What are the recommendations for such a disease as chronic heart failure? It is customary to single out primary prevention with a high risk of pathology, as well as secondary measures that prevent the progress of the disease.

Primary Prevention Methods

Primary prevention includes streamlining a person's lifestyle.

Activities include:

drawing up an appropriate diet;
selection of physical activity;
refusal to drink alcoholic beverages and smoking;
weight normalization.

Secondary prevention

Secondary prevention involves a set of measures aimed at eliminating existing vascular and heart diseases, as well as preventing the progress of existing CHF.

With arterial hypertension, the optimal combination of drugs is used. They contribute to the normalization of blood pressure indicators and protect the organs that take on the main load.

The implementation of secondary measures involves:

optimization of blood circulation;
normalization of lipid metabolism;
elimination of arrhythmia;
conducting surgical and drug therapy in the presence of heart disease.

CHF: classification. Symptoms of chronic heart failure, treatment

Chronic heart failure (CHF) is a condition in which the volume of blood ejected by the heart for each heartbeat decreases, that is, the pumping function of the heart decreases, as a result of which organs and tissues experience a lack of oxygen. About 15 million Russians suffer from this disease.

Depending on how quickly heart failure develops, it is divided into acute and chronic. Acute heart failure can be associated with trauma, toxins, heart disease, and can quickly be fatal if left untreated.

Chronic heart failure develops for a long time and is manifested by a complex of characteristic symptoms (shortness of breath, fatigue and decreased physical activity, edema, etc.), which are associated with inadequate perfusion of organs and tissues at rest or during exercise and often with fluid retention in the body.

We will talk about the causes of this life-threatening condition, symptoms and methods of treatment, including folk remedies, in this article.

Classification

According to the classification according to V. Kh. Vasilenko, N. D. Strazhesko, G. F. Lang, three stages are distinguished in the development of chronic heart failure:

I st. (HI) initial or latent insufficiency, which manifests itself in the form of shortness of breath and palpitations only with significant physical exertion, which previously did not cause it. At rest, hemodynamics and organ functions are not disturbed, working capacity is somewhat reduced.
II stage - expressed, prolonged circulatory failure, hemodynamic disturbance (stagnation in the pulmonary circulation) with little physical exertion, sometimes at rest. In this stage, there are 2 periods: period A and period B.
H IIA stage - shortness of breath and palpitations with moderate exertion. Slight cyanosis. As a rule, circulatory insufficiency is predominantly in the pulmonary circulation: periodic dry cough, sometimes hemoptysis, manifestations of congestion in the lungs (crepitus and inaudible moist rales in the lower sections), palpitations, interruptions in the heart area. At this stage, there are initial manifestations of stagnation in the systemic circulation (small swelling in the feet and lower legs, a slight increase in the liver). By morning, these phenomena are reduced. Employability is drastically reduced.
H IIB stage - shortness of breath at rest. All objective symptoms of heart failure increase dramatically: pronounced cyanosis, congestive changes in the lungs, prolonged aching pain, interruptions in the heart, palpitations; signs of circulatory insufficiency in the systemic circulation, constant edema of the lower extremities and torso, enlarged dense liver (cardiac cirrhosis of the liver), hydrothorax, ascites, severe oliguria join. The patients are disabled.
Stage III (H III) - final, degenerative stage of insufficiency In addition to hemodynamic disturbances, morphologically irreversible changes in organs develop (diffuse pneumosclerosis, cirrhosis of the liver, congestive kidney, etc.). Metabolism is disturbed, exhaustion of patients develops. Treatment is ineffective.

Depending on the phases of cardiac dysfunction are isolated:

Systolic heart failure (associated with a violation of systole - the period of contraction of the ventricles of the heart);
Diastolic heart failure (associated with a violation of diastole - a period of relaxation of the ventricles of the heart);
Mixed heart failure (associated with a violation of both systole and diastole).

Depending on the zones of preferential stagnation of blood secrete:

Right ventricular heart failure (with stagnation of blood in the pulmonary circulation, that is, in the vessels of the lungs);
Left ventricular heart failure (with stagnation of blood in the systemic circulation, that is, in the vessels of all organs except the lungs);
Biventricular (biventricular) heart failure (with stagnation of blood in both circles of blood circulation).

Depending on the physical examination results are determined by classes on the Killip scale:

I (no signs of heart failure);
II (mild heart failure, few wheezing);
III (more severe heart failure, more wheezing);
IV (cardiogenic shock, systolic blood pressure below 90 mmHg).

Mortality in people with chronic heart failure is 4-8 times higher than in their peers. Without proper and timely treatment in the stage of decompensation, the survival rate for a year is 50%, which is comparable to some cancers.

Causes of chronic heart failure

Why does CHF develop, and what is it? The cause of chronic heart failure is usually damage to the heart or a violation of its ability to pump the right amount of blood through the vessels.

The main causes of the disease called:

ischemic heart disease;
heart defects.

There are also other precipitating factors disease development:

cardiomyopathy - a disease of the myocardium;
- violation of the heart rhythm;
myocarditis - inflammation of the heart muscle (myocardium);
cardiosclerosis - damage to the heart, which is characterized by the growth of connective tissue;
smoking and alcohol abuse.

According to statistics, in men the most common cause of the disease is coronary heart disease. In women, this disease is caused mainly by arterial hypertension.

The mechanism of development of CHF

The throughput (pumping) capacity of the heart decreases - the first symptoms of the disease appear: intolerance to physical exertion, shortness of breath.
Compensatory mechanisms are activated aimed at maintaining the normal functioning of the heart: strengthening the heart muscle, increasing the level of adrenaline, increasing blood volume due to fluid retention.
Malnutrition of the heart: muscle cells became much larger, and the number of blood vessels increased slightly.
Compensatory mechanisms are exhausted. The work of the heart deteriorates significantly - with each push it pushes out insufficient blood.

signs

The following symptoms can be distinguished as the main signs of the disease:

Frequent shortness of breath - a condition when there is an impression of lack of air, so it becomes rapid and not very deep;
Fatigue, which is characterized by the speed of loss of strength during the performance of a particular process;
Ascending number of heart beats in a minute;
Peripheral edema, which indicate a poor removal of fluid from the body, begin to appear from the heels, and then move higher and higher to the lower back, where they stop;
Cough - from the very beginning of the clothes it is dry with this disease, and then sputum begins to stand out.

Chronic heart failure usually develops slowly, many people consider it a manifestation of the aging of their body. In such cases, patients often delay contacting a cardiologist until the last moment. Of course, this complicates and lengthens the treatment process.

Symptoms of chronic heart failure

The initial stages of chronic heart failure can develop according to the left and right ventricular, left and right atrial types. With a long course of the disease, there are dysfunctions of all parts of the heart. In the clinical picture, the main symptoms of chronic heart failure can be distinguished:

fast fatiguability;
shortness of breath, ;
peripheral edema;
heartbeat.

Complaints of rapid fatigue are presented by the majority of patients. The presence of this symptom is due to the following factors:

low cardiac output;
insufficient peripheral blood flow;
state of tissue hypoxia;
development of muscle weakness.

Shortness of breath in heart failure increases gradually - at first it occurs during physical exertion, then it appears with minor movements and even at rest. With decompensation of cardiac activity, the so-called cardiac asthma develops - episodes of suffocation that occur at night.

Paroxysmal (spontaneous, paroxysmal) nocturnal dyspnea can manifest itself as:

short attacks of paroxysmal nocturnal dyspnea, passing on their own;
typical attacks of cardiac asthma;
acute pulmonary edema.

Cardiac asthma and pulmonary edema are essentially acute heart failure that developed against the background of chronic heart failure. Cardiac asthma usually occurs in the second half of the night, but in some cases it is provoked by physical effort or emotional excitement during the day.

In mild cases the attack lasts for several minutes and is characterized by a feeling of lack of air. The patient sits down, hard breathing is heard in the lungs. Sometimes this condition is accompanied by a cough with a small amount of sputum. Attacks can be rare - after a few days or weeks, but can also be repeated several times during the night.
In more severe cases, a severe prolonged attack of cardiac asthma develops. The patient wakes up, sits down, tilts the body forward, rests his hands on his hips or the edge of the bed. Breathing becomes rapid, deep, usually with difficulty inhaling and exhaling. Wheezing in the lungs may be absent. In some cases, bronchospasm may be associated, which increases ventilation disorders and the work of breathing.

The episodes can be so unpleasant that the patient may be afraid to go to bed, even after the symptoms have disappeared.

Diagnosis of CHF

In diagnosis, you need to start with an analysis of complaints, identifying symptoms. Patients complain of shortness of breath, fatigue, palpitations.

The doctor asks the patient:

How does he sleep?
Has the number of pillows changed in the last week?
Whether the person began to sleep sitting, and not lying down.

The second stage of diagnosis is physical examination, including:

skin examination;
Assessment of the severity of fat and muscle mass;
Checking for edema;
Palpation of the pulse;
Palpation of the liver;
auscultation of the lungs;
Auscultation of the heart (I tone, systolic murmur at the 1st auscultation point, analysis of the II tone, "gallop rhythm");
Weighing (a decrease in body weight by 1% in 30 days indicates the onset of cachexia).

Diagnostic goals:

Early detection of the presence of heart failure.
Clarification of the severity of the pathological process.
Determining the etiology of heart failure.
Assessment of the risk of complications and rapid progression of pathology.
Forecast evaluation.
Assessment of the likelihood of complications of the disease.
Monitoring the course of the disease and timely response to changes in the patient's condition.

Diagnostic tasks:

Objective confirmation of the presence or absence of pathological changes in the myocardium.
Identification of signs of heart failure: shortness of breath, fatigue, palpitations, peripheral edema, moist rales in the lungs.
Identification of the pathology that led to the development of chronic heart failure.
Determination of the stage and functional class of heart failure according to NYHA (New York Heart Association).
Identification of the predominant mechanism for the development of heart failure.
Identification of provoking causes and factors that aggravate the course of the disease.
Identification of concomitant diseases, assessment of their relationship with heart failure and its treatment.
Collecting enough objective data to prescribe the necessary treatment.
Identification of the presence or absence of indications for the use of surgical methods of treatment.

Diagnosis of heart failure should be made using additional examination methods:

The ECG usually shows signs of myocardial hypertrophy and ischemia. Quite often this research allows to reveal the accompanying arrhythmia or disturbance of conductivity.
An exercise test is performed to determine tolerance to it, as well as changes characteristic of coronary heart disease (ST segment deviation on the ECG from the isoline).
24-hour Holter monitoring allows you to clarify the state of the heart muscle with typical patient behavior, as well as during sleep.
A characteristic sign of CHF is a decrease in ejection fraction, which can be easily seen with ultrasound. If you additionally conduct Dopplerography, then heart defects will become obvious, and with proper skill, you can even identify their degree.
Coronary angiography and ventriculography are performed to clarify the state of the coronary bed, as well as in terms of preoperative preparation for open interventions on the heart.

When diagnosing, the doctor asks the patient about complaints and tries to identify signs typical of CHF. Among the evidence for the diagnosis, the discovery of a history of heart disease in a person is important. At this stage, it is best to use an ECG or determine the natriuretic peptide. If no deviations from the norm are found, the person does not have CHF. If manifestations of myocardial damage are detected, the patient should be referred for echocardiography in order to clarify the nature of cardiac lesions, diastolic disorders, etc.

At the subsequent stages of diagnosis, doctors identify the causes of chronic heart failure, specify the severity, reversibility of changes in order to determine adequate treatment. Additional studies may be ordered.

Complications

Patients with chronic heart failure may develop dangerous conditions such as

frequent and protracted;
pathological myocardial hypertrophy;
numerous thromboembolism due to thrombosis;
general depletion of the body;
violation of the heart rhythm and conduction of the heart;
dysfunction of the liver and kidneys;
sudden death from cardiac arrest;
thromboembolic complications (, thromboembolism of the pulmonary arteries).

Prevention of the development of complications is the use of prescribed medications, the timely determination of indications for surgical treatment, the appointment of anticoagulants according to indications, antibiotic therapy for lesions of the bronchopulmonary system.

Treatment of chronic heart failure

First of all, patients are advised to follow an appropriate diet and limit physical activity. You should completely abandon fast carbohydrates, hydrogenated fats, in particular, animal origin, and carefully monitor salt intake. You should also stop smoking and drinking alcohol immediately.

All methods of therapeutic treatment of chronic heart failure consist of a set of measures that are aimed at creating the necessary conditions in everyday life, contributing to the rapid reduction of the load on the C.S.S., as well as the use of drugs designed to help the myocardium work and influence the disturbed processes of water salt exchange. The appointment of the volume of therapeutic measures is associated with the stage of development of the disease itself.

Treatment of chronic heart failure is long-term. It includes:

Medical therapy aimed at combating the symptoms of the underlying disease and eliminating the causes that contribute to its development.
rational mode, including the restriction of labor activity according to the forms of the stages of the disease. This does not mean that the patient must always be in bed. He can move around the room, physical therapy is recommended.
Diet therapy. It is necessary to monitor the calorie content of food. It should correspond to the prescribed regimen of the patient. For overweight people, the calorie content of food is reduced by 30%. And patients with exhaustion, on the contrary, are prescribed enhanced nutrition. If necessary, unloading days are held.
Cardiotonic therapy.
Treatment with diuretics aimed at restoring the water-salt and acid-base balance.

Patients with the first stage are fully able-bodied, with the second stage there is a limited ability to work or it is completely lost. But in the third stage, patients with chronic heart failure need permanent care.

Medical treatment

Drug treatment of chronic heart failure is aimed at improving the functions of contraction and ridding the body of excess fluid. Depending on the stage and severity of symptoms in heart failure, the following groups of drugs are prescribed:

Vasodilators and ACE inhibitors- angiotensin-converting enzyme (, ramipril) - lower vascular tone, dilate veins and arteries, thereby reducing vascular resistance during heart contractions and contributing to an increase in cardiac output;
Cardiac glycosides (digoxin, strophanthin, etc.)- increase myocardial contractility, increase its pumping function and diuresis, contribute to satisfactory exercise tolerance;
Nitrates (nitroglycerin, nitrong, sustak, etc.)- improve blood supply to the ventricles, increase cardiac output, dilate the coronary arteries;
Diuretics (, spironolactone)- reduce the retention of excess fluid in the body;
Β-blockers ()- reduce heart rate, improve blood supply to the heart, increase cardiac output;
Drugs that improve myocardial metabolism(vitamins of group B, ascorbic acid, riboxin, potassium preparations);
Anticoagulants ( , )- prevent thrombosis in the vessels.

Monotherapy in the treatment of CHF is rarely used, and only ACE inhibitors can be used in this capacity in the initial stages of CHF.

Triple therapy (ACE inhibitor + diuretic + glycoside) - was the standard in the treatment of CHF in the 80s, and now remains an effective regimen in the treatment of CHF, however, for patients with sinus rhythm, it is recommended to replace the glycoside with a beta-blocker. The gold standard from the early 90s to the present is a combination of four drugs - ACE inhibitor + diuretic + glycoside + beta-blocker.

Prevention and prognosis

To prevent heart failure, proper nutrition, sufficient physical activity, and the rejection of bad habits are necessary. All diseases of the cardiovascular system must be detected and treated in a timely manner.

The prognosis in the absence of CHF treatment is unfavorable, since most heart diseases lead to wear and tear and the development of severe complications. When conducting medical and / or cardiac surgical treatment, the prognosis is favorable, because there is a slowdown in the progression of insufficiency or a radical cure for the underlying disease.

Classification of chronic heart failure

In our country, two clinical classifications of chronic HF are used, which significantly complement each other. One of them, created by N.D. Strazhesko and V.Kh. Vasilenko with the participation of G.F. Lang and approved at the XII All-Union Congress of Therapists (1935), based on functional and morphological principles assessment of the dynamics of clinical manifestations of cardiac decompensation (table 1). The classification is given with modern additions recommended by N.M. Mukharlyamov, L.I. Olbinskaya and others.

Table 1

Classification of chronic heart failure, adopted at the XII All-Union Congress of Physicians in 1935 (with modern additions)

Stage	Period	Clinical and morphological characteristics
I stage (initial)	At rest, hemodynamic changes are absent and are detected only during physical activity.
	Period A (stage Ia)	Preclinical chronic heart failure. Patients practically do not show complaints. During exercise, there is a slight asymptomatic decrease in EF and an increase in LV EDV.
	Period B (stage Ib)	Latent chronic HF. Manifested only during physical exertion - shortness of breath, tachycardia, fatigue. At rest, these clinical signs disappear, and hemodynamics normalize.
II stage	Hemodynamic disorders in the form of stagnation of blood in the small and / or large circles of blood circulation remain at rest
	Period A (stage IIa)	*Signs of chronic HF at rest are moderate. Hemodynamics is disturbed only in one of the departments* cardiovascular system (in the small or large circle of blood circulation)**
	Period B (stage IIb)	*The end of a long stage of progression of chronic heart failure. Severe hemodynamic disturbances involving the entire cardiovascular system ( both small and large circles of blood circulation)*
III stage	Expressed hemodynamic disorders and signs of venous stasis in both circles of blood circulation, as well as significant disorders of perfusion and metabolism of organs and tissues
	Period A (stage IIIa)	Pronounced signs of severe biventricular heart failure with stagnation in both circles of blood circulation (with peripheral edema up to anasarca, hydrothorax, ascites, etc.). With active complex therapy for heart failure, it is possible to eliminate the severity of stagnation, stabilize hemodynamics and partially restore the functions of vital organs.
	Period B (stage IIIb)	The final dystrophic stage with severe widespread hemodynamic disorders, persistent metabolic changes and irreversible changes in the structure and function of organs and tissues

Although the classification of N.D. Strazhesko and V.Kh. Vasilenko is convenient for characterizing biventricular (total) chronic HF, it cannot be used to assess the severity of isolated right ventricular failure, for example, decompensated cor pulmonale.

Functional classification of chronic HF New York Heart Association (NYHA, 1964) is based on a purely functional principle of assessing the severity of the condition of patients with chronic heart failure without characterizing morphological changes and hemodynamic disorders in the systemic or pulmonary circulation. It is simple and convenient for use in clinical practice and is recommended for use by the International and European Societies of Cardiology.

According to this classification, 4 functional classes (FC) are distinguished depending on the patient's tolerance to physical activity (Table 2).

table 2

New York classification of the functional state of patients with chronic heart failure (modified), NYHA, 1964.

Functional class (FC)	Limitation of physical activity and clinical manifestations
I FC	There are no restrictions on physical activity. Ordinary physical activity does not cause severe fatigue, weakness, shortness of breath or palpitations
II FC	Moderate limitation of physical activity. At rest, there are no pathological symptoms. Ordinary physical activity causes weakness, fatigue, palpitations, shortness of breath, and other symptoms
III FC	Severe limitation of physical activity. The patient feels comfortable only at rest, but the slightest physical exertion leads to weakness, palpitations, shortness of breath, etc.
IV FC	The inability to perform any load without the appearance of discomfort. Symptoms of heart failure are present at rest and worsen with any physical activity.

When formulating the diagnosis of chronic heart failure, it is advisable to use both classifications, which significantly complement each other. In this case, the stage of chronic HF according to N.D. should be indicated. Strazhesko and V.Kh. Vasilenko, and in brackets - the functional class of HF according to NYHA, reflecting the functional capabilities of this patient. Both classifications are fairly easy to use because they are based on an assessment of the clinical signs of heart failure.