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Getting A Line On Heart Failure

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By MAYA GUGLIN, MD, Ph.D., Tribune correspondent

Published: February 22, 2008

A 43-year old man visited several doctors and the emergency room complaining of difficulty breathing. He was diagnosed as having allergy with sinusitis, and then bronchitis. Neither Benadryl nor a prescribed inhaler helped. It was challenging for him to climb stairs, and he couldn't do his carpentry work.

A chest X-ray showed fluid in his lungs, and the patient was prescribed antibiotics for pneumonia. He was admitted to the hospital, and discharged two days later. But he couldn't sleep and woke up gasping for air. He called an ambulance, was hospitalized again, and finally received a definitive diagnosis: heart failure.

He joins the half-million Americans diagnosed with this condition yearly.

Heart failure is caused by weakness of the heart muscle. It is frequently the common final pathway of other cardiac conditions that put strain on the heart, including high blood pressure, heart attacks, heart valve leakage, malfunctioning of the heart's electrical system that supports heart muscle or infection involving the heart.

Some conditions affect the heart muscle directly. Heart attacks cause infarcts and scar part of the cardiac muscle, reducing the intact muscle and weakening the contraction. Longstanding, poorly-treated high blood pressure exhausts the reserves of the heart, and it eventually fails.

Excessive alcohol consumption is well-tolerated by many, but some respond by developing heart failure, and it is impossible to identify those people in advance. Fortunately, this type of heart failure may be reversible, but only in about half the patients.

Some young women develop heart failure soon after childbirth, and it can recur with subsequent pregnancies.

The chemotherapy that kills cancer cells also may be toxic to the heart. Sometimes, finding the cause of heart failure is impossible — we call this idiopathic cardiomyopathy.

Whatever the cause, the outcome is the same. The damaged heart can't pump enough blood and starts to beat faster to compensate. The heart's workload increases, leading to water retention. As fluid builds up in the lungs, the person experiences breathlessness — first during strenuous exertion, then during daily activities, and finally while resting.

Normal sleep becomes impossible as patients wake up short of breath. Other symptoms include swelling of the feet, hips and abdomen, a feeling of fullness when beginning to eat, fatigue and pulmonary hypertension. When it becomes very weak, the heart may develop abnormally fast electrical impulses (ventricular tachycardia) that can trigger cardiac arrest.

Although many physicians recognize heart failure, sometimes the diagnosis is not so simple. In addition to a complete medical history and physical exam, tests are typically ordered based on the cause of the condition.

For instance, if the physician suspects plaques are blocking coronary arteries, then a stress test is a good initial screening, followed by cardiac catheterization or coronary angiography. Almost invariably, the physician will order an echocardiogram, because it shows how the heart contracts, the size of its chambers, and how well the valves are working. A blood test called brain natriuretic peptide may also help with the diagnosis.

Heart failure kills more women than breast or lung cancer, and more men than prostate or lung cancer. Although the diagnosis can be frightening, the disease advances differently in different patients, and many good treatment options are available to improve and prolong life. I will discuss those in a future column.

Dr. Guglin is director of the Heart Failure Program and assistant professor of medicine at USF Health.

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