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HEART Insight:
doi: 10.1097/01.HEARTI.0000351616.35679.3f
Features: Risk Factors

Heart Failure Is Not A Death Sentence

Lippert, Joan

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Abstract

Long-Term Management Requires Taking An Active Role In Your Health

It's sure scary sounding, but “heart failure” doesn't mean your heart has actually stopped beating—just that the heart muscle isn't squeezing as hard as it should to pump blood to the body's other organs. As blood flow out of the heart slows, blood returning to the heart through the veins backs up. Fluid leaks into the lungs, legs, ankles — in fact, throughout the body.

Heart failure (HF) creeps up on you over weeks and months as your heart becomes weaker and less able to pump the blood that your body needs. By the time the condition is diagnosed, chances are the heart has been losing steam for quite a while. At first the heart tries to compensate by becoming larger and more muscular, and by pumping faster. The rest of the body pitches in to help out the heart: Blood vessels narrow to elevate blood pressure as a way to make up for the heart's loss of pumping power, and blood is diverted from less important tissues and organs to maintain adequate flow to the heart and brain.

But these are just “work-arounds” that mask the problem without fixing it. Still, the body is often so good at coping with a failing heart that some people may not become aware of their condition until years after their heart begins its decline (a good reason to have regular checkups with your internist or cardiologist). Eventually, the heart and body just can't keep up, and one or more symptoms develop (see box).

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PUMP AND CIRCUMSTANCE

As our population ages, the incidence of HF is expected to rise. You want to know how to avoid becoming a statistic? “Numbers one, two and three are ‘control blood pressure, control blood pressure and control blood pressure,’” says Mariell Jessup, M.D., Professor of Medicine and Medical Director of the Heart Failure and Cardiac Transplant program at the University of Pennsylvania Health System in Philadelphia.

These other risk factors can also lead to HF: clogged arteries that don't carry enough blood into the heart; a previous heart attack, with scar tissue that interferes with the heart muscle's normal work; heart defects present since birth; heart valve disease due to past rheumatic fever or other causes; cardiomyopathy and other diseases of the heart muscle; and myocarditis and/or endocarditis (infection of the heart and/or heart valves).

HF can worsen without treatment, and can lead to heart rhythm disturbances (arrhythmias), such as atrial fibrillation or ventricular tachycardia, which require appropriate medical treatment. But with proper medical care most people with mild and moderate HF can expect to live a full and enjoyable life.

Once HF is diagnosed — usually by echocardiography (a type of ultrasound) — the doctor will decide which combination of medications will help the most, based on the underlying cause:

▸ Angiotensin-converting enzyme (ACE) inhibitors lower blood pressure to decrease the heart's workload;

▸ Angiotensin-receptor blockers (ARBs) also lower blood pressure and are used for patients with allergies to angiotensin converting enzyme inhibitors;

▸ Vasodilators like nitrates or hydralazine, expand blood vessels to allow blood to flow more easily, making less work for the heart;

▸ Beta-blockers slow the heart rate and improve how forcefully the heart's left lower chamber (left ventricle) pushes blood to the farthest reaches of the body;

▸ Digitalis increases the pumping action of the heart; and

▸ Diuretics help the kidneys remove salt and water from the bloodstream, which can relieve the heart's workload and alleviate symptoms of congestion.

Slowing the progression of HF depends on taking medicine exactly as recommended. Alarm clocks and pill boxes with a compartment for each day can help you stay on schedule. “If you forget to fill your pill box, enlist the help of your son, daughter or neighbor to fill it on Sunday night,” advises Kathleen L. Grady, Ph.D., A.P.N, Administrative Director of the Center for Heart Failure at Northwestern University's Bluhm Cardiovascular Institute in Chicago.

But HF management doesn't stop at the medicine cabinet. Your doctor will also advise that you weigh yourself daily to check for fluid retention; eat a healthy diet low in salt and saturated fat; and pace yourself. “It helps to schedule more difficult activities at a time when you feel more energetic — for example, in the morning rather than later on when you're tired,” says Ileana L. Piña, M.D., Director of Heart Failure and Cardiac Transplantation at Case Western Reserve University in Cleveland.

You may be surprised to learn that physical activity is also an important component of HF management. People often believe that exercise is harmful to a failing heart — a misconception reinforced by shortness of breath and a tendency to tire easily.

Over time, daily physical activity will increase stamina to keep fatigue in check — plus it's easier to manage elevated blood pressure and cholesterol levels, as well as to lose weight and keep it off. “Exercise is incredibly safe. Of course, you should check in with your doctor before starting an exercise program,” says Piña. Even patients with more advanced disease can benefit from some activity, such as walking, standing from a chair and moving from chair to bed.

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KNOWING YOUR HEART

One key term you should know is “left ventricular ejection fraction” — the amount of blood released during each contraction of this lower heart chamber. An ejection fraction of 60 percent — which is normal — means that 60 percent of the total amount of blood in the left ventricle is expelled with each heartbeat. “It's always good for patients to know how well their pump is working,” says Piña.

Knowing your ejection fraction gives you a starting point from which to track your improvement over time.

Eleven years ago Cindy Wolforth, 55, a purchasing agent for a Chicago chemical company, found out she had heart failure caused by tachycardia, a rapid heartbeat that overworked her heart. At the time, her ejection fraction was only 17 percent. An ablation procedure to remove the heart tissue where the abnormal electrical activity originated controlled the tachycardia and improved her heart function for many years.

But she later developed clogged arteries, which further stressed the heart; a quadruple bypass was unsuccessful. With the walk from the parking lot to her desk at work becoming increasingly taxing, she went on short-term disability. After an angioplasty (a balloon is inserted into the arteries and inflated to push out the blockage), her doctors prescribed an ACE inhibitor and a beta-blocker. Now that her ejection fraction is up to about 40 percent, she's planning a triumphal return to the office. “I have much more energy now,” she says.

For people whose HF has progressed enough that they are experiencing abnormal heart rhythms originating in the ventricles, an implantable defibrillator may be necessary. Even in the most advanced cases there's hope. Heart failure patients can benefit from two types of open-heart surgery: valve repair or replacement, and heart transplant. “Heart-failure patients who have these operations can go on to live full lives for many years,” says Grady.

Case in point: Philadelphia attorney James Eisenhower III (a distant relative of former president Dwight D. Eisenhower) was always on the thin side, and an avid distance runner. But in the fall of 2003 he began to notice shortness of breath and suddenly collapsed one night.

Then 45 years old, Eisenhower had surgery to repair a leaky mitral valve (mitral regurgitation), which if untreated can cause heart failure. Mitral regurgitation occurs because changes in the size of the heart can make it difficult for this valve — which is located between the heart's left upper and lower chambers — to close normally.

While many patients with mitral regurgitation typically return to normal life soon after surgical repair, Eisenhower felt terribly fatigued for months. “I could barely walk,” he says. A follow-up cardiac ultrasound (echocardiogram) revealed his ejection fraction was down to 30 percent — a sign of full-blown HF.

Now on an ACE inhibitor and beta blocker, his ejection fraction is better than 50 percent, which is considered a good target. Equally important to him, “I work out in the gym, play golf, even do a treadmill,” he says. He wears a monitor so he doesn't exceed the speed limit of 145 heartbeats per minute.

In the worst-case scenarios — when a suitable donor heart is not available for transplant or a patient isn't a good candidate for the procedure — doctors may implant a left ventricular assist device (LVAD) to take over the work of the left ventricle. More than half of patients using an LVAD survive one year, but may eventually succumb to infection, blood clots, failure in other parts of the heart or other organ failures.

Heart failure remains a treatment challenge for healthcare professionals — and certainly for people living with it day after day. But two facts remain: “Many times, heart failure can be reversed — for example, when valves are repaired or replaced,” notes Jessup. “And even when heart disease can't be reversed, the heart can usually be stabilized and prevented from deteriorating further.”

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Heart Failure: The Symptoms

Swelling (edema) of the legs or ankles

Shortness of breath not related to physical activity or exertion, especially when lying down

▸ Sudden weight gain—as much as three or more pounds in a day, or five or more pounds in a week — as fluid builds up in the body. Weight gain caused by eating too much occurs gradually, so if your weight is increasing this quickly the American Heart Association recommends that you see your doctor right away.

▸ Abdominal swelling or pain

Trouble sleeping—particularly, waking up short of breath or needing to be propped up with extra pillows.

▸ Frequent dry, hacking cough

▸ Increased fatigue

Confusion or trouble thinking clearly

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Heart Failure: The Numbers

▸ About 5.7 million Americans are living with heart failure.

570,000 people are newly diagnosed with HF each year.

▸ Seventy-five percent of people with HF had high blood pressure first. Compared with people whose blood pressure is 140/90 mm Hg, the risk of HF doubles among those whose blood pressure is 160/90 mm Hg.

▸ At age 40, your chance of developing HF over your lifetime is 1 in 5.

▸ The prevalence of diabetes is increasing among older people with HF, and diabetes is a risk factor for death in these individuals. The five-year survival rate is 46 percent for those with heart failure alone but only 37 percent for those with heart failure and diabetes.

▸ The estimated direct and indirect cost of heart failure in the United States for 2009 is $37.2 billion.

© 2009 American Heart Association, Inc.

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