Heart failure:
A livable condition
Standing just shy of 6 feet tall in heels, Ellen Morris knows she has a problem with her weight, readily admitting that she has “junk in her trunk.”
Her aversion to stepping on a weight scale goes back to law school. But with her 50th birthday fast approaching this summer, Morris has undergone a transformation of sorts. She even went out and bought her own scale.
For Morris, watching her weight wasn’t about vanity; it was life and death.
“I plan to spend my 50th birthday in Las Vegas, not in a funeral parlor,” she boasted.
Heart failure, also known as congestive heart failure, is a common cardiovascular condition, affecting about 5 million people in this country, and Morris is one of them.
The American Heart Association estimates that roughly 550,000 new cases are diagnosed annually, and almost 300,000 people die from the disease each year.
There’s no real cure, and recognizing symptoms is often as difficult as living with the chronic disease.
As Dr. Eldrin Lewis sees it, living with heart failure can sometimes be a matter of pounds.
Lewis, a cardiologist at Brigham and Women’s Hospital, is not talking about obesity — though that is a risk factor for all sorts of illnesses. For those with heart failure, an increase of just two or three pounds in a single day could signal trouble.
Lewis explained that people with heart failure must weigh themselves every day, preferably at the same time in the morning — and on the same scale.
It’s no surprise, then, that Morris is one of Lewis’ patients.
She now takes the disease more seriously, especially since under the care of Lewis. “He makes you want to do it for yourself,” she said. “I have to own this.”
Heart failure occurs when the heart cannot function sufficiently enough to meet the body’s needs. A healthy heart pumps blood to the lungs, where it picks up oxygen. The heart then pumps the oxygen-rich blood to the organs and muscles.
The major causes of heart failure are conditions that weaken the heart — heart attacks, uncontrolled high blood pressure and diabetes. In coronary artery disease, plaque buildup narrows the arteries and restricts blood flow to the heart, causing damage and, possibly, heart attacks. High blood pressure has another effect; it stiffens the arteries and makes the heart work harder. In diabetes, sugar accumulates in the blood and can damage blood vessels in the heart.
Several other conditions and diseases can cause heart failure — disorders of the heart valves; arrhythmias, or irregular heartbeats; viruses; congenital birth defects; and alcohol and drug abuse. In almost half of all cases, the cause is uncertain.
For blacks, heart failure is all too commonplace. Blacks experience symptoms of heart failure at a younger age, suffer more severe forms of the disease, and have more hospital visits due to heart failure than other racial groups. Death rates from heart failure may be higher in blacks than in whites partly due to the high incidence of diabetes and hypertension, the two leading causes of heart failure.
Despite its name, heart failure does not mean that the heart is going to stop working or that a heart attack is imminent. Nor is heart failure usually sudden. More often than not, the disease progresses over time and may be ignored by patients.
Such was the case with Morris.
It started with a pain in her chest.
The discomfort occurred in July 2000, and she said it felt like heartburn. She went to her primary care physician, who ordered a treadmill test. It came back negative, and though her doctor also ordered an EKG and an echocardiogram, an ultrasound of the heart, she cancelled those tests, convincing herself she “could work through it.” Eventually, the heartburn went away.
Four months later, Morris said, her “heart started racing.” She had palpitations and, again, a pain in her chest. She again called her doctor, but this time she was told: “Ellen, sit down and call an ambulance.” Morris still was not alarmed.
She called, and as the ambulance approached, she walked outside to greet them. The paramedics came running and ordered her to sit down inside the house.
She was taken to Newton Wellesley Hospital, where she got the bad news: Her left ventricle, the major pumping chamber of the heart, was barely working and, as a result, her organs and muscles were not receiving the oxygen-rich blood they needed to survive. The problem was severe, she was told. “I have never seen two doctors look so afraid,” she recalled.
Even then, Morris said, she was still in complete denial despite being transferred to Brigham and Women’s Hospital.
And that is one of the problems with heart failure.
According to Lewis, patients often ignore the first symptoms of heart failure. “When they tire easily, they attribute it to old age,” he explained. “If they get short of breath, they think, ‘I must have a cold or the flu.’”
Lewis pointed out that some physical conditions can cause the same symptoms of heart failure. For instance, he said, if someone is obese, they get winded by walking up a flight of stairs. “But it may be the first sign of heart failure,” he said.
Doctors also can delay the diagnosis because of more common diseases being considered first. Some patients get treatment for lung disease, Lewis said, when it is really heart failure. “We might not be doing a good enough job explaining it,” he said. “We should tell patients that this is a lethal disease, a dangerous disease and survival [rates] can be worse than [those for] cancer.”
Although not as common as other cardiovascular diseases, such as stroke and high blood pressure, heart failure takes an economic toll, and is one of the most common reasons for hospital admissions. According to the Centers for Disease Control and Prevention, between 1979 and 2005, hospital discharges for heart failure increased 171 percent. In fiscal year 2005, heart failure was the fourth most common diagnosis for hospital admissions in Massachusetts. It is estimated that the total cost of heart failure in the United States — both direct and indirect — will be $34.8 billion this year.
Heart failure can occur at any age, but is more common in people 65 and older. It is the most frequent reason for hospital admission for Medicare recipients. It occurs more often in people who are overweight or obese due to excess strain on the heart and higher incidence of type 2 diabetes.
The symptoms of heart failure are both obscure and distinct. The most common are shortness of breath, fatigue, reduced ability to exercise and swelling in the ankles, legs and abdomen. Other telltale signs include waking up at night because of difficulty in breathing or having to sleep with the head propped up on several pillows. Some people may experience chest pain or coughing.
A common test for heart failure — the ejection fraction (EF), which measures the strength of the heartbeat — is not a reliable indicator of how a person feels. It is possible to produce a normal EF while experiencing signs of failure.
Some cases of heart failure are mild, and with good medicine and lifestyle changes, can remain mild. In very severe cases, heart transplants are required. Of the 5 million people living with the disease, only about 2,500 transplants are performed each year.
But it doesn’t have to get to that stage. Lewis is clear on that point.
“Patients have to be proactive,” he said. “Medicines are improving and patients are living longer — survival continues to improve. Don’t run from it. Some people have the attitude — ‘I have high blood pressure and diabetes and I also have heart failure.’ Don’t just add it to a list. It takes work to make it better.”
It’s also possible to prevent heart failure: Lose weight, exercise, watch what you eat.
Just controlling high blood pressure goes a long way. “It is frustrating as well,” Lewis said. “I have a story about two brothers — both got high blood pressure in their 30s. One got good treatment; the other did not. The one who got treatment is doing well — his heart function looks great. The other got heart failure in his 50s.”
Lewis also urged patients not to look for a magic remedy. “People want to look for a new pill to prevent heart disease,” he said. “Look at the basics. If your blood pressure is over 140/90 — get it down. If you’re diabetic, get the blood pressure under 130/85.”
It wasn’t that simple for Morris.
She now takes about 12 pills a day, including diuretics.
She had a defibrillator inserted. Without one, she was told, she could die in her sleep.
The defibrillator is about the size of an iPod and monitors heart rhythms. If the beats are off, the defibrillator shocks the heart back to normal.
It took a while before Morris became comfortable with the defibrillator. She said she thought the implant had control over her life and, worse, lulled her into a false sense of security. “If the machine was OK, I was OK,” she said she thought at first.
But a few years ago, the defibrillator shorted out and stopped functioning, and did not respond well enough when she went into cardiac arrest. That problem was fixed when doctors implanted what she called a “super-duper model.”
“I’m now a bionic woman,” she exclaimed.
She tries to steer clear of fast foods that are high in fats and salt. Even though she loves Chinese food, she orders the dishes that do not contain MSG. She joined a gym and was exercising regularly until she recently pulled a muscle.
She said she also monitors the number of pillows she uses to sleep. She knows she’s headed for trouble if she has to be elevated to sleep,
The trick, she says, is to recognize the symptoms and get help.
“It does sneak up on you,” she said. “Even seven years down the line, I still slip up. I should know better. But I don’t look or feel sick. I laugh, joke and go dancing. It took me over seven years to realize that I am really sick. I am an educated woman, and if my kid was sick, I’d make sure she took her medication and did everything the doctor recommended. As adults, we get busy and complacent.”
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| It has taken Ellen Morris over seven years to come to terms with her heart failure. By working closely with her cardiologist, she is now better able to control her symptoms. |
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Eldrin Foster Lewis, M.D., M.P.H.
Cardiologist
Brigham and Women’s Hospital
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