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Causes and signs of heart failure

Myocardial infarction, stroke, oncology - these are terrible diseases that can be fatal. However, there is another disease that can kill quickly and unnoticed. It is called heart failure: its causes, characteristic symptoms of development, severity class (acute, chronic, and others), how to provide first aid with subsequent treatment are described further in the article.

What is heart failure?

The disease is associated with chronic or acute disorders of the heart (diastolic murmur) and is a clinical syndrome. The heart muscle gradually weakens, it is not able to bleed the blood in the normal circulation of the large circle. At this time, the blood that returns from the internal organs gradually stagnates in the heart. The disease is accompanied by a decrease in blood flow to the aorta and a decrease in the blood supply to the heart.

Heart Failure Syndrome has several types of clinical symptoms, which are divided into stages. There is shortness of breath, which is accompanied by coughing up blood. You can find them during sports. The patient may complain of general weakness, fatigue. Some patients complain of a decrease in the amount of urine during night visits to the toilet. When the disease can be observed blue tint on the skin of the hands, feet, nose, earlobes.

Acute Heart Failure

With acute decompensation, doctors distinguish two types. Coronary insufficiency of the heart of the right ventricle is determined by the blue tint of the fingers, the tip of the nose and chin, the neck veins swell, the liver increases markedly. Acute left ventricular failure can be identified by the occurrence of shortness of breath (it can reach asphyxiation), orthopnea (difficult to sit in any posture, except when the legs are down), wheezing, like bursting bubbles.

Chronic

The stages of the symptoms of chronic disease were determined by Kh.V. Vasilenko. CHF is divided into three stages: initial, severe, final:

  1. At the initial stage, it is difficult to identify the symptoms. There is shortness of breath, heart palpitations when playing sports.
  2. Severe chronic stages:
    • Grade 1 - venous congestion with low cardiac output or impaired blood circulation in the small circle,
    • Grade 2 - the occurrence of shortness of breath, heart palpitations with moderate exercise, cyanosis, dry cough sometimes with blood, wheezing in the lungs, interruption of heartbeat,
    • Grade 3 - shortness of breath, pronounced cyanosis, congestion in the lungs, aching pain in the heart area, swelling of the lower extremities, cirrhosis of the liver, ascites, oliguria.
  3. In the third stage of chronic insufficiency, hemodynamic disturbances occur, irreversible changes that are accompanied by cirrhosis of the liver, manifestation of kidney stasis, diffuse pneumosclerosis. Significantly disturbed metabolism. At this stage, treatment is considered ineffective.

This pathology is manifested by edema in the legs. This happens in the afternoon or evening. Edema affects the feet and lower parts of the legs. In the morning swelling disappear. In the second stage of the disease, edema appears constantly in the lower back, arms, abdomen, and above the knee. In severe chronic stage of the disease, edema of the whole body appears - anasarca.

Pulmonary congestion

Symptoms may manifest as congestion in the lungs. There are asthma attacks during physical exertion, sports, cough with frothy transparent sputum, body weight increases. Congestion develops swelling of the legs, they accumulate fluid. Congestive events are reflected in cardiac rhythm disturbances (an increase in heartbeat rate), cardiac asthma. Observed pulmonary hypertension or pulmonary pathology. The disease contributes to the progression to other internal organs.

Clinical symptoms of diseases of the cardiovascular system (cardiovascular insufficiency) are considered the main manifestation of this disease. Observed shortness of breath, pain in the heart, arrhythmia, rapid heartbeat. The pain can be stabbing, burning, constricting and strong. It is associated with thrombovasculitis, necrosis in the muscle of the organ. Middle-aged women experience aching pain in the sternum for 3 days. With the progression of pathology, severe, burning pains are observed.

The factors that provoked the development of the syndrome may be transferred or current diseases that are related to myocardial damage. The causes of development are characterized by:

  • cardiac ventricular myocardial hypertrophy,
  • myocardial ischemia,
  • high blood pressure in the pulmonary vessels,
  • valvular heart disease
  • renal failure
  • congenital heart disease or mitral disease,
  • lung diseases (chronic respiratory diseases) or wounds, infections. The disease develops due to the contraction of the ventricles and the contraction of the myocardium.

With the development of this disease in a child there is increased fatigue, difficulty breathing or shortness of breath, loss of consciousness, dizziness, blackening of the eyes, the skin turns pale, lips, toes and hands darken, tachycardia, restless sleep, cough with wheezing, vomiting. In children, there is frequent regurgitation, specific swelling of the limbs. In the early stages of the disease, shortness of breath is observed in children while running, and in the later stages, sleep is disturbed due to asphyxiation or at rest. Children slowly gain weight, do not tolerate any kind of sports, like adults.

Classification

According to the classifications of insufficiency, there are two forms of the rate of development of the disease by myocardial damage. The acute form has a rapid development, manifested as cardiac asthma and cardiogenic shock. Causes - rupture of the walls of the left ventricle, myocardial infarction. The chronic form develops gradually, over several weeks, months, years. Causes - valvular heart disease, chronic respiratory failure, anemia, low blood pressure.

There are four functional stages of this disease:

  • At the first stage, when playing sports, there is no weakness, an accelerated heartbeat and any pain in the chest.
  • In the second stage of the disease, the patient has moderate restrictions on playing sports. At rest, the patient feels well, but while playing sports, shortness of breath appears.
  • In the third stage of the disease, the patient feels comfortable in a state of rest.
  • At the fourth stage of the disease, discomfort is observed during any activity, load. Angina syndrome is observed only at rest.

Diagnostics

Functional diagnosis of this disease is as follows. Doctors conduct a clinical examination, using instrumental methods of examination. In the initial study, the specialist determines the severity of the symptoms and the patient's condition. To do this, check the symptoms of the disease during physical exertion and during the period of rest, check the objective signs of heart failure during rest.

At the stage of instrumental methods, ECG is used, measuring the dimensions of the cavity of the left and right atrium, both ventricles, the magnitude of the ejection fraction. A mandatory examination criterion is Doppler EchoCG, which allows you to determine the speed of blood flow, pressure, the presence of pathological discharge of blood. With negative assessments of doctors, the patient is sent for treatment in cardiology.

There are two types of treatment for this disease - drug and non-drug therapy. In the treatment of drugs prescribed to the patient after the diagnosis Drug-free treatment of heart failure is a diet, physical rehabilitation, bed rest. The diet should be strict, without salt. The patient should not eat fish, canned meat, hard cheese, vegetable juices, black and white bread, semi-finished products. On the day he should drink at least 2 liters of liquid, but not more. It is recommended to consult a doctor to avoid dehydration.

Physical activity consists of walking or training on exercise bikes. On the day, the patient must exercise for 25 minutes. At the same time, doctors should monitor the patient's health and pulse (increase or decrease the frequency). Regarding bed rest. Experts do not recommend patients absolute peace and bed rest, as the heart needs movement. Treatment of chronic heart failure occurs through physical exercise.

First aid

With the manifestation of shortness of breath, cough, noisy breathing, the presence of fear, anxiety, the patient must be given first aid:

  • The person should be put in a comfortable position, while the back should be as high as possible.
  • Hands and feet can be dipped in hot water.
  • Then you should call an ambulance, the dispatcher must describe all the symptoms.
  • After that, sit the patient closer to the open window, take off your breathing-tight clothing. Then measure the pressure and support the person.
  • With a low systolic pressure (above 90 mm), give the patient a nitroglycerin tablet and a diuretic tablet.
  • Twenty minutes after you set the patient down, apply a tourniquet on one hip. When cardiac arrest is necessary to do an indirect heart massage, artificial respiration, precordial stroke, that is, a set of measures for cardiopulmonary resuscitation.

Angiotensin inhibitors affect renin-angiotensin-aldosterone activity. They slow the progression of the disease. These include Captopril and Quinapril. Captopril can not be used for severe violations of the liver, cardiogenic shock, hypotension, pregnancy, lactation and children under 18 years. It is taken 1 hour before meals, the dosage of each individual. To eliminate the symptoms - shortness of breath or choking - the patient is prescribed morphine.

Β-adrenergic blocker reduces the risk of death from a lack of cardiac activity and blocks the transmission of impulses to organs and tissues of the body. These include the non-cardio selective carvediol. This tool can not be used for arterial hypotension, severe bradycardia, cardiogenic shock and bronchial asthma. First, the patient is given 6.25 mg per day, gradually increasing the dose to 50 mg in 14 days.

Drugs that improve muscle blood supply and myocardial metabolism or cardiac glycosides. These include Erinit and Nitrosorbitol:

  • Erynite is slowly absorbed. It is an effective tool. To prevent attacks in chronic coronary insufficiency are taken orally.
  • Nitrosorbitol has a similar effect and prolonged absorption.

Surgery

If a patient is prescribed a surgical intervention to treat a disease, then a heart transplant or cardiomyoplasty can be done. Cardiomyoplasty is that during surgery, the surgeon cuts out a flap from the broad back muscle, envelops the patient's heart with it to improve the contractile function. In acute form, emergency medical therapy is required, which is aimed at reducing the contractile function of the right ventricular cardiac cavity (photo).

What can be predicted for this disease depends entirely on its severity. With timely treatment, the use of modern means of mortality is reduced to 30%. In the early stages of the disease, medicine can help stabilize the symptoms, this is a chance to increase the patient's life expectancy. If you correctly perform all appointments specialist, the disease will slow down for months or for many years.

How many live with heart failure

According to statistics, in patients with insufficiency in dangerous late stages, mortality rises to 70%. In the early stages, the disease can be cured. According to statistics from scientists, almost 50% of patients with a diagnosis of deficiency live for five or more years, playing sports and leading a normal way of life. However, it is impossible to get rid of this disease completely.

Prevention

To prevent complications of the disease, preventive measures are the following: you need to eat properly and varied, exercise regularly, maintain the daily regimen, give up bad habits, visit the cardiologist often. Patients need to constantly physically move, for example, using fast walking for 30-50 minutes a day.

Signs and symptoms

The intensity and nature of symptoms in heart failure depends on the degree and location of the affected part of the heart. In most cases, the first signs of such violations are fatigue and weakness.

With the localization of the pathological process in the left ventricle, the patient has the following symptoms of stagnation of blood in the small circle of blood circulation and lungs:

  • shortness of breath (its severity increases with the progression of pathology),
  • blue fingers and lips
  • cough with white or pink sputum,
  • dry rales.

This condition of the patient may be complicated by an attack of cardiac asthma:

  • cough with poorly separated sputum,
  • feeling short of breath,
  • increase in shortness of breath until suffocation,
  • decrease in blood pressure
  • severe weakness
  • cold sweat,
  • pallor turning into acrocyanosis and cyanosis,
  • arrhythmic pulse.

Severe asthma attack can lead to the development of pulmonary edema:

  • sputum with pink foam,
  • orthopnea,
  • swelling of the veins on the neck,
  • filamentous and arrhythmic pulse,
  • decrease in blood pressure
  • moist rales in the lungs.

In the case of late medical emergency, this complication can be fatal.

With the defeat of the right ventricle in a patient, the symptoms of stagnation in the major circulation are determined:

  • swelling of the lower extremities (especially on the ankles), which increase in the evening, and during sleep decrease or disappear,
  • feeling of heaviness and discomfort in the right hypochondrium,
  • enlarged liver
  • ascites

Circulatory failure has a negative effect on the functioning of the nervous system and can manifest itself in the form of confusion, loss of memory and mental activity (especially in elderly patients). Over time, functional insufficiency of one of the parts of the heart leads to the development of disorders in the small and large circulation.

The prognosis of the course of heart failure is variable and depends on the severity, lifestyle and comorbidities. Timely treatment of this condition in many cases allows to compensate and stabilize the patient's condition. Already at stage III-IV of heart failure, the prognosis of the effectiveness of its further treatment becomes less favorable: only 50% of patients survive for 5 years.

The main measures to prevent the development, progression and decompensation of heart failure are measures to prevent the development of those pathologies that provoke it (coronary artery disease, hypertension, cardiomyopathy, heart disease, etc.). When heart failure has already begun, the patient is recommended to have a regular follow-up observation by a cardiologist and the mandatory observance of all his recommendations for treatment and the mode of physical activity.

Causes of Heart Failure

The main causes of heart failure are:

  • ischemic heart disease and myocardial infarction,
  • dilated cardiomyopathy,
  • rheumatic heart disease.

In elderly patients, diabetes mellitus type II and arterial hypertension are often the causes of heart failure.

There are a number of factors that can reduce myocardial compensatory mechanisms and provoke the development of heart failure. These include:

  • pulmonary embolism (PE),
  • severe arrhythmia,
  • psycho-emotional or physical stress,
  • progressive coronary heart disease,
  • hypertensive crises,
  • acute and chronic renal failure,
  • severe anemia
  • pneumonia,
  • severe colds,
  • hyperthyroidism
  • long-term use of certain medications (epinephrine, ephedrine, corticosteroids, estrogens, nonsteroidal anti-inflammatory drugs),
  • infective endocarditis,
  • rheumatism,
  • myocarditis,
  • a sharp increase in the volume of circulating blood with an incorrect calculation of the volume of intravenously injected liquid,
  • alcoholism,
  • quick and significant weight gain.

Elimination of risk factors helps prevent the development of heart failure or slow its progression.

Heart failure is acute and chronic. Symptoms of acute heart failure appear and progress very quickly, from several minutes to several days. Chronic forms slowly over several years.

Acute heart failure can develop in one of two types:

  • left atrial or left ventricular failure (left type),
  • right ventricular failure (right type).

In accordance with the classification Vasilenko - Strazhesko in the development of chronic heart failure, there are the following stages:

I. Stage of initial manifestations. В состоянии покоя гемодинамические нарушения у пациента отсутствуют.Exercise causes excessive fatigue, tachycardia, shortness of breath.

Ii. Stage pronounced changes. Signs of long-lasting hemodynamic disorders and circulatory failure are well pronounced and at rest. Stagnation in the small and large circles of blood circulation cause a sharp decline in the ability to work. During this stage, there are two periods:

  • IIA - moderately pronounced hemodynamic disturbances in one of the parts of the heart, working capacity is sharply reduced, even normal exercise leads to severe shortness of breath. The main symptoms are: hard breathing, a slight increase in the liver, swelling of the lower limbs, cyanosis.
  • IIB - pronounced hemodynamic disorders in both the large and the small circle of blood circulation, the ability to work is completely lost. The main clinical signs: marked edema, ascites, cyanosis, shortness of breath at rest.

Iii. Stage of dystrophic changes (terminal or terminal). Persistent circulatory failure is formed, leading to serious metabolic disorders and irreversible disturbances in the morphological structure of the internal organs (kidneys, lungs, liver), and depletion.

Gas exchange disorder

Slowing blood flow in the microvasculature increases the absorption of oxygen by the tissues in half. As a result, the difference between arterial and venous blood oxygenation increases, which contributes to the development of acidosis. In the blood accumulate oxidized metabolites, activating the rate of basal metabolism. As a result, a vicious circle is formed, the body needs more oxygen, and the circulatory system cannot provide these needs. The disorder of gas exchange leads to the appearance of such symptoms of heart failure as shortness of breath and cyanosis.

With blood stasis in the system of the pulmonary circulation and the deterioration of its oxygenation (oxygen saturation), central cyanosis occurs. Increased utilization of oxygen in the tissues of the body and slow blood flow cause peripheral cyanosis (acrocyanosis).

The development of edema in the background of heart failure leads to:

  • slowing blood flow and increasing capillary pressure, which contributes to increased plasma extravasation in interstitial space,
  • violation of water-salt metabolism, leading to a delay in the body of sodium and water,
  • disorder of protein metabolism, which violates the osmotic pressure of plasma,
  • decrease in liver inactivation of antidiuretic hormone and aldosterone.

In the initial stage of heart failure, edema is hidden and manifested by pathological weight gain, decreased diuresis. Later they become visible. First, the lower limbs or the sacral region swell (in bed patients). Subsequently, fluid accumulates in the body cavities, which leads to the development of hydropericardium, hydrothorax, and / or ascites. This condition is called abdominal dropsy.

Congestive changes in the internal organs

Hemodynamic disorders in the pulmonary circulation lead to the development of congestion in the lungs. Against this background, the mobility of the pulmonary edges is limited, the respiratory excursion of the chest decreases, and the rigidity of the lungs is formed. Hemoptysis appears in patients, cardiogenic pneumosclerosis, congestive bronchitis develops.

Congestion in the systemic circulation begins with an increase in the size of the liver (hepatomegaly). In the future, the death of hepatocytes occurs with their replacement by connective tissue, that is, cardiac fibrosis of the liver is formed.

In chronic heart failure, the atrial and ventricular cavities gradually widen, which leads to relative atrioventricular valve insufficiency. Clinically, this is manifested by the expansion of the boundaries of the heart, tachycardia, and swelling of the neck veins.

Signs of congestive gastritis are loss of appetite, nausea, vomiting, flatulence, a tendency to constipation, weight loss.

With long-term chronic heart failure, patients develop cardiac cachexia - an extreme degree of exhaustion.

Kidney stagnation causes the development of the following symptoms of heart failure:

Heart failure has a pronounced negative effect on the function of the central nervous system. This leads to the development of:

  • depressive states
  • increased fatigue
  • sleep disorders,
  • decrease in physical and mental performance,
  • increased irritability.

The clinical manifestations of heart failure are also determined by its appearance.

Symptoms of acute heart failure

Acute heart failure may be due to a decrease in the pumping function of the right ventricle, left ventricle, or left atrium.

Acute failure of the left ventricle develops as a complication of myocardial infarction, aortic defect, hypertensive crisis. Reduction of the contractile activity of the myocardium of the left ventricle leads to an increase in pressure in the veins, capillaries and arterioles of the lungs, an increase in the permeability of their walls. This causes sweating of blood plasma and development of pulmonary edema.

According to clinical manifestations, acute heart failure is similar to acute vascular insufficiency, therefore it is sometimes called acute collapse.

Clinically acute left ventricular failure is manifested by symptoms of cardiac asthma or alveolar pulmonary edema.

The development of an attack of cardiac asthma usually occurs at night. The patient wakes up in fear from sudden choking. Trying to alleviate his condition, he assumes a forced posture: sitting, with his legs down (orthopnea position). On examination, the following signs are noteworthy:

  • paleness of the skin,
  • acrocyanosis
  • cold sweat,
  • severe shortness of breath,
  • in the lungs hard breathing with single moist rales,
  • low blood pressure
  • deaf heart sounds
  • appearance of gallop rhythm,
  • expanding the boundaries of the heart to the left
  • pulse arrhythmic, frequent, weak filling.

With further increase in stagnation in the pulmonary circulation, alveolar pulmonary edema develops. His symptoms are:

  • sharp choking
  • cough, with a pink foamy sputum (due to blood admixture),
  • a bubbling breath with a mass of moist rales (a symptom of a “boiling samovar”),
  • cyanosis of the face
  • cold sweat,
  • swelling of the neck veins,
  • a sharp decrease in blood pressure,
  • arrhythmic, filamentous pulse.

If urgent medical care is not provided to the patient, then against the background of an increase in cardiac and respiratory failure, death will occur.

At a mitral stenosis acute insufficiency of the left auricle forms. Clinically, this condition manifests itself in the same way as acute left ventricular heart failure.

Acute right ventricular failure usually develops as a result of pulmonary embolism (PE) or its major branches. The patient develops stagnation in the systemic circulation, which manifests itself:

  • pain in the right hypochondrium,
  • swelling of the lower extremities,
  • swelling and pulsation of the veins of the neck,
  • pressure or pain in the heart,
  • cyanosis
  • shortness of breath
  • expanding the boundaries of the heart to the right
  • increased central venous pressure
  • a sharp decrease in blood pressure,
  • threadlike pulse (frequent, weak filling).

Signs of Chronic Heart Failure

Chronic heart failure develops in the right and left atrial, right and left ventricular type.

Chronic left ventricular failure is formed as a complication of coronary heart disease, arterial hypertension, mitral valve insufficiency, aortic defect and is associated with stagnation of blood in the pulmonary circulation. It is characterized by gas and vascular changes in the lungs. Clinically manifested:

  • increased fatigue,
  • dry cough (rarely with hemoptysis),
  • heart attack
  • cyanosis
  • suffocation attacks that occur more often at night,
  • shortness of breath.

With chronic insufficiency of the left atrium in patients with mitral valve stenosis, congestion in the system of the pulmonary circulation is even more pronounced. The initial signs of heart failure in this case are cough with hemoptysis, severe shortness of breath and cyanosis. Gradually, in the small circle vessels and in the lungs, sclerotic processes begin. This leads to the creation of additional barriers to blood flow in the small circle and further increases the pressure in the pulmonary artery pool. As a result, the load on the right ventricle increases, causing the gradual formation of its insufficiency.

Chronic right ventricular insufficiency usually accompanies pulmonary emphysema, pneumosclerosis, mitral heart defects and is characterized by the appearance of signs of blood stagnation in the system of the pulmonary circulation. Patients complain of shortness of breath during physical exertion, an increase and spreading of the abdomen, a decrease in the amount of urine excreted, the appearance of edema of the lower extremities, heaviness and pain in the right hypochondrium. On examination revealed:

  • cyanosis of the skin and mucous membranes,
  • peripheral and cervical veins swelling,
  • hepatomegaly (enlarged liver),
  • ascites

The insufficiency of only one part of the heart cannot remain isolated for a long time. In the future, it necessarily turns into general chronic heart failure with the development of venous stagnation in both the minor and the large circulation.

Heart Failure Treatment

In heart failure, therapy is primarily aimed at the underlying disease (myocarditis, rheumatism, hypertension, coronary heart disease). Indications for surgery can be adhesive pericarditis, cardiac aneurysm, heart defects.

Strict bed rest and emotional rest are prescribed only to patients with acute and severe chronic heart failure. In all other cases, recommended physical activity that does not cause deterioration of health.

Heart failure is a serious medical and social problem, as it is accompanied by high rates of disability and mortality.

Properly organized diet food plays an important role in the treatment of heart failure. Meals should be easily digestible. The diet should include fresh fruits and vegetables as a source of vitamins and minerals. The amount of salt is limited to 1-2 g per day, and fluid intake to 500-600 ml.

To improve the quality of life and extend it allows pharmacotherapy, including the following groups of drugs:

  • cardiac glycosides - increase the contractile and pumping function of the myocardium, stimulate diuresis, allow to increase the level of exercise tolerance,
  • ACE inhibitors (angiotensin-converting enzyme) and vasodilators - reduce vascular tone, expand the lumen of blood vessels, thereby reducing vascular resistance and increasing cardiac output,
  • nitrates - expand the coronary arteries, increase the emission of the heart and improve the filling of the blood of the ventricles,
  • diuretics - remove excess fluid from the body, thereby reducing edema,
  • β-blockers - increase cardiac output, improve the filling of the heart chambers with blood, reduce the heart rate,
  • anticoagulants - reduce the risk of blood clots in the vessels and, accordingly, thromboembolic complications,
  • Means improving metabolic processes in the heart muscle (potassium preparations, vitamins).

With the development of cardiac asthma or pulmonary edema (acute left ventricular failure), the patient needs emergency hospitalization. Prescribe drugs that increase cardiac output, diuretics, nitrates. Necessarily carried out oxygen therapy.

Removal of fluid from the body cavities (abdominal, pleural, pericardium) is performed by puncture.

Why heart is weakening

With a variety of cardiac pathologies, too much blood may flow to the heart, it may be weak, or it may be difficult to pump blood against the increased pressure in the vessels (see also the causes of heart pain). In any of these cases, the underlying disease may be complicated by heart failure, the main causes of which are worth telling.

Myocardial causes

They are associated with the immediate weakness of the heart muscle as a result of:

  • inflammation (myocarditis)
  • necrosis (acute myocardial infarction)
  • expansion of the cavities of the heart (dilated myocardiopathy)
  • muscle wasting (myocardial dystrophy)
  • myocardial eating disorders (ischemic disease, coronary atherosclerosis, diabetes mellitus).

  • compression of the heart with inflammatory effusion in the cardiac bag (pericarditis)
  • blood (wounds or rupture of the heart)
  • atrial fibrillation
  • atrial fibrillation
  • paroxysmal tachycardia
  • ventricular fibrillation
  • overdose of cardiac glycosides, calcium antagonists, blockers
  • alcoholic myocardiopathy

Volume overload also leads to heart failure symptoms.

It is based on the deterioration of blood flow conditions with an increase in venous return to the heart in case of insufficiency of the heart valves, defects of the heart walls, hypervolemia, polycythemia, or the resistance of the blood flow to cardiac output during arterial hypertension, congenital and acquired (rheumatic) heart defects with stenosis of the valves and large vessels constrictive myocardiopathy. Another overload can be in case of pulmonary thrombembolia, pneumonia, obstructive pulmonary diseases and bronchial asthma.

Combined variants develop with weakness of the heart muscle and increasing load on the heart, for example, with complex heart defects (Fallot's tetrad)

How fast the problem develops

Depending on how quickly the symptoms of heart failure increase, they talk about acute or chronic variants.

  • Acute heart failure builds up over several hours or even minutes. It is preceded by various heart catastrophes: acute myocardial infarction, pulmonary thrombembolia. At the same time, the left or right ventricle of the heart may be involved in the pathological process.
  • Chronic heart failure is the result of a long illness. It progresses gradually and becomes heavier from minimal manifestations to severe multiorgan failure. It can develop in one of the circles of blood circulation.

Acute left ventricular failure

Acute left ventricular failure is a situation that can develop in two ways (cardiac asthma or pulmonary edema). Both of them are characterized by stagnation in the vessels of the small (pulmonary) circle.

Their basis is impaired coronary blood flow, which is less than adequate only when the heart muscle is relaxed (diastole).

At the time of contraction (systole), the blood does not fully flow into the aorta, stagnating in the left ventricle. The pressure in the left parts of the heart increases, and the right ones overflow with blood, provoking pulmonary stagnation.

Cardiac asthma

Cardiac asthma is, in fact, cardiopulmonary failure. Symptoms of it may gradually increase:

  • Pathology manifests itself in the early stages of shortness of breath. It occurs first with physical exertion, the tolerance for which gradually decreases. Dyspnea is inspiratory in nature and with it, unlike bronchial asthma, breathing is difficult. With the further development of the process, shortness of breath appears alone, causing patients to sleep on higher pillows.
  • Then shortness of breath gives way to episodes of choking, which often accompany a night's sleep. At the same time, the patient has to sit in bed, occupy a forced position with legs down from the bed and resting on the arms in order to enable the respiratory muscles to work.
  • Seizures are often combined with fear of death, palpitations and sweating.
  • Cough for heart failure - with scanty, difficult to discharge sputum. If you look at the face of a person at the time of an attack, you can see the blue nasolabial triangle against the background of pale or grayish skin. Also marked and frequent respiratory movements of the chest, cyanosis of the fingers. Bullets are often non-rhythmic and weak, blood pressure is reduced.

Comparative characteristics of asthma in heart and bronchial asthma

Pulmonary edema

Pulmonary edema is a significant effusion of the liquid portion of blood into the lung tissue. Depending on where this fluid goes, pulmonary edema is divided into interstitial and alveolar. In the first case, the effusion takes up the entire lung tissue, in the second, the alveoli are predominantly clogged with bloody sputum. Pulmonary edema develops at any time of the day or night, as an attack of sharp suffocation. The patient's condition is rapidly progressively deteriorating:

  • growing shortage of air, shortness of breath,
  • the blueness of the limbs and face
  • palpitations, cold sweats
  • impairment of consciousness from motor and speech arousal up to fainting.
  • hoarse bubbling breaths heard in the distance.
  • при альвеолярном отеке выделяется большое количество розовой пены.
  • если отек развивается на фоне снижения сердечного выброса (при инфаркте миокарда, миокардите), то есть риск развития кардиогенного шока.

Острая недостаточность правого желудочка

This is an acute pulmonary heart, which leads to stagnation in the systemic circulation. The most likely causes of its occurrence:

  • thrombembolia large branch of the pulmonary artery
  • pneumothorax
  • lung atelectasis
  • asthmatic status

It may also be complicated by myocardial infarction or acute myocarditis. Increased pressure in the pulmonary circle of blood circulation increases the load on the right ventricle and decreases blood flow to the left heart, which reduces cardiac output. As a result, coronary blood flow suffers and pulmonary ventilation falls.

With such acute heart failure, the symptoms are as follows:

  • The patient begins to be disturbed by shortness of breath and a feeling of lack of air.
  • His neck veins are inflated, which is more noticeable while inhaling.
  • The face and fingers become bluish.
  • Then joins the pulsation in the upper abdomen, an increase in the liver and heaviness in the right hypochondrium.
  • Pastoznost develops, and then swelling of the legs, face and anterior abdominal wall.

How to share chronic heart failure

In all cases when heart failure (symptoms and organ disorders) develop slowly, they speak of its chronic form. As the symptoms increase, this option is divided into stages. So, according to Vasilenko-Strazhesko there are three of them.

  • initial stage
    • I - at rest there are no manifestations of pathology.
    • IA is a preclinical stage, which is detected only by functional tests.
    • IB - The symptoms of heart failure manifest themselves during exercise and are completely at rest.
  • Stage Two
    • II is characterized by the presence of signs of pathology at rest.
    • IIA - stagnation in a large or small circle with moderate manifestations at rest.
    • IIB-disorders are detected in both circles of blood circulation.
  • Stage Three
    • III - dystrophic changes in organs and tissues on the background of circulatory disorders in both circles.
    • IIIA - Organ disorders are treatable.
    • IIIB- Dystrophic changes are irreversible.

The current classification of chronic heart failure takes into account exercise tolerance and the promise of therapy. For this purpose, functional classes are used, which may change with successful therapy.

  • Class I - is the lack of restrictions with the usual physical exertion. Increased load may be accompanied by minimal manifestations of dyspnea.
  • Class II implies a slight limitation of physical activity: there are no symptoms at rest, and the usual exercise may be accompanied by shortness of breath or palpitations.
  • Grade III is the appearance of symptoms with a minimum load and their absence at rest.
  • IV functional class does not allow to withstand even the minimum load, the symptoms are at rest.

Symptoms of chronic heart failure

Such a variant of heart failure is often the outcome of many chronic heart diseases. It flows through the right or left ventricular type, and may be total. The mechanisms of its development are similar to acute forms, but stretched in time, due to which oxygen starvation and dystrophy of organs and tissues come to the fore.

Insufficiency of the right heart chambers

leads to disturbances in the pulmonary circulation and is manifested by pulmonary symptoms. In the first place among the complaints of patients stands:

  • dyspnea that progresses and reduces the quality of life
  • there is a need to sleep with a raised head, to periodically occupy the position of orthopnea (to sit with the support on the hands).
  • gradually, coughing with a small amount of clear sputum joins the dyspnea.
  • as heart failure progresses, choking episodes may occur.
  • patients have a grayish-bluish color, cyanosis in the area of ​​the nasolabial triangle, hands and feet. Fingers take the form of drum sticks. Fingernails become excessively convex and thickened.

Left ventricular weakness leads to changes in the great circle

  • Patients are concerned about palpitations (paroxysmal tachycardia, atrial fibrillation, extrasystoles), weakness and fatigue.
  • Edematous syndrome appears. Gradually, swelling in heart failure is increasing, spreading to the legs, anterior abdominal wall, lower back and genitals. Massive swelling is called anasarki.
  • First, it is the pastos of the feet and legs and hidden edemas, which are revealed during weighing.
  • Impaired blood flow in the kidneys causes a decrease in the amount of urine discharge up to anuria.
  • Increased liver manifests long-term congestive heart failure. Her symptoms are heaviness and pain in the right hypochondrium due to puffiness of the capsule in the edematous liver.
  • Problems with cerebral circulation lead to sleep disorders, memory and even mental and mental disorders.

Comparative features of cardiac and renal edema

The first signs of heart failure

Heart failure is a serious illness, accompanied by a violation of the ability of the heart muscle to provide adequate blood circulation. This leads to hypoxia and the deterioration of tissue trophism. Symptoms of heart failure can even more affect the patient's quality of life than the manifestations of other chronic diseases, such as diabetes or arthritis.

The first signs of heart failure - the topic of the article. In heart failure, there may be:

• increased fatigue - especially in severe form,

• dyspnea - at first appears only during exercise, but in the later stages it can also occur at rest,

■ cough with a white or pink foamy sputum associated with fluid retention and congestion in the lungs,

• swelling - the accumulation of excess fluid in the tissues, localized on the legs in walking patients and in the lumbosacral region and on the thighs - in the supine,

• weight loss - the disease is often accompanied by a decrease in appetite, nausea and vomiting,

• abdominal pain - may occur due to stagnation in the liver.

Heart failure occurs when the heart is damaged or overloaded - for example, against one of the following diseases:

• coronary heart disease - often associated with damage to the myocardium of the left ventricle of the heart,

• chronic pathology of the heart muscle - for example, due to viral infections or alcoholism,

• hypertension - leads to a decrease in the elasticity of the arterial wall, which complicates the work of the heart,

• acute or chronic myocarditis (inflammation of the heart muscle) - may be a complication of viral and bacterial infections,

■ heart defects - changes in the heart valves of a congenital, degenerative nature or due to damage,

• aortic stenosis - congenital abnormality,

• inconsistency of the minute release of the heart with the needs of the body - when the body is working with an increased load to saturate the tissues with oxygen,

• impaired venous flow - for example, chronic thickening of the pericardium limits blood flow to the heart, as a result of which it maintains an increased load to maintain blood circulation.

Heart function

The heart is a muscle pump that pumps blood to all organs, saturating them with oxygen and nutrients. The heart makes about 100,000 beats per day, pumping 25-30 liters of blood per minute. The heart is divided into left and right halves, each of which consists of an atrium and a ventricle. Oxygen-poor blood from the hollow veins enters the right atrium. From here, it is pumped through the right ventricle into the vessels of the lungs. The left atrium receives blood enriched with oxygen from the pulmonary circulation, throwing it into the left ventricle, from where it is pumped into the systemic circulation. Heart valves prevent the return of blood. The heart muscle has its own blood supply provided by the coronary arteries. The bilayer covering the heart is called the pericardium. The diagnosis of heart failure is made on the basis of clinical data, but additional research allows us to clarify its causes and select the optimal treatment. Symptoms such as shortness of breath and swelling can be suspected of heart failure.

In the process of diagnosis, conduct the following studies:

• blood tests - a comprehensive blood test, biochemical studies to assess the function of the liver, kidneys and the thyroid gland, determining the level of cardiac enzymes (in myocardial infarction, it is elevated),

• X-ray of the chest organs - to detect an increase in the size of the heart, the presence of fluid in the lungs, and the sealing of artery walls

• electrocardiogram (ECG) - in patients with heart failure, pathological ECG changes are usually observed,

• echocardiography - a key study to assess the function of the left ventricle, heart valves and pericardium, color Doppler - is used to study the state of the valves of the heart and intracardiac blood flow,

■ cardiac catheterization - allows you to measure the pressure in the heart chambers and main vessels,

• stress tests - allow you to assess the response of the heart to exercise.

Patients with decompensated heart failure are usually indicated for hospitalization. Whenever possible, they treat diseases that underlie the development of heart failure, such as anemia. Providing peace to the patient reduces the burden on the heart, but stay in bed should be limited to avoid the formation of blood clots in the vessels of the lower extremities. All therapeutic manipulations are best done in a sitting, not lying position. Food should be in small portions, with salt restriction. Alcohol and smoking are excluded. For the treatment of heart failure, the following drugs are used: diuretics - help to increase the amount of urine output, lower blood pressure, reduce the severity of edema and shortness of breath, beta-blockers - normalize heart function, slowing heart rate, but at the beginning of their reception, physician control, angiotensin inhibitors are needed converting enzyme (ACE inhibitor) - help prevent the progression of the disease, as well as reduce mortality from chronic heart failure and myocardial infarction. The initial dose selection should be under the supervision of a physician.

• angiotensin II receptor antagonists - in their action are similar to an ACE inhibitor, but have fewer side effects,

• digoxin - often causes nausea, in addition, often there are difficulties with the selection of the dose. It is used mainly for the purpose of normalizing heart rhythm with arrhythmias.

Many patients have been shown combination therapy with multiple drugs. Heart failure can develop at any age, however it is observed mainly in the elderly. Chronic heart failure affects from 0.4 to 2% of the adult population. With age, the risk of developing heart failure gradually increases. Among all patients who come to medical institutions in Russia, 38.6% have signs of chronic heart failure. Despite the development of treatment methods, the prognosis for heart failure patients often remains unfavorable. Survival rates among them are worse than with some common types of cancer. About 50% of patients with severe heart failure die within two years from the time of diagnosis.

Heart failure What to do? Signs, symptoms, and causes.

04/17/15 | Comments 0 | Health | More news from this section:

Heart failure is a common disease among older people, both men and women. It progresses quickly, so the sooner you see a doctor, the better. Do not miss the first signs of illness!

When our heart (“motor”) ceases to cope with the load, heart failure develops. Moreover, in women and men, heart failure occurs in different ways. In women, the disease is explained by the fact that the heart muscle does not relax - the heart is constantly in tension, as if it "turns to stone." And for men - on the contrary, the weakening of his work: the heart with each stroke pumps blood more poorly.

Heart Failure - Causes and Signs

The most common causes of heart failure are: hypertension, coronary heart disease, valvular heart disease, myocardial infarction, inflammation of the heart muscle and other vascular and heart pathologies.

Passion for alcoholic beverages is also one of the reasons for the development of heart failure, which can undermine the work of one of the important organs in our body.

Once inside, alcohol causes fluctuations in the lumen of blood vessels, changing blood pressure. The heart is experiencing overload and is increasing in size. With its reduction, not all blood leaves the ventricle (pumping function decreases), it becomes harder for it to “push” portions of blood through the vessels, and heart failure develops.

Heart Failure - Symptoms

The earliest signs or diseases are not easy to recognize. Symptoms such as weight gain, weakness and fast fatigue, people tend to blame on any health problems, but not heart.

But it is these bells that are the first to report heart problems, and only then do dyspnea, swelling, cyanosis of the nails and nasolabial triangle, a feeling of pain or pain in the upper part of the abdominal cavity, characteristic of heart failure occur.

At an early stage of this disease, it is enough to change lifestyle (quitting smoking and alcohol, physical activity are necessary). But if the symptoms of heart failure are increasing, be sure to consult a doctor. Take the medication strictly according to the prescribed schedule and follow the prescribed diet!

Heart failure - how to respond?

Weakness, fatigue - a consequence of oxygen deficiency in the body. More fresh air, go out of town. Ventilate the room often, especially before bedtime. Give yourself an extra rest during the day, do not overdo it.

Weight gain In heart failure, fluid is retained in the body, and it causes weight gain. Even more exacerbated by the problem of excessive salt intake. From now on, your rate is 1-1.5 tsp. Salt per day. When you buy food, read the composition: there may also be salt (sodium chloride). Do not add salt to food - add salt-free spices. Avoid ready-made store foods, convenience foods and canned goods.

Every morning after going to the toilet, weigh yourself. This should be done before the meal, the scales should stand in the same place, so the readings will be more accurate. If you scored 1 -1.5 kg per day or 1.5-2 kg in 5 days, this means that the disease is progressing.

Swelling of the feet in heart failure

For heart failure is characterized by swelling of the ankles of the legs in the evening. If the disease is not running, they pass in the morning. In more severe cases, swelling is always present.

Shortness of breath in heart failure

With shortness of breath, breathing becomes more frequent and worse, usually it happens during exercise. If you notice shortness of breath, stop doing what provoked it, and rest until your breathing returns to normal. If dyspnea is observed at rest, lie down and make the headboard taller. If you have shortness of breath after sleeping, sit in bed, hang your legs and move your feet, or walk around the room.

With a frequent, irregular, weakly filled pulse, the main thing is not to panic. Take a deep breath, hold your breath, then breathe out slowly. Repeat several times until breathing returns. Call an ambulance and try to relax and calm down. If the heart is still “fluttering”, close your eyes and gently squeeze the eyeballs.

"Acute" case of heart failure

It happens that heart failure does not develop gradually, but in a matter of hours and even minutes. There is a fluttering breath and frothy sputum, a hacking cough, shortness of breath increases, the pulse quickens, the cyanosis of the tip of the nose and lips appears, the skin becomes cold and moist, the blood pressure drops.

This usually happens at night - the patient wakes up from suffocation, is very anxious and fearsome. In this case, you should call an ambulance or an ambulance and ask what first aid measures should be taken before the arrival of the doctor.

In women, heart failure catches up later than men. This happens due to the sex hormone estrogen, which protects the heart. As soon as menopause arrives, the female heart loses its protection.

Heart failure: main signs, symptoms, treatment

Heart failure This is a pathological condition that occurs when the contractile function of the heart decreases, leading to stagnation of blood in organs and tissues and a lack of oxygen.

Heart Failure Classification

  • 1) Acute heart failure *
  • 2) Chronic heart failure

* Поскольку острая сердечная недостаточность – неотложное, скоротечно развивающееся состояние, требующее реанимационных мероприятий, в этой статье мы не будем специально его подробно освещать. Далее мы рассмотрим хроническую сердечную недостаточность, которая развивается медленно и может приносить страдания пациенту на протяжении многих лет.

  • • Right ventricular - with predominant violation of the activity of the right ventricle of the heart.
  • • Left ventricular - with predominant violation of the activity of the left ventricle of the heart.

Classification of heart failure proposed by N. D. Strazhesko and co-authors.

  • • Stage I - initial: latent circulatory failure, manifested only during physical activity in the form of shortness of breath, tachycardia, and increased fatigue. At rest, the hemodynamics and function of the organs are not changed, the ability to work is reduced.
  • • Stage II A - mild hemodynamic disturbances in the large and small circulation that occur during exercise,
  • • Stage II B - deep violations of hemodynamics in the large and in the small circle of blood circulation occurring at rest. There are pronounced swelling, accumulation of fluid in the body cavities.
  • • Stage III - the final one with severe hemodynamic disorders, persistent metabolic disorders and the function of all organs, the development of irreversible changes in the structure of organs and tissues, loss of working ability.

The classification of heart failure proposed by the New Yorkcardiological association.

  • • Class 1. There are no restrictions on physical activity and influence on the patient's quality of life.
  • • Class 2. Weak restrictions on physical activity and complete lack of inconvenience during rest.
  • • Class 3. Perceptible decline in performance, symptoms disappear during rest.
  • • Class 4. Full or partial loss of performance, symptoms of heart failure and chest pain occur even during rest.

Both classifications are required for use in Russia!

Causes and mechanisms of development

The main mechanisms leading to the development of CHF include:

The first cause leading to heart failure heart defects. Depending on the type of heart disease, there may be either a violation of the blood filling the heart for its further “pumping” throughout the body, or a violation of the expulsion of blood from the heart. In any case, there is stagnation of blood in the vessels and oxygen starvation in the tissues.

The second reason for the development of heart failure lies in the violation of myocardial contractility. This is the most common cause of heart failure. For example, myocardial infarction, cardiosclerosis, myocarditis do not allow the heart muscle to fully reduce, and therefore maintain normal hemodynamics (blood flow).

The third cause of heart failure lies in the compression of the heart from the outside. The most frequent cause of compression is pericarditis (effusion or adhesive), tumors, lymph nodes, chest deformity.

In addition, the possible development of heart failure in patients with hypertension, when the heart is overloaded with a large volume of blood, which the heart does not have time to “pump”.

Signs and symptoms of heart failure and an explanation of their development (tolinear manifestations )

The main clinical manifestations of CHF are tachycardia, shortness of breath, cyanosis, edema, enlarged liver.

Tachycardia - persistent symptom of heart failure. It occurs as a result of myocardial ischemia, a decrease in cardiac output and (or) blood stagnation in the vessels of the lungs. Tachycardia is manifested by an increase in heart rate (more than 85-90 beats per minute at rest). The physiological meaning of tachycardia lies in the body's attempts to speed up blood flow and ensure the “unloading” of blood-filled vessels and improving the nutrition of tissues that do not receive oxygen. Tachycardia is very energy-intensive for the body, in addition there is an excessive oxygen consumption of the heart muscle, and therefore a vicious circle is started to partially withdraw from which you can either effectively compensating the body for the heart’s work or by eliminating the causes of heart failure.

Dyspnea (feeling short of air, even choking) - permanent symptom. Shortness of breath begins to bother patients at first with physical exertion, and then at rest. The causes of dyspnea in heart failure are an overflow of blood vessels to the lungs, impaired blood enrichment with oxygen in the lungs and a decrease in oxygen supply to tissues and organs. The result of respiratory failure is an increase in blood acidity and stimulation of the respiratory center of the brain. Dyspnea is clinically manifested by increased breathing more than 18–20 “inhale-exhale” cycles in 1 minute. The lack of oxygen in the body in heart failure, as well as impaired blood circulation in the tissues lead to several more symptoms of cyanosis and edema.

Cyanosis (staining of tissues in bluish color). Oxygenated blood has a bright red color. The decrease in the oxygen content in the blood caused by the disturbance of gas exchange in the lungs changes the color of hemoglobin and the darker. Therefore, the tissues of the body in which the slowed blood flow becomes bluish. Cyanosis indicates severe hemodynamic disturbances in the lungs and throughout the body.

Edemas - arise due to an increase in hydrostatic pressure in the vessels, and subsequently due to electrolyte imbalance. The body tries to reduce the hydrostatic pressure, "dropping" the liquid part of the blood from the vessels into the tissue and cavity. Cardiac edema in the early stages of heart failure appear in the evening. But as the progression of the disease does not disappear at all. A characteristic feature of cardiac edema is their "ability to move." For example, when the patient is sitting, edema occurs in the lower part of the body, if the patient lies down, then move to the back, side, etc. The accumulation of fluid in the pericardial cavity and in the pleural cavities exacerbates the severity of the patient's condition, aggravating shortness of breath and other signs of heart failure.

In addition, the symptoms of heart failure include:

  • • Enlarged liver
  • • Increased red blood cell count
  • • Swelling of the veins in the temples, neck

Diagnosis of heart failure

All the above mentioned symptoms cannot be considered pathognomonic (that is, characteristic of any one particular disease), and therefore, if they appear, they should immediately consult a doctor.

For the diagnosis of heart failure using various diagnostic techniques, most of which are functional.

  • • Electrocardiography (ECG) - a routine diagnostic method that starts the examination of a cardiological patient
  • • Electrocardiography (ECG)
  • • Electrocardiography (ECG)
  • • Electrocardiography (ECG)
  • • Echocardiography - allows you to evaluate the most important indicators of the heart, assess the structure of the valvular apparatus, evaluate the contractility of the myocardium, calculate the indicators of intracardiac blood flow, etc.
  • • Holter monitoring - allows you to assess daily heart rate
  • • Bicycle ergometry (trad mil) - evaluates the activity of the heart and lungs during various modes of exercise

This is not a complete list of examinations performed for the diagnosis and differential diagnosis of heart failure.

Heart Failure Treatment

After identifying the causes of heart failure, you must eliminate them. The main areas of struggle:

  • • Surgical treatment of heart defects and blood vessels
  • • Correction of blood pressure
  • • Heart rhythm recovery (medication or pacemaker implantation)
  • • Restoration of blood flow in the coronary arteries (stenting, aorto-coronary bypass)

Unfortunately, not always (for various reasons), it is possible to radically affect the cause of heart failure, and then therapeutic measures are reduced to supportive drug therapy and oxygen therapy. Proved that long-term oxygen therapy can reduce blood pressure in the pulmonary artery, and thereby reduces the severity of heart failure. In addition, treatment in some cases, oxygen therapy is the only effective tool in the fight against heart failure, as well as reducing the manifestations of oxygen starvation of tissues.

Experienced doctors in this case offer to use an oxygen apparatus, called the oxygen concentrator. With its help, it is possible to conduct more efficiently long-term oxygen therapy sessions (i.e., to breathe highly concentrated medical oxygen for at least 15 hours a day, for several months of treatment).

Article prepared Gershevich Vadim Mikhailovich

(Thoracic surgeon, Candidate of Medical Sciences).

What oxygen concentrator to choose for oxygen therapy for heart failure?

The absolute leaders in the class of reliability and trust of experienced medical specialists are oxygen concentrators manufactured in Germany.

The main advantages of these devices are: high reliability, stable operation, long service life, the lowest noise level, high-quality filtering system, the availability of the latest developments in the warning system.

Conventionally, in the second place you can put the oxygen apparatus produced in the United States. They are not much inferior in terms of the main characteristics of the German devices, but perhaps their main disadvantage is the purchase price. Although it is impossible not to note the weight of American devices, they are the lightest in the class of stationary oxygen concentrators (the weight of some models of devices reaches only 13.6 kg.).

From the number of budget models of oxygen concentrators, we recommend to pay attention to reliable devices developed and produced in China by the Armed brand.

The main plus of these devices The main plus of these devices is their low price in comparison with the western oxygen devices.

For lovers of extra comfort of movement and desire to maximize the mobile lifestyle, we recommend to pay attention to the acquisition of the most convenient and compact portable oxygen concentrators.

Patients who use these portable oxygen concentrators have complete freedom of movement. The device can be hung on the shoulder, or transported using a convenient trolley. Portable oxygen concentrators are also used as an autonomous source of oxygen supply to the patient at home, which needs continuous oxygen therapy, but for some reason, there are interruptions in electricity at his home. In the west, many patients are gradually abandoning stationary oxygen concentrators, preferring to them these devices:

Just call us now by toll free line 8 800 100 75 76 and we will be happy to assist you in choosing the device, advise you competently and answer all your questions. Blood circulation of oxygen concentrators, development of heart, heart failure

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