By Michael Balk, MD, as told to John Donovan
When we talk about heart failure, the first thing I do with people is ask a number of questions about diet and other potential conditions that can cause heart failure. The most common is probably high blood pressure. Then there is coronary artery disease. Diabetes. Some viruses can affect the heart. Obesity probably has a big role. Sleep apnea is very common.
We have significant data indicating that these comorbidities – conditions that are present with another condition – affect the survival rates of people with heart failure. If you treat obesity, treat sleep apnea, treat high blood pressure, you’ll probably live longer.
So we have to go through all sorts of “normal” things that can cause heart failure. And there are certain conditions that we also call restrictive cardiomyopathies, the buildup of material inside the heart. These are much rarer. (Cardiomyopathy is simply heart disease.)
Once we have determined the causes, we can have a better idea of the treatment.
Different paths
We break down the processing into categories. First, there will be the lifestyle modification category. Then there is the category of drugs. In particular, we use the term “recommended medical therapy” to describe drugs that have been clearly shown to improve survival, allow people to live longer and reduce the risk of hospitalization. In fact, doctors are held to a standard in prescribing these drugs, for a reason: they work.
After that, we have more advanced therapies to prevent arrhythmias or irregular heartbeats. These include things like defibrillators and pacemakers. And we have newer devices that weren’t available 20 years ago that can help people with weak hearts recover, if they have a particular type of heart condition called left bundle cardiomyopathy.
We also have advanced treatments which include:
- Heart transplant
- Left Ventricular Assist Devices (LVADs)
- IV pharmacotherapy; certain intravenous medications that we can administer that seem to improve symptoms.
Sometimes we do them as a bridge to transplants, sometimes it’s what we call destination therapy (when you’re not a transplant candidate). We may install one of these devices or give you an intravenous home infusion to keep you feeling well.
But it all starts with the lifestyle.
A change in your way of life
Diet is so important. Of course, the amount of salt you eat is most important. We have kind of a general limit of 1,500 milligrams of sodium that we want people to use. Reducing salt decreases the amount of fluid left in your body, lowers blood pressure, and allows your heart to pump blood more easily.
Then, of course, there is exercise.
You think, “How does exercise work?” Well, when you think of heart failure, it’s an imbalance between supply and demand. Your heart cannot pump enough blood for your body’s needs. But if you can make your body more efficient, you can get by with less.
It’s no different than when we were making smaller cars. You can’t put a 4 cylinder engine in a big old Cadillac and expect it to have enough power. If you have a heart pumping half as hard, it’s like running a 4-cylinder engine in a big 1960s car. It doesn’t work so well. So if we work on getting more activity, we can make you more efficient and make a lot of progress there.
Once we’ve covered the first type of lifestyle, we’ll go over what you need to do each day, such as:
- Monitor your weight
- Looking for Signs and Symptoms of Leg Swelling
- get up every day
- Urinate
- Step on the scale and check your weight. I have many people who use their weight and their symptoms to decide whether to take additional diuretics. They don’t even talk to me about it anymore. And that’s great.
Find the right drugs
There are many types of drugs that doctors use to treat heart failure, including:
- ACE (angiotensin converting enzyme) inhibitors
- ARBs (angiotensin receptor blockers)
- Beta-blockers
- Mineralocorticoid Receptor Agonists (MRAs)
- SGLT2 inhibitors
- Diuretics
- Vasodilators
- Ivabradine
- Vericiguat
- Digoxin
Diuretics help the body get rid of salt and water. They probably don’t do much in terms of survival. They are there to treat the symptoms, to make you feel better. But often we give other drugs to make the heart stronger, and we won’t have to give them as many diuretics.
We have a whole series of other drugs that have just made a radical change. When I was a medical student 35 years ago, you would never give someone with heart failure a beta-blocker. Never. They were thought to weaken hearts. Well, it turns out it blocks adrenaline, which a beta blocker actually does. improved survival. It makes the heart stronger, because the blockage of adrenaline calms the heart.
A drug came out a few years ago called Carvedilol that was life changing when it came to heart failure. I vividly remember in the early 90s giving drugs like this thinking, “This doesn’t make any sense.” Ultimately, it became the standard of care.
Only three beta-blockers are what we consider recommended therapy. They work. Each has been shown to improve survival, allow people to live longer, make them feel better, and decrease their rehospitalization rate:
- Carvedilol (Coreg)
- Metoprolol (Toprol)
- Bisoprolol (Zebeta)
ACE inhibitors, and their sisters ARBs, lower blood pressure and make it easier for the heart to pump blood forward. We call this “unloading the heart”. These drugs, for probably 30 years now, we’ve known improve survival, live longer, and can actually reduce the size of the heart and prevent the heart from getting worse.
These drugs led to a new drug called neprilysin inhibitor. It can lower blood pressure and really improve the functioning of your heart. It’s quite striking.
A few others show some advantages. But these are the mainstays of therapy.
Also, remember that not all medications are the same. There is actually another set of drug combinations that you can use instead of ACE inhibitors called hydralazine and nitrates. These seem to do well with African Americans. Often, depending on the person, we essentially personalize their medical treatment.
Surgical options
When you talk about treatment, if your heart failure is due to a bad valve or a blockage, we obviously work on that too. This is where surgery, say valve replacement or angioplasty, can sometimes help.
We can put on a pacemaker to control irregular heartbeats. It can help. Implanted defibrillators, in most cases, are there to prevent sudden death. They monitor irregular heartbeats and can deliver an electric shock to correct them. But they don’t actually strengthen your core. There is currently one type of defibrillator, a bi-ventricular defibrillator (BiVICD, or biventricular implantable cardiac defibrillator), used for a specific type of heart failure, which can improve sudden death rates and sometimes help your heart work better.
When you move on to the next phase – the LVADs (the left ventricular assist devices) – it’s a big deal. You have to enter the heart, you have to open the chest, etc. But, again, for people who fail all other things, it’s an option, before a transplant.
Hope for people with heart failure
In the past 30 years alone, there has been a fundamental shift in the way we approach heart failure, particularly with regard to beta-blockers. To see the heart working better… it was mind blowing when we saw an ejection fraction (a measure of how well the heart is working) of 5 or 10%, something really bad. Then you put them on these meds and we check in 6 months and it’s normal. It’s so cool. And the heart sinks. It starts big and gets smaller. It’s getting better.
Wow.
There are lots of great things we can do to make people feel better and live longer. And I think that’s the most important thing: that people don’t lose hope. It’s totally encouraging.
