Oh, my failing heart
The article below appeared in the February 2 issue of Health with Perdana, a regular column in The Star by Perdana University faculty members. This week’s article is contributed by Dr. Isriyanti Mohd Rafae, Lecturer in Family Medicine, and Prof. Dr. Anthony Gabriel Cummins, Academic Lead, Associate Professor in Family Medicine Perdana University Royal College of Surgeons in Ireland.
Though scary, there are effective drugs to improve outcomes of chronic heart failure.
A husband to his wife:
“I am so tired these days. No energy. Short of breath with the slightest effort. Even going up the stairs. I will see my GP today.”
Ten years ago George Lee was diagnosed with hypertension. Last year he had a heart attack. He reduced his cigarettes to 10 daily and drinks whiskey only weekends (used be every night before his heart attack). Thanks to Institut Jantung Negara (IJN) he survived but now has developed new symptoms.
Why is this happening?
Let’s find out:
His GP thought it was heart failure. This was a shock. Totally unexpected. He’s scared. He should have brought his wife. She did want to come but he said “no need lah. It’ll be nothing”. Deep down he was frightened.
His GP advised re-referral to IJN. Urgently. George wondered why ‘urgently”. Too scared to ask. Said “Thank you, Doctor”, took the referral letter and left.
“What did the doctor say? asked Jane when he returned.
“Oh God! Are you going to die?”
What is it?
Heart failure does NOT mean that your heart’s going to stop at any minute. It means that it is not functioning well. It is caused mainly coronary artery disease and hypertension. Symptoms include ankle swelling, breathlessness and tiredness. Medication reduces symptoms and improves long-term outcome.
Coronary artery disease, the main cause, is due to narrowing or blockage of the coronary arteries, the heart’s blood supply, leading to angina and heart attack. Hypertension is the other main cause. The coronary arteries are shown in Figure 1:
Figure 1: Coronary Arteries
Years ago, heart attacks were fatal. Now with effective drugs, many survive. But at risk of heart failure.
After a heart attack some drugs improve survival:
*Some patients develop a persistent dry cough with ACE inhibitors so alternatives, ARBs (Angiotensin Receptor Blockers), are available e.g. irbesartan, candesartan and valsartan.
This also applies to angina & those with a previous heart bypass or angioplasty.
Who gets chronic heart failure?
Mainly middle-aged and elderly. Mr. Lee has both coronary artery disease and hypertension so is at increased risk.
With a heart attack the heart muscle becomes ineffective as a pump, there is a build-up of fluid in the lungs causing breathlessness, first noticed during exercise when the heart must pump more blood.
Other features, fatigue, lack of energy and ankle swelling, also develop.
How does it affect them?
Most notice progressive fatigue and breathlessness over months. The symptom severity is graded using New York Heart Association Class (NYHA). NYHA Class I, the mildest, shows little or no symptoms. NYHA Class IV , the worst, shows symptoms on minimal exercise e.g. towelling after a shower.
How was Mr. Lee’s heart failure found?
Mr. Lee’s GP arranged tests. Diagnosis of heart failure based on symptoms is very difficult because they are not caused only by that. Tiredness could be from anaemia. Breathlessness could be kidney disease. Tests are essential for accurate diagnosis.
Blood test: BNP (Brain Natriuretic Peptide)
If raised, heart failure likely. Refer for echocardiogram.
If not raised, consider anaemia, kidney disease etc and investigate accordingly:
ECG: A heart tracing showing the electrical pattern of the heart
Echocardiogram (“Echo”): Scan for pumping function
Mr. Lee’s BNP was raised. The echo confirmed heart failure with reduced pumping or ejection fraction.
Managing chronic heart failure
His GP explained that effective treatments are available improving long-term survival and reducing hospital admission.
Mr. Lee has now started ramipril. This will be increased every few weeks. Later, bisoprolol will be added. Should he still have symptoms despite them spironolactone could be added. Mr. Lee’s GP also prescribed a diuretic (water tablet), furosemide, to take if his ankles swell further.
Weight reduction through exercise is beneficial. Taking furosemide for swollen ankles also helps. Stopping smoking and reducing alcohol also. Vaccination against ‘flu and pneumonia are worthwhile. Infections worsen heart failure leading to admission.
Some patients develop depression from living with heart failure. Mr. Lee’s doctor will check for depression from time to time.
Chronic heart failure is increasingly common, especially in the elderly. Though scary, there are effective drugs to improve outcomes and reduce hospital admissions.
Patient Info: Congestive Heart Failure (https://patient.info/heart-health/heart-failure-leaflet)
NICE Pathways: Chronic heart failure (https://pathways.nice.org.uk/pathways/chronic-heart-failure)
CKS: Clinical Knowledge Summaries: Chronic heart failure (https://cks.nice.org.uk/heart-failure-chronic)