Heart failure is a growing problem, not just in the United States but worldwide. It is estimated that there are approximately 20 million cases of heart failure and about 5 to 6 million of those patients live in the United States. The biggest myth about heart failure is that it is the same as a heart attack. A heart attack occurs from a blood vessel that's blocked where the nourishment of blood to the heart is lost for a period of time. Heart failure is a more chronic disease where the pump function of the heart, predominantly the left ventricle, is in disarray. This causes the heart to pump less efficiently. The term heart failure evokes a sense of despair when in reality there is much that can be done for a patient with pump dysfunction or heart failure.
Heart failure is a chronic disease that manifests itself with shortness of breath or just undue tiredness. Typically, patients notice that they are unable to use the same level of physical exertion as they could previously. They tire easily and very quickly from simple activities like picking up the mail. When the heart muscle is inefficient and unable to pump effectively forward, it congests and fills up the lungs with fluid which results in the blood being unable to move or circulate in an efficient fashion. This often leads to congestion where the legs become swollen from veins that are engorged and the liver can also become swollen giving rise to abdominal pain. Without the heart muscle pumping in a forward motion, proper circulation cannot be achieved and fatigue may follow.
Heart failure is a clinical diagnosis. This means that a competent physician has to evaluate the patient and look at the entire constellation of signs and symptoms. More importantly, a heart failure diagnosis is made by measuring the pumping capacity of the heart or by observing that the heart muscle has become very stiff. Diagnosing heart failure can be done with simple tools like an echocardiogram.
Heart failure should not be considered as a negative, pessimistic diagnosis. There are many wonderful medications that not only make people feel better, but clearly prolong life as well. ACE Inhibitors were one of the first medications proven to be beneficial in treating heart failure. Now, beta-blockers are being used with great success. Digoxin, which withstood 250 years of existence, is used for patients who have advanced cases of heart failure. In addition to those medications, we use water pills or diuretics for patients who need to be decongested.
Digoxin comes from a plant and was discovered almost 250 years ago. It's one of the oldest medicines we have in cardiovascular medicine. The plant was discovered by Sir William Withering in 1773. It is a very old drug that is used to increase the pumping capacity of the heart, but it is usually reserved for later stages of heart failure.
Beta-blockers are drugs that slow the heart rate and actually depress the pumping capacity of the heart. For a number of years, physicians were taught to never prescribe a beta-blocker for heart failure because it was counter intuitive. Now it has been proven that when beta-blockers are given over an extended period of time, the heart muscle improves its pumping capacity because it's been rested well. Patients who receive beta-blockers tend to live much longer than patients who do not.
These medicines can and should be given in combination with each other. Combinations of these medicines create synergistic effects where the medications work with each other and improve the pumping capacity of the heart. Patients who receive combinations of heart medications feel better and live longer.
Yes, it can. It used to be that heart failure was an end-stage diagnosis and that nothing could be done about heart failure. At UMMC there are six physicians who do nothing but take care of patients with heart failure. The outcome for patients with heart failure is improving every day.
The appearance of heart failure is a part of a continuum of risk. For example, the disease really starts with a constellation of risk factors. Some of those risk factors can be things like smoking, obesity, diabetes, even advanced age. These risk factors in combination with genetic factors such as high blood pressure or cholesterol, can lead to heart attacks, heart rhythm disturbances and heart valve problems. Prevention is the best medicine for patients who are at risk for heart failure. Key ingredients to obtaining heart health include: reaching and maintaining a healthy weight, cessation of smoking, and control of cholesterol, blood pressure and diabetes.
It's an evolving science that involves knowing which area of the human genome is affected and interpreting that information. However, the technique is as simple as taking a blood test. The concept of personalized medicine looks at an individual's profile which is created from their genetic makeup. Genetics play a very important role, not only in determining the fate of a patient with risk factors, but also in determining their response to treatment. Some patients don't respond well to beta-blockers or ACE Inhibitors and with personalized medicine, we can predict who those patients are, based on the genome type.
We are very excited about the evolution of treatment of heart failure into what we now call regenerative medicine. The idea is to reverse heart dysfunction by using stem cells. Stem cells are cells that are seen in routine embryology. For instance, as various tissues grow or take birth, the stem cells transform themselves into various cells in the body. Not only are stem cells resident within the heart, they can come from bone marrow or cells from your blood and be coaxed into forming heart cells using different chemicals. The way this works is that stem cells target areas that are injured and then adhere to the area. They then transform themselves into the needed heart muscle cells and help recruit more function. At this point, it is experimental and we have to use it under the guidance of experimental clinical protocols, but it's in use today.
There are many stages of heart failure and the early stages tend to respond wonderfully to lifestyle changes and medications. But there is a distinct sub-set of patients who transition to very severe forms of heart failure. These are patients who can't get out of bed, medications have stopped working even some of the specialized pacemakers we use to improve heart muscle function are non-responsive. In these cases we employ new technology called Left Ventricular Assist Devices (LVAD).
These devices are like blood vacuum pumps. They are placed into the chamber of the left ventricle and they relieve the stress of pumping from the heart muscle. They actually take blood away from the heart and pump it out in an artificial manner. For short-term therapy, these pumps can be put in through the groin, just as a routine heart catheterization is performed. These pumps are usually only left in for a few days or a week because there are complications that can occur. By that time, the pump has served its purpose and either has recovered the heart back to its healed state or has given the medical team enough time to arrive at a more permanent solution. Permanently implantable devices, on the other hand, must be put in using advanced surgical techniques. For patients who need longer-lasting heart pumps, permanent LVADs are used. These devices used to be large and bulky, but now are smaller than the size of a battery. We are very fortunate at UMMC to have a group of surgical colleagues who are leaders in this technology worldwide. We have access to some of the latest pumps and technology and the Jarvik pump is one such device.
It depends on what kind of heart pump the patient has and what their restrictions were before the pump was implanted. The goal of surgery is to restore the patient to an absolutely normal lifestyle. However, it may take a few weeks or several months for a patient to fully recover from the surgery. During recovery, patients are very debilitated because their bodies are recovering from the effects of living with long-term heart failure.
Certainly. We are restricted in the number of heart transplants performed in the United States and only do approximately 2,200 heart transplants a year due to the small number of donors. This is why artificial heart pumps are so important. However, nothing to date has shown the same success rate of biological replacement (heart transplant). There are patients who can live as long as 10 years with a heart transplant—the longest surviving heart transplant recipient lived for 31 years. Patients have to take medicine every day to suppress the immune system so the body doesn't reject the new heart, but people do very well. The outcome from a heart transplant is unparalleled in patients with advanced heart failure.