6004688 heart failure and your heart

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Introduction to the Heart

What does the heart do? Our heart is essentially two distinct, but

anatomically connected pumps:

1. Right sided - Receives blood frombody and pumps blood into lungsto gather oxygen

2. Left sided - Receives oxygenatedblood from lungs and sends out tobody

The PULMONARY circulation isresponsible for taking up oxygen andreleasing carbon dioxide. The SYSTEMIC circulation delivers the oxygenated blood

to our tissues.

It may seem odd that the right and left sides on the diagram appear reversed. This is because all references tthe right or left side of the heart use our outside point of reference (as if they are facing you for inspection).Problems can arise with either the right or left side of the heart alone, but this will ultimately lead tocomplications for the other side of the heart.

The normal adult human heart weights about 11 ounces (0.3 kilograms) and is about the size of a clenched fis

Click here for anatomical diagrams of the heart.

How does the heart work?

Electrical signals travel through specific cell pathways in the heart that signal and stimulate the heart to beginpumping. In response to this, the chambers of the heart rhythmically contract to push blood through thecirculation -- first both atria contract, then the ventricles. In the average lifetime, the heart will beat more thanone billion (1,000,000,000) times! The ventricles do the majority of the work pushing the blood through thebody. Blood typically leaves the heart at a speed of about one foot per second (0.3 meters per second) but carise to nearly six feet per second with moderate activity! The atrial contraction primarily is done to assist fillingthe ventricles with more blood to push out of the heart. People can survive with atria that do not contractefficiently; however, if the ventricle stops pumping, death occurs within minutes!

As much as it is the heart's job to push the blood to deliver oxygen to all tissues, it also must have its ownsupply of oxygen to perform work. It receives this oxygen from the coronary arteries. If this supply is interruptefor any reason, heart tissue can die causing a heart attack- a possible cause of the onset of heart failure.



Introduction to the Circulatory System

What does the circulatory system do? Our circulatory system can be thought of as a network of living pipesthat allows our body to transport oxygen as well as nutrients to thetissues. Chemical wastes produced by our cells enter the blood to

be filtered and eliminated by our body (largely by the kidney andliver). Our body circulates about 5 liters (5.3 quarts) of blood; at rest,the heart moves it at a rate of 5 liters per minute. In summary, evenwithout activity, blood can run the entire circuit of the body in oneminute. During heavy exercise, the whole loop can be completed inten seconds.

The main components of the circulation are pictured on the left:

1. Arteries - the red vessels represent arteries. Hemoglobin,the oxygen carrying chemical in red blood cells, takes onblood's distinctive red color when it is combined withoxygen. Arteries carry blood away from the heart and

branch into smaller vessels (first arterioles, then capillaries)in order to facilitate delivery of its cargo to the organs andother tissues.

2. Veins - the blue vessels represent veins. This bluish tint isalso due to hemoglobin. After releasing oxygen to livingcells, hemoglobin undergoes a chemical change that gives ita distinctive reddish-blue tone. Veins also have a series ofone-way valves built into their structure. This is crucial forproper circulation, as gravity could cause blood to poolbelow the heart otherwise!

The body's circulation is a "closed loop". This necessarily means that an irregularity or back-up in one part of

the system will affect blood flow elsewhere in the loop. If the structures in the path seem unfamiliar, click herefor a graphical review.



How does the circulatory system work? Contractions from the heart eject blood into the lungs and body. The vascular network must be vast incomplexity and length to cover all of this volume. The combined length of all of the tubing would cover nearly60,000 miles (100,000 kilometers) - more than TWICE around the earth - if plumbed in a straight line! Thevascular system, with the help of neuroendocrine input, can contract and relax different arteries and veins toguide both the speed and destination of blood flow, depending on the needs of the body. This facilitatescirculation in performing more specialized tasks.

During physical exertion, the vessels going to muscles can dilate to deliver more oxygen to those tissues.Furthermore, blood also serves as a method to distribute our body heat. By dilating blood vessels at our skinsurface, the body allows conductive heat loss during exercise, while contracting their diameter conserves bodyheat when the environment becomes colder.

As mentioned before, the circulatory system is a closed loop. If there are any serious blockages or changes invessel resistance along the line, it is like putting a bend or kink in a garden hose - flow through the bend isslowed and pressure to push through the reduced opening may increase. This resistance to flow is of concernin heart failure, not only because of the workload it imposes on the heart, but because it hampers delivery ofblood's precious cargoes (food, oxygen, etc.). Placing the heart under such stressful conditions (i.e. increasedheart rate and contraction force with a curtailed oxygen supply) will reduce its ability to compensate for the

needs of the body. For more information on high blood pressure, also known as hypertension, click here.

Introduction to the LungsWhat do the lungs do? The lungs are two flexible, elastic organs that draw in and collect surrounding air. They are protected by the ricage as they are made of very thin tissue that is relatively easy to puncture. Air travels from the mouth and nodown to the trachea, which splits into two channels called the bronchi (plural for bronchus). After this initial spl

the passages continue to diverge and get smaller until they end in tiny clusters of grape-like air sacs or alveoli(plural for alveolus). These air sacs contain the region where gas exchange takes place. Capillaries enteralveoli to uptake the air in the lungs and carry it back to the heart and, eventually, the body tissues. At the samtime that it takes up oxygen the blood releases carbon dioxide it has picked up from the body and releases it.



How do the lungs work? WE BREATHE BECAUSE OUR TISSUES BREATHE! The lungs basically work as a pair of bellows - as thechest expands they draw in air (of which oxygen is a component). Upon exhaling the chest uses its elasticproperties to passively "snap back" to its original size.

Oxygen and carbon dioxide can travel between the lungs and bloodstream because the capillaries thatsurround the air sacs are permeable to gases. In essence, this means that oxygen and carbon dioxidemolecules are small enough to passively diffuse through the tissues that compose both the blood vessels andalveoli. This same principal applies to gas exchange between the blood in the capillaries and tissues in thebody. In heart failure conditions, however, if the blood is leaving the lung against a high pressure downstreamthe left atrium, fluid can actually diffuse into the lungs. This condition, known as pulmonary edema, can inhibitgas exchange and make it very difficult and uncomfortable to breathe.

Introduction to the Neuroendocrine System

What does the neuroendocrine system do? The heart utilizes electrochemical signals to control the rate at which it contracts. It accomplishes this usingbundles of "pacemaker cells" whose signals maintain an internal rhythm independent of the body. However, arest the rhythm it maintains is slightly faster than what is ordinarily required. The neuroendocrine system usuadampens this rate, but it can elevate it as well using electrical or chemical signals (during exercise or stress).

The neuroendocrine ( neuro-nerve; endocrine-hormone) system is a compilation of inputs from the nervoussystem as well as glands throughout the body that secrete chemicals. Both usually work together to account fotransient or even chronic changes in the body. Using nerve signals or hormones, the neuroendocrine systemchanges cell activities that alter the diameter of blood vessels, the heart's rate and strength of contraction, andeven the amount of fluid the body retains.

How does the neuroendocrine system work? This system works as a complex series of checks and balances on the heart and circulatory system in a waysimilar to the action of a thermostat. A thermostat detects transient changes in temperature and has a maximuand minimum temperature range allowed. When the room temperature falls below the minimum, the thermostsignals to the furnace to turn on and raise the temperature in the room. When the addition of heat causes the



maximum temperature to be reached, the thermostat signals to the furnace to turn off. Much the same way, thneuroendocrine system monitors certain variables in the body and makes adjustments when variables aren't inthe needed range.

When using the diagram below, think of the brain as a "thermostat" detecting changes, while organs act tochange what the brain dictates. Move the mouse over each symbol to identify it and its role in neuroendocrine

regulation:

This diagram represents a "feedback loop". Just as the brain sends signals to alter activity in the heart, bloodvessels, and adrenaline glands, it must likewise receive input when the condition has been properly changed.When it receives this input (demonstrated by the animated arrows triggered by the heart and artery), it will haltits own signaling and allow the system to work more independently.This particular example is a negativefeedback loop, as it reacts to reverse a situation and bring it within a threshold range.

Unfortunately, the changes made by the system are not necessarily beneficial in the long run. Imagine that thethermostat in the above example is reset to a higher than desirable level. Once the furnace turns on, it will notreceive any input that the room is too hot and will continue to pump heat into the room until the new thresholdtemperature is reached. In a similar sense, if the brain doesn't receive a proper "off" signal, it will continue toraise blood pressure unnecessarily. Going one step further, impaired heart function will lead to ineffective,sustained signalling activity by the nervous system, which will further create conditions that strain the heart,driving it towards failure.

The system isn't perfect, but under normal conditions it affords the body a great deal of flexibility. Whetherresting or working, neuroendocrine feedback works in the background to address the changing needs of thebody.



Heart Failure and Your Heart

Once the heart has been injured, the body will attempt to compensate for reduced blood flow. Unfortunately,many of the countermeasures actually increase strain on the heart and further the development of heart failure

The heart, after suffering damage or being placed under physical stress by high blood pressure, will begin tochange its own shape. This deforming of the ventricles' shape is known as remodeling or hypertrophy. Thisremodeling occurs in two primary patterns - concentric and dilated (as shown below):

Key h = Thickness c = Concentricr = Radius n = Normald = Dilated

These diagrams represent cross-sections of the left ventricle, the chamber that supplies the body withoxygenated blood flow. The triangular notches are cut into each ventricle to demonstrate how the wall haschanged in shape and thickness.

For comparative terms, the normal heart essentially looks like a football. When the wall thickens in concentriccircles (lower left), The heart works less effectively and takes on the shape of a large fist. This may be causedby hypertension, a blocked aortic valve, or underlying genetics. Dilation of the ventricle walls (lower right) givethe weakened heart a beach-ball shape and an inefficient contraction. This prohibits blood from leaving theheart as it normally would. This remodeling pattern follows damage from a heart attack, sustained

hypertension, viral infection, or genetic causes.



Heart failure occurs when the heart can't pump blood to the body as quickly as needed. Blood returning to theheart faster than the heart can eject it congests the system behind it. Decreased blood flow to organs, such asthe kidneys, causes the body to retain more fluid which complicates the problem further. The relationshipbetween the heart and other organs can be a delicate one - once one is injured, it can send off a cascade ofevents that damage other organs and worsens heart failure.

Heart Failure and Your Circulation

Coronary Artery Disease (also known as CAD)

Cause Coronary Artery Disease is a condition where fatty deposits and cell-proliferation build-up in the arteries

supplying the heart muscle. These plaques form commonly in a condition called atherosclerosis. Genetic

factors or a diet of foods high in cholesterol or saturated fat that result in high blood cholesterol can increaseyour risk for this disease. Fatty deposits form silently; no symptoms arise until they are large enough tosignificantly restrict blood flow to an area of heart muscle. When this occurs, angina pectoris (chest tightness odiscomfort) usually results. Normally a 70% or greater blockage in the diameter of a coronary artery will causesymptoms of chest discomfort or pain with exercise.

An abrupt closure of a coronary artery due to a blood clot forming (associated with a fissure of a plaque) cancause a heart attack (or myocardial infarction).



Cause Blood pressure refers to the pressure of blood against the walls of arteries and is measured in units ofmillimeters of mercury (mmHg), which is a reference to the fluid historically used with blood pressure cuffs.Blood pressure is always measured by two numbers on this scale. The range of the first number is usually 100140 mmHg, which is referred to as systolic (the peak pressure in the arteries after the heart contracts). Therange of the second number is usually 60-90 mmHg and is referred to as diastolic (the minimum pressurereached in the arteries when the heart relaxes just before the next contraction). The usual cause ofhypertension is not known - the brain's "set-point" for a usual BP increases. Uncommonly, renal artery stenosi(a blockage of the arteries) going to the kidneys or hormone producing tumors can also be causes. For a morethorough explanation,

Symptoms Usually none, but headaches and flushing are sometimes evident.

Diagnosis

Blood pressure cuff (sphygmomanometer), Chest X-ray and echocardiogram (to observe hypertrophy).

Treatment

Hypertension is managed with a combination of hygienic approaches and medication. A low salt diet, exerciseweight loss when obesity is present, and stress reduction may all help. Most individuals also require medicatio

to maintain a blood pressure lower than 140/90. If the blood pressure has caused cardiac remodeling (see

diagram) reducing blood pressure can encourage the heart to return to its former shape and function.

Heart Failure and Your LungsShortness of breath with activity is the most common symptom of heart failure. In many cases of heart failurethe left ventricle of the heart, which pumps blood to the body, is rendered unable to properly eject its contents

As the left ventricle's abilities are diminished, blood tends to pool and back-up behind it in the pulmonary (lungcirculation. This back-up is under increased pressure, as the right side of the heart is still pumping into thiscirculation. The result is fluid leakage into the lungs, a condition called pulmonary edema. Fluid retention in thebody by the kidneys can also be a culprit in developing pulmonary edema. This situation translates intoshortness of breath. The diagram below illustrates just how apparent this problem can develop in somepatients:



Individual genetic and other factors may influence how likely this is to occur at any given pressure backed upbehind the left ventricle. Pulmonary edema can prevent the individual from breathing properly and comfortablyFurthermore, it can strongly impair one's ability to exercise and lead an active life. A primary way to improve this the use of diuretics. Diuretics are a family of drugs that reduce the kidney's ability to retain the body's salt an

water in favor of excreting it in urine. Shedding body salt and water allows for the reduction of symptomsassociated with pulmonary edema as well as reducing the strain of volume overload on the heart.

Heart Failure and Your Neuroendocrine System

Paradoxically, activity of the neuroendocrine (body regulation) system, that normally functions to maintain the

circulation, can actually worsen heart failure if sustained over time. By following the feedback control it isprogrammed to, it inadvertently adds strain to the heart. Examine the scenario below where the body is enteri

the early stages of heart failure due to blocked heart arteries. Click here to see a quick overview of the

neuroendocrine system, if necessary.



With time, the heart failure becomes worse and worse. High blood volumes and remodeling increase heart sizover time, which further impacts its ability to adequately eject blood. In this way, a system designed to supportour heart has caused it to fail when attempting to compensate for heart injury.

Why would the body do this to itself? Consider that the design of this system has evolved in such a way as toprotect our body not from heart damage, but from exterior threats. For example, if one suffers an injury where

blood is being lost (see example), survival is dependent on maintaining an adequate blood pressure to all vita

organs. If blood is lost, then blood pressure in our arteries will drop accordingly. Fluid retention serves to keephigh blood volumes to buffer the loss due to injury. By constricting our arteries as shown before, the remainin

blood gets mobilized more efficiently to tissues at an adequate pressure. Therefore, possibly the situationshown in the chart isn't so much an error in design of the neuroendocrine system so much as a misapplicationof a control mechanism initiated by initial heart and circulatory impairment.

Coronary Obstructions and Disease

Blood itself is mostly water. Its characteristic properties and color are more related to the many different typescells, salts, and proteins that reside in the fluid. In terms of oxygen delivery, the red blood cells are the mostimportant. These cells contain an oxygen (O2) trapping molecule called hemoglobin that will uptake oxygen inthe lungs and deliver it to where the circulation leads. All living tissues require oxygen, especially the brain and

heart. Without this O2 delivery, tissues weaken and die. In cases of a heart attack (or myocardial infarction) thoccurs because of an occlusion, or blockage, of a coronary artery feeding the ventricles or main pumpingchambers of the heart.



In this example, a fatty deposit or "plaque" has reduced the diameter that blood can flow through. This occurs a condition called atherosclerosis, the thickening and hardening of arterial walls. The plaques are not simplyaccumulations of fats - current thinking involves inflamed smooth muscle tissues inside the vessel interminglinwith cholesterol and mineral deposits. Atherosclerosis is the major cause of Coronary Artery Disease (CAD)In the above example, a partial blockage would likely cause angina, chest pain or pressure caused byinadequate oxygen delivery to heart tissue. However, as this plaque enhances blood clot (thrombus) formation(with a partial blockage progressing rapidly to a complete occlusion), a myocardial infarction (heart attack)becomes more probable.

CAD is responsible for 75% of all deaths from heart disease in the United States! CAD is not simply amatter of diet though - its occurrence has a strong link to genetics and advancing age. While lifestyle can impaits onset greatly (e.g. smoking, lack of exercise, stress) other disease states are also responsible (for example

diabetes and hyper-cholesterolemia). It is largely treated by medical regimens, angioplasty, and bypass

surgery along with changes in lifestyle.

The injuries caused to the heart by a blocked coronary artery vary with the location and severity of theocclusion. Dead heart tissue will cease to contract properly and will interfere with conduction of signals thatcause the rest of the heart to contract.

Arrythmias such as ventricular fibrillation may be fatal unless promptly converted with electrical paddles. This

area of dead or dying heart tissue is called a myocardial infarction, often causing or referred to as a heartattack. This may cause severe chest pain or pressure that radiates to the left arm, neck and jaw. Someindividuals with diabetes may experience a heart attack with no awareness of chest pain. Blockages that aresevere, but not completely closed, may also hamper the heart's ability to function as a pump. In either way,coronary artery disease can ultimately lead to a decrease in the reserve of heart output and start a decline intoheart failure.

Causes of Heart FailureFor heart failure to occur, there must be an unresolved impairment of the heart that compromises its ability towork as a pump. The source of this can be a cutoff of blood supply, an increase in workload due to high bloodpressure caused by non-functioning valves or a genetic predisposition. Heart failure can be worsened by a podiet and lifestyle. Its development follows the scheme below:



Conditions That May Lead To Heart Failure

Coronary Artery Disease (CAD) This is the most common cause of heart failure in the U.S. today. CAD causing obstruction to the coronaryarteries prevents blood flow and, therefore, oxygen delivery to the heart. CAD is a manifestation ofatherosclerosis, which can affect any artery of the body. Risk factors for CAD also include smoking, highcholesterol, hypertension, and diabetes.

Hypertension This is more commonly known as high blood pressure. It is a condition that is treatable and simple to diagnosewith a blood pressure cuff. Although most individuals will not have symptoms, hypertension is detected by asimple measurement with a blood pressure cuff and stethoscope. It is also a risk factor for CAD, stroke,peripheral vascular disease, or kidney impairment.

Valvular Heart Disease A condition that occurs when the valves between the chambers of the heart are faulty, either due to birth defecor injury.

Cardiomyopathy A disease of the heart muscle. This can be one of many varieties. It can arise because of genetic causes, a viinfection, or consumption of toxins (lead, alcohol, etc.). In peripartum cardiomyopathy, women who have

recently given birth can develop heart muscle impairment. In many cases, the condition is called "idiopathic",which means it has occurred of uncertain origin or cause.

In addition to those causes above, the following factors also can play a role in determining if heart failure will affect you:

1. family history of heart failure2. diabetes3. marked obesity



4. heavy consumption of alcohol, or drug abuse5. failure to take medications6. large salt intake in diet7. sustained rapid heart rhythms

Many other conditions can actually simulate heart failure symptoms - it is important to seek evaluation from a

medical professional for a definitive diagnosis. Some of these are:

1. lung impairment2. anemia3. kidney impairment

4. pericardial disease (rare)

Symptoms and Signs

Swollen Ankles or Legs Swollen ankles or legs, known as peripheral edema,

may be a result of right-sided heart failure since

fluid cannot be pumped to the lungs at an efficientrate. In right-sided heart failure, fluid backs up in theveins, leaks out of capillaries and accumulates intissues. Also, a decrease in blood flow to the kidneyscan lead to an increase in fluid retention. Diuretics areoften prescribed to get rid of this excess fluid andreduce the strain on the heart.

In the absence of heart failure, peripheral edema maycommonly be due to obesity or venous insufficiencywith stretched venous valves.

Shortness of Breath Shortness of breath can be caused bycongestion in the lungs. This congestion is

known as pulmonary edema. One sign towatch out for is whether your shortness ofbreath is worse when you lay flat.Orthopnea is the shortness of breath whichoccurs when blood kept in the legs bygravity returns to the chest when you laydown.

Shortness of breath can also occur at night.Shortness of breath that comes onsuddenly at night is known as paroxysmal(par-ox-iz-mal) nocturnal dyspnea.

Angina Angina is chest or arm discomfort due to a blockage ofthe coronary arteries. Heart cells typically do not getenough oxygen when blood flow to the heart muscle isreduced. Often, angina comes on with exertion and isrelieved by rest. This is because your heart may havean adequate blood supply when it is not working veryhard but not when under stress. Other commoncauses of chest pain unrelated to the heart are chestmuscle, bone or joint disease, and acid in theesophagus.

Fatigue Fatigue is often attributed to getting old orbeing out of shape. However, if thiscondition persists for long periods of time, itmay be the result of heart failure.Sluggishness may be the result of yourorgans not getting enough oxygen. Youmay feel as tired after getting up in themorning as you did when you went to bed.Let your doctor know if this happens on aregular basis.

Weight Gain or Loss

Excess fluid in the body may cause an increase inweight. Similarly, when excess fluid is excreted, yourweight may fall. Weight increases by about twopounds for each extra quart of fluid. You may noticethat your weight has risen before you notice swellingof the ankles or extremities. Inform your doctor ofchanges of more than five pounds.



Medical Tests and Findings

Chest X-ray Your doctor can use an x-ray to look at your heart, lungs, and blood vessels. He or she can see if your heart isenlarged or if there is fluid around your lungs. Pulmonary congestion shows up as cloudy areas on the x-ray. Achest x-ray requires only a brief exposure to x-rays and is generally considered safe.

Echocardiogram

The echocardiogram is a procedure used to visualize the pumping action of the heart. It is an ultrasound

examination of the heart that can also measure blood flow into and out of the heart.

Electrocardiogram This test also known as an "ECG" or "EKG", measures the electrical activity of the heart. An electrocardiogracan check the heart's rhythm, evidence of enlargement, and the presence of a prior or recent heart attack.Electrical wires with adhesive ends are attached to the skin on your chest, arms, and legs. The electrical activof the heart is then recorded on a piece of paper.

Tracer Studies Radioactive tracers given through a hand or arm IV are another tool used in the diagnosis of heart failure.Radioactivity is detected as the blood moves through the heart. In this way, doctors can outline the chambers the heart, measure the ejection fraction, and assess blood flow to regions of the heart muscle.

Treadmill Test This test is known as a "stress test" because your heart's activity is being monitored with an electrocardiograduring exercise. By walking on a treadmill for specific intervals of time at differing intensity levels, your doctorcan see if your symptoms are brought on by exertion and if they correlate with patterns on anelectrocardiogram.

Stress tests can be done using radioactive tracers such as thallium, Sesta MIBI, and Myoview. First, the trace

is injected into an IV tube in the arm before and during exercise on the treadmill. After exercise, pictures of theheart can be taken to see where the tracer has been deposited, telling the doctor which areas are gettingenough blood and which are not.

Alternatively, stress testing can be done without exercise. The effects of stress on heart blood flow can besimulated through the use of an IV drug such as adenosine or persantine that dilates heart blood vessels, ordobutamine that increases heart rate and function.



Catheterization Doctors can insert a catheter, or small tube, into a leg (femoral) artery via a needle stick and direct it to a regioof the heart with x-ray guidance. Once in place, the catheter can measure pressures in the heart and direct adye used to visualize heart chambers or blood vessels. This visualization technique is called angiography. Thex-rays show areas of narrowing or blockage. Catheters are also used to open blocked heart arteries with

angioplasty and stenting.

Treatment

Heart failure and other cardiac disorders are hot areas of research. With so many new drugs and emergenttechnologies becoming available, it is critical that you educate yourself on what is available to you. Building abasic knowledge of the types of drugs and treatments that are now used as well as how they work will facilitatyour learning process.

Outpatient treatments Your doctor can prescribe several treatments for heart failure that do not require hospitalization. Thesetreatments include diuretics, ACE inhibitors, vasodilators, beta-blockers, digitalis, and anticoagulants.

Inpatient treatment In cases of advanced heart failure, your doctor may choose to keep you in the hospital for close supervision. Hor she may prescribe intravenous (IV) medications since some medications are not active when taken orally.

Compliance

It is important to follow your doctor's instructions carefully. Don't alter the dosage of your medications or

stop any medication suddenly. Keep follow-up appointments and inform your doctor of any new symptoms.

Procedures and Surgeries Your doctor may suggest surgical treatment for your heart failure. Many of the options available are relatively

non-invasive procedures. When called for, however, there are many more aggressive surgeries that can be

used. Possible options are angioplasty, coronary bypass surgery, valve surgery, or heart transplantation.

Cardiac Medications – OutpatientDiuretics

Diuretics, also known as water pills, help eliminate excess fluids from the body. They cause the kidneys tomake more urine and increase the body's excretion of sodium, chloride, and potassium. Since the use of mostdiuretics can cause potassium levels in the body to be depleted be sure to include foods high in potassium inyour diet.

Diuretics are used to relieve both pulmonary and peripheral edema. In addition, they may be used to treathypertension since they dilate blood vessels.

Potential Side effects: dizziness, severe leg cramps, high blood sugar levels, high cholesterol levels

Examples: Furosemide(Lasix, shown below ), Bumetanide(Bumex), Hydrochlorthiazide(HCTZ)

6004688 heart failure and your heart

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