The most common reason to be admitted to a hospital in the United States after age 65 is heart failure. The initial symptoms at presentation may be acute or more chronic in onset. Acute heart failure can be very scary. The symptoms may come on suddenly, and it is not uncommon to occur in the middle of the night. You may wake up short of breath and have to sit upright to breathe. Any attempt to lie back down is thwarted by more breathlessness. These symptoms can worsen in just minutes and one can feel as if they are suffocating. Calling 911 and quickly getting to an emergency room for treatment becomes a priority.
A second type of heart failure presentation is more insidious. The first symptom may be a little more fatigue than usual. Over the course of several weeks mild ankle swelling (edema) might be noticed. With exertional activity one may experience a little more shortness of breath. A second pillow may be needed at night to help sleep just a little more upright, making breathing easier. Simple activities like taking a shower or getting dressed can cause breathlessness. You may get on the scale and find out that there has been a 10-pound weight gain in less than a week. This is not really true weight gain but actually water weight. These are signs a person is slipping into heart failure.
There are multiple and sometimes complicated causes of heart failure. I will discuss the three most common etiologies.
The first and most common is pump failure. The heart’s left ventricle becomes weak (reduced ejection fraction) and cannot keep up with the body’s demands. One of the most common causes of a damaged left ventricle is a heart attack. Other etiologies include familial cardiomyopathies, viral myocarditis (a virus attacks the heart), and non-ischemic cardiomyopathies (reduced ejection fraction not caused by coronary blockage).
A second and very frequent cause of heart failure is diastolic dysfunction, also called heart failure with preserved ejection fraction. This type of heart failure is even difficult for cardiologists to understand. The best way I can explain it is that the left ventricle becomes stiff and does not relax normally to allow proper filling of the left ventricle with blood. In simplistic terms, the blood backs up causing fluid to build up in the lungs and body tissues. We believe we are seeing more diastolic heart failure because people are living a lot longer. Most people after the age of 70 have measurable diastolic dysfunction or a stiff left ventricle and if it progresses it may lead to heart failure.
The third kind of heart failure I wanted to bring to your attention is caused by heart valve disease. The most common valve problems doctors see are aortic stenosis and mitral valve insufficiency. The aortic valve can become thickened and stiff and eventually become very narrow (stenosis) causing the left ventricle to work overtime to push the blood out through the little opening. Eventually, the aortic stenosis will cause the heart to fail, and when that happens you probably only have a few months to live unless the valve is replaced. Mitral valve insufficiency is a leaky mitral valve. When the left ventricle contracts to pump blood to the body a significant portion of the blood leaks through the mitral valve and backward toward the lung. If this gets bad enough the lungs get congested with fluid and you are in heart failure.
The initial treatment for most all forms of heart failure is diuretic use. This removes fluid from the body but more specifically decongests the lungs to treat the breathlessness. The most common diuretic used is furosemide (Lasix), but torsemide (Demadex) and bumetanide (Bumex) are used frequently as well.
With heart failure caused by a weak left ventricle there are several scientifically proven medications that can make a big difference in improving outcome. Most patients should be started on either an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker, depending on the clinical situation and the doctor’s preference. There also is a new medication now available for severe heart failure that is a combination of two medications: sacubitril/valsartan. It is available by the trade name Entresto. It was proven to be even more effective than ACE inhibitors, but it can be quite expensive if insurance does not cover it.
Several specific beta-blockers have shown favorable results in controlled studies and should be used in combination with the ACE inhibitor, ARB or Entresto. The two beta-blocker agents most widely used are carvedilol and metoprolol succinate. Treating heart failure caused by a weak left ventricle usually entails the use of three or four medications in combination.
If you have heart failure because of a stiff left ventricle, the mainstay of treatment is diuretics since multiple other meds have been studied and failed in this particular cause of heart failure. This can be a particularly challenging type of heart failure to treat and is just as serious as having pump failure.
With valvular heart disease, the treatment in general is to repair or replace the valve. Some people will be candidates for less invasive options then open-heart surgery. These include replacing the aortic valve by TAVR or repairing the mitral valve with a mitral clip.
If you have or are at high risk for heart failure there are lifestyle changes that can be made to help take control of the situation. A healthy diet with aggressive salt restriction can make a big difference. If overweight, you can take some of the load off the heart by losing 15 or 20 pounds. Finally, scientific studies have proven that even with advanced heart failure, there can be measurable improvement with a program of monitored exercise.
As God’s children we have received the gift of an advanced intellect that has developed the tools needed to treat many of the earthly diseases that afflict us. We can continue to serve our Lord even if we are challenged with health problems like heart failure. Remember what it says in Romans 5:1-5: “Now that we have been justified by faith, we are at peace with God through our Lord Jesus Christ. Through him we have gained access by faith to the grace in which we now stand, and we boast of our hope for the glory of God. But not only that — we even boast of our afflictions! We know that afflictions make for endurance, and endurance for tested virtue, and tested virtue for hope. And this hope will not leave us disappointed, because the love of God had been poured out in our hearts through the Holy Spirit who has been given to us.”
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