Understanding Heart Failure: Diagnosis, Symptoms, Treatments, and Hope for Patients

Heart failure necessarily doesn't mean that your heart has stopped working. It means that it is becoming weak.

How common would you say heart failure is?

Overall, generally speaking, over a lifetime, roughly one in four people are at risk of developing it. Heart failure is serious. It's not anything to ignore. It's not going to go away on its own. Historically, about half the people who are alive at five years after diagnosis, if people are not treated adequately, it is a scary diagnosis. It is a serious condition, but a treatable one, you can see that you're not going to be able to do that.

How are you?

I'm good. How are you, Lena?

Good, good. It's good to see you and be back. I think this is an important episode. If someone says heart failure, I think everyone has the same kind of opinion about your heart has just kind of given up. So now I think there's a lot more to it and a lot more that we'll learn. So let's kind of hop in. So is there a message that you wanted to mention?

Heart failure, the two words that put fear in anybody's, so to speak, heart. If a patient hears heart problems, they're scared. And then you add the word failure to it, you know, that escalates it to a whole different level. So what does it mean? It is one of the most prevalent problems in the cardiac pathology world. And uh so many patients live with heart failure or congestive heart failure that I thought this was an important topic to just kind of discuss it in a patient-facing question and answer format so that people kind of can demystify some of the treatments that go along with it, some of the diagnoses that go along with it. So my message is to anybody, anybody listening that that it is a scary diagnosis. It is a serious condition, but a treatable one. So it's important to uh understand that treatment has come a long way. It's improved enormously over the last couple of decades, and many people live active and full lives, even along with congestive heart failure. So we're gonna dive deeper into it and understand what it is.

And that sounds definitely reassuring for anyone who may have recently been diagnosed with it. So let's just kind of start simply. What is heart failure exactly?

Yeah, so heart failure necessarily doesn't mean that your heart has stopped working. It means that it is becoming weak. And the weakening of the heart muscle can occur in two forms: what is called heart failure with reduced ejection fraction. Ejection fraction is a number that we measure to understand the pumping action of the heart, or it can be heart failure with preserved ejection fraction. So it's either your heart is not pumping well or it's not relaxing well to receive blood and then pump it out. So heart failure essentially is that your main pump, think of it as a the pump of the body, it is either becoming really weak or it is becoming very stiff, where it is not able to pump effectively or relax effectively, and that leads to blood backing up into the lungs, for example. And when blood backs up into the lungs, you know, you might get symptoms of shortness of breath, for example. It can back up into other organs. But predominantly what happens is that you're not getting good forward flow from the heart muscle, and that leads to congestion, which leads to the term congestive heart failure.

And now you mentioned heart failure and congestive heart failure, but are they different or are they the same?

So essentially it is the same thing. Congestive heart failure refers to the congestion, meaning that the fluid that backs up into the lungs or other organs like the belly or the legs that leads to edema or swelling, doctors will use that whole kind of clinical syndrome as defining heart failure. But doctors will use both terms congestive heart failure or heart failure to kind of talk to patients about their clinical syndrome of decompensation where fluid is built up in the body.

And what are some of the symptoms that you think people should watch out for?

Yeah, so the classic symptoms of heart failure, we see this every single day in our clinic where people come in with having shortness of breath on minimal exertion, for example, shorter breath more than usual. That usually occurs when fluid is starting to build up in the lungs because it is backed up. They can also have associated symptoms of not being able to lay flat and sleep. So some patients will come in and say, you know, for the last couple of months, I've been sleeping in my recliner because every time I lie lay down in my bed, I feel like I can't catch my breath. Those are subtle signs that you gotta pick up on, and that represents uh what's called orthopnea. Sometimes they wake up short of breath in the middle of the night, night, and that's referred to as PND or proxismal nocturnal dyspnea, meaning that, you know, when they're laying flat, sometimes again, fluid is backing up to the lungs. But those symptoms are the classic kind of common symptoms of heart failure. Other things that happen as fluid backs up is swelling in the legs, ankles, some fluid accumulation that happens in the abdomen. You might have weight gain. We tell our heart failure patients to constantly watch out for a sudden weight gain that happens two or three pounds over the course of a week when they haven't really changed anything else in their eating habits. Because they've got edema in their belly, fluid accumulation, they might actually have reduced appetite. Those are symptoms that you want to watch out for before they decompensate to a point where they have to be admitted to the hospital for treatment.

And now, are there different types of heart failure?

Like I said, the two most common things are either your pumping action is weak or relaxation properties. So the heart has to relax to fill with blood first before it can pump that out. So if the heart muscle is stiff, it doesn't relax, it's not elastic, it's not compliant, it doesn't fill adequately with uh blood. So in that case, you get what's called diastolic dysfunction. Instead of systolic dysfunction, systole refers to the heart's uh pumping action, forward flow. Diastolic function refers to the heart's relaxation properties. Diastolic dysfunction will then lead to heart failure with preserved ejection fractions, that's one category, or you can have heart failure with reduced ejection fraction, where the heart pumping action is weak. Normal ejection fraction of the heart is about 55 to 60 percent. When that goes down to say 35-40%, you've got systolic dysfunction. The heart muscle is weak, it doesn't pump adequately. That leads to heart failure with reduced ejection fraction. On the other hand, in heart failure with preserved ejection fraction, you know, the muscle is stiff, it doesn't relax properly, and your ejection fraction might be totally normal. And roughly half the number of people have this. So those are the different kinds of heart failure categories broadly, and then there's different stages within the heart failure, stage A, B, C, D, uh, going from at-risk to advanced uh disease. The point is that you want to recognize it early, you want to catch it early before it's too late.

Speaking about symptoms and things like that, what actually causes heart failure?

So again, the most common thing is underlying ischemic heart disease or blockages. Cornear artery disease leads to heart attacks. Heart attacks lead to muscle getting injured and then forming scar tissue, and that leads to loss of contractility of the heart muscle, leading to uh heart failure with reduced ejection fraction. Other things that can cause heart muscle to become weak or not relax properly, are uncontrolled high blood pressure, uncontrolled diabetes, obesity, metabolic disease, irregular rhythms like atrial fibrillation. If the heart is working hard, we've talked about that in previous episodes, it can lead to weakening of the heart muscle. Cardiomyopathies, which are a weakening of the heart muscle, whether it's a genetic component or a viral component or alcohol-mediated cardiomyopathy or drug-related cardiomyopathy, those all lead to the heart muscle being weak, and that leads to heart failure again. And certain diseases like amyloidosis, which is abnormal protein deposition into the heart muscle, sarcoidosis, chemotherapy, all these things lead to heart muscle becoming weak, leading to heart failure. So these are generally the broad categories why somebody might uh have a weakened heart muscle. Now, most commonly we see it because of blockages and heart attacks, but you can see it in people abusing alcohol, like I mentioned. If they're drinking chronically, drinking heavily, they might not have any blockages, but they get what's called a non-eschemic cardiomyopathy. The heart muscle becomes weak and floppy due to the toxic effects of alcohol. That's one of the common examples that we've seen in the community.

And about how common would you say heart failure is?

The epidemiology is, you know, it's one of the most common things that occurs in medicine. It is a large component of the healthcare expenditure that happens in this country. That's why there's a large emphasis on reducing heart failure admissions to hospitals. Readmissions to hospitals are a big burden to the healthcare budget. So about $67 million in the US and more than 60 million people have congestive heart failure. And this leads to decompensated episodes of current admissions. That leads to a lot of drain of healthcare funds. And as people live longer, uh and more and more people are diagnosed with high blood pressure and diabetes and ischemic heart disease and obesity, more and more people are developing congestive heart failure. So, overall, generally speaking, over a lifetime, roughly one in four people are at risk of developing it. So pretty common.

That is, that's a really big statistic. And who do you think is most at risk? And also, what do you think is the outlook with heart failure?

So risk, number one thing is age. Risk rises with age, um, but heart failure affects younger people as well. It could come in a variety of forms, like I mentioned. It could be age-related cornear disease leading to that, or it could be non-achemic causes like viral syndromes, connective tissue disorders, amyloidosis, sarcoidosis, chronic kidney disease, diabetes, sleep apnea, arrhythmias, all these things put you at risk of cardiomyopathies and then weakening of the heart muscle as a result leading to heart failure. So some populations are more at risk. African Americans tend to develop heart failure earlier. They have higher rates as well. Women are more likely to develop heart failure with preserved ejection fraction than men. That's generally the kind of epidemiology of fit. I think you asked me what is the outlook with it as well, the second part to your question. Heart failure is serious. It's not anything to ignore. It's not going to go away on its own. Historically, about half the people who uh, you know, are alive at five years after diagnosis if people are not treated adequately. It remains, like I mentioned, a leading cause of uh hospitalization. But those numbers, again, are getting better as we have better and better treatments. We today have newer medications that have come out, newer devices that have come out that give hope to people so that the trajectory of their clinical course can be altered and they're not just doomed to have a poor kind of prognosis over the next five to ten years. Outcomes, you know, can be improved, but it also depends on what the underlying cause is, how early you start the treatment, how compliant the patients are with their medications and their treatment regimen. All those things are really, really important. It's one of those diseases where constant kind of reevaluation, constant, you know, monitoring of patients' symptoms like weight and fluid status and clinical status like breathing, all those things have to be uh monitored very, very closely so that somebody doesn't fall off that compensated clinical course uh and go into decompensated heart failure. Those patients who are diagnosed early do the best, who are treated fully, who are followed closely essentially, do the best in this category.

And let's talk a little bit about the evaluation and the testing. So what happens at a patient's first visit?

Yeah, so when a patient walks in, depends on whether they've already got a diagnosis of heart failure or not. But if they're walking in naive, you're trying to figure out what's going on, you know, your doctor might ask you about your symptoms such as shortness of breath, swelling in the legs, your previous history, whether you have a heart attack or not. They also dive deeper into your functional capacity, like how far you can walk. They'll ask you about, you know, how many pillows are you using to sleep. You know, somebody says I used to be able to lay flat on the bed and now I have to use three pillows every night. You know, that's a sign that they can't lay flat and that they might be having symptoms suggestive of congestive heart failure at night. Your doctor will ask you about things like your family history, genetics play an important role in certain cardiomyopathies, alcohol and drug use history is also important. So your doctor might ask all these things as part of the diagnostic evaluation that takes place. So a detailed physical examination along with the history is an important part of the workup. So after that, they might delve further into diagnostic tests.

And then speaking about diagnostic tests, what tests are used to actually diagnose heart failure?

Yeah, so basic blood testing is done, first of all. Um, you know, your doctor is gonna look at your kidney function, look at your electrolytes, look at your uh blood counts. They might measure something called BNP, which is a natural erratic peptide released by the heart muscle when it's stretched. Elevated levels in the blood might suggest, you know, that the patient might have heart failure. They might check your cholesterol levels, your sugar levels to further risk stratify you, an electrocardiogram to see what your EKG looks like, if you've got a history of any heart problems, any arrhythmias. And then they might order things like a chest x-ray followed by an ultrasound of the heart to assess your cardiac function, both systolic function and diastolic function, meaning the pumping action of the heart and the relaxation properties of the heart are pretty well assessed within echocardiogram, which is the ultrasound of the heart. So that's one of the key tests to give us, you know, an insight into where somebody's uh heart function stands. If they're not finding the answers, they might get it further into it. You know, more imaging like cardiac MRIs are done in certain conditions. Amyloid scans are done to look for things like amyloid doses. And if there's suspicion for uh underlying cardiovyopathy as a corneary disease, the next step is usually a cardiac catheterization, which we've spoken about, which is essentially injecting dye into the arteries of the heart. It's an invasive procedure and to see if there's any blockages there.

Definitely sounds like a lot of different tests. But is there one test that can really tell you everything? Or is it more of a combination of different tests?

I wish I could say yes. I mean, you know, it would be great if we just had the holy grail of tests, you know, but we don't, and it's about putting it all together from the history to the physical examination to the risk profile, and then combining all these different tests. Every test gives us a different answer to the puzzle. And uh, you know, whether it's an echocardiogram or a blood test, all kind of have to be put together to come up with what's going on with the patient. Echo is probably one of the most important tests and heart failure, but every test has its value.

How is heart failure actually monitored or measured over time?

Yeah, so there's a huge emphasis on very, very close follow-up of these patients. Like I said, early diagnosis, appropriate therapy, and then close monitoring are the three pillars, in my view, of monitoring these heart failure patients. You don't want to let them kind of build up and get decompensated for a couple of weeks, and then you'll be behind the eight ball trying to catch up and trying to treat them. So repeat blood tests when necessary, follow-up chest x-rays, monitoring their blood pressure, monitoring their weight, monitoring their urine output, things like that, very, very important. And then sometimes you can do things like remote monitoring. If they have devices in place, we can actually interrogate those devices like pacemakers and defibrillators to see if they're building up fluid, uh, certain parameters in those devices can tell us if they've started decompensating, uh, you know, they're going towards a hospital admission for heart failure. So that's where we are.

And with treatments, what are the goals of treatment?

The three goals. The idea is to closely monitor these patients, but the goals are to make sure that they're compensated. When you monitor them, that they stay compensated. So number one is that they should stay compensated, and that leads to them feeling better. Number two is keeping them out of the hospital because you're they're not decompensating. And number three is improving their mortality and having them live longer. So that's the short-term and long-term goals of treatment of congestive heart failure. Making sure that they stay out of the hospital, make sure that they're carrying out their activities of daily living and they're not decompensated and making sure that they're improving their mortality. There's certain drugs, medications, pharmacotherapies, device therapies that have shown to improve survival in heart failure patients. So making sure that you're doing everything for your patient to improve their mortality as well and survival.

And then let's talk about medicines for a bit. What's the foundation of treatment for weak EF heart failure?

So when you talk about heart failure with reduced EF or reduced ejection fraction, there are four pillars of medicines that are very, very important. The idea is to optimize these patients on these medications because each medication has shown to have an added benefit in either their morbidity or their mortality, either decreasing hospitalization, improving functional capacity, or increasing their survival. So the first class of drugs that we use in heart failure with reduced ejection fraction is beta blockers. Beta blockers slow the heart rate down, protect the body from stress hormones, decrease the demand on the heart. And these are drugs like carvatolol, mitoperol that your doctor might have put you on. Number two is what are called angiotensin receptor neprolycin inhibitors or short RNAs, or ACE inhibitors, or angiotensin receptor blockers. These are essentially, again, blood pressure medications that work to reduce the strain on the heart. They are what are called afterload-reducing medications. They've shown benefit in multiple trials to improve mortality and improve survival for patients with congestive heart failure with reduced suggestion fraction. The third class of drugs are mineral corticoid receptor antagonists, which are MRAs. These are drugs like spernolactone and plarinone, which block a hormone that causes salt and fluid retention and scarring of the heart. And the fourth class of drugs is what are called SGLT2 inhibitors. These are drugs that came out over the last five to ten years. They were originally supposed to be diabetes drugs like Jardian sinpharsega, these are their trade names, and they've reduced hospitalizations and deaths and heart failure, whether or not the patient has diabetes. So independent of diabetes, these drugs showed benefit for patients who have congestive heart failure. So these four drugs, ARNIs, beta blockers, MRAs, mineral corticoid receptor antagonists, and SGLT2 innovators, are essentially the drugs you want your heart failure patients on to improve their outcomes.

And what about water pills? I haven't heard much about water pills. What exactly are those and what do they do?

So water pills, such as, you know, your doctor might put you on water pills like LASIKs or torsamite, they don't extend somebody's survival. They've never shown to improve mortality, but they're a very key component in your medical regimen because they uh help remove the extra fluid that is built up in the setting of decompensated heart failure. They keep people out of heart failure by reducing the swelling and reducing the fluid status, you know, in their body. So we try to use as low a dose as possible to keep somebody out of heart failure, and we adjust it based on your weight and your symptoms and your status of your edema in your legs, for example. So they're really, really important drugs that we use on a very regular basis, but it's important that you follow things like kidney function, make sure that you're careful that people don't get dehydrated on these diuretics.

What can patients do themselves every day?

The idea is to avoid decompensated heart failure. So we really need the patients to be advocates for themselves and monitor their own clinical situation on a daily basis. So they need to watch out for the amount of fluid that they're consuming. They need to watch out, keep on the lookout for weight gain. Uh, they need to weigh themselves on a daily basis. Heart failure patients, if they gain a couple of pounds in a day or two or five pounds in a week, we get concerned because that suggests that they're accumulating fluid. We tell them to watch out for, you know, their sodium intake because that can cause fluid retention. You know, simple things like dietary indiscretions, like going out to eat salty meals, it's nice to do that on a Friday night, but sometimes that in itself can lead to a decompensated episode over the weekend. So uh it's really Really important that they watch how they feel, where they are, where their fluid status stands. It's important not to smoke. It's important to limit the alcohol. Because they've got this chronic condition, we ask them to get vaccinated appropriately for the flu, for pneumonia, etc. Certain medications like NSATs, like ibuprofen and a proxin, can cause fluid retention. A doctor might say, I don't want you using a leave, you know, an NSAT because it's not good for your heart. Also, certain herbal medications that uh I always ask my patient, what are they taking? Is there something that can cause fluid retention? So the bottom line is that they need to be vigilant, they need to keep an eye on their fluid status, they need to keep you on the lookout for warning signs.

And in addition to medicine, some patients get a device as well. So what are those devices and what do they really do?

Yeah, so in certain conditions, we, you know, we use what are called implantable defibrillators. When a heart muscle becomes really weak, we uh might implant a defibrillator. It is because the patient's heart is then prone to going into these ventricular kind of arrhythmia as dangerous rhythms, which can cause them to have sudden cardiac death. So your cardiologist might recommend a defibrillator for you. One of the other things that we do is what's called uh CRT or cardiac resynchronization therapy, meaning that it's a special kind of a pacemaker defibrillator that improves the contraction of the heart muscle and kind of makes it synchronous so that it decreases your heart failure episodes and actually might improve your morbidity and mortality. We might implant a pacemaker or defibrillator depending on your heart muscle. So that's something to keep in mind.

And let's talk about LVAD for a minute. So what exactly is it and who is it for? And also how well do they really work?

Yeah, so now we're talking about advanced heart failure or end stage heart failure where you've exhausted most of the other therapies like medical therapies or cardiac resynchronization therapies or defibrillators. You've gotten to a point where now you need a left ventricular assist device, a surgical procedure, which is attached to your heart. It's a small mechanical pump which is now performing the function of your heart muscle. And it is used as in two ways. It is either a bridge to transplant, heart transplant for somebody who, let's say, is a 45-year-old patient who's got a weak heart muscle and they're listed on the transplant list, you might put an LVAD left ventricular cyst device in because now their heart muscle is just not functioning at all. Or it can be used as a destination therapy where the chances of getting heart transplant are not that great for somebody, and this is their new heart, mechanical heart that they're using. So that's a left ventricular cyst device that is used. And the most common iteration is what's called a heart mate three. You know, in certain trials like the momentum three trial, more patients were alive at two years with fewer strokes and fewer clots, and their clinical status and their functioning abilities showed improvement. So that's essentially an end-stage therapy that patients might undergo. Obviously, it's it's got its own risks like bleeding and infection and strokes, but when you're out of options, it is a viable option. These devices have gotten better over the years, and it is definitely a viable option. It leads to a heart transplant in certain cases. And uh, you know, if you're lucky you get a heart from a donor, it is the best long-term treatment that we have for end-stage heart disease. And in the US, we have about 4,000 to 5,000 heart transplants that are performed each year. Demand exceeds the supply of hearts and uh what heart transplant patients overall, you know, are doing better and better.

And I think that's something that's important to touch on as well is how it can be hard to cope and hard to deal with this diagnosis. So how do patients and families tend to cope emotionally?

Yeah, so heart failure is a tough diagnosis because it's a chronic condition. They're in and out of the hospital sometimes. It requires a village to kind of keep a patient out of the hospital, whether it's their family members, you know, making sure that the patient is eating the right food, whether it's their doctor, whether it's the patient themselves. It is constant kind of surveillance that is needed. And it can have a poor outcome after all of the things. So it leads to a lot of depression, leads to a lot of anxiety. And those are things that need to be addressed as part of the comprehensive care that you provide the patient. So, you know, uh sometimes a 40-year-old person might be affected so poorly that they're not able to do basic things like go to the grocery store or take a walk on the boardwalk. So it is something that we need to understand. Positive thing is that heart failure therapies have come a long way. We we do much better with keeping patients out of the hospital. We have much better survival timelines. So I'm optimistic about what's coming in the future as well.

Like you said, it's been a lot more developments and changes for the for the better in terms of treatments and things like that. So hopefully it will continue to happen. And before we do wrap up the episode, are there any final thoughts or any other takeaways that you really want our listeners to keep from this episode?

All I want to say is heart failure is a serious condition. You know, recognize it early, seek medical attention early. And when you do see a physician, ask them certain key questions, know what kind of heart failure you have, ask them what are my treatment options, ask them whether you're on the right medical regimen that is available out there. Ask your physicians do you need a device? Ask them what you can do to stay out of the hospital and stay compensated. Those are questions that are really, very important. But yeah, it's not a hopeless condition. It's a chronic condition. Sometimes you have to live with it. But stay connected with your healthcare team, stay connected with the latest treatment options that are out there. Make sure that your physician is up to date on things. And uh, you know, we've got really great medical regimens out there that can help you provide good treatment and improve your outcomes.

And this episode, again, for all of our listeners, is for education only and is not a substitute for personal medical advice, but make sure that you are talking with your own cardiologist about your care. Well, thank you, Dr. Myra. Thanks for all this really helpful information and for also giving patients a positive outlook on their diagnosis as well and knowing that it is something that is treatable. And for everyone listening, make sure you're following, subscribing, and sharing the show. It's been another great episode of cardiovascular therapeutics unplugged. And Dr. Myra, it was nice speaking with you as always, and we'll talk soon.