|Welcome to the Heart Failure Clinic at the NCH Heart Institute |
You are here to continue treatment for heart failure. What an unpleasant term and diagnosis! It covers lots of situations. The important concept is that careful attention to your medical therapy can add years to your prognosis, and function and comfort to your days.
Heart failure comes in two flavors. The traditional concept is one of a weak heart, as measured by a poor ejection fraction. The normal heart ejects about 60% of the blood it contains with each contraction. The abnormally weakened heart is characterized by an ejection fraction less that 40%. A very low ejection fraction is less than 20%.
It is important to know that ejection fraction does not correlate strictly with symptoms. There are many people with very weak hearts who are not inconvenienced, just as there are many with a normal heart strength that have severe symptoms.
The second flavor of heart failure is that in those with preserved heart strength, greater than 40%. This is diastolic heart failure. Diastole is the filling phase of the pumping cycle. The heart has not only a pumping function, but needs to fill for the next heartbeat. Diastolic dysfunction can be thought of as a stiff heart that is more difficult to fill. This results in increased initial pressures inside the heart that are translated to symptoms of shortness of breath and edema.
This clinic is meant to be responsive to your questions and needs. On your card, you will find the number of a clinic member who can address your important questions and concerns directly. You will still call (239) 624-4200 for usual concerns, such as non-emergent appointments and medication refills. We hope to be responsive, and beg your forgiveness if we are not.
|Other Therapies for Heart Failure|
What Causes Heart Failure?
In our culture, the major causes are coronary disease and hypertension. We are careful to look for ischemia, the presence of limited blood flow to the heart muscle as a result of blocked arteries, because it can be specifically treated by opening blocked arteries.
Another cause with specific treatment is valvular heart disease; mostly of malfunction in the aortic and mitral valves, which can cause such extreme inefficiency as to cause heart failure. Some people have genetically determined weakness or abnormal thickness of the heart muscle; some have acquired diseases that infiltrate the heart muscle and cause failure.
In the three decades that I have been a participant and observer in Cardiology there have been many surprising developments, not less so in the realm of heart failure.
There are a number of medications that have been extremely helpful, and have each decreased heart failure mortality by about 30%. When the heart is failing, a number of hormonal signals are generated that are paradoxically neither protective nor helpful. When I was a student these were identified as protecting blood flow to the kidney, and the ‘wisdom of the body’ was thought to be paramount.
The first of these therapies was the use of ACE inhibition; ACE for angiotensin converting enzyme. As the increase in renin during heart failure was neutralized by these agents, beneficial results included an increase in longevity and well-being. These medications include captopril, the first ACE inhibitor, enalapril, lisinopril, ramipril, and several others. They are occasionally associated with a troublesome cough, resulting in the substitution of their cousins, the ARB group (angiotensin receptor blocker).
The second addition to the armament neutralized an increase in epinephrine seen in the failing heart; this use of beta-blockers added another 30% improvement in mortality. The term beta-blocker refers to the blockade of beta receptors in the heart responsible for heart rate and blood pressure control. The first beta blocker was Inderal (generic as propanolol), followed by longer acting agents, and generally prescribed now as metoprolol (Toprol). A newer cousin, carvedilol, improves on this track record.
The third antagonist is spironolactone, a mineralocorticoid receptor antagonist. A newer molecule is called eplerenone. Medications are generally added sequentially based on response. These medications are nominally for the treatment of hypertension, but are added even in the absence of high blood pressure. If they are slowly increased, a reasonable dose can generally be achieved without side effects.
None of these medications are useful if they are not taken. Keeping a medication log along with a daily weight chart is key in helping to control symptoms.
|Diuretics for Heart Failure|| |
The primary therapy that provides comfort for the patient with heart failure is a diuretic. The patient confronts symptoms of shortness of breath and swelling of the legs by adding a diuretic. The failing heart signals the body to retain salt and fluid, and achieving a new balance is the first priority.
It is a simple matter of input and output; the person drinks and eats a quantity, and urinates a quantity. If it is in balance, the person neither gains nor loses water weight. With the initial presentation in heart failure the usual requirement is one of negative fluid balance, achieved by taking loop diuretics (so called because of their site of action in the kidney) which are generally powerful. Those in general use are furosemide, bumetanide, and torsemide. Another class is the thiazide group, generally milder, and longer acting.
Of course it is not so simple a matter. If a diuretic has action for six hours, the body can escape that beneficial effect by holding fluid for the next eighteen hours. The patient may not be particularly vigilant about limited fluid and salt intake, and may not have the desired result. A common misconception surrounds the need for increased fluid consumption to flush out the kidneys. The important insight is careful attention to fluid and salt intake. It is possible to limit fluid intake to 50 fl oz, or 1.5 liters daily. This can be visualized as four 12 oz soda cans a day, and should account for all fluid including coffee and soup and ice cream. This is a difficult ration, especially as patients become more thirsty. A common strategy is to use ice chips to take the edge from the thirst.
All the extra edema or swelling also consists of salt. This becomes a difficult target, because so much of it is not apparent. Less than 20% of our salt intake is generally discretionary, in terms of added salt at the table. The rest is buried in prepared food. A reasonable target to establish is of 2 grams of sodium daily. This is the equivalent of 2,000 milligrams (mg) of sodium a day, and of 4 grams of salt (4,000 mg of sodium chloride) daily. Most labels list this as milligrams of sodium, and it is not unusual for an organic healthy soup can to contain 600 mg.
A successful patient achieves and maintains a fluid balance; the need for fluid restriction and diuretics is obviously directly related to the severity of swelling the patient suffers. The careful patient monitors his weight daily and responds to changes appropriately.
For more information or an appointment, call 239-624-4200 M-F, 8am-4pm
|The Physicians of the|
NCH Heart Institute
David Axline, MD
Francis Boucek, MD
Michael Flynn, MD
Adam Frank, MD
Bruce Gelinas, MD
Robert Pascotto, MD
Tracey Roth, MD
Carlo Santos-Ocampo, MD
Herman Spilker, MD
David Stone, MD
Silvio Travalia, MD
Shona Velamakanni, MD
James Venable, MD
| 399 9th Street North • Suite 300 • Naples|