Mr John has been having breathlessness on exertion for about a year, which became increasingly bothersome in the past four to five months. He is a 66 year old hypertensive patient on irregular medications. He used to climb up to two floors without difficulty, but that became a challenge with the onset of breathlessness. He started getting up in the middle of the night feeling very breathless and unable to lie down again to sleep for the next few hours. His feet swell up and get worse at the end of the day. He became extremely tired after he started to feel his heart beating irregularly, sometimes going very fast (palpitations). Finally, he went to consult a doctor and after some tests and a scan, he was informed that he had a weak and swollen heart. He was given a drug to increase his urine output and some others to control his blood pressure. After starting them, he felt much better. A few months later, his condition slowly deteriorated again and this time he was rushed to the hospital because of sudden worsening breathlessness. He was sweating profusely as he reached the hospital and had to be connected to a ventilator (lung support machine). Multiple injections were administered to stabilise his heart function as he developed acute kidney failure and underwent haemodialysis. He has however made a good recovery, surviving the ordeal.
Dr Avitso Liegise (DNB, DM) Cardiologist
This is a typical history encountered in the OPD of patients with heart failure. Some important issues in heart failure management are in the story and I wish to highlight them and explain why we do what we do as physicians in treating heart failure, and more importantly, why many people with heart failure fail to get the best out of their treatment. I will attempt to explain the problem through a series of questions and answers.
What is heart failure?
The heart is an organ that pumps blood to the different parts of the body. When the heart fails to do this effectively (low ejection fraction), we say the person has heart failure. Ejection fraction (EF) is a term that conveys how much blood is pumped out with each heartbeat. Normally it is 60-70%; once the EF falls to less than 50%, we say the person has heart failure with left ventricular (LV) systolic dysfunction.
There are various reasons for heart failure. Heart muscle ischemia (Ischemic cardiomyopathy) is a common one where the blood vessels supplying the cardiac (heart) muscles are diseased: a condition called coronary artery disease. If this is severe, it will result in inadequate blood supply causing pump failure. The other reasons involve cardiac muscle dysfunction in the absence of coronary artery disease, commonly referred to as dilated cardiomyopathy. The cause is not apparent a lot of times in these cases despite extensive investigations.
Depending on the underlying cause for heart failure, the treatment strategy differs to some extent. However, the basic principles of heart failure management are the same.
What happens to the body when the heart fails?
When the heart fails to keep up with the demands of the body, the kidneys try to remedy the problem by increasing the blood volume through a chemical called Angiotensin which stimulates the kidneys to absorb more salt (sodium) and water. This however makes the body to swell up as heart failure progresses. Initially the swelling is limited to the legs at the end of the day on prolonged sitting or standing, or in dependant areas like the back after getting up in the morning. Once this continues beyond a certain limit, fluid starts accumulating in the lungs and breathlessness becomes more and more troublesome. When such a person lies down flat, the extra blood returning to the heart from the lower limbs stresses out the already failing heart, and a condition called orthopnoea sets in – breathlessness on lying down. For some this happens in the middle of the night after being asleep for a few hours when they suddenly wake up feeling very breathless unable to lie down again for hours – a condition referred to as paroxysmal nocturnal dyspnea (PND) and is a particularly specific symptom of heart failure.
So, the foremost imbalance in heart failure is one of excess salt and water accumulation causing symptoms ranging from breathlessness to loss of appetite.
What are the early signs of heart failure?
The common symptom at the initial stages of heart failure is breathlessness on exertion (walking long distances, climbing stairs, carrying heavy weights, etc.) as the failing heart struggles to eject blood adequately, causing blood to pile up in the lungs. If this happens acutely and is not remedied in time, water starts pouring out into the airways with sudden deterioration as patients basically “drown” in their own body fluids. A person may be absolutely well at rest or on minimal exertion, but on exposure to unaccustomed work will develop acute heart failure and pulmonary edema (Fluid overload in the lungs) as more blood returns to the heart; an additional load a failing heart cannot tolerate. Another important symptom is fatigue (tiredness). Other symptoms like chest discomfort on walking uphill suggests ischemic heart disease; palpitations (heart pounding) suggest valvular heart diseases. In fairly advanced cases of heart failure, orthopnoea, PND and leg swelling occur.
How do we treat heart failure?
Lifestyle modifications: Management of heart failure is grossly incomplete without lifestyle modifications. Two points are absolutely crucial in this regard; low salt and limited fluid intake. Given that the body tries to actively retain salt (Sodium), it is logical to decrease salt and water intake. Salt (NaCl) should be restricted to less than 6 grams per day, which is about a teaspoon of the common salt we add to our food. You should however remember that there is salt in basically almost any kind of food and not just the ones you cook in the kitchen. Hence, you should not ration the entire day’s salt to the home kitchen food only but allow some to be accounted for by other “miscellaneous” food sources. Water should be restricted to 1.2 to 1.5 litres a day. Once again, we are trying to remove excess water from the body by using diuretics (drugs that increase the urine output) and so it does not make sense to replenish them voluntarily! Other lifestyle changes like avoiding smoking, tobacco, alcohol, and other intoxicants goes without saying. Alcohol in particular can induce sudden cardiac arrhythmias like AF (Atrial fibrillation) which is detrimental to cardiac function in a person who already has heart failure.
Medications: Cardiac medications for heart failure management are designed to target specific mechanisms that make heart failure a progressive condition. There are four classes of drugs that are absolutely essential. These are i) beta blockers (usually metoprolol, carvedilol and bisoprolol), ii) ACE inhibitors (ACEi – ramipril, enalapril) and angiotensin receptor blockers (ARBs – telmisartan, valsartan, losartan), iii) aldosterone inhibitors (spironolactone, eplerenone) and iv) diuretics (torsemide, frusemide). They are the four pillars of heart failure management and if anyone of them is missing the “table” becomes very shaky and unstable. Beta blockers reduce the stress imposed on the failing heart; it cuts down on something called the sympathetic drive that forces the heart to beat faster and stronger. This goes a long way in preventing cardiac remodelling that causes the heart to dilate and become more inefficient. ACEi and ARBs interferes with Angiotensin mentioned earlier, mitigating the excess blood volume that tends to accumulate as heart failure progresses. They also have anti-inflammatory effects that prevent further damage to cardiac muscles. Aldosterone inhibitors have a similar effect acting on a slightly different location in the chain of events with additive benefits in rescuing the heart from undue stress. And finally, diuretics, which remove excess salt and water that accumulates in the body. There are a number of other drugs that are available but not crucial in heart failure treatment; additional add-on drugs that may have some beneficial effects but not on the same level as the “big four” mentioned earlier.
Heart failure treatment requires the use of a combination of drugs. Targeting different points in the cascade of events that result in congestive heart failure is the key to effective therapy.
Why does the doctor keep changing medication doses?
Maximizing treatment benefits involve the fine tuning of the drug doses on subsequent hospital visits. All the drugs apart from the diuretics have a maximum dose that we physicians target. Some are able to achieve such targets, while others are unable to. Hence, we use a term “maximal tolerable dose”, which is the dose a person is able to take without significant side-effects. Regular hospital visits are crucial for this and dose escalation is absolutely essential in this regard. Patients need to understand this strategy to successful heart failure treatment and not be alarmed by medication dose enhancements during follow-up visits.
Do I need to be on lifelong medications?
Most likely. Heart failure treatment is not a short term affair. If treatment is discontinued prematurely, we are back to square one and all the benefits accrued over the few months of treatment will be wasted. It is like a person desperately trying to reach the top of a multi-storeyed building who, after climbing a few floors up, feels good about it and for some silly reason jumps back to the ground floor. Doesn’t make sense, does it?
If you are one of those lucky ones whose ejection fraction (EF) recovers completely after treatment and there is no residual heart chamber deformities, the medications could be slowly withdrawn. However more often than not, medications are lifelong.
Will these drugs damage my body if taken for a long time?
Some of them can cause temporary renal dysfunction and electrolyte imbalance, especially in the initial stages of treatment. Hence it is important to recheck kidney function once every 2 to 3 weeks after starting the medications (some would prefer more frequent testing), and once the kidneys are stable the frequency of testing can be far less.
These drugs have been studied extensively with multiple high quality trials showing time and again that benefits of treatment are significant, far outweighing the potential side-effects.
What actually happened to Mr John?
Mr. John’s symptoms became intolerable after he experienced palpitations. Palpitations in heart failure can be for multiple reasons, but there is one in particular that is known to cause rapid worsening called atrial fibrillation (AF). With this, the heart suddenly loses an additional 20% pump capacity. With the heart already functioning sub-optimally, this is detrimental.
Once he was diagnosed with heart failure and medications were started, he did well. Unfortunately, he stopped them after a few months because he was feeling great and thought he could do without them. He went into cardiogenic shock (low BP) and almost did not make it. After recovery, he was told to strictly monitor his weight and report if his weight increases by 1.5 to 2 kgs over a 3 to 4 days period. This self-weight monitoring is important in detecting subclinical congestion early so that necessary treatment escalation can be initiated before the patients lands up in hospital with severe symptoms.
There are two important states of heart failure – compensated and decompensated heart failure. Mr. John was in compensated heart failure after the initial treatment, but with non-compliance to treatment he suddenly decompensated and had to be rushed to the hospital. So being in a compensated state does not mean that you are cured. It means that you have reached a certain state of equilibrium with the medications, and the intention is to keep you in that state as long as possible while allowing the heart to heal without being stressed too much. If you are careless, cardiac decompensation will happen sooner or later, and the acute deterioration may be too severe to recover from.
Heart failure is a complicated condition, but our understanding of it is also rigorous and the management strategy is very clear with several drug trials undergirding the standard recommendations. With the need for multiple drugs to arrest the progressive nature of the illness, it is absolutely essential that patients have a good grasp of their condition and feel in control, taking active part in effective management. Lifestyle modifications are as important as taking medicines regularly; without such disciplines, heart failure treatment will fail to stay afloat and sink in the “open sea of salt and water.”