HEART FAILURE - Full extract 

It was 3 AM when my answering service rang to tell me that Clarrie Jones had called about his wife. I knew Mrs. Jones had high blood pressure but she hadn't been to the surgery for ages. When I rang back, Clarrie said his wife was coughing and a bit distressed. " She's not too bad doc, but we would be grateful if you had a look."  

As I pulled up in the car Clarrie was there to meet me, wringing his hands and looking very worried. " She's worse doc. I don't know what to do." Mrs. Jones was sitting on the side of the bed and was obviously short of breath. She was clammy, pale and barely able to speak. Her blood pressure was normal but she had a rapid heart rate. A quick listen to her chest revealed a lot of moist crackly sounds. It was evident that she had acute pulmonary oedema, or acute heart failure.  

I phoned an ambulance, and also the hospital to let them know that Mrs. Jones would be coming into casualty as an emergency. Clarrie helped me lug in my cardiograph and a portable oxygen cylinder from the car. I quickly explained to Mrs. Jones what the problem was and gave her some oxygen by a facemask. I put a tourniquet on her upper arm and gave her an intravenous injection of Lasix, to help clear the fluid from her lungs. She was also given some morphine to make her less agitated.  

The ambulance officers soon arrived, and the Jones' bedroom was a hive of activity. The cardiograph showed no sign of a heart attack but the rhythm was slightly irregular, something that could be sorted out in casualty. Clarrie went off in the ambulance with his wife. I tidied up my gear, pulled the door shut, and headed off home. 

The heart is basically a muscular pump that pushes blood around the circulation. When it fails, a build-up of fluid may occur, leading to congestion on the lungs and shortness of breath. This is usually most obvious on exertion but it can also occur at night when the person lies down. Heart failure may also cause an accumulation of fluid in the legs, making them very swollen. There may also be other symptoms such as increasing fatigue and lack of energy. 

There are many causes of heart failure. Longstanding high blood pressure can put a strain on the heart, causing it to enlarge and eventually fail. Coronary artery disease can also lead to heart failure, even without a specific heart attack. Abnormal heart rhythms can prevent the heart pumping properly. Likewise, problems with heart valves can cause heart failure. Viral infections can damage the heart and cause it to fail, as can alcoholic heart disease. Other medical conditions such as an overactive thyroid gland and anaemia can also contribute to heart failure, especially in older people. Sometimes the exact cause is not identified. 

In recent years we have learnt a lot more about the various responses that the body uses to maintain blood pressure when the heart starts to fail. This includes an increase in both the heart rate and the resistance in the walls of the arterial blood vessels. There is also a decrease in the amount of salt and water passed in the urine. While these responses help in situations like acute blood loss, in heart failure they actually put further strain on the heart and make the problem worse.  

There are a number of clues that help doctors diagnose heart failure at an early stage, long before people go into acute pulmonary oedema. Sometimes the main veins in the neck are more prominent and there may be swelling of the ankles. Listening to the chest may reveal extra heart sounds or signs of congestion on the lungs. A chest X-ray sometimes shows enlargement of the heart and lung congestion. However, like cardiographs they can be quite normal in early heart failure. Cardiac ultrasounds are being used more these days; they give useful information about how well the the heart is working. Other specialized tests are available, and an assessment by a cardiologist is often advised.

A major change in the treatment of heart failure in recent years has been the use of medications called ACE-inhibitors, to reverse and prevent many of the body's responses to heart failure. They are effective in most types of heart failure, and are also being increasingly used for high blood pressure. They include medications such as Capoten, Renitec and Monopril. The early use of ACE-inhibitors in heart failure seems to greatly improve both the quality of life and the prognosis.

Diuretics or fluid tablets also have a role in the treatment of heart failure. They act on the kidney to help get rid of salt and water. Lasix, Chlotride and Dyazide are some of the more common diuretics. These medications can occasionally lower the serum potassium level, and supplements like slow K may be required. Sometimes other medications such as beta-blockers, digoxin and spironolactone are also used for heart failure.

People under the age of 65 years, who have severe heart failure not responding to medication, are sometimes offered cardiac transplantation as an option.

Aspects of treatment such as adequate rest should also be kept in mind. Conditions such as high blood pressure that might be aggravating the heart failure also need to be managed. Excess alcohol intake may be an issue that needs to be addressed. Likewise, stopping smoking is also important. A graded exercise program can help to maintain the person's overall fitness. Regular reviews by the doctor are also important in case further investigations or adjustments to medication are required.

A newer approach these days has been the establishment of specialized cardiac failure units within some major hospitals. Cardiologists, specialist nursing staff and other team members have been able to significantly improve the outlook for cardiac failure patients.

Health Tips:
* Breathlessness and swelling of the ankles are more obvious  signs of heart failure. Fatigue and lack of energy can be  earlier clues. 

* The earlier that heart failure is recognized and treated,  the better the prognosis. 

 Web links:
 ¹ www.heartfoundation.com.au

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001