The Unrelaxing Heart (Part Two)
The second in a four-part series on heart failure.
Heart failure may not be what you think it is. Many believe it is a heart attack.Or that a heart is about to stop — as in, fail to beat anymore. Neither is accurate. “Heart failure is any circumstance where the heart is not working properly, and as a consequence, the person does less well,” said Clyde W. Yancy, past president of the American Heart Association and associate director of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital in Chicago.
In our first installment of this series, we talked about heart failure (HF) caused by a weakened heart muscle, which typically causes the left ventricle to enlarge. However, heart failure can also occur when the heart muscle is intact but another condition is keeping the heart from pumping efficiently. This condition, which we are calling HF with intact heart muscle, is also known as HF with preserved ejection fraction, diastolic dysfunction or diastolic HF. “It’s not how well the heart squeezes,” Yancy said, “but how well it relaxes.”
Dr. Clyde Yancy
This type of HF can occur as a result of a person getting older and the heart muscle gets stiff. It may occur because of high blood pressure or atrial fibrillation or coronary artery disease. Other medical conditions such as chronic kidney disease, diabetes, sleep apnea or obstructive lung disease can also result in HF with the heart muscle intact. “About 90 percent of everyone who has heart failure with an intact heart muscle has one or more of those other conditions,” Yancy said. “To give a sense of scale, about half of the people who have heart failure right now have heart failure with an intact heart muscle, and we have reason to believe that that number has actually increased.” As for outcomes, both types of HF result in about equal hospitalization rates and death rates.
In order to diagnose which type of HF a person has, physicians take a picture of the heart. If the heart muscle is intact, they investigate these other causes. “We especially focus on blood pressure,” Yancy said. “We know that bringing blood pressure closer to normal helps those patients feel and do better. And then we focus on fluid because if we can relieve congestion,the person will do better.”
Beyond dealing with blood pressure and fluids, which are common in either type of HF, treatment is dictated by the underlying condition. “We yield to where the evidence is good,” Yancy said. “If the evidence is good for atrial fibrillation (Afib), we make certain that we treat that as well as we can. If the evidence is good about treating high blood pressure, we focus on that problem. In short, if there is good evidence about the cause and therapies that have been associated with better outcomes for that other condition, that’s how we start.”
Patients with HF with intact muscle are best treated by a team approach. If kidney disease is present, a nephrologist will be part of the team. If diabetes is the underlying condition, an endocrinologist is necessary; or an electrophysiologist for AFib. In essence, each patient is unique, “[so] we have to come together to identify what uniquely works with one person versus another,” Yancy said.“It won’t be the same template or prescription for everyone. But the goal is the same — to alleviate the symptoms, and as best as we can, improve the outcomes.”
Co-occurring diseases make treatment challenging, especially since most research is disease specific. The combination of HF with AFib or chronic liver disease, or HF with high blood pressure has not been investigated. “Research into multiple morbidities is almost absent,” Yancy said.“That gets us into a peculiar space where we can’t fully address the issues we like to address.”
But that does not mean that there are not treatments currently available, it just means there is more than one way to treat it. There are straight forward things that can be done to make patients feel better: “They can expect to work hand-in-hand with their provider to understand all their other conditions and develop an individualized plan that focuses on these other conditions,”Yancy said. “There is no reason to be dismayed by this diagnosis.”
Family caregivers are an integral part of the HF team. Caregivers have to be aware of any special dietary considerations as well as helping their loved one maintain a reasonable level of physical activity. Caregivers play an important role in the medical and medication regimen, including doctor visits. “It is a lot for the patient to digest,” Yancy said, “and it is incredibly helpful for the caregiver to step up and make a difference.”
In addition to the involvement of family members, Yancy suggests that it is important for HF patients with heart muscle intact to work closely with a HF nurse or other mid-level provider. “They’re able to be readily accessible to the patient,” Yancy said. They are trained to recognize problems caused by the other condition, such as AFib or kidney problems. “There are a number of questions that have to be addressed in this condition that are very different from HF with weakened heart muscle.”
Yancy emphasizes that part of the problem of HF is the confusion between heart attack and heart failure.“Heart failure basically implies defeat from the word ‘go,’” he said. “We spend a lot of time trying to reorient patients that there is something that can be done. We can treat this; we can help you do better.
“And there is ongoing research that is getting closer to identifying which of these co-occurring conditions might be the culprit condition. If we correct that condition, the heart failure will go away. But the real enthusiasm in heart failure with intact function is the evidence that’s emerging now that we may be able to prevent this condition, especially with regard to the treatment of high blood pressure. Imagine not having to ever have a condition. That’s so much better than dealing with what we’ve just been talking about. We may not be that far away from understanding what it takes for that to be the case.”
Queen Latifah & Her Mom
Adapted from American Heart Association News Blog
Rita Owens taught high school art for many years, and she had that sweet disposition that goes with that profession. She ended every class with the same little ditty — “Clean up, please.” Her tone was that of a loving mother and, in a sense, she was. Owens cared for these students so much that she ran an after-school program that helped steer kids in the right direction in life.
So her daughter, entertainer Queen Latifah, knew something was wrong when she called her mother’s classroom one afternoon and heard her mom deliver that trademark tune with “a little less of a song to it — not the same brightness.”
“I could hear her being more short-tempered with her students,” Latifah said. “She had a lot of patience, so if she was short, it was very noticeable. I also noticed she was more fatigued. I could tell she wasn’t feeling well.”
Rita was an energetic woman who didn’t smoke or drink, and was never overweight. To her loved ones, this change in her personality was more of a curiosity than a major concern.
Until the day when she passed out at school.
Latifah was in the hospital when the doctor delivered her mother’s diagnosis: heart failure.
That’s a scary phrase for anyone. For Latifah, it was magnified because about a year earlier her grandmother died from it. As Rita’s doctor discussed which medicines she should take, Latifah recognized several as being the same ones her grandmother had taken.
“But my mom was in her 50s!” Latifah told the doctor. “She’s too young for this. What does it mean? She’s going to be OK, isn’t she?”
No one could say so on that day, but it’s been 11 years and Rita is still going strong. So strong that she and Latifah are working with the American Heart Association to spread the word that patients can “RiseAbove Heart Failure,” and to help teach them how.
There are good reasons to be optimistic that we can make a difference. The best reasons are the success stories — the people like Rita.
Rita has been a model patient, from taking medication to making lifestyle changes, such as following a low-sodium diet.
She received an implantable defibrillator to protect her heart from going into cardiac arrest. She also uses oxygen to help with a lung problem, one she believes stems from her heart condition. (She also has sleep apnea; a sleep study following her heart failure diagnosis showed that she stopped breathing more than 100 times in a night.)
Latifah and her siblings dote on Rita, providing all the personal attention they can. They also realize that they, too, are at risk.
A key component of Rise Above Heart Failure is encouraging people to make small changes that can make a big difference. More than just a spokeswoman, Latifah is leading by example.
“We as a family have all started eating better,” Latifah said. “We eat less fat, especially less saturated fats, less sugar and less sodium. I very rarely add salt to my food. I was already heading in that direction, but I’ve become more cognizant of what I eat.
“I’m also trying to maintain a healthier lifestyle in general — exercise more, rest more, sleep better, just taking care of myself and keeping my stress down. I’m trying to avoid all the things that contribute to heart problems.”
“We’re sharing our story to get these messages out, to help people prevent heart failure and avoid being hospitalized as frequently,” Latifah said. “We want people to live longer, healthier lives.”