When the Heart gets Tired

Local St. Maarten health professionals received an update on hypertension statistics and were made aware of an interesting statistic: the prevalence of  heart attack rate is lower and heart failure rate is higher in comparison to people with hypertension and coronary disease in The Netherlands or the USA.  Lifestyle and genes might have a relation.

All of us lose some blood-pumping ability in our hearts as we age. But the more serious loss that we call heart failure, results from the added stress of health conditions that either damage the heart or make it continuously work too hard. In fact, all of the behaviors that you probably associate with heart disease or heart attack — such as having high blood pressure, smoking, being overweight, eating foods high in fat and cholesterol, not exercising and having diabetes — can also cause heart failure. In some cases people who develop heart failure were born with structural heart defects, while in others a virus damaged the heart muscle.

Compensatory Mechanisms

The body has several mechanisms to compensate for heart failure. The body’s first response to duress and strain, including that due to heart failure, is to release the fight-or-flight hormones,  like epinefrin (adrenalin). These hormones cause the heart to pump faster and more forcefully. They help the heart increase the amount of blood pumped out (cardiac output), sometimes to a normal circulating amount of blood required, and thus help compensate partially and temporarily for the heart’s impaired pumping ability.

People who do not have heart disease usually benefit from release of these hormones when more work is temporarily required of the heart. However, for people who have chronic heart failure, this response results in increased demands on an already damaged heart. Over time, the increased demands lead to further deterioration of heart function.

Another of the body’s main compensatory mechanisms for heart failure is to decrease the amount of salt and water excreted by the kidneys. Retaining salt and water instead of excreting it into urine increases the volume of blood in the bloodstream and helps maintain blood pressure. The larger volume of blood also stretches the heart muscle, enlarging the heart chambers, particularly the ventricles, which pump blood out of the heart.

The more the heart muscle is stretched, the more forcefully it contracts. At first, this mechanism improves heart function, but at some point, stretching no longer helps but instead weakens the heart’s contractions (like a rubber band being overstretched). Consequently, heart failure worsens.

Another important compensatory mechanism is enlargement of the muscular walls of the ventricles (ventricular hypertrophy). When the heart must work harder, the heart’s walls enlarge and thicken, as biceps muscles enlarge after months of weight training. At first, the thickened heart walls can contract more forcefully. However, the thickened heart walls eventually will become stiff, worsening diastolic dysfunction. Eventually, the contractions become weaker, causing systolic dysfunction.

The more common forms of heart failure — those due to damage that has accumulated over time — can’t be cured. But they can be treated, quite often with improvement in symptoms. We tend to think of treatment as something from our doctors — like a pill or a surgical procedure. That’s not the case with heart failure. Rather, successful treatment depends on your willingness to get involved in managing this condition, whether you’re the one diagnosed or you’re caring for someone who is. The three most important treatment strategies include…

  • Lifestyle changes
  • Medications
  • Surgery

LIFESTYLE CHANGES

Following recommendations about diet, exercise and other habits can help to alleviate symptoms, slow the disease’s progression and improve everyday life. In fact, people with mild to moderate heart failure often can lead nearly normal lives as a result of:

  • Quit smoking
  • Lose weight
  • Avoid alcohol
  • Eat a low-saturated-fat, low-sodium diet
  • Exercise on your own or participate in a structured rehabilitation program
  • Reduce stress

Making these changes is easier said than done. Dealing with new restrictions and responsibilities is challenging, but working these changes into your routine one at a time can make a real difference.

MEDICATIONS

Most people with heart failure take a number of medications that work in different ways. Some help to improve circulation by strengthening the heart muscle’s pumping action or expanding the blood vessels. Others help to reduce the amount of water and sodium in the body, which in turn reduces the heart’s workload..

ACE Inhibitors such as captopril,  ramipril or lisinopril are most used locally ACE inhibitors (angiotensin-converting-enzyme inhibitors) are now considered first-choice treatment and are the cornerstone of heart failure drug therapy.  ACE inhibitors have been proven to slow the progression of heart failure. They are a type of vasodilator, which are medications that cause the blood vessels to expand, lowering blood pressure and reducing the heart’s workload. ACE inhibitors prevent the body from creating angiotensin, a substance in the blood that causes vessels to tighten and raises blood pressure.
There are some side effects to look out for when taking an ACE inhibitor. Some people develop a persistent cough.

Diuretics (Water Pills)hydrochlorothiazide, furosemide, spironolactone or indapamide are common examples. Diuretics are prescribed for almost all patients who have fluid buildup in the body and swelling in the tissues. A diuretic causes the kidneys to remove more sodium and water from the bloodstream than usual and convert it into urine. This helps to relieve the heart’s workload, since there’s less fluid to pump throughout the body. It also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods.

Many people find it best to take diuretics in the morning so trips to the bathroom to urinate happen during the day. Taking diuretics in the evening or at night often results in interrupted sleep, because the urge to empty the bladder continues for hours. Furosemide is a special fast and short acting diuretic which may be taken as well around 4pm to relieve water before bedtime Spironolacton is a mild diuretic but has also a beneficial effect on the heartmuscle.

Vasodilators i.e isosorbide dinitrate, hydralazine , rilmedine
Vasodilators cause the blood vessel walls to widen or relax, allowing blood to flow more easily. We’ve already described one type of vasodilator, called ACE inhibitors. People who can’t tolerate an ACE inhibitor are often prescribed other types of vasodilators  to relieve symptoms and improve their tolerance for exercise.

Nitroglycerin tablets are a type of vasodilator prescribed to ease chest pain. Patients are usually instructed to take one, wait five minutes, and take another if the chest pain is still there. If the chest pain doesn’t go away after  3 pills, they should call an a doctor right away.

Side effects to watch out for include a drop in blood pressure upon sitting or standing, which can cause fainting or dizziness; headaches; flushing; heart palpitations, which feel like the heart is pounding or racing; and nasal congestion.

Digoxin (Lanoxin)
Digoxin increases the force of the heart’s contractions, which can be beneficial in heart failure. This relieves heart failure symptoms, especially when the patient isn’t responding to ACE inhibitors and diuretics. Most people continue taking the drug even after they feel well, to keep the heart working effectively.

Beta Blockers i.e carvedilol  metoprolol , atenolol.
The heart tries to compensate for its weakened pumping action by beating faster, which puts more strain on it. Beta blockers reduce the heart’s tendency to beat faster. The drugs block specific receptors (“beta receptors”). This allows the heart to maintain a slower rate and lowers blood pressure. Beta blockers are used for mild to moderate heart failure and often with other drugs such as diuretics, ACE inhibitors and digoxin.

Angiotensin II Receptor Blockers ie losartan, valsartan, telmisartan ACE inhibitors prevent the formation of  angiotensin II. Rather than lowering levels of angiotensin II , angiotensin II receptor blockers prevent this chemical from having effects on the heart and blood vessels. This keeps blood pressure from rising. Angiotensin II receptor blockers don’t appear to cause any significant side effects.

Calcium Channel Blockers ie amlodipine and nifedipine
Muscles of the heart and blood vessels need calcium to contract. Calcium channel blockers are used to treat the high blood pressure often associated with heart failure, because these drugs interfere with calcium’s role in the contraction of these muscles. This causes the muscles to relax. This lowers blood pressure and can improve the blood circulation in the heart. These medications aren’t used often to treat heart failure.

As with most drugs that improve the blood flow through the body, calcium channel blockers can cause headaches, facial flushing and dizziness. They also can cause ankle swelling. These symptoms generally disappear with continued treatment.

Drugs to be aware off

Anti-inflammatory painkillers (Ibuprofen, Aleve etc.) can give water retention (salt) and vasoconstriction esp. in the kidneys which may increase symptoms of heart failure.  Since these drugs are available without prescription one has to be careful with them.

SURGERY

Surgery is the other treatment option for heart failure. In some cases coronary artery bypass surgery (or a non-surgical procedure known as angioplasty) can ease heart failure symptoms by increasing blood flow to the heart.