Heart failure

With more than five million Americans affected and more than 400,000 new cases diagnosed every year, heart failure (HF) remains the number ONE medical cause of hospitalisation in the adult population above the age of 50 years. In addition, it is estimated that more people die each year from HF than ALL cancer deaths combined!

And while the survival from cancer had markedly improved over the past two decades, HF mortality remains steadily on the rise.

What is heart failure?

It is the inability of the heart to pump enough blood to the body in an effort to match its needs, especially with effort. The heart is composed of four chambers: two upper ones called atria and two lower chambers called ventricles. The left ventricle plays a key role in pumping blood to the entire body.

There are two main types of HF:

• Systolic HF: the left ventricle is too weak and does not squeeze forcefully enough.

• Diastolic HF: the left ventricle is stiff, so after it pumps, it does not sufficiently relax to fill up with enough blood for the next beat.

Heart failure causes:

• Coronary heart disease is the most common cause. Portions of the heart muscle are deprived of oxygen and the heart does not perform its work properly. It can lead to a heart attack (myocardial infarction), which may cause permanent damage and weakness to the heart muscle, with consequent HF.

• Hypertension. In people with high blood pressure, the heart must work harder to overcome the high tension in the vessels before it can squeeze out blood. Over time, this increased workload can weaken the heart muscle.

• Valve disease. The valves inside the heart chambers can become narrowed, which interferes with blood flow through the valve, or leaky, causing blood to splash backward instead of being efficiently pumped forward.

• Cardiomyopathy or internal disease of the heart muscle, can be genetic or acquired.

• Rhythm disorder. A fast beat, like atrial fibrillation, can tire out and weaken the heart muscle.

Heart failure symptoms:

• Shortness of breath, driving one to be less active or sleep with several pillows.

• Weakness, lightheadedness, or fatigue.

• Swelling in legs and feet (oedema) or in the abdomen (ascites).

Heart failure diagnosis:

While physical exam remains the cornerstone to diagnosing heart failure, there is a large battery of tests available to confirm HF diagnosis, clarify its cause and guide the treatment; some are quite invasive and sophisticated.

However, the four tests routinely used are:

• Electrocardiogram. It may detect conditions, such as a previous heart attack or an abnormal rhythm that could lead to HF.

• A BNP blood test. BNP is elevated in HF.

• Chest X-ray shows if the heart is enlarged and the lungs are filled with fluid.

• Echocardiogram uses ultrasound waves to assess the size and function of the heart’s chambers and valves.

Heart failure treatment:

In most people, HF is a chronic problem that is generally treatable but rarely curable. Treatment is first targeted at correcting the cause (see above) and secondly, at improving the patient’s symptoms and longevity.

The latter strategy includes a combination of lifestyle measures, medications and sometimes a cardiac device.

Lifestyle:

• Low salt (less than two grams a day) and fluid intake (less than 40 ounces from all sources)

• A quick weight gain can be a sign of fluid retention.

• Limit alcohol as it can weaken the heart muscle.

• Cardiac rehab and exercise.

• Medications. Three diverse classes have proven to prolong life “beta” blockers, “RAAS” inhibitors and a hydralazine-nitrate combo. Two others help manage symptoms and fluid retention only: digoxin and diuretics. It is imperative that patients comply to these medicines, every day.

• Cardiac devices. In some HF people, a defibrillator (ICD) is recommended. Depending on the patient’s condition, an extra wire to help with strengthening the heart muscle could also be added to the ICD. In other cases, a pumping assist device (VAD) could be implanted that takes over the heart performance.

• Transplantation. Reserved for severe HF, not responsive to other therapies. The supply of hearts for transplant is limited, so most people must wait months to years before one becomes available.

•Joe Yammine is a cardiologist at Bermuda Hospitals Board. He trained at the State University of New York, Brown University and Brigham and Women’s Hospital. He holds five American Board certifications. He was in academic practice between 2007 and 2014, when he joined BHB. During his career in the US, he was awarded multiple teaching and patients’ care recognition awards.

The information herein is not intended as medical advice nor as a substitute for professional medical opinion. Always seek the advice of your physician. You should never delay seeking medical advice, disregard medical advice or discontinue treatment because of any information in this article.