Signs and Symptoms With Etiology Extra heart sound, the S3, or ventricular gallop This can be detected

d upon auscultation. It is caused by a large volume of fluid entering the ventricle at the beginning of diastole. Pulmonary crackles Adventitious breath sounds may be heard in various areas of the lungs. Usually, bibasilar crackles that do not clear with coughing are detected in the early phase of left ventricular failure. As the failure worsens and pulmonary congestion increases, crackles may be auscultated throughout all lung fields. At this point, oxygen saturation may increase. Cough The cough associated with left ventricular failure is initially dry and non-productive. Most often, patients complain of a dry hacking cough that may be mislabelled as asthma or chronic obstructive pulmonary disease (COPD). The cough may become moist over time. Large quantities of frothy sputum, which is sometimes pink (blood-tinged), may be produced usually indicating severe pulmonary congestion (pulmonary edema). Dyspnea or shortness of breath - When the heart begins to fail, blood backs up in the veins attempting to carry oxygenated blood from the lungs to the heart. As fluid pools in the lungs, it interferes with normal breathing. Orthopnea or difficulty breathing when lying flat Individuals with orthopnea find that the condition feels worse when they are in a reclining position because the backflow of fluid and buildup in pressure from the heart interferes directly with the free flow of oxygen in the lungs. Normally, oxygen is easily exchanged through the thin spongy tissue of the lungs. If this tissue becomes waterlogged, as it does in heart failure, less oxygen can be transferred to the blood. If there is not enough oxygen, certain reflexes stimulate faster breathing. People with lung congestion as a result of heart failure usually have to prop themselves up with extra pillows in order to sleep. Paroxysmal nocturnal dyspnea or waking up at night due to shortness of breath Fluid that accumulated in the dependent extremities during the day begins to be reabsorbed into the circulating blood volume when the patient lies down. Because the impaired left ventricle cannot eject the increased circulating blood volume, the pressure in the pulmonary circulation increases, causing further shifting of fluid into the alveoli. The fluid-filled alveoli cannot exchange oxygen and carbon dioxide. Without sufficient oxygen, the patient experiences dyspnea and has difficulty getting sleep. Oliguria Blood flow to the kidneys decreases, causing decreased perfusion and reduced urine output known as oliguria. Nocturia Renal perfusion falls, which results in the release of renin from the kidney. Release of renin leads to aldosterone secretion and increased intravascular volume. However, when the patient is sleeping, the cardiac workload is decreased, improving renal perfusion, which may then lead to frequent urination at night. This condition is called as nocturia. Altered digestion Decreased cardiac output decreases gastrointestinal perfusion causing altered digestion. When the liver and digestive system become congested they fail to receive a

normal supply of blood. This can make the patient feel nauseous or full, even if he/she hasn't eaten. Palpitations Decreases in ejected ventricular volume cause the sympathetic nervous system to increase the heart rate (tachycardia), often causing the patient to complain of palpitations. The heart may speed up to compensate for its failing ability to adequately pump blood throughout the body. Patients may feel a fluttering in the heart (palpitations) or a heartbeat that seems irregular or out of rhythm. This often is described as a pounding or racing sensation in the chest. Dizziness, light-headedness, confusion, restlessness, and anxiety These are caused by decreased brain perfusion and decreased oxygenation and blood flow. Abnormal levels of certain substances, such as sodium, in the blood and reduced blood flow to the brain can cause memory loss or disorientation, which the patient may or may not be aware of. Pallor and cold, clammy skin As anxiety increases, so does dyspnea, increasing anxiety and creating a vicious cycle. Stimulation of the sympathetic system also causes the peripheral vessels to constrict, so the skin appears pale or ashen and feels cool and clammy. Fatigue Without adequate cardiac output, the body cannot respond to increased energy demands, and the patient becomes easily fatigued and has decreased activity tolerance. Fatigue also results from the increased energy expended in breathing. Insomnia This results from respiratory distress, coughing and nocturia.

Risk Factors With Etiology Non Modifiable Factors Age As with coronary artery disease, the incidence of heart failure increases with age. Although HF can affect people of all ages, the prevalence in people older than 75 years of age is about 10%. HF is the most common reason for hospitalization of people older than 65 years of age and the second most common reason for visits to a physicians office. Older age is a risk factor for heart disease. In fact, about 4 of every 5 deaths due to heart disease occur in people older than 65. As we age, our hearts tend to not work as well. The heart's walls may thicken, arteries may stiffen and harden, and the heart is less able to pump blood to the muscles of the body. Because of these changes, the risk of developing cardiovascular disease increases with age. Genetics - You have a family history of early heart disease if a first-degree relative (parent, brother or sister, or child) was diagnosed with heart disease or died suddenly from heart problems before age 65 in female relatives, or before age 55 in male relatives. Heart disease is a complex disease that is partly caused by genes inherited from your parents. These genetic factors and their interaction with lifestyle factors (such as diet and exercise) determine your likelihood of developing heart disease and heart disease risk factors. Heart disease tends to cluster in families because genes that predispose someone to develop major heart disease risk factors (such as diabetes, high blood pressure, and high cholesterol) run in families. In addition, families often share unhealthy habits such as smoking, lack of exercise, and poor diet. In addition to genes, siblings usually grow up with the same lifestyle risk factors (such as bad diet and lack of exercise). A Swedish study also found that heart disease is more likely to be inherited from your mother than your father possibly because of conditions in the womb, and because children often spend more time with their mothers and so may be more likely to acquire unhealthy behaviors from them. Gender - Overall, men have a higher risk of heart attack than women. But the difference narrows after women reach menopause. After the age of 65, the risk of heart disease is about the same between the sexes when other risk factors are similar. For women, cardiovascular events occur an average of ten years later in life than in men, but overall, women tend to have a higher incidence of complications from cardiovascular disease and a higher mortality. Women tend not to recognize the symptoms as early as men and to wait longer to report their symptoms and seek medical assistance. In women younger than 55 years of age, the incidence of CAD is significantly lower than in men. However, in women older than 55 years of age, the incidence of CAD is approximately equal to that in men. The age difference between women and men newly diagnosed with CAD was traditionally thought to be related to estrogen. It is now recognized that menopause is a milestone in the aging process during which risk factors tend to accumulate and it was believed that the female hormone estrogen had cardioprotective effects.

Modifiable Factors Smoking First, the inhalation of smoke increases the blood carbon monoxide level, and haemoglobin, the oxygen carrying component of blood, combines more readily with carbon monoxide than with oxygen. A decreased amount of available oxygen may decrease the hearts ability to pump. Second, the nicotinic acid in tobacco triggers the release of catecholamines, which raise the heart rate and blood pressure. Nicotinic acid can also cause the coronary arteries to constrict. Smokers have a tenfold increase in risk for sudden cardiac death. The increase in catecholamines may be a factor in sudden cardiac death. Third, use of tobacco causes a detrimental vascular response and increases platelet adhesion, leading to a higher probability of a thrombus formation. Diet (caffeine, fatty foods) Caffeine. One of the most noticeable side effects from caffeine is an increase in heart rate. The main reason caffeine raises the heart rate is its stimulant properties. Caffeine takes about 45 minutes to be absorbed into the bloodstream. Once there, caffeine can make its way to the heart, where it acts as a stimulant by binding, or attaching itself to, specific receptors on the heart tissues causing the heart rate to increase. Once at the heart, caffeine mimics the actions of epinephrine and binds with receptors that are commonly used by enzymes to block the production of cAMP (cyclic adenosine monophosphate). cAMp is a substance that activates protein kinase, which produces the adenosine triphosphate (ATP) needed for muscle contractions and relaxation of the heart. The increase of ATP causes the heart to beat at a faster pace. Fatty foods. Saturated fat and cholesterol in the food you eat make your blood cholesterol level go up. Saturated fat is the main culprit, but cholesterol in foods also matters. When there is too much cholesterol (a fat-like substance) in your blood, it builds up in the walls of your arteries. Over time, this buildup causes "hardening of the arteries" so that arteries become narrowed and blood flow to the heart is slowed down or blocked. The blood carries oxygen to the heart, and if enough blood and oxygen cannot reach your heart, you may suffer chest pain. If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack. Diabetes Mellitus It is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both. Hyperglycemia fosters dyslipidemia, increased platelet aggregation, and altered red blood cell function, which can lead to thrombus formation. Stress - Stressful situations raise your heart rate and blood pressure, increasing the heart's need for oxygen. This need for oxygen can bring on angina pectoris, or chest pain, in people who already have heart disease. During times of stress, the nervous system releases extra hormones (most often adrenaline). These hormones raise blood pressure, which can injure the lining of the arteries. When the arteries heal, the walls may harden or thicken, making is easier for plaque to build up.

Stress also increases the amount of blood clotting factors that circulate in your blood, and makes it more likely that a clot will form. Clots may then block an artery narrowed by plaque and cause a heart attack. Stress may also contribute to other risk factors. For example, people who are stressed may overeat for comfort, start smoking, or smoke more than they normally would. Coronary Artery Disease Very simply coronary heart disease is a potentially life threatening condition resulting from the narrowing of the coronary arteries by the build up of fatty deposits known as plaque. The process of depositing plaque is called atherosclerosis. The heart, like any other muscle, needs a constant supply of oxygen and nutrients. As the coronary arteries become increasingly clogged by plaque the heart becomes starved and unable to function properly. Coronary heart disease, of course, makes the heart work harder. But the problem is much more serious than that. A number of other serious conditions can (and very often do) result including angina (chest pains which can be quite painful), myocardial infarction (heart attack due to irreversible heart muscle damage), congestive heart failure (a condition in which the heart cannot effectively supply the rest of the body with blood), arrhythmia (irregular heart rate which can lead to sudden cardiac death). Myocardial Infarction - Myocardial infarction (MI) means that part of the heart muscle suddenly loses its blood supply. Without prompt treatment, this can lead to damage to the affected part of the heart. An MI is sometimes called a heart attack or a coronary thrombosis. If a large area of the heart muscle is damaged, then the pumping ability of the heart may be reduced. Less blood than usual is then pumped around the body, especially when extra blood is needed when you exercise. Symptoms such as breathlessness, tiredness, and swollen ankles may develop. This can lead to heart failure. Mild heart failure can often be treated with medication. Severe heart failure can be serious and even life-threatening.