When the heart fails
With the National Institute for Health and Care Excellence about to issue guidance on the treatment and management of acute heart failure in NHS hospitals in England, Wales and Northern Ireland, and exciting research going on into the use of stem cells to grow new heart muscle, the condition is entering an exciting new phase destined to further improve survival rates.
Martin Cowie, professor of cardiology at Imperial College London, with a special interest in heart failure, says: “We already have a lot of people alive today who would have died years ago. We’re in an exciting era where we have new guidelines on treatment, as well as new therapeutic options. This means people with heart failure will no longer see their diagnosis as the end of the world.”
The key to how someone with heart failure fares, he says, is rapid diagnosis and getting the correct treatment tailored to their needs.
“Problems only occur,” the professor adds, “when this doesn’t happen and the patient ends up being frequently readmitted to hospital and with a poor quality of life.”
He is optimistic the new guidelines, due out next month, will ensure every patient wherever they live and whatever their age will get a rapid diagnosis by a cardiologist. This will improve survival rates, he believes, particularly among older patients who sometimes end up on a medical or geriatric ward unseen by a cardiologist.
More than 800,000 people in the UK are living with heart failure, according to the National Heart Failure Audit 2012-13. Over the next 20 years this figure will soar to 1.2 million as a result of our burgeoning elderly population and more people surviving a heart attack.
Heart failure is caused by abnormalities in the structure and function of the heart that mean it is unable to pump sufficient blood to meet the body’s demands. For example, the tissue in the heart muscle gets damaged during a heart attack or a valve has deteriorated through the ageing process. British Heart Foundation statistics show heart failure rises steeply with age, affecting 13.1 per cent of men and 11.9 per cent of women over 75.
Apart from a heart attack, heart failure can be due to angina, where the coronary arteries leading to the heart muscle become narrowed, high blood pressure, a viral infection such as rheumatic fever, a genetic disorder, valve disease and an irregular heart rhythm.
SYMPTOMS AND TREATMENT
Those with mild to moderate heart failure often have few symptoms, but those whose condition is more severe get short of breath, develop chest pain, retain fluid making their feet and ankles swell, and feel fatigued.
Patients undergo blood tests, which detect biomarkers released into the blood when the heart is damaged, have an exercise electrocardiogram (ECG) and an echocardiogram – an ultrasound of the heart – and are then put on medication.
The key to how someone with heart failure fares is rapid diagnosis and getting the correct treatment tailored to their needs
Most are prescribed diuretics, ACE (angiotensin converting enzyme) inhibitors and beta blockers. Those with an irregular heart rhythm also get an anti-coagulant to prevent blood clots.
ACE inhibitors reduce the activity of a chemical called angiotensin which can cause blood vessels to narrow and the body to retain fluid. Some patients may experience a dry persistent cough. They can be switched on to ARBs (angiotensin receptor blockers) which act in a similar way.
Beta blockers lower blood pressure and reduce the risk of a further heart attack. As well as slowing the heart, they can slow the body making patients sluggish and tired, but dosage can be adjusted.
Calcium channel blockers reduce the amount of calcium getting into the cells of coronary arteries, making them relax and widen. This increases blood supply to the heart.
Implantable devices, such as pacemakers and cardioverter defibrillators, are used when the heart pumps out of sync or has an abnormal rhythm.
“Getting patients on the right tablets at the correct dosage is a matter of fine-tuning,” Professor Cowie says. “The job isn’t finished when they are discharged from hospital. You need to see them within two weeks to assess how they are doing on their medication and they need following up at regular intervals, either at the hospital clinic or by a community heart failure nurse or a GP with a special interest in heart problems.”
The test results, says Julie Ward, a senior cardiac nurse with the British Heart Foundation, enable treatment and exercise to be tailored individually.
“If excess fluid is a frequent problem, a higher dosage of diuretics [to promote production of urine] will be prescribed. Patients are advised to take these at breakfast in order not to be woken at night by the need to use the toilet,” she says.
“They should check their weight first thing to see if there has been an accumulation of fluid overnight. If so, they may need three diuretic tablets that day.”
Professor Cowie adds: “You need to do something that makes you breathless then have a rest and then do a bit more. If you exercise, you’ll get a little fitter, regain your confidence and this may keep you out of a nursing home.”
In the past someone with heart failure after a moderate heart attack was prescribed bed rest. Today, says Ms Ward, the emphasis is on what exercise they can manage.
“While one person will struggle to climb stairs, another will be able to climb two flights to bed. It’s a question of tailoring what you can do to the degree of heart failure you have. If you get breathless walking to the shop, you need a good rest afterwards or to rest half way there. You’ll have good and bad days. If you’ve been doing a bit more one day, it’s not unusual to need to rest a little more the next,” she says.
“Keeping a daily record of how you’re feeling emotionally and physically, as well as noting what you’ve eaten, your weight, the exercise you’ve done and your blood pressure can be very helpful when you next see your GP or cardiologist. It enables you to have your say and puts you back in control.”