Rising Numbers The study we reference looked at Centers for Disease Control and Prevention data that included underlying and contributing causes of death from death certificates filed in the 50 states and the District of Columbia. The analysis showed that more than 647,000 Americans died from heart disease in 2017:  about 51,000 more than in 2011. Of those deaths, 80,000 had heart failure as the underlying cause, about 22,000 more than in 2011. Overall, the number of deaths increased by 38 percent for heart failure, with most of these deaths occurring in people age 65 and older.

These numbers are worrying, says Mount Sinai cardiologist Bruce Darrow, MD, PhD, though he offers some words of caution. “It’s possible the data don’t reflect a genuine rise in heart failure deaths as much as they do better diagnostic techniques,” he explains. “Without a diagnosis of heart failure, a person’s death certificate might not code for the condition—but if somebody had previously been diagnosed with heart failure, their death certificate is more likely to list it as a cause of death.”

That said, previous research has pointed to an increase in heart failure incidence. The fact America is rapidly aging likely plays a role: the population of adults age 65 and older increased from 41.4 million to 50.9 million during the study period, and seniors are more likely to develop heart failure. The United States also has high rates of obesity and diabetes, both of which are associated with heart failure.

What Causes Heart Failure? Common underlying causes of heart failure include high blood pressure and heart attack—ironically, one of the main reasons why more than 6 million Americans now have heart failure is the fact that medical advances have helped more people survive heart attacks that might have been fatal a decade ago. Other factors that can underpin heart failure include coronary artery disease, in which the arteries that supply the heart become narrowed or blocked by cholesterol deposits, problems with the valves that control the passage of blood through the heart, and cardiomyopathies (diseases that affect the heart muscle). “Along with high blood pressure, all of these can impede blood flow, which forces the heart to work harder than it should,” Dr. Darrow observes.

Systolic or Diastolic? There are two types of heart failure: systolic and diastolic. Which you have depends on your heart’s ejection fraction: the amount of blood the left ventricle (the heart’s main pumping chamber) pumps out to the body.

• Systolic heart failure A healthy heart’s ejection fraction is 50 percent or greater (meaning that 50 percent or more of the blood in the left ventricle is pumped out to the body each time the heart contracts). But in systolic heart failure, this number can fall to as low as 10 percent. The decrease occurs because the heart is unable to contract properly, and—ironically—this is related to the body’s own attempts to compensate for impeded blood flow. As your heart struggles to meet your body’s need for oxygen, your nervous system releases a hormone called norepinephrine. This stimulates the heart to contract faster and more forcefully, which, in turn, causes the heart to “remodel” (change shape). “Just as other muscles gain bulk in response to exercise, the heart’s increased workload causes the heart muscle to thicken and enlarge,” Dr. Darrow says. “Initially this helps the heart pump out a normal volume of blood with each beat. But over time, the walls of the heart become too stretched to contract properly, and the heart is unable to keep up with the body’s demands.”
• Diastolic heart failure differs from the systolic version in that it doesn’t affect the heart’s ejection fraction. It occurs because the heart muscle has become too stiff to relax between contractions. This very brief period of relaxation is necessary for oxygenated blood to travel from the left atrium to the left ventricle. If the heart is too stiff to relax sufficiently, the left ventricle cannot fill properly—so even if 50 percent or more of the blood inside the ventricle is being pumped out, it’s 50 percent of a smaller amount of blood.

Preventing Heart Failure Heart failure symptoms—including fatigue; shortness of breath; swelling of the feet, ankles, legs and abdomen due to fluid retention; and dizziness—can significantly affect quality of life, making simple activities of daily living a challenge. This is why it is so vital to address risk factors that can make you vulnerable to heart failure. High blood pressure is key: it affects about three-quarters of heart failure patients, and can go undetected for years. If you have high blood pressure, follow your doctor’s advice when it comes to taking medication to control the condition. “Don’t stop taking blood pressure medication because you feel well,” Dr. Darrow cautions. “High blood pressure typically causes no symptoms even while it is damaging the heart.”

Keeping your blood sugar, cholesterol, and weight at healthy levels also is crucial. Along with high blood pressure, these risk factors can be managed by eating a diet that is high in fruits and vegetables, whole grains, and healthy fats (found in nuts and fatty fish) and low in refined (white) grains and red meat. Physical activity also is important—regular walking can help you meet exercise guidelines (aim for 30 minutes of brisk walking each day, which can be spread across three 10-minute sessions). Also quit smoking and get adequate sleep.

Lifestyle Counts After Diagnosis, Too Even if you have been diagnosed with heart failure, you can preserve and even improve your health. Important steps include making many of the same lifestyle modifications that reduce heart failure risk. Get plenty of rest, but also aim to exercise, since physical activity can reduce heart failure symptoms and lower your risk of hospitalization for the condition. If you’re unsure of how much exercise you should be getting and what intensity to aim for, discuss your concerns with your doctor. He or she may recommend a formal cardiac rehabilitation program.

Don’t let your healthy diet lapse because you’ve already been diagnosed with heart failure, since nutritious foods can help slow heart failure progression. Take particular care over the amount of sodium (a component of salt) and fluids you consume—both may result in high blood volume that forces the heart to work harder than it should and also contributes to swelling. The AHA recommends a maximum of 2,000 milligrams (mg) of sodium per day for people with heart failure (as a rough guide, one teaspoon of salt contains 2,300 mg of sodium). “Your doctor also may recommend a daily fluid allowance,” Dr. Darrow says. “Be sure to factor in fluid-rich foods such as soup.”

Medical Treatments Improvements in medication and device therapies also are helping to make heart failure manageable. Drugs can help to lower blood pressure, stabilize the heart rate, and improve the heart’s pumping ability. Some people with heart failure may benefit from a pacemaker or an implantable cardioverter defibrillator, both of which can help the heart maintain a normal rhythm.

Research suggests that about one-third of heart failure patients return to normal with optimal medical therapy, and another third can improve their strength and quality of life through medication and lifestyle changes. “Compliance with medications and your doctor’s recommendations makes a huge difference, as does monitoring your day-to-day symptoms,” Dr. Darrow confirms. Overall, stay focused on the fact that heart failure is not an inevitable part of aging—and that despite its name, your situation isn’t hopeless if you are diagnosed with heart failure.   

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In some cases, the heart gets too weak to adequately pump blood through the vascular system. In other instances, the heart muscle stiffens to a point at which it cannot adequately fill with blood. In both cases, fluid backs up into lungs and other tissues, which causes congestion and swelling. Although heart failure often is called “congestive heart failure,” congestion in the lungs is not always present. For that reason, it is now simply called “heart failure.”

Systolic vs. Diastolic Heart Failure

Heart failure is categorized according to “ejection fraction,” which is the percentage of blood the heart pumps out with each contraction. A normal ejection is 50 to 70 percent, according to the AHA.

Systolic heart failure, also called heart failure with reduced ejection fraction (HFrEF), occurs when the left ventricle becomes so large and contracts so weakly that it cannot efficiently expel blood to the body. People with this condition have an ejection fraction of 10 to 40 percent, which means their heart only pumps 10 to 40 percent of the blood in the ventricles with each beat. It is more common in men, probably because men are more likely to have heart attacks that lead to heart failure.

Diastolic heart failure, also called heart failure with preserved ejection fraction (HFpEF), occurs when pumping strength is preserved, but the ventricles become stiff and cannot expand properly to fill with blood—therefore, the heart cannot pump efficiently.

Diastolic heart failure is more common in women, probably because women tend to have high blood pressure, chronic disease, and other disorders that precede diastolic heart failure. Women with diastolic heart failure live longer than men with diastolic heart failure. But women tend to be hospitalized more frequently and have limited physical ability due to shortness of breath.

Trying to Compensate

Whatever the type of heart failure, the heart tries to compensate by either getting bigger (enlarging) to help pump blood to the rest of the body, by developing more muscle mass to become stronger (in the short term), or by beating faster to increase output. All three are short-term efforts that mask the problem. Sooner or later, they cause more problems than they solve.

Not a Stand-Alone Disease

Heart failure is seldom a stand-alone disease. It is associated with other underlying factors. A heart attack is the most obvious risk factor, but other examples are diseases that affect the heart muscle (cardiomyopathies), high blood pressure (hypertension), diabetes, heart valve disease, heart valve damage, congenital heart disease, cancer drugs and radiation, severe lung diseases, and obesity.

To learn more about heart failure, purchase Managing Heart Failure at www.UniversityHealthNews.com.

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Among the conditions are having a heart attack, diseases that affect the heart muscle, high blood pressure, diabetes, heart valve diseases, congenital heart disease, medications, lung conditions, being overweight, and alcohol or drug abuse, plus air pollution—not a disease but an environmental risk factor that has now been linked with heart failure. More than half of all Medicare patients with heart failure have four or more other non-cardiovascular risk factors. A family history of heart failure is also a risk factor. In fact, The Framingham Heart Study showed a 70 percent increased risk for heart failure in people who had a parent with heart failure.

Heart Attack

A heart attack happens when a chain of events culminates with a blood clot that cuts off most or all of the blood supply to the heart. When the flow of blood slows or stops, the area of heart muscle fed by that artery does not receive nourishment from oxygen-enriched blood. The more time that passes without treatment, the greater the damage to the heart.

Plaque: Hard vs. Soft

Fatty deposits (plaques) caused by atherosclerosis (hardening, narrowing of arteries) can interfere with blood flow in two ways. In one form, they grow slowly, becoming hard over time, gradually reducing the diameter of the artery. Patients with hard plaques experience chest pain (angina pectoris) when they exercise, exert themselves, or consume a big meal. How well you sleep can affect your risk of atherosclerosis (see “Poor Sleep Linked to Atherosclerosis”).

A second type of plaque is even more dangerous. This plaque has a soft, fatty (lipid) core covered by a fibrous cap. The cap may rupture, releasing a variety of substances into the bloodstream that cause the blood to clot. If the clot blocks the flow of blood, a sudden heart attack occurs. Blood flow has to be restored quickly to prevent part of the heart muscle from dying, causing scarring and permanent damage. Damaged areas of heart muscle cannot contract. As a result, the heart cannot squeeze as strongly as it did prior to the damage.

Angina: Stable vs. Unstable

Angina is a chest discomfort or pain that occurs when the muscle is not receiving enough blood. Stable angina disappears with rest and can be treated with medications to dilate and relax the arteries.

As the disease progresses, stable angina may become unpredictable and more frequent, and it may begin to occur at rest. This is called unstable angina, and it can be the precursor to a heart attack.

Unstable angina often is treated in the catheterization lab with balloon angioplasty and stenting, or by coronary artery bypass surgery. Even with treatment, however, a heart attack may occur. If it does, it may lead to a weakened heart muscle and heart failure.

Heart Muscle Problems

Up to half of all heart failure cases are caused by cardiomyopathies—diseases that primarily affect the heart muscle. Cardiomyopathies often occur without a known reason, but they also can be caused by various medical conditions, including infections (usually viral), metabolic disorders, endocrine disorders, and adverse reactions to medications. Cardiomyopathy may have an autoimmune or genetic component and can be associated with alcohol or drug abuse, pregnancy, and prior radiation or chemotherapy.

Patients who have heart failure due to cardiomyopathy may want to encourage their children to be screened. The chance they have not inherited an increased risk of heart failure is very good. However, if early signs of heart failure are found, medications and lifestyle changes can delay its development.

Studies now underway—specifically those focused on genetic mutations associated with cardiomyopathies—may allow earlier diagnosis and treatment. They may also describe preventive measures to delay or prevent the development of heart failure.

Types of Cardiomyopathies

In dilated cardiomyopathy, all chambers of the heart enlarge (dilate), and the ability of the left ventricle to contract is weakened. More blood than normal remains in the enlarged ventricle after a heartbeat, meaning that less blood is pumped out with each contraction.

In hypertrophic cardiomyopathy, the muscle mass and thickness of the left ventricle increase, which decreases the interior size of the ventricle.

In hypertrophic obstructive cardio­myopathy, the wall between the two ventricles becomes enlarged and obstructs blood flowing out of the left ventricle.

In non-obstructive hypertrophic cardiomyopathy, the thickened muscle does not obstruct blood flow and may contract vigorously, but it becomes stiff and is unable to relax normally. This causes improper filling between heartbeats: Less blood enters the ventricle, so less blood is pumped out. Improper filling causes blood to back up in the veins of the lungs, where it produces elevated blood pressure.

Restrictive cardiomyopathy is a different, uncommon form of the disease. It happens when the heart is stiff and cannot fill properly, even though its pumping strength may be normal. An insufficient amount of blood enters the heart, so too little is pumped out. This form may be caused by abnormal scarring (fibrosis), abnormal infiltration of the heart muscle with iron or protein, or an unknown reason.

Arrythmogenic right ventricular dysplasia is a rare, often inherited, form of cardiomyopathy in which the muscle tissue in the right ventricle dies and is replaced with fibrous scar tissue. This disrupts the normal conduction of electrical signals in the heart and can cause arrhythmias. It most commonly affects teenagers or young adults.

High Blood Pressure

Almost half of Americans have high blood pressure (HTN), and one in five adults don’t know they even have it, according to the Centers for Disease Control and Prevention. Taking medications as prescribed is a problem for many patients, and it’s estimated that nearly 30 percent of patients who have high blood pressure don’t control their condition with medications. There are many reasons why heart failure may occur, and high blood pressure is a major culprit.

An Inside View

When the heart pumps, pressure is created to expel blood by way of arteries and capillaries to nourish the entire body. Veins bring the blood back to the heart. In the first phase, called systolic pressure, blood is forced out of the heart and pressure is at its peak. In the second (diastolic) phase, the heart fills and pressure is at its lowest. These two pressures are represented in numbers—such as 130 over 80 (130/80). Systolic is the top number; diastolic, the lower figure.

Elevated blood pressure can create tiny tears in arteries. This enables substances in the blood, such as fat and cholesterol, to stick more easily to arterial walls. The substances cause arteriosclerosis, which forces the heart to work harder to circulate blood.

High blood pressure is common as we get older because blood vessels naturally thicken and stiffen over time. This age-related trend might lead some people to believe that it’s okay to skip medications and to stop taking regular readings.

Some of those with elevated blood pressure may feel perfectly fine. But high blood HTN is a silent predator that can strike without notice and result in serious, life-altering consequences.

New Guidelines. Based on American College of Cardiology (ACC) and American Heart Association (AHA) guidelines, high blood pressure should be treated earlier with lifestyle changes and in some patients, with medication, at 130/80 rather than 140/90.

Newer guidelines—the first since 2003—lower the definition of high blood pressure to account for complications that can occur at lower numbers and to allow for earlier intervention. The new definition has resulted in nearly half of the U.S. adult population having high blood pressure.

In a person who has high blood pressure, there is more resistance to the flow of blood through the arteries, so the heart has to work harder to push blood through the body. It’s like adding weight to a barbell—adding more weight makes the barbell harder to lift.

About 75 percent of people with heart failure have a history of hypertension, and the lifetime risk of developing heart failure with a blood pressure higher than 160/90 is double that of blood pressure lower than 140/90 millimeter of mercury (mmHg).

Although up to 90 percent of people ages 80 and older have some degree of hypertension, it is not normal, and it greatly increases the risk of heart attack or stroke. Using medications to bring blood pressure down below 120/80 mmHg can reduce the risk of heart failure, even in the very elderly.

Controlling High Blood Pressure. Lifestyle modifications can lower blood pressure, in some cases as much as 20 points. Lifestyle changes should be the first course of action. Here are five specific suggestions:

• Lose weight if you are overweight.
• Stop smoking.
• Follow the DASH diet (Dietary Approaches to Stop Hypertension).
• Limit salt intake to 2,300 milligrams (mg) per day.
• Break a sweat with exercise at least 30 minutes a day most days of the week.

The next course of action is medications, which should be started if blood pressure readings are in the 140s. Work with your doctor in evaluating your tolerance to a new medication and reporting blood pressure changes, if any. Take your blood pressure daily, in the morning, and keep a written log.

In addition, HTN should be regularly monitored and managed by a physician. The length of time between follow-up appointments will be based on your current health and other medical conditions.

A primary care physician can initiate and manage therapy. However, if your blood pressure is difficult to treat or if other conditions complicate medication choices, you may be referred to a cardiologist.

Diabetes Connection

Diabetes has long been recognized as a risk factor for heart failure. Because heart failure tends to occur at an older age, when type 2 diabetes is the predominant type, the connection between type 2 diabetes and heart failure has been confirmed. Here are key takeaways from recent and relevant research:

• Men with type 2 diabetes have a 2.4-fold increased risk of developing heart failure, and women with type 2 diabetes have a five-fold increased risk, based on findings of the Framingham Heart Study. The presence of other risk factors, such as coronary artery disease or hypertension, further increases the risk.
• People with diabetes or prediabetes who are hospitalized with heart failure have an increased risk of dying in the hospital and require intensive glucose control to lower the risk. The study, published in Diabetes Care, May 2016, included more than 13,000 subjects in the Atherosclerosis Risk in Communities study.
• Type 1 diabetes quadruples the risk of heart failure, although the risk is still low among young adults. This study was the first time the role of type 1 diabetes was clearly defined. When type 1 diabetes is poorly controlled, the risk is even greater—10 times that of people without diabetes. The study was published in The Lancet Diabetes & Endocrinology, November 2015. A more recent study published in the journal Circulation in June 2018 also found that the risk of death from heart failure was higher in patients with type 1 diabetes than with type 2 diabetes.
• The drug Metformin, already used to treat type 2 diabetes, also may be effective in treating heart failure, according to a study published in the Journal of General Physiology (see “Diabetes Drug Metformin Could Help Heart Failure Patients”).
• Women with type 1 diabetes have a higher risk of heart failure than men with type 1 diabetes. The risk was especially high among women between the ages of 35 and 59. The study appeared in The Lancet Diabetes & Endocrinology, September 2015.
• Approximately 40 to 50 percent of heart failure patients have chronic kidney disease, a common complication of diabetes. The severity of renal dysfunction is associated with an increased risk of death, according to a study in Circulation, July 2016.

A study published in late 2018 revealed that a molecule called methylglyoxal builds up in heart muscle tissue and interferes with its ability to contract normally (see “Diabetic Cellular Changes May Cause Heart Failure”).

Heart Valve Disease

Your heart moves 83 or more gallons of blood through your body every hour. For that astounding amount to make its way through the heart and the rest of your body, every moving part has to work perfectly. But sometimes those parts don’t work perfectly, and the cause is often related to the heart’s four valves.

• Mitral and tricuspid valves control the flow of blood between the upper and lower chambers of the heart. They are the valves most likely to be affected by heart valve disease.
• The pulmonary valve controls the flow of blood from the heart to the lungs.
• The aortic valve controls the flow of blood between the heart and the aorta as it makes it way to blood vessels in the rest of the body.

10 Risk Factors

Ten may not be an absolute number, but it’s close. Whether you call them causes or risk factors, they include:

• Age (heart tissue may degenerate with age)
• High blood pressure
• Atherosclerosis
• Bacterial infection (of the inner lining of the heart muscle and heart valves)
• Heart disease or heart attack (that can damage muscles that control heart valves)
• Radiation therapy
• High cholesterol
• Diabetes
• Congenital heart disease
• Medications (for migraine headaches and some diet drugs)

Effects on Heart Valves

The Texas Heart Institute identifies two types of problems that can disrupt the flow of blood through the valves.

• Regurgitation (backflow) happens when a valve doesn’t close properly, causing blood to leak backward instead of moving forward. The heart compensates by working harder, which eventually leads to an enlarged heart that is less able to pump blood.
• Stenosis is a narrowing caused by the valves’ flap-like door not opening properly. The valves may become thickened, stiff, or fused and do not open fully, causing the heart to have to work harder to pump blood through the narrowed opening.

The National Heart, Lung, and Blood Institute adds a third problem called atresia, which happens if a heart valve does not have a clear opening through which blood can pass. Instead of an opening, there is a sheet of tissue that obstructs blood flow between chambers. Babies born with this condition may have a hole between the ventricles so that some blood can get through.

There are no medicines that can cure heart valve disease, but there are ways to relieve its symptoms through lifestyle choices such as not smoking, eating low-salt, low-fat foods, and taking prescribed medications. Valve surgery can repair or replace a defective valve.

Congenital Heart Defects

The ACC says there are at least 18 known distinct types of heart defects, with many more anatomic variations. They range from relatively minor issues to complex, life-threatening problems. Some heart defects do not need immediate attention, but others may require surgeries. For the first time, more adults are living with congenital heart disease than children.

Adult congenital heart disease normally takes one of two forms. The first is a defect with no symptoms early in life that becomes associated with symptoms later in life. The second is a complex defect repaired during childhood that requires further repair or new treatment in adulthood.

Because repaired congenital heart defects can still cause problems later on, patients with a defect repaired in childhood need regular cardiac care throughout their lives. Occasionally, an adult will experience symptoms of a more complicated defect for the first time as an adult.

In addition to heart failure, people with a congenital heart defect have an increased risk for other heart problems, including stroke, pulmonary hypertension, and arrhythmia.

Common Congenital Defects

The most common types of minor congenital heart defects diagnosed in an adult are septal defects, valve defects, and narrow blood vessels, according to the University of Ottawa Heart Institute.

• Holes in the Heart (Septal Defects). A septal defect can occur between the two pumping chambers (ventricles) of the heart, or between the two filling chambers. With either type, oxygenated blood coming from the lungs gets mixed with deoxygenated blood returning from the body. A serious complication of septal defects occurs when the direction of the mixing of blood causes the blood supply leaving the heart to contain less oxygen than normal.
• Heart Valve Defects. A valve in the heart may be unable to open completely or unable to close completely due to a defect, or the valve may be abnormally shaped.
• Narrow Blood Vessels. Blood vessels can be too narrow or they can be connected incorrectly, sending deoxygenated blood to the body or already oxygenated blood back to the lungs.

Cancer Drugs and Radiation

Some chemotherapy cancer drugs may be toxic to the heart muscle cells and increase the risk of heart failure. These include doxorubicin (Adriamycin), bevicizumab (Avastin), mitomycin (Mutamycin), mitoxantrone (Novantrone), sorafenib (Nexavar), sunitinib (Sutent), and trastuzumab (Herceptin). The angiotensin-receptor blocker candesartan (Atacand), a common heart medication, may help preserve the heart’s function in patients who have just begun taking chemotherapy drugs.

Treatment with radiation for lymphoma, and breast, lung, or esophageal cancer also can result in heart failure, particularly when radiation is given in conjunction with one of the above drugs or given to patients with other risk factors for developing heart failure. Patients who take these chemotherapy agents should be monitored regularly for signs of cardiac dysfunction.

Lung Conditions

In patients with heart failure, chronic obstructive pulmonary disease (COPD) is a consistent predictor of hospitalization and death. Research has shown that this is particularly true for women.The two conditions are connected, and shortness of breath is the hallmark symptom associated
with both.

In heart failure, fluid levels and blood can back up into both the heart and lungs, leading to shortness of breath.

COPD is a chronic, progressive condition that slowly damages the tissues of the lungs. The conditions that cause COPD, such as chronic bronchitis and emphysema, result in irritation and damage to airways or air sacs, making it difficult to breathe.

People with COPD are short of breath when they are physically active. When they exhale, the damage prevents oxygen from being fully released before the next breath is taken.

If you are having shortness of breath for whatever reason, see a physician to get a correct diagnosis and treatment. A study at the University of British Columbia found that permanent damage caused by COPD starts earlier than previously thought—even before patients begin to show symptoms (see “Permanent Damage Caused by COPD Starts Earlier Than Previously Thought”).

Obesity: It’s a Paradox

Obesity increases the risk of developing other risk factors for heart disease. It triggers inflammatory processes that can lead to atherosclerosis, and it can change the structure of the heart. Among its other negative effects are hypertension, elevated cholesterol, type 2 diabetes, metabolic syndrome, enlarged heart, increased stress on the heart, and the list goes on.

Then there’s the obesity paradox. While study after study has shown that obesity dramatically increases the risk of heart failure, a significant number of studies have shown that persons who are overweight or obese have lower mortality rates related to heart failure compared to people of normal weight. They are more likely to have heart failure, but less likely to die from it. It is a paradox that has perplexed the medical community
for decades.

The Paradox Debunked?

In 2018, the obesity paradox was challenged by a study of nearly 300,000 people published in the European Heart Journal. The research showed that the risk of heart and blood vessel problems, such as heart attacks, strokes, and high blood pressure, increases as body mass index rises beyond healthy levels. The cardiovascular disease risk also increases steadily the more fat a person carries around their waist (see “Excessive Waist Fat Is a Risk Factor for Cardiovascular Disease”).

The new evidence, according to the authors, refute previous conflicting findings. They add, “Any public misconception of a potential protective effect of fat on heart and stroke risks should be challenged.”

Air Pollution

The AHA is on record stating that exposure to air pollution contributes to cardiovascular illness, including heart failure and mortality. Short-term exposure can increase the risk of heart attack, stroke, arrhythmias, and heart failure in susceptible people.

The risk is greater from long-term exposure. Air pollution may play a role in high blood pressure, heart failure, and diabetes. A study published in 2018 found a correlation between living near a busy road, which exposed residents to a pollutant, and having enlarged hearts (see “Low-Level Air Pollution Correlated with Heart Enlargement in Adults”).

Other Causes

The following conditions also are associated with the risk of heart failure:

• Heart valve infection
• Inflammation of the heart muscle
• Untreated rapid heart rhythms
• Anemia
• Pregnancy
• Hyperthyroidism
• Emphysema
• Sleep apnea

A Heart Remodeled

The extra workload on the heart causes the heart muscle to thicken, a process that occurs naturally with any muscle that is exercised. Unlike a bicep in the upper arm, a thickened heart muscle is not good. As the heart walls become thicker, the heart demands more oxygen and it becomes more difficult for the muscle to relax. These conditions cause the body to release various hormones, peptides, and inflammatory substances.

These neurohormonal changes lead to a phenomenon called remodeling, in which the left ventricle (the heart’s main pumping chamber) becomes enlarged, and the individual heart muscle cells change size and shape. Having the walls of the heart stretch may be beneficial at first, but like an overstretched rubber band, they eventually become too stretched to contract adequately.

Remodeling triggers an increase in heart rate initially, which helps the heart pump out more blood. Because it raises the demand for oxygen in the heart muscle, it may lead to myocardial ischemia—an inability to deliver enough oxygen-rich blood to the heart muscle.

Reduced blood flow to the inner layer of the heart muscle further impairs heart function. The increased heart rate has the potential to directly damage heart muscle.

Unless an attempt to restore balance is made, the cycle continues. The heart tries to compensate, and in time these efforts cause increasing damage. Eventually, heart failure may progress to the point where the heart no longer can compensate for the stresses placed on it. Breathlessness and fatigue become so severe that hospitalization is necessary.

At this point, heart failure is said to be decompensated, or acute. It implies a rapid onset of symptoms. American Nurse Today describes acute decompensated heart failure as a condition in which cardiac output fails to meet the body’s metabolic needs. It requires immediate treatment because it impairs organs and jeopardizes their function.

What’s Next?

A person can have heart failure and not even know it until symptoms develop. Chapter 3 describes the symptoms and what they mean.

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Heart failure is a life-changing disease, but a relatively common one because it is age-related, and the American population is getting older. The risk becomes even higher for those who are over age 65 and have had a heart attack.

Heart failure is treatable with a variety of non-invasive and surgical options. Often it can be prevented making heart-healthy lifestyle decisions. Even something as simple as walking can make a difference. A study at the University of Buffalo found that 30 to 45 minutes of daily walking reduced the risk of heart failure by nine percent (see “Walking May Protect Older Women Against Heart Failure”).

Defining Heart Failure

The American Heart Association (AHA) defines heart failure as a condition in which the heart does not pump blood as efficiently as it should. As a result, the heart cannot keep up with its workload, preventing the body from getting enough oxygen to operate normally.

In some cases, the heart gets too weak to adequately pump blood through the vascular system. In other instances, the heart muscle stiffens to a point at which it cannot adequately fill with blood. In both cases, fluid backs up into lungs and other tissues, which causes congestion and swelling. Although heart failure often is called “congestive heart failure,” congestion in the lungs is not always present. For that reason, it is now simply called “heart failure.”

Systolic vs. Diastolic Heart Failure

Heart failure is categorized according to “ejection fraction,” which is the percentage of blood the heart pumps out with each contraction. A normal ejection is 50 to 70 percent, according to the AHA.

Systolic heart failure, also called heart failure with reduced ejection fraction (HFrEF), occurs when the left ventricle becomes so large and contracts so weakly that it cannot efficiently expel blood to the body. People with this condition have an ejection fraction of 10 to 40 percent, which means their heart only pumps 10 to 40 percent of the blood in the ventricles with each beat. It is more common in men, probably because men are more likely to have heart attacks that lead to heart failure.

Diastolic heart failure, also called heart failure with preserved ejection fraction (HFpEF), occurs when pumping strength is preserved, but the ventricles become stiff and cannot expand properly to fill with blood—therefore, the heart cannot pump efficiently.

Diastolic heart failure is more common in women, probably because women tend to have high blood pressure, chronic disease, and other disorders that precede diastolic heart failure. Women with diastolic heart failure live longer than men with diastolic heart failure. But women tend to be hospitalized more frequently and have limited physical ability due to shortness of breath.

Trying to Compensate

Whatever the type of heart failure, the heart tries to compensate by either getting bigger (enlarging) to help pump blood to the rest of the body, by developing more muscle mass to become stronger (in the short term), or by beating faster to increase output. All three are short-term efforts that mask the problem. Sooner or later, they cause more problems than they solve.

Not a Stand-Alone Disease

Heart failure is seldom a stand-alone disease. It is associated with other underlying factors. A heart attack is the most obvious risk factor, but other examples are diseases that affect the heart muscle (cardiomyopathies), high blood pressure (hypertension), diabetes, heart valve disease, heart valve damage, congenital heart disease, cancer drugs and radiation, severe lung diseases, and obesity—all are discussed in Chapter 2.

Who Is Most Susceptible?

People ages 65 and older are susceptible because the heart muscle gets weaker with age. They also may have had a lifetime of diseases such as diabetes, cardiovascular disease, and hypertension that could have affected the heart’s function.

African Americans are more likely to have heart failure than other races, have symptoms at younger ages, have more hospital visits due to heart failure, and a higher mortality rate because of heart failure.

People who are overweight put a greater-than-normal strain on the heart. The excess weight also increases the risk of other heart diseases and type 2 diabetes.

People who have had a heart attack may have heart damage that weakens the heart muscle and can lead to heart failure.

Children who have congenital heart defects can develop heart failure. Congenital heart defects make the heart work harder, which weakens the heart muscle and can lead to
heart failure.

Concerning Condition

The heart failure problem is getting worse. An estimated 6.5 million Americans show symptoms of the condition, while 5.7 million actually have been diagnosed with heart failure, and the AHA expects that number to grow to 8 million in the next decade.

As noted earlier, heart failure is related to age and to an increase in the number of people who have had heart attacks. An estimated 75 percent of people ages 65 and older who have a heart attack will develop heart failure within five years, according to a 2018 study published in the American Heart Association’s journal Circulation. Hospitalization rates for those with heart failure increased in all race and gender groups.

A more alarming finding of the study showed that the average one-year mortality rate for patients hospitalized for the first time with acute heart failure was near 30 percent, regardless of race, gender, or type of heart failure. Acute heart failure is defined as a rapid onset of new or worsening signs of heart failure.

Although recent research has shown that heart failure survival rates are improving, survival varies in different population groups. Systolic heart failure was more common in African American and Caucasian men, while diastolic heart failure was more common in Caucasian women. Hospitalization rates for acute heart failure rose over time, with higher rates in African American people and rising rates in patients with diastolic heart failure.

Costly Chronic Disease

The cost of cardiovascular diseases, including heart failure, is staggering and increasing. Below are some examples provided by the American Heart Association/American Stroke Association and peer-reviewed scientific journals:

• Heart failure in the U.S. costs $31 billion annually, including health-care services, medications to treat heart failure, and missed days of work. These costs are expected to rise to $70 billion by 2030.
• Worldwide, 1 to 2 percent of health-care budgets are spent on heart failure.
• Stroke and heart failure are the most expensive chronic conditions among Medicare patients.
• Expenses for stroke and heart failure are expected to rise dramatically in the next decade.
• The number of people diagnosed with heart failure is projected to rise by 46 percent by 2030.
• By the year 2035, half of the U.S. population will have some form of cardiovascular disease.
• The average cost of a heart failure-related hospitalization is $14,631.

A Pump of Muscle Tissue

Before describing some of the ways a heart can begin to fail, it’s important to understand how a normal heart is supposed to operate.

One Purpose

The heart is the control center of a network of blood vessels that delivers oxygen-carrying blood to every part of the body. The heart is basically a pump. It is made of muscle tissue with strong walls that contract and relax in a coordinated method to expel blood throughout the body at a rate of five or six liters (about 20 cups) per minute at rest. The body’s vital organs need this much oxygen-rich blood to function.

Four Chambers

The heart has four chambers: two upper chambers called atria and two lower chambers known as ventricles. Valves placed between these chambers open and close at the right moments to direct blood flow through the heart and out to the body without allowing it to back up. The atria pump blood into the ventricles, and the ventricles pump blood out into the lungs and body. The heart has to squeeze forcefully to pump blood to all parts of the body, but it also must relax between beats to fill properly with blood. If either part is damaged or weakened, heart failure can result.

Three Responsibilities

To maintain its normal function, the heart has to constantly perform these three tasks:

• Keep the blood flowing efficiently. The heart’s four valves are designed to keep blood flowing in the right direction. If and when the blood starts to back up instead of moving forward, one of the consequences is heart failure. Blood takes about 20 seconds to circulate throughout the entire vascular system.
• Maintain the heart muscle’s health. The heart needs its own supply of oxygenated blood and other nutrients to stay healthy. A healthy heart can properly contract and relax. Both phases affect the ability of the heart to pump out enough blood with each beat.
• Regulate the heartbeat’s timing. The heart’s electrical system maintains your heart rate (number of contractions per minute) and rhythm (regularity of heart beats). The normal resting heart rate for an adult is 60 to 100 beats per minute. Problems with this system can cause an arrhythmia, which means that your heart chambers are beating in an uncoordinated way: Your heart may beat too fast (tachycardia) or too slow (bradycardia).

Living Longer, Healthier

There are reasons to be optimistic about living with heart failure, as the condition can be treated. Scientists, physicians, and clinicians are developing new drugs and surgical procedures every year that relieve heart failure symptoms. Making lifestyle changes can extend life for some patients and prevent, slow the progression of, or delay the problem for others.

What’s Next?

Chapter 2 describes nine underlying problems that could lead to heart failure and how to avoid them.

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ambulatory monitors: Portable electrocardiograph machines that record and measure changes in blood pressure throughout the day.

angina (angina pectoris): Discomfort or pain in the chest, neck, jaw, or arms that occurs when fatty plaques that narrow coronary arteries interfere with blood supply to the heart muscle.

angiotensin converting enzyme (ACE) inhibitors: Drugs that dilate blood vessels to improve the heart’s output and increase blood flow to the kidneys.

angiotensin receptor blockers (ARBs): Drugs that dilate blood vessels by blocking the effects of angiotensin II at the tissue level. ARBs are similar to ACE inhibitors but have fewer side effects.

antiarrhythmics: Drugs that control the heart’s rhythm.

anticoagulants: Drugs that prevent blood from clotting.

aorta: The large, main artery exiting the heart.

aorta valve: The valve that controls the flow of blood between the heart and the aorta.

arrhythmias: Abnormal heart rhythms.

atherosclerosis: Hardening or narrowing of the arteries due to deposits of fatty substances, cholesterol, calcium, and fibrin that slow or block blood flow.

atrial fibrillation (A-fib): A heart-rhythm disorder (arrhythmia) in which the upper chambers of the heart contract rapidly, creating a fast, irregular heart rhythm.

bendopnea: Shortness of breath when bending over at the waist.

beta-blockers: Drugs that modulate the activity of the sympathetic nervous system, slowing the heart rate and reducing blood pressure.

blood clot (thrombus): A clot forms when clotting factors in the blood cause it to coagulate or become a jelly-like mass.

bradycardia: A heartbeat that is too slow.

bypass: A surgical procedure that increases blood flow to an organ or extremity by rerouting blood around a blocked artery.

calcification: A process in which tissue becomes hardened due to deposits of calcium salts and is a factor in the development of atherosclerosis.

calcium-channel blocker: A drug that reduces blood vessel spasms, lowers blood pressure, and controls angina.

cardiac catheterization: An imaging procedure that involves inserting a catheter into a blood vessel in the arm or leg and guiding it to the heart with the aid of x-ray movies. Contrast dye injected through the catheter allows the coronary arteries to be seen.

cardiac output: The amount of blood the heart pumps out in one minute, measured in liters per minute.

cardiac resynchronization therapy: A method of making the ventricles contract properly by implanting a pacemaker.

cardiomyopathies: A group of diseases that primarily affect the heart muscle.

chronic: A condition in which a disease (like heart failure) is long-lasting.

clinical trials: Research studies that test medical treatments in humans, best designed when subjects are randomly assigned to treatment groups.

congestion: Excess fluid in the tissues and organs.

chronic obstructive pulmonary disease (COPD): A progressive condition that slowly damages the tissues of the lungs.

coronary artery disease (CAD): A build-up of fatty material in the walls of the coronary artery (atherosclerosis) that narrows the artery.

cyanosis: Blue lips and fingernails caused by inadequate oxygenated blood in the extremities.

diabetes: A disease that affects the body’s ability to metabolize sugar, either because the pancreas does not produce insulin (type 1 diabetes) or because the body is resistant to the effects of insulin (type 2 diabetes).

diastolic pressure: The blood pressure in the arteries when the heart is filling with blood. It is the lower (bottom) of two blood pressure measurements.

digoxin: A drug that increases the heart’s pumping ability.

dilated cardiomyopathy: A condition in which all chambers of the heart enlarge, making the ability of the left ventricle to contract weaker.

diuretics: Drugs (water pills) that remove excess fluid from the tissues and bloodstream, lessen swelling, and make breathing easier.

Doppler echocardiogram: A regular echocardiogram that also assesses blood flow by measuring changes in the frequency of sound waves.

double-blind trials: A clinical study in which neither the researchers nor the patients know which therapy any patient has received until the study is over.

dyspnea: Shortness of breath.

echocardiogram (ECG or EKG): An imaging procedure that creates a moving picture of the heart’s valves and chambers that is used to evaluate blood flow through the heart’s valves.

edema: Swelling from water retention.

ejection fraction: The percentage of blood in the ventricles pumped out with each beat. A normal ejection fraction is 50 to 70 percent. The lower the percentage, the more advanced the heart failure.

exercise stress test: A test used to provide information about how the heart responds to stress that usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty.

fibrin: A protein that forms a blood clot.

heart failure: A chronic, progressive disease in which the heart muscle weakens and no longer can pump enough blood to meet the body’s needs.

hibernating myocardium: Heart muscle cells that appear dead after a heart attack but revive after blood flow is restored.

hypertension: High blood pressure.

hyperkalemia: Elevated potassium levels.

hypertrophic cardiomyopathy: An increase in the muscle mass and thickness of the left ventricle, which decreases the interior size of the ventricle.

idiopathic: A disease or condition of unknown cause.

inotropic agent: A type of drug that stimulates the heart to contract.

ischemia: Inadequate blood supply to the heart muscle (or any other organ or tissue).

left-sided heart failure: A condition in which the left side of the heart has to work harder to pump the same amount of blood.

left ventricular assist device (LVAD): An implanted mechanical device that pumps blood directly to assist a failing heart.

lumen: The inside space of an artery.

mitral valve: The valve between the left atrium and the left ventricle of the heart.

myocardial perfusion: A measure of how the heart muscle is nourished by blood.

myocardium: The heart muscle.

pacemaker: An electronic device that is implanted under the skin and sends electrical impulses to the heart muscle to maintain a desired heart rate.

pericardium: The sac that surrounds the heart.

progressive: A disease or condition (like heart failure) that keeps getting worse unless treated.

pulse rate: The number of heartbeats per minute.

placebo: An inactive pill, capsule, or device used in clinical trials.

plaque: Fatty deposit caused by atherosclerosis.

pulmonary valve: The valve that controls the flow of blood from the heart to the lungs.

rales: Crackling noises in the lungs that can be heard with a stethoscope.

regurgitation: Backflow of blood, causing it to leak backward instead of moving forward.

remodeling: Changes in the size, shape, and function of the heart and its blood vessels.

revascularization: Procedures, such as coronary artery bypass grafting and balloon angioplasty with stenting, that restore or increase blood flow through a coronary artery.

right-sided heart failure: A condition in which blood backs up in the right side of the heart and causes swelling or congestion in the legs, ankles, abdomen, or lungs.

septal heart defects: Holes in the “wall” or septum separating the two sides of the heart.

septum: The wall between the two sides (left and right) of the heart. There is a septum between the upper chambers (atria) and lower chambers (ventricles).

stroke volume: The amount of blood pumped out each time the heart contracts.

systolic pressure: The pressure of the blood in the arteries when the heart contracts. It is the higher (top) of two blood pressure measurements.

tachycardia: A heartbeat that is too fast.

vasodilators: Drugs that cause blood vessels to relax, improving blood flow.

ventricular fibrillation: An abnormal heart rhythm that is similar to atrial fibrillation but causes the ventricles (the lower chambers of the heart) to quiver in a rapid and uncoordinated way. Unless treated immediately, death may occur.

ventricular tachycardia: An abnormal heart rhythm (possibly a medical emergency) characterized by a heart rate of 100 beats per minute or more, combined with three or more irregular beats in a row.

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• Heart attack
• High blood pressure
• Coronary artery disease
• Heart valve disease
• Abnormal heart rhythms
• Diseases of the heart muscle (cardiomyopathies)
• Diabetes

There are two types of heart failure: systolic and diastolic. In systolic heart failure (which is more common in men), the left ventricle becomes enlarged and contracts so weakly that it can’t pump blood from the heart to the body. In diastolic heart failure (more common in women), the heart’s pumping strength is preserved—however, the ventricles don’t relax sufficiently between beats, meaning they can’t fill properly with blood.

Heart Failure Basics

If you have heart failure, you will be monitored by your doctor in order to ensure that your condition doesn’t worsen. If your heart failure is considered stable, you may only see your doctor two to four times per year—and with this in mind, Mount Sinai cardiologist Bruce Darrow, MD, PhD, emphasizes the importance of self-monitoring between doctor visits. “The cornerstone of managing patients with heart failure is symptom reporting,” he says. “Recognizing the warning signs of worsening heart failure and alerting your doctor can sometimes help you avoid hospital admission. A simple change in your medication, for example, may be all that is needed to prevent your heart function from deteriorating further.”

Dr. Darrow points to these areas as key when it comes to being vigilant about your health if you have heart failure:

• Exercise capacity: One of the two systems your doctor may use to classify the severity of your heart failure is based on your ability to engage in physical activity (see “How Heart Failure Severity is Classified,” below).

  Exercise is just as good for people with heart failure as it is healthy individuals: research shows it can improve quality of life for heart failure patients, as well as reduce symptoms, hospital re-admissions, and mortality. Check with your doctor about what types of exercise are suitable for you, and what level of intensity you should aim for (also ask about local cardiac rehabilitation programs, since these are individualized and supervised).

  As a rule, combine aerobic activities like walking, swimming or cycling with flexibility exercises (yoga, tai chi) and strength training (check weight limits with your doctor). “Exercise at whatever time of day you tend to have the most energy,” Dr. Darrow advises. “You may be advised to avoid certain exercises, and modify exercise intensity in certain conditions—for example, hot weather.”

  When you’re exercising, you can expect to feel short of breath (see below). Your heart rate will also increase, and you’ll sweat. However, if you feel very short of breath and experience dizziness, pause for a rest. “Call your doctor if the symptoms return once you begin exercising again, and also if your heart rate increases above 130-140 beats per minute,” Dr. Darrow cautions. “If you experience pain and/or a sensation of pressure or tightness in your chest, shoulder, arm and/or jaw, immediately stop exercising and call 911.”

• Shortness of breath: This is a common symptom for people with heart failure, and occurs because a failing heart can’t effectively pump blood out to the body. One of the results of this is that fluid accumulates in the lungs, causing shortness of breath (known as dyspnea).

In mild heart failure, you may feel short of breath only when exercising. But if you start to notice that you’re breathing harder than usual while exercising or when you’re at rest, or if you wake from sleep feeling short of breath, tell your doctor.

“No longer being able to lie flat is a marker for worsening heart failure,” Dr. Darrow notes, “so if your doctor has previously advised you to prop yourself up on pillows while sleeping to avoid shortness of breath, tell him or her if you find that you now need more pillows than before.”

• Fatigue: Heart failure causes fatigue because your heart’s decreased pumping ability reduces the amount of oxygen reaching your muscles. Staying physcially active can help you build up your exercise capacity, but if you feel more fatigued than usual while exercising, mention it to your doctor. “It’s a good idea to keep a daily journal noting your energy levels at different times and after any exercise sessions,” Dr. Darrow advises. “It can help identify a pattern of increased fatigue.”
SOURCES & RESOURCES
HOW HEART FAILURE SEVERITY IS CLASSIFIED
If you have heart failure, your doctor will classify its severity using one of two systems:
• New York Heart Association. This divides patients into groups according to how impaired they are when it comes to physical activity. Class I patients are able to engage in physical activity without undue fatigue, heart palpitations, dyspnea (shortness of breath), and chest pain (angina). The classification progresses through Classes II (mild-to-moderate), III (moderate) and IV (severe), with each category marking an increase in symptoms.
• American College of Cardiology/American Heart Association. This classifies heart failure based on its progression rather than on a patient’s functional capacity. Stage A includes people who are high risk for heart failure but have no structural disorder of the heart, Stage B is for those who have a structural disorder but exhibit no heart failure symptoms, Stage C is for people with heart failure symptoms caused by underlying structural disease, and Stage D includes patients with end-stage heart failure.
• Blood pressure: You will likely be advised to monitor your blood pressure at home, since it is an important measure of your heart health and how well your medications are working. Ask your doctor what range of measurements is right for you, and call him or her if your blood pressure is higher than normal. Dr. Darrow recommends that you purchase a digital blood pressure monitor with a cuff than inflates automatically. “Research suggests that arm cuffs are more accurate than wrist cuffs,” he adds.

• Increasing weight: Checking your weight is an important part of daily self-monitoring if you have heart failure—however, research suggests that fewer than half of heart failure patients do this, even if they have been recently discharged from hospital after an exacerbation of their condition.

  “Excess weight is a major risk factor for worsening heart failure, so be sure to follow a healthful, nutritious Mediterranean-style diet that prioritizes fresh fruits and vegetables, and whole grains,” Dr. Darrow says. “Limit your sodium intake too—sodium causes the body to retain fluid, which increases blood volume and gives your failing heart a heavier workload.”

  Weigh yourself daily, after urinating and before eating, and report any weight gain of two to three pounds or more in two days to your doctor, since this can signal fluid retention. Also stay alert for abdominal bloating (your clothes may seem tighter), and swelling in your fingers (rings may feel tighter) and feet (shoes may feel tighter), which also can signal fluid retention.

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]]> https://universityhealthnews.com/daily/heart-health/what-is-cardiomyopathy/ Mon, 14 Aug 2017 19:06:17 +0000 https://universityhealthnews.com/?p=89648 Nearly half of all heart failure cases are caused by diseases that primarily affect the heart muscle. Together, these are known as cardiomyopathies. What is cardiomyopathy? Cardiomyopathy is a heart disease that often occurs without a known reason, but can be caused by various medical conditions, including infections (usually viral), metabolic disorders, endocrine disorders, and […]

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]]> Nearly half of all heart failure cases are caused by diseases that primarily affect the heart muscle. Together, these are known as cardiomyopathies. What is cardiomyopathy? Cardiomyopathy is a heart disease that often occurs without a known reason, but can be caused by various medical conditions, including infections (usually viral), metabolic disorders, endocrine disorders, and adverse reactions to medications. A cardiomyopathy may have an autoimmune or genetic component, and can also be associated with alcohol or drug abuse, pregnancy, and prior radiation or chemotherapy.

Certain forms of heart failure appear to have a genetic basis. An analysis of participants in the Framingham Heart Study showed a 70 percent increased risk of heart failure in people who had a parent with heart failure. In 10 years of follow-up, 2.7 percent of study participants with a family history of heart failure developed heart failure themselves, compared with 1.6 percent in those without a family history of heart failure. This means that patients who have heart failure from cardiomyopathy may want to encourage their children to be screened with a simple ultrasound test. The chance they have not inherited an increased risk of heart failure is very good. However, if early signs of heart failure are found, medications and lifestyle changes may be needed to delay its development.

It is hoped that genetic studies now underway, specifically those focused on genetic mutations associated with cardiomyopathies, will allow earlier diagnosis and treatment, or identification of preventive measures to delay or prevent the development of heart failure.

There are three major forms of cardiomyopathy, all of which may have a genetic component:

Dilated Cardiomyopathy

In this form, all chambers of the heart enlarge (dilate), and the ability of the left ventricle to contract is weakened. More blood than normal remains in the enlarged ventricle after a heartbeat, meaning less blood is pumped out with each contraction.

In dilated cardiomyopathy, the electrical signals that stimulate the heart to contract are sometimes unable to follow the right path, because the ventricle walls have been stretched out. As a result, in about 30 percent of patients with this condition, the free wall and septum of the left ventricle move out of synch, making ejection more difficult. This is called dyssynchrony, and it causes the ejection fraction to drop and heart failure to worsen.

A procedure called cardiac resynchronization therapy (CRT) can help make the ventricles contract properly. CRT involves implanting a biventricular pacemaker, usually in the left front chest below the collarbone. Its electrodes are programmed to stimulate both sides of the heart to contract at the same time. The procedure improves heart function, causing less need for diuretics. CRT also improves heart failure symptoms and quality of life, and reduces complications and the risk of sudden death. It may also improve left ventricular function, and reverse remodeling in some patients.

Hypertrophic Cardiomyopathy

This form of cardiomyopathy is characterized by an increase in muscle mass and thickness of the left ventricle, which decreases the interior size of the ventricle. It can be obstructive or non-obstructive.

In hypertrophic obstructive cardiomyopathy (HOCM), the wall between the two ventricles (septum) becomes enlarged and obstructs blood flowing out of the left ventricle.

In non-obstructive hypertrophic cardiomyopathy, the thickened muscle does not obstruct blood flow and may contract vigorously, but it becomes stiff and is unable to relax normally. This causes improper filling between heartbeats: Less blood enters the ventricle, so less blood is pumped out. Improper filling causes blood to back up in the veins of the lungs, producing high blood pressure in the lungs (secondary pulmonary hypertension).

Because of the strong genetic component of hypertrophic cardiomyopathy, anyone diagnosed with the disease should encourage their children and siblings to have an echocardiogram and, possibly, a genetic test. At minimum, they should receive genetic counseling. Recent research indicates their risk of having heart failure or hypertrophic cardiomyopathy is 70 percent greater than normal.

Restrictive Cardiomyopathy

In this type of cardiomyopathy, the heart is stiff and cannot fill properly, even though its pumping strength may be normal. An insufficient amount of blood enters the heart, so too little is pumped out. This uncommon form of cardiomyopathy may be caused by abnormal scarring (fibrosis), abnormal infiltration of the heart muscle with iron (hemochromatosis) or protein (amyloid), or unknown reasons.

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]]> https://universityhealthnews.com/topics/heart-health-topics/heart-failure-treatment-options/ Fri, 23 Jun 2017 17:35:26 +0000 https://universityhealthnews.com/?p=87881 A new report from the American Heart Association (AHA) suggests that U.S. heart failure rates are rising. The number of Americans who have the condition increased from about 5.7 million between 2009 and 2012 to about 6.5 million between 2011 and 2014, according to the AHA’s Heart Disease and Stroke Statistics Update—2017. The uptick in […]

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]]> A new report from the American Heart Association (AHA) suggests that U.S. heart failure rates are rising. The number of Americans who have the condition increased from about 5.7 million between 2009 and 2012 to about 6.5 million between 2011 and 2014, according to the AHA’s Heart Disease and Stroke Statistics Update—2017.

The uptick in heart failure can partly be attributed to medical advances that mean more people are surviving heart attacks, which raise the risk for heart failure. Cardiomyopathies (diseases that affect the heart muscle) are also a major underlying cause. Other common health issues—including coronary artery disease (in which the arteries that nourish the heart become blocked or narrowed by fatty deposits called plaque), heart valve problems, high blood pressure, diabetes, severe lung disease, and obesity—also make you more vulnerable to heart failure, as does increasing age.

Quality of Life Suffers Heart failure can drastically impact your quality of life—studies suggest that many seniors with the condition find simple activities of daily living, such as grocery shopping and walking moderate distances, a challenge. Heart failure patients often need to utilize home care services, and about 10 percent eventually need nursing home care. Even so, heart failure is treatable, says Mount Sinai cardiologist Bruce Darrow, MD, PhD. “Therapeutic advances, along with appropriate lifestyle changes, can markedly improve survival and quality of life for many people with the condition,” he observes. These measures are most effective when started as early as possible, so get informed about heart failure symptoms (see our April issue for more on the symptoms that suggest existing heart failure may be worsening), and mention any concerns to your doctor.

Heart Failure Medications A range of medications is used to treat heart failure, with the most effective option and dosage varying according to how severe the condition is. Heart failure drugs are designed to lower your blood pressure, stabilize your heart rate, and improve your heart’s pumping ability.

• To lower high blood pressure, which increases the heart’s workload, most patients are treated with an angiotensin converting enzyme (ACE) inhibitor, such as lisinopril (Prinivil®, Zestril®) or enalapril (Vasotec®), or an angiotensin receptor blocker (ARB), such as valsartan (Diovan®) or candesartan (Atacand®). “ACE inhibitors and ARBs have both been demonstrated to help patients with heart failure live longer, though most patients will be on one type or the other, not both,” Dr. Darrow says. He adds that these drugs also improve exercise tolerance, and may help prevent a phenomenon called “remodeling.” This is a heart failure side effect in which the left ventricle (the heart’s main pumping chamber) enlarges. “While remodeling initially helps the heart pump out more blood, it increases the heart’s demand for oxygen,” Dr. Darrow explains, “and over time, the walls of the heart muscle become too stretched to contract effectively.”
• Other first-line drugs include diuretics and beta-blockers. Diuretics, which include hydrochlorothiazide (Hydrodiuril®), and spironolactone (Aldactone®), lower blood pressure by helping the body eliminate excess fluid and sodium. “Beta-blockers are another blood pressure medication, but this class of drugs also may reverse remodeling, and slow the heart rate,” Dr. Darrow says. “This is important, since an increased heart rate may raise the risk for hospitalization and death in heart failure patients.” Options approved to treat heart failure include bisoprolol (Zebeta®), carvedilol (Coreg®), and metoprolol (Toprol®). “These beta-blockers have also been shown in studies to help heart failure patients live longer,” Dr. Darrow notes.
• Drugs that may be added to this regimen include statins, and anti-arrhythmia drugs if necessary. “Digoxin also may be prescribed,” Dr. Darrow adds. “At low doses, this medication can improve symptoms, functional capacity, exercise tolerance, and quality of life for people with heart failure.” Some patients also may benefit from taking aldosterone antagonists like spironolactone (Aldactone®) or eplerenone (Inspra®). These have a diuretic effect, and research also suggests that they may reverse remodeling, and improve survival.

Help Yourself With Lifestyle Measures Following a healthy lifestyle and avoiding unhealthy habits can slow the progression of heart failure and improve your quality of life, as well as help you avoid a second heart attack if that is what caused your heart failure.

• Quit smoking This is one of the most important lifestyle measures you can take, since smoking damages the lining of arteries. If you find it hard to quit, speak to your doctor about smoking cessation methods, programs, and counseling.
• Get plenty of rest, and don’t schedule too many activities in one day. Ensure you get enough sleep at night by avoiding caffeine and alcohol in the late afternoon and evening, developing “bedtime rituals” to signal your body that it’s time to wind down ahead of sleeping, and going to bed and getting up at about the same time every day. If you suspect that your medications may be interfering with your sleep, ask your doctor if the dosage time can be adjusted.
• Don’t avoid exercise While rest is important, Dr. Darrow emphasizes that you shouldn’t avoid exercise. “Studies suggest that even light exercise can improve heart failure patients’ quality of life, and reduce symptoms, mortality, and hospital readmissions,” he says. “Exercise also will provide an energy boost, help you sleep better, and aid in managing your weight.” He recommends you ask your cardiologist how much exercise you can do each day, and what kind of activities are best. Walking is a good, gentle exercise—aim to walk for 30 minutes each day, and keep in mind that you can spread this across three 10-minute walks. Also consider taking part in a cardiac rehabilitation program (see box)—ask your doctor about local programs if you are not referred to one.
• A heart-healthy diet is vital Research suggests that the Mediterranean diet and Dietary Approaches to Stop Hypertension (DASH) diet may offer protection against death from heart failure. Both approaches prioritize fruits, vegetables, whole grains, and healthy fats, and limit the saturated fat and sodium that can harm cardiovascular health. Your doctor also may advise that you limit your intake of fluids, since too much fluid exacerbates swelling and increases the workload on your heart. Be sure to count fluid-based foods (including soup, pudding, frozen yogurt, applesauce, and all fruits, particularly citrus) against your daily fluid allowance. “Also limit your alcohol intake to no more than one drink per day,” Dr. Darrow adds, “and count it against your fluid allowance.”

Surgical Options If heart failure worsens, surgery may be recommended.

• Coronary artery bypass surgery is an option if CAD is affecting your heart function—however, this is major open surgery that is carried out less often since the development of angioplasty.
• Angioplasty is performed using a catheter inserted into an artery through a small incision in the arm or groin. “At the tip of the catheter is an inflatable balloon, which is fed through the artery to the blocked coronary artery,” Dr. Darrow explains. “Once in position, the balloon is expanded to compress plaque, thus clearing the blockage.” This method also may be used to position a stent: a tiny mesh tube that remains in place to keep the artery open once the catheter is removed.
• Surgery also can be used to replace faulty heart valves, and repair underlying congenital defects.
• Cardiac resynchronization therapy (CRT) may be an option for patients who have slow conduction of electricity across the heart. It involves having a small device called a biventricular pacemaker implanted under the skin of the chest. Electrodes are threaded through a vein in the heart and positioned in the right atrium (upper chamber) and both ventricles (lower chambers). “The electrodes stimulate both chambers of the heart so they contract in a synchronized manner,” says Dr. Darrow.

A similar device, called an implantable cardioverter defibrillator (ICD, see image above) monitors the heart’s rhythm for signs of impending cardiac arrest (which kills about half of all heart failure patients), and delivers a mild electric shock if necessary to reset the rhythm. “Some patients benefit from both CRT and ICD therapy, and might receive a combined CRT-D device,” Dr. Darrow says. “In appropriate patients, both CRT and ICD therapy help extend life.”   

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]]> https://universityhealthnews.com/daily/heart-health/understand-the-different-types-and-causes-of-cardiomyopathy/ Wed, 24 May 2017 07:00:34 +0000 https://universityhealthnews.com/?p=86189 You may know cardiomyopathy as a type of heart disease, but it’s actually more than that. Cardiomyopathy is really a group of diseases affecting the heart muscle. There are several kinds of cardiomyopathies, and each one has its own set of possible causes and outcomes. One of the common characteristics of cardiomyopathies is that the […]

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]]> You may know cardiomyopathy as a type of heart disease, but it’s actually more than that. Cardiomyopathy is really a group of diseases affecting the heart muscle. There are several kinds of cardiomyopathies, and each one has its own set of possible causes and outcomes.

One of the common characteristics of cardiomyopathies is that the heart muscle becomes bigger and sometimes weaker. In many cases, cardiomyopathy can lead to heart failure and possibly the need for a heart transplant. But depending on the type of cardiomyopathy they have (they may be mechanical or electrical problems), some individuals can live with the condition a long time.

Categorizing Cardiomyopathy Types

Some types of cardiomyopathy are acquired, while others affect those who are genetically predisposed to the condition. There are several classifications for cardiomyopathies. One way cardiomyopathies are categorized is as a primary or secondary cardiomyopathy.

Primary cardiomyopathy is a condition in which only the heart is involved. Some types of primary cardiomyopathy are passed from one generation to the next because of an abnormal gene. Secondary cardiomyopathy is a condition associated with multiorgan involvement including the heart. Examples include amyloidosis, sarcoidosis, and systemic lupus erythematosus. The treatment goal for secondary cardiomyopathies is to manage the underlying cause, as well as the heart manifestations.

Types of Cardiomyopathy

Understanding the nature of cardiomyopathies will be helpful if you or someone you know receives such a diagnosis. The following is a list of common and rare cardiomyopathies, as well as some details of these potentially serious diseases.

• Dilated cardiomyopathy: The ventricles (the heart’s two lower chambers) enlarge and then grow weaker. Dilated cardiomyopathy usually starts in the left ventricle, and can eventually affect the right one, too. The left ventricle pumps blood out through the aorta to the body. The right ventricle pumps blood out to the lungs to exchange carbon dioxide for oxygen. If the ventricles start to pump blood less effectively, the heart muscle works harder to meet the body’s demands for oxygenated blood. Over time, this causes the heart to weaken more, which can eventually result in heart failure—the inability of the heart to effectively pump enough blood to meet the body’s demand.

  Dilated cardiomyopathy, experts say, is probably the most common cardiomyopathy worldwide. Some cases cause acute symptoms that require hospitalization and even advanced life support. Others may be chronic but stable. Causes can include infections, drugs, alcohol use, and gene mutations in up to 35 percent of cases.

  Patients of dilated cardiomyopathy should usually be treated with beta blockers, and sometimes with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and sometimes diuretics, including spironolactone. A newer medication, Entresto, combines an ARB and a neprilysin inhibitor.

• Hypertrophic cardiomyopathy (HCM): HCM is associated with mutations in the heart muscle proteins (sarcomeres) in over half of cases. The ventricles and the septum (the wall separating the right and left sides of the heart) thicken. This may cause an obstruction that prevents blood from exiting the heart to the body. In addition to causing a stiffening of the ventricles, HCM can also cause mitral valve problems and changes in the cellular structure of the heart. These changes can lead to changes in the heart’s electrical activity and abnormal heart rhythms (arrhythmias).

Hypertrophic cardiomyopathy may yield, for some, few symptoms and may not preclude a normal life expectancy. Others may advance to a state where they have weakened hearts and must address heart failure, atrial fibrillation, or risk of sudden cardiac death.

First-line treatment for HCM is usually beta blockers and calcium channel blockers. Other medications may be needed to help control heart rate. Patients at risk for sudden cardiac death may also receive an implantable cardioverter defibrillator (ICD) to help control their arrhythmia.

• Arrhythmogenic right ventricle dysplasia (ARVD): This condition sometimes goes by other names, such as right ventricular cardiomyopathy and right ventricular dysplasia. It’s a rare condition that occurs when tissue in the right ventricle dies and is replaced with scar tissue. People with ARVD usually have an arrhythmia, which can raise the risk of sudden cardiac death, especially in young people.

  ARVD often runs in families. It appears that certain gene abnormalities affect the proteins in the heart muscle, which eventually lead to ARVD.

  Gene testing for cardiomyopathy is still in its early stages, and there are clinical trials going on now that could result in medications that can prevent the development of inherited cardiomyopathy.

Other Types of Cardiomyopathy

Among the least common types of cardiomyopathy is restrictive cardiomyopathy, which occurs when the walls of the ventricles become abnormally stiff and don’t have the flexibility to allow the chambers to fill with blood in between each heartbeat. As with most other forms of cardiomyopathy, heart failure is a likely outcome of restrictive cardiomyopathy.

There are other forms of cardiomyopathy, including chemotherapy-induced cardiomyopathy. This can occur when cancer-fighting drugs used during chemotherapy harm the heart muscle. A branch of medicine called cardio-oncology is designed to help patients receive effective cancer treatment while preserving heart function.

A cardio-oncologist is one of many types of doctors that treat cardiomyopathy. Some doctors specialize primarily in HCM, or in dilated cardiomyopathy, or any of the other forms of this disease.

One form of the condition, known as peripartum cardiomyopathy, develops during pregnancy. It’s a rare form of heart failure that is, fortunately, often reversible after the birth of the child. Many women who experience peripartum cardiomyopathy regain most if not all of their heart function. Also, a stress cardiomyopathy—referred to sometimes as broken heart syndrome—is triggered by emotional or physical stress and is more common in older women. Fortunately, this type of cardiomyopathy is also reversible.

Be Proactive

While you can’t prevent inherited forms of cardiomyopathy, you can try to manage certain risk factors that might increase your odds of developing acquired types of the disease.

Even if you carry a gene for cardiomyopathy, you should still try to manage your blood pressure and cholesterol and control your alcohol consumption. A healthy diet and daily exercise are also advised for everyone, not just those at risk of a heart condition such as cardiomyopathy.

If there are cases of cardiomyopathy in your family history, get a screening—an electrocardiogram, echocardiogram, and possibly gene testing, even if you have no obvious symptoms.

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]]> https://universityhealthnews.com/topics/heart-health-topics/stay-vigilant-for-worsening-heart-failure/ Tue, 21 Mar 2017 18:31:58 +0000 https://universityhealthnews.com/?p=84420 More than five million Americans have heart failure, and 500,000 more cases are diagnosed each year. The condition develops gradually, due to injury to or weakness of the heart—underlying causes include heart attack, high blood pressure, coronary artery disease, heart valve disease, abnormal heart rhythms, diseases of the heart muscle (cardiomyopathies), and diabetes, among other […]

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]]> More than five million Americans have heart failure, and 500,000 more cases are diagnosed each year. The condition develops gradually, due to injury to or weakness of the heart—underlying causes include heart attack, high blood pressure, coronary artery disease, heart valve disease, abnormal heart rhythms, diseases of the heart muscle (cardiomyopathies), and diabetes, among other conditions.

There are two types of heart failure: systolic and diastolic. In systolic heart failure (which is more common in men), the left ventricle becomes enlarged and contracts so weakly that it can’t pump blood from the heart to the body. In diastolic heart failure (more common in women), the heart’s pumping strength is preserved—however, the ventricles don’t relax sufficiently between beats, meaning they can’t fill properly with blood.

If you have heart failure, you will be monitored by your doctor in order to ensure that your condition doesn’t worsen. If your heart failure is considered stable, you may only see your doctor two to four times per year—and with this in mind, Mount Sinai cardiologist Bruce Darrow, MD, PhD, emphasizes the importance of self-monitoring between doctor visits. “The cornerstone of managing patients with heart failure is symptom reporting,” he says. “Recognizing the warning signs of worsening heart failure and alerting your doctor can sometimes help you avoid hospital admission. A simple change in your medication, for example, may be all that is needed to prevent your heart function from deteriorating further.”

Dr. Darrow points to these areas as key when it comes to being vigilant about your health if you have heart failure:

1. Exercise Capacity One of the two systems your doctor may use to classify the severity of your heart failure is based on your ability to engage in physical activity (see How Heart Failure Severity is Classified, below).

Exercise is just as good for people with heart failure as it is healthy individuals: research shows it can improve quality of life for heart failure patients, as well as reduce symptoms, hospital readmissions, and mortality. Check with your doctor about what types of exercise are suitable for you, and what level of intensity you should aim for (also ask about local cardiac rehabilitation programs, since these are individualized and supervised).

As a rule, combine aerobic activities like walking, swimming or cycling with flexibility exercises (yoga, tai chi) and strength training (check weight limits with your doctor). “Exercise at whatever time of day you tend to have the most energy,” Dr. Darrow advises. “You may be advised to avoid certain exercises, and modify exercise intensity in certain conditions—for example, hot weather.”

When you’re exercising, you can expect to feel short of breath (see below). Your heart rate will also increase, and you’ll sweat. However, if you feel very short of breath and experience dizziness, pause for a rest. “Call your doctor if the symptoms return once you begin exercising again, and also if your heart rate increases above 130-140 beats per minute,” Dr. Darrow cautions. “If you experience pain and/or a sensation of pressure or tightness in your chest, shoulder, arm and/or jaw, immediately stop exercising and call 911.”

2. Shortness of Breath This is a common symptom for people with heart failure, and occurs because a failing heart can’t effectively pump blood out to the body. One of the results of this is that fluid accumulates in the lungs, causing shortness of breath (known as dyspnea).

In mild heart failure, you may only feel short of breath when you are exercising. But if you start to notice that you are breathing harder than usual while exercising or when you are at rest, or if you wake from sleep feeling short of breath, tell your doctor. “No longer being able to lie flat is a marker for worsening heart failure,” Dr. Darrow notes, “so if your doctor has previously advised you to prop yourself up on pillows while sleeping to avoid shortness of breath, tell him or her if you find that you now need more pillows than before.”

3. Fatigue Heart failure causes fatigue because your heart’s decreased pumping ability reduces the amount of oxygen reaching your muscles. Staying physcially active can help you build up your exercise capacity, but if you feel more fatigued than usual while exercising, mention it to your doctor. “It’s a good idea to keep a daily journal noting your energy levels at different times and after any exercise sessions,” Dr. Darrow advises. “It can help identify a pattern of increased fatigue.”   

4. Blood Pressure You will likely be advised to monitor your blood pressure at home, since it is an important measure of your heart health and how well your medications are working. Ask your doctor what range of measurements is right for you, and call him or her if your blood pressure is higher than normal. Dr. Darrow recommends that you purchase a digital blood pressure monitor with a cuff than inflates automatically. “Research suggests that arm cuffs are more accurate than wrist cuffs,” he adds. (See our June 2016 issue for more tips on choosing and using a home blood pressure monitor.)

5. Increasing Weight Checking your weight is an important part of daily self-monitoring if you have heart failure—however, research suggests that fewer than half of heart failure patients do this, even if they have been recently discharged from hospital after an exacerbation of their condition. “Excess weight is a major risk factor for worsening heart failure, so be sure to follow a healthful, nutritious Mediterranean-style diet that prioritizes fresh fruits and vegetables, and whole grains,” Dr. Darrow says. “Limit your sodium intake too—sodium causes the body to retain fluid, which increases blood volume and gives your failing heart a heavier workload.”

Weigh yourself daily, after urinating and before eating, and report any weight gain of two to three pounds or more in two days to your doctor, since this can signal fluid retention. Also stay alert for abdominal bloating (your clothes may seem tighter), and swelling in your fingers (rings may feel tighter) and feet (shoes may feel tighter), which also can signal fluid retention.   

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