When the Heart gets Tired

Your Heart

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.

The New Cholesterol Guidelines

The New Cholesterol Guidelines

Bringing the Science to your Dinner Table

Cholesterol is a waxy substance produced by the body and found in foods that come from animals. Cholesterol is needed by your body to make hormones, skin oils, digestive juices and vitamin D. You could not live without some cholesterol in your body.

However, too much cholesterol is a major risk factor for heart disease, particularly LDL (low density lipoprotein) cholesterol. LDL causes the build-up of fatty deposits within your arteries, reducing or blocking the flow of blood and oxygen to your heart.

It is estimated that millions of people are at much greater risk for heart disease than previously realized. This means more and more people will be walking away from their doctor’s office with a cholesterol-lowering drug prescription in hand. Medications aside, the new guidelines also vividly illustrate the growing epidemic of poor dietary habits, obesity, hypertension, hyperlipidemia and sedentary lifestyles that lead to the number one killer in the “Civilised World” today.

Measure your LDL and other blood lipids

Everyone age 20 and older should have their cholesterol checked at least every five years through a blood test. The guidelines recommend you have a complete “lipoprotein profile” that measures total cholesterol, LDL, high-density lipoprotein (HDL, the good cholesterol that may help prevent heart disease), and triglycerides, another type of fat in the blood stream. The test should be performed after fasting.

Low density lipoprotein (LDL) goal values:

  • Less than 70 mg/dL for those with heart or blood vessel disease and for other patients at very high risk of heart disease (those with metabolic syndrome,(obese, diabetes, hypertension)
  • Less than 100 mg/dL for high risk patients (for example: some patients who have diabetes or multiple heart disease risk factors)
  • Less than 130 mg/dL otherwise

Total cholesterol (TC) goal values:

  • 75-169 mg/dL for those age 20 and younger
  • 100-199 mg/dL for those over age 21

High density lipoprotein (HDL) goal value:

  • Greater than 45 mg/dl (the higher the better)

Triglyceride (TG) goal value:

  • Less than 150 mg/dl

Should I take cholesterol-lowering medication?

Drugs to reduce LDL include the “statins,” bile acid sequestrants, nicotinic acid and fibric acid. If your LDL and heart-disease risk are both high, doctors may prescribe medications at the same time as lifestyle changes. For others, medication may be added if six to 12 weeks on the TLC plan fail to adequately reduce LDL. Those who are started on a cholesterol-lowering medication will need to continue lifestyle changes.

Identifying those with metabolic syndrome

A group of specific risk factors, known as the metabolic syndrome, raise your risk for coronary disease at any LDL cholesterol level. If you have three of the following risk factors, you may have metabolic syndrome, and need more rigorous cholesterol lowering:

  • Abdominal obesity (a waistline over 35 inches in women and 40 inches in men)
  • Triglycerides of 150 of higher
  • Low HDL (lower than 40 in men and lower than 50 in women)
  • Blood pressure of 130/85 mm Hg or higher
  • Fasting glucose of 110 mg/dL or higher

Middle-aged men (age 35-65) are predisposed to abdominal obesity and the metabolic syndrome. As a result, they carry a relatively high risk for heart disease. For those with high risk, intensive LDL reducing strategies should be followed.

Because of all the above the guidelines for nutrition, physical activity and weight control in the treatment of elevated cholesterol have been modified and called the “Therapeutic Lifestyle Changes” (TLC) treatment plan. Even if you come out with a gold star on your cholesterol level and overall risk for coronary heart disease, most of us would surely benefit from implementing these guidelines.  Why the word therapeutic in the TLC guidelines?, because if you would stick to it you probably have a better effect than taking medications.
The following table can help you implement the guidelines into practical terms you and your family can enjoy and reap heart-healthy benefits:

New TLC guidelines

Why?  What does this mean?
Examples
Why?: Saturated Fat – less than 7% of total calories
What does this mean? Saturated fats are thought to have the most potent cholesterol raising potential.
Examples: Fatty cuts of meat, skin on poultry, egg yolks, lard, butter, palm oil, coconut oil, desserts and sweets, fried foods and most snack foods and fast foods.
Why?: Trans Fat – as little as possible
What does this mean? Trans fatty acids are formed when a liquid fat is turned into a solid one; a process called hydrogenation.
Examples: Limit foods with the following ingredients: partially hydrogenated oil, hydrogenated oil, stick margarine and shortening. Limit your intake of fried foods, cakes, pies.

Why?: Polyunsaturated Fat – up to 10% of total calories
What does this mean? Diets moderate in polyunsaturated fats are generally recommended. .
Examples: Margarine, soybean, safflower, sunflower, cottonseed and corn oils, pumpkin and sunflower seeds, most salad dressings and mayonnaise.

Why?: Monounsaturated Fat – up to 20% of total calories
What does this mean? Most desirable source of fat in the diet.
Examples: Olive and canola oils, nuts, nut butters and oils (e.g. peanut butter, almond oil), avocados and olives.


Total Fat – 25% – 35% of total calories

All of the fat you consume on a daily basis should not exceed 35% of total calories.
All of the sources of fat noted above.
Dietary Cholesterol – less than 200 milligrams each day
Excesses in dietary cholesterol have been linked to increases in coronary heart disease.
Cholesterol comes from two sources – that which your body creates and that which is found in animal products (meat, poultry, fish, egg yolks and dairy contain dietary cholesterol)


Carbohydrates – 50% of total calories

Why?: Carbohydrates are the building blocks of a heart-healthy diet.

What does this mean? Choose complex carbohydrates (instead of refined ones with white flour) to get the maximum nutritional benefit from these foods.
Examples: Whole grain or oat based breads, crackers, pastas and cereals, other whole wheat/grain based flour products; brown or wild rice; couscous, quinoa, barley, buckwheat; lentils, split peas and beans; fruits and vegetables.

Fiber – 20-30 grams per day

Why?: Dietary fiber, specifically the viscous (soluble) form, is associated with a decrease in cholesterol and contributes to a host of other health benefits.
What does this mean? All of the above complex carbohydrate food sources.

Examples: Aim for a minimum of 10 or more grams of viscous (soluble) fiber each day by increasing oats, barley, lentils, split peas, beans, fruits and vegetables


Protein – Approximately 20% of total calories

Dietary protein can come from both plant and animal sources and is an essential nutrient to good health. The problem is, many protein sources (especially animal sources) contain a lot of saturated fat and cholesterol so choose your protein sources wisely.
Major sources of protein in the diet: beef, veal, pork, fish, chicken, legumes like lentils and beans, dairy products, nuts, seeds and soy foods.
Total Calories – balance energy intake with output to achieve or maintain a desirable body weight
Excessive calories, regardless of the source, results in weight gain.

General advise: Aim to consume 4-6 small meals and snacks daily. Avoid skipping meals and eating late at night.

You may wonder HOW it is you can incorporate these guidelines into your and your families hectic lifestyle. Take the following steps one day at a time and focus first on the foods in your diet that are high in saturated fat and cholesterol. Start making simple substitutions for saturated fats with mono and polyunsaturated fats, couple this with a focus on fruits, vegetables and whole grains, some physical activity and you are well on your way towards reaching your nutritional goals. Below is an example of how the TLC guidelines would be implemented for someone on a 1,800-calorie diet. You may require more or less calories for weight loss or maintenance, see your registered dietitian or physician for more information on your caloric needs.

Nutrient

For a 1,800-calorie diet

  • Saturated fat, <7% of calories
  • 14 grams or less per day

Polyunsaturated fat, up to 10% of calories

  • Up to 20 grams per day

Monounsaturated fat, up to 20% of calories

  • Up to 40 grams per day

Total fat, 25% to 35% of calories

  • Between 50 and 70 grams per day

Carbohydrate, 50% to 60% of calories

  • Between 225 and 270 grams per day

Protein, about 15% of calories

  • Around 67 grams per day

Cholesterol

  • Less than 200 milligrams per day

Fiber

  • 20-30 grams per day with a focus on viscous (soluble) fiber

If the above is still to difficult to implement in your dietary habits, the statins are for most people a effective strategy to maintain or even regain better cardiovascular health and lower their risks for heart attack and stroke.