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  •   Living with Heart Failure

        Doctor and patient photo
    J.L. Means, left looks at
    his test results with
    cardiologist Hamid Taheria.

    (Gerald Martineau – TWP)
    By Don Colburn

    Tuesday, May 19, 1998; Page Z12

    For J.L. Means, the moment of truth came in March as he dashed across Atlanta's sprawling airport to catch a connecting flight to Washington.

    Over the previous few months, he had noticed fatigue and shortness of breath catching up with him more often. Wheezing sometimes interrupted his sleep. But it wasn't until he nearly missed his flight in Atlanta that Means realized something was seriously wrong. The hurried walk between terminals left him gasping and exhausted -- even though he carried only a briefcase and stopped midway to rest.

    By the next week, when Means showed up at the cardiology clinic at George Washington University Medical Center, "he could barely walk across a room," said his wife, Margie. She noticed the words "heart failure" after his name on the sign-in sheet, and wondered if he could be having another heart attack.

    He wasn't. But tests on Means's heart confirmed that his heart disease had progressed to an attention-focusing diagnosis: heart failure.

    "Another whole ballgame," Means said.

    Like nearly 5 million other Americans, J.L. Means, 70, of Colonial Beach, Va., is living with heart failure, a condition in which the heart beats less forcefully than normal. Although it can be an acute medical emergency (usually in patients suffering a heart attack), heart failure is most often a chronic and progressive illness. There is no cure, but it can be kept in check with treatment.

    When the heart doesn't pump efficiently, it squeezes less blood out with each heartbeat and creates a cardiac plumbing problem. Blood that is not pumped out of the heart's main pumping chamber into the body's circulation system has to go somewhere. Like a traffic jam behind an accident on the Beltway, blood backs up into the veins leading to the heart. Eventually it may flood the lungs, causing trouble with breathing, and it can also waterlog the liver, the kidneys and other vital organs.

    The most obvious symptoms of heart failure are the ones Means felt in the Atlanta airport: weakness, fatigue and shortness of breath. Others include painful swelling in the abdomen, legs and feet. Some patients have a nagging dry cough.

    By far the most common causes of heart failure are coronary artery disease (including damage from a heart attack) and hypertension, or high blood pressure. It also comes from heart valve defects, excessive drinking, drug abuse and viral infections -- anything that damages the heart muscle.

    The name itself is somewhat misleading. Heart failure -- sometimes called congestive heart failure -- does not mean the heart stops beating.

    "It can be a very frightening term to a layperson," said Charles Curry, chief of cardiology at Howard University Medical Center. He often must explain to heart failure patients that they did not have a heart attack or cardiac arrest.

    "People think heart failure is a death sentence," said Alan G. Wasserman, the cardiologist who treated Means at GW Medical Center. "But for the overwhelming majority of patients, heart failure is a livable condition that can be controlled by medication."

    A growing array of medications, including a new class of drugs known as ACE inhibitors, has revolutionized heart failure treatment in the past decade, Wasserman said.

    Three main types of drugs are used against heart failure: diuretics, or "water pills," to reduce fluid overload by increasing urination; digitalis to boost the heart's pumping strength; and vasodilators, including ACE inhibitors, that relax blood vessels and make it easier for the heart to pump blood through the circulatory system.

    "People come into the hospital and can hardly breathe -- near death," Wasserman said. "We get the fluid out and put them on these drugs and they go home. They are amazed they can go back to their lives, feeling totally normal."

    ACE inhibitors don't work in all patients, and produce unwelcome side effects, such as a chronic cough or dizziness, in some. With many varieties of ACE inhibitors available, doctors can try different ones to find the best match for relieving symptoms with a minimum of side effects.

    A fourth type of medication -- anti-hypertension drugs called beta blockers -- is sometimes used in heart failure patients for whom other drugs don't work, or in combination with the others. Beta blockers must be used selectively because they slow the heart down, which is dangerous for patients with low blood pressure.

    Surgery is usually not an option for heart failure patients, unless their condition is due to a correctable heart valve defect or clogged coronary arteries that can be surgically bypassed. Two other surgical possibilities are extremely rare. One is a heart transplant, restricted by the shortage of available organs. The other is a still-experimental operation pioneered by the Brazilian surgeon Randas Batista, in which a slice of the heart muscle is removed to reduce the size of its pumping chamber. Only the sickest patients are considered for either operation.

    More Cases, Better Treatment

    Heart failure is something of a public health paradox. Recent advances in treatment are keeping patients alive longer, and freer of disabling symptoms. Yet the total number of cases -- and the annual death toll -- are still rising sharply.

    It remains a lethal disease. Heart failure is a contributing factor in the deaths of 250,000 Americans a year. People with heart failure are six to nine times more likely than others to die of sudden cardiac arrest.

    Heart failure sends more 65-and-older Medicare patients to the hospital than any other illness. The federal Health Care Financing Administration, which pays the bills for Medicare, spent $3.1 billion on hospital care for heart failure in 1996, more than twice as much as for heart attacks.

    "It's the most expensive health care problem we have," said Michael R. Bristow, chief of cardiology at the University of Colorado Health Sciences Center in Denver.

    Hospitalizations and deaths from heart failure more than doubled between 1979 and 1995, according to the National Center for Health Statistics. That's partly because the average age of the population is rising, and heart failure tends to be a disease of old age. It's also because more people today are able to survive heart attacks and hypertension, conditions that take a toll on the heart muscle and put survivors at higher risk for developing heart failure.

    J.L. Means, for instance. He has taken medication to control high blood pressure for most of his adult life, and he also had a heart attack six years ago. Five days after his heart attack, he underwent bypass surgery to relieve blocked coronary arteries. Both the lifelong hypertension and the heart attack contributed to his heart failure, cardiologist Wasserman said.

    When Wasserman examined him this spring, Means could hardly breathe, his lungs congested from the backup in his heart. Wasserman admitted him directly to GW Hospital and put him on a new series of medications, including an ACE inhibitor, digoxin (a form of digitalis) and intravenous diuretics to wring excess fluid out of his body. He lost 15 pounds of fluid in three days.

    The medications cleared up Means's symptoms, easing his breathing and restoring his stamina, but did not cure the underlying condition of heart failure. He may still have to undergo another bypass -- a bypass of the original bypass. Doctors hope that the drugs he takes will not only relieve the symptoms but strengthen the heart enough to make surgery unnecessary -- or less risky.

    "I'm buying time," Means said.

    He also feels rejuvenated. "I feel like I could get out and run six blocks," said Means, who is semi-retired from a career in the oil and gas industry. "I can't, and I won't, but I feel that good."

    The lack of symptoms can be misleading, he knows. Patients diagnosed with heart failure have a 50 percent chance of dying within five years, although that estimate predates widespread treatment with ACE inhibitors.

    "The prognosis for heart failure is much better than it was 10 years ago," Colorado's Bristow said. Survival of heart failure will continue to lengthen, he said, as more patients receive the latest drug treatments.

    Breathless and Exhausted

    Two days before Christmas, Olar Bell, 51, of Northeast Washington, came home from the Safeway and was suddenly so weak and winded that she couldn't lift the groceries out of the car. She staggered to her ground floor apartment and collapsed on the sofa for nearly an hour to get her breath back.

    "I was wheezing like I was having an asthma attack," recalled Bell, who works as a cashier in the cafeteria at the federal Department of Health and Human Services.

    Over the next couple of months, attacks of breathlessness came and went. Bell had to sleep propped up against three pillows. Any exertion, even bending over to tie her shoes, tired her out. She thought it was because she was overweight.

    Late in February, her condition worsened. Breathing with difficulty and barely able to walk, she took a taxi to the outpatient clinic at GW Medical Center. Doctors admitted her to the hospital overnight for the first time in her life (her four grown children were delivered at home by a midwife). They put Bell on several medicines, including diuretics, and overnight she lost 18 pounds in fluid.

    Now she takes three drugs: digoxin, the diuretic Lasix and an ACE inhibitor. And she feels better than she has in years -- "like I've never been sick."

    Better Drugs Change Treatment Goals

    "The last 20 years represents a revolution in our understanding and treatment of heart failure," Jay N. Cohn, a cardiologist at the University of Minnesota and president of the Heart Failure Society of America.

    Previously, the goal was merely to relieve symptoms. The mainstays of treatment were diuretics and digitalis -- drugs that help keep people out of the hospital by relieving symptoms but do not prolong lives.

    With the advent of improved drugs, the approach has shifted. Now, instead of merely relieving symptoms, the aim is to delay or prevent those symptoms by keeping the heart from enlarging.

    Two discoveries drove this change. First, studies showed that drugs called vasodilators, which relieve blood pressure by relaxing or widening blood vessels, also control heart failure. Then researchers developed a new class of vasodilators, ACE inhibitors, which are more potent than the originals yet have fewer side effects. ACE inhibitors block a chemical called the angiotensin-converting enzyme, which constricts blood vessels.

    Studies over the past decade have shown that ACE inhibitors can help patients with heart failure live longer and feel better.

    A variety of ACE inhibitors is available, sold under many generic and brand names. These include benazepril (sold as Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil), losartan (Cozaar), quinapril (Accupril), ramipril (Altace) and valsartan (Diovan).

    ACE inhibitors are now recommended by the American College of Cardiology and federal health guidelines as first-line therapy against heart failure, often in combination with diuretics and digoxin.

    Yet heart specialists are concerned that many patients with heart failure are not receiving this recommended treatment. Studies show that primary care doctors, particularly outside of major medical centers, are less likely to prescribe ACE inhibitors -- or more likely to prescribe them at less effective doses -- than heart specialists are. Only about half of the eligible patients with heart failure are being treated with ACE inhibitors, cardiologist Bristow said.

    Another concern is that heart failure's main symptoms -- shortness of breath, fatigue and swollen ankles -- sometimes get passed off by elderly people as "simply feeling old," Wasserman said. Because untreated heart failure is a life-threatening condition, he emphasized the urgency of having such symptoms checked by a doctor.

    The failing heart compensates for its pumping weakness in several ways. It beats faster. It dilates, or widens, to let more blood into its chambers. In a patient with heart failure, it is not uncommon for the heart to double in size.

    "The problem is, the compensatory changes can defeat the purpose," said GW's Wasserman. Added bulk doesn't strengthen the heartbeat, and a faster pulse may simply strain an already overworked heart.

    "There's been a reversal of the traditional view of heart failure," said Minnesota's Cohn. Until recently, it was thought that enlargement of the heart was simply the organ's way of making up for its loss of pumping efficiency. Now, growing evidence suggests that enlargement is also part of the disease itself -- and should be prevented if possible.

    When the heart enlarges, it does not grow new cells. Its existing cells simply get bulkier. "All they can do is get bigger," Cohn said. "And that bigness is bad."

    Doctors measure the heart's pumping efficiency by something called the ejection rate -- the percentage of blood that is pumped out of the left ventricle with each heartbeat. The normal healthy heart pumps half or more of the blood out with each beat -- an ejection rate of 50 to 60 percent.

    But if the heart is enlarged and inefficient, it may pump out 40 percent or less blood with each beat. ACE inhibitors, Wasserman said, enable some patients with ejection rates as low as 10 percent -- which would have been fatal years ago -- to live normal lives today.

    Four Drugs Every Day

    When Valerie Babb started having trouble breathing three years ago, no one suspected heart failure. She was in her late thirties, a nonsmoker who kept her weight down and exercised regularly.

    Yet she found herself chronically exhausted, and had to catch her breath after walking a long hallway. The wheezing in her lungs kept her awake at night. Her knees and ankles swelled.

    Doctors finally diagnosed the problem after chest X-rays ruled out asthma and revealed an enlarged heart. The cause remains a mystery. Their best guess is a viral infection -- possibly years ago -- that attacked the heart.

    When GW's Wasserman told Babb she had heart failure, "it was surreal, out of the blue," she recalled. She was struck by how calmly he could talk about a thing called heart failure. In the best-case scenario, he told her, medication would make her symptoms go away. Worst-case, she'd have to try for a heart transplant.

    "At that point, the severity of the situation came through to me," said Babb, 42, a professor of English at Georgetown University.

    Babb takes four medications daily: digoxin, Lasix, an ACE inhibitor and an aspirin to prevent blood clots. Except for occasional tiredness, her symptoms have gone away. Her heartbeat has strengthened, and her doctors hope the drugs have halted the progression toward an enlarged heart and heart failure.

    "Heart failure doesn't mean the end of a normal life," Babb said. "You may not always feel your old self, but you can go on to lead a productive life."

    The Ailing Pump

    Emotion aside, the human heart is basically a muscular pump.

    Actually it's two pumps -- right and left. The right side takes oxygen-starved blood returning from the rest of the body and pumps it toward the lungs. The left side takes oxygen-rich blood returning from the lungs and propels it throughout the body.

    In the healthy heart, inflow and outflow are exactly in balance. The amount of blood leaving the heart's right and left pumping chambers, or ventricles, through arteries is the same as the amount entering via veins. With each heartbeat, for example, the healthy left ventricle pumps half or more of the blood within it into the aorta, the main artery leading to the rest of body.

    In heart failure, however, the weakened left ventricle pumps less blood per beat. That allows blood to collect in the heart and in the veins leading to the heart -- eventually causing a backup of fluid that may waterlog the lungs.

    The same problem can affect the heart's right side. A weakened right ventricle cannot pump blood to the lungs as rapidly as it arrives from the rest of the body. Congestion backs up through the veins, causing the abdomen, legs and feet to swell.

    Congestive heart failure can result from weakened pumping ability in the left or right ventricle -- or both.

    SOURCES: "How Your Heart Works" by Ralph M. Myerson, M.D.; Department of Health and Human Services

    Heart Failure Is a Misleading Term

    Heart failure does not mean the heart stops beating. It means the heart is pumping less efficiently than normal. As a result, the body does not get enough oxygen-rich blood, and fluid may back up into the lungs. For most patients this is a chronic condition that can be treated but not cured.

    With the rise in the average age of the population, heart failure has become more prevalent. It is the most common reason for hospitalization in Americans over 65 and is a contributing factor in about 250,000 deaths a year.

    At the same time, improved treatment has allowed many people to live longer and more actively with a failing heart.

    WHO GETS IT: 4.9 million Americans, including nearly 700,000 new cases a year. About 10 percent of the population over age 70 has congestive heart failure.

    SYMPTOMS: Shortness of breath; extreme fatigue; dry cough; swelling in the legs and feet.

    CAUSES: Anything that damages the heart muscle, such as coronary artery disease, heart attack, high blood pressure, heart valve disease, cardiac infections, drug or alcohol abuse.

    TREATMENT: Mainly medication to lessen the strain on the heart, control blood pressure, reduce fluid in the body and strengthen the heartbeat. In rare cases, a heart transplant is done.

    PREVENTION: Control of blood pressure and weight; low-fat, low-salt diet; not smoking; limited alcohol; moderate exercise.

    Source: Agency for Health Care Policy and Research, American Heart Association

    © Copyright 1998 The Washington Post Company

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