Heart Failure Treatable with Careful Diagnosis

Heart failure: The very term sounds terrifying. According to the National Heart, Lung and Blood Institute (NHLBI), about 5 million people in the United States have heart failure, and the number continues growing. Each year, more than 550,000 people are diagnosed for the first time. It contributes to or causes about 300,000 deaths each year. More Medicare dollars are spent on heart failure than for any other diagnosis, creating a major burden on the health system.

Simply put, heart failure is a condition in which the heart cannot pump enough blood throughout the body. It does not mean the heart has stopped or is about to. Most cases involve the left side of the heart, where the heart cannot pump enough oxygen-rich blood to the rest of the body. With right-sided failure, the heart cannot effectively pump blood to the lungs where it picks up oxygen to circulate through the rest of the body. Both sides can be affected, however.

Slightly more women develop heart failure than men, but many more women die of the condition than men, according to a 2004 statistical update by the American Heart Association.

"Heart failure is a complex area, more so than coronary artery disease or heart attack," says Michael P. Cinquegrani, MD, FACC, FACP, FSCAI, Associate Chief of Cardiovascular Medicine and Professor of Cardiovascular Medicine at the Medical College of Wisconsin. "Diagnosing it can be challenging." Accurate diagnosis determines the best treatment for each patient, he says.

Symptoms and Diagnosis
How do you know if you have heart failure?

"Patients may experience shortness of breath, swelling of the ankles, feet or legs, or fatigue," Dr. Cinquegrani says. "Their physician may recognize that these are typical symptoms of heart failure - especially in patients with such risk factors as high blood pressure, high cholesterol, diabetes, or if they are smokers. The risk factors parallel those of coronary disease." Risk factors, in fact, include angina and heart attack. NHLBI says most heart failure patients have hypertension, and one in three have diabetes. A history of stroke or kidney disease could also increase risks.

When he sees patients suspected of heart failure, Dr. Cinquegrani orders a series of diagnostic procedures that might include a physical examination, an electrocardiogram, chest X-ray, an echocardiogram and blood tests that measure kidney and thyroid functions. Also used for the past five years is a blood test called BNP. It checks the level of a hormone called B-type natriuretic peptide that is shown to rise in heart failure. "The BNP test is helpful in distinguishing heart failure from lung disease in patients with breathing problems," he says. Other tests might include:

• Holter monitor: A device usually worn for 24 hours to provide a continuous recording of heart rhythm during normal activity
• Cardiac blood pool scan: Using a radioactive agent, this procedure shows how well the heart is pumping blood to the rest of the body
• Cardiac catheterization: This test looks inside the arteries for any blockage. It can also check the pressure and blood flow in the heart's chambers, and collect blood samples from the heart.

The echocardiogram can distinguish the type of heart failure the patient is experiencing, which helps guide the type of treatment, Dr. Cinquegrani says. "If it is systolic heart failure - in which the heart's pumping function is reduced and the heart has enlarged - it's easier to treat. We have drug treatments that can improve dilation of the heart and increase the quality of life." Systolic refers to the contraction of the heart that drives blood through the aorta and pulmonary artery, and maintains circulation.

However, if the echocardiogram shows it's a diastolic dysfunction, that indicates the heart failure does not stem from a pumping problem. Diastolic refers to the period of time when the cavities of the heart fill with blood. "With this type of heart failure, the architecture of the heart has changed and become stiffened. The size of the heart and the pumping ability are normal, but when the heart fills with blood, the pressure in the heart increases above normal, causing the patient to have symptoms of shortness of breath or ankle swelling.

Diastolic heart failure is more difficult to treat. Usually, diuretics and other medications that control blood pressure are used, though patients may remain symptomatic despite therapy, Dr. Cinquegrani says. Diastolic heart failure is more common in women, particularly older women.

Living with Heart Failure
Heart failure is now classified by stages, ranging from A for patients with risk factors but no symptoms, to D, where patients are so debilitated they might be eligible for specialized advanced treatment - including cardiac transplantation - or compassionate end-of-life care such as hospice. The American College of Cardiology (ACC) and the American Heart Association (AHA) announced stages and guidelines for treatment in August.

"Most patients in Stages A, B, and C can be stabilized by medications," Dr. Cinquegrani says. "One key is to keep hypertension under control and to properly modify dietary intake of salt." The ACC and AHA joint news release noted that controlling hypertension can reduce the incidence of heart failure by 50%. The release also supports his view about the complexity of treating heart failure, noting: "More treatments have made decision-making far more complex since the last ACC/AHA heart failure guidelines only four years ago." The guidelines were scheduled for publication September 20 in several medical journals.

The 2005 guidelines also change the name of the condition from congestive heart failure to heart failure. This reflects the broad spectrum of the disease, according to the release, which says: "Congestion occurs when the heart cannot efficiently pump or eject blood from its chambers. This causes fluid buildup in the lungs and heart, resulting in stiff, fluid-filled lungs and shortness of breath. The panel dropped the word 'congestive' because people can have few or no symptoms of congestion, and still have a severely abnormal heart with symptoms of fatigue and exercise intolerance caused by poor cardiac output."

"For patients with ongoing symptoms, we can offer advanced therapies such as implantable cardioverter-defibrillators (ICDs) and biventricular implantable pacing (BiV) devices that help stabilize them," Dr. Cinquegrani says. The Medical College participated in clinical trials of the BiV about six years ago, he notes, adding, "We were one of the early adapters, and the Medical College is part of a registry of medical centers generating data about the BiV pacing system." BiVs resynchronize heart function.

In addition to keeping hypertension well-controlled, at-risk patients who smoke should stop, Dr. Cinquegrani says. Those who drink alcohol - even in moderation - might consider alcohol's toxic effects on heart muscle, he says, which can weaken the heart muscle.

"The big thing," he says, "is we have successful treatments that improve the health status of many patients with heart failure - and can improve their mortality risk. It's important, however, for those patients to be under the care of a physician who's well-versed in diagnosing and treating the problem."

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.