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Chat Overview with Dr. Ron Oren – February 21, 2006
Heart failure is a condition where the heart is unable to pump efficiently. This leads to several different symptoms including those where fluid backs up and produces ankle swelling, abdominal swelling and/or bloating and shortness of breath.
A variety of heart conditions can lead to the development of heart failure. The most common of which is a condition called dilated cardiomyopathy.
Q. Would you explain dilated cardiomyopathy?
A. In this illness the heart is enlarged from normal and doesn't squeeze as hard as normal. There can be two forms of dilated cardiomyopathy. The first problem is with the blood vessels. The muscle would work properly if it received adequate blood flow. This is called ischemic dilated cardiomyopathy. In the second form, the blood vessels and blood flow are fine but there is a problem with the muscle itself. This is called idiopathic dilated cardiomyopathy.
Q. My mother had two angiograms done approximately 30 days apart. About two weeks after the second angiogram, she lost her taste and could only taste a metallic taste to food. She was taking Atenolol and Zocor. Why? Do you think this could be the dye from the angiograms being so close together?
A. The symptoms that your mother is having are not common after an angiogram and I think it is unlikely they are related.
Q. I have a morning blood pressure reading of 120 - 130 over 70 - 80. When would be another good time to take it to get a good comparison? I am not on blood pressure medicine but it has been recommended. It is always high in the Dr. office.
A. Having high blood pressure only in the doctor's office is common and is called white coat hypertension. It is not a condition that leads to future problems. It sounds like your blood pressures are well controlled at home.
Q. Will you see pitting edema or could it just be barely visible?
A. Sometimes the fluid does not accumulate in the ankles and accumulates elsewhere. Other times much fluid can accumulate in the ankles and it is not detectable.
Q. In last week's chat Dr. Campbell said heart failure can't be diagnosed by CTA and that it is a clinical diagnosis. What does that mean exactly?
A. Because heart failure is defined by a group of symptoms, it can't be diagnosed with blood tests or x-ray type tests.
Q. My father has CHF. His ejection rate is 20%. Specifically, what does this mean in terms of longevity?
A. This is a confusing issue. You can consider heart failure as a spectrum of severity. On the good end of the spectrum, patients feel normal and can do whatever they want. On the bad end, they feel poorly and are severely limited. One would think that where one's at on the spectrum is determined by how hard the heart pumps. This would make sense. Unfortunately this is not the case. Patients can be on the good end of the spectrum and have a heart that pumps relatively poorly. Patients can be on the bad end and have a heart that pumps relatively better.
We have known this observation for 12-15 years. Much research has gone into explaining this confusing observation. It appears that where someone's at on the spectrum (how sick their heart is) is related to other factors. These other factors revolve around how the rest of the body (lungs, liver, kidneys, blood vessels and muscles) adapts to the heart not pumping well.
Q. If you are looking mainly at symptoms, can heart failure be confused with other things?
A. Yes you are correct. The symptoms of heart failure including swelling, shortness of breath, tiredness are also the symptoms of many other conditions. Separating these can be a challenge to doctors and nurses.
Q. How often do you see depression co-morbid with CHF...do you think this significantly worsens outcomes?
A. Psychologic conditions are commonly associated with CHF. Both depression and anxiety very commonly coexist with heart failure. This is certainly understandable, as many heart failure patients can't do the things they like to do.
Q. What advice would you give to a heart failure patient regarding diet and exercise?
A. The nonpharmacologic aspect of heart failure treatment that you mention is very important. The drugs we use will not be effective in the absence of appropriate diet and exercise. The diet must restrict sodium and fluid. This is because the heart and the kidneys cannot remove a normal amount of salt and water intake. When this occurs salt and fluid accumulates and swelling results. Following a sodium restricted diet is a challenge. Many patients, incorrectly, feel that if they simply don't add salt from a shaker then their salt intake will be OK. However there are many hidden forms of salt of which patients may be unaware. I suggest consulting with a dietitian or heart failure coordinator to find these hidden sources of salt. Very similarly following an appropriate fluid restrictions can be difficult. As the heart worsens certain signaling systems are activated that actually increase thirst. So the more fluid you retain the thirstier you become. Just like the diet I suggest discussing with a dietitian or heart failure coordinator different techniques to monitor fluid intake and reduce the thirst sensation. Exercise is also important. It turns out that there are specific abnormalities of the skeletal muscles (of the arms and legs) that are seen in heart failure patients. These abnormalities contribute to the symptoms of tiredness and fatigue. These abnormalities of the skeletal muscles can be reduced with moderate exercise.
Q. A 55 y.o. male is waiting for heart transplant. He had a heart attack at 35, weak arteries & aneurysm areas. No family hx of heart disease. How did he get this?
A. Unfortunately current medical science does not understand a great deal about how we get various illnesses. Sadly there are circumstances like the one you describe where illnesses occur without any rhyme or reason.
Q. What is the most common procedure performed for repair of dilated cardiomyopathy?
A. There is no real repair procedure for dilated cardiomyopathy. In this illness the individual muscle cells are abnormal and thus a surgical type repair is impractical. The medications that are used improve the abnormal cellular function.
Q. How would you treat someone you knew or suspected had co-morbid depression and what treatments would you be concerned with compromising the CHF they are dealing with?
A. Unfortunately depression when associated with heart failure is difficult to treat. Often improving the heart failure results in an improved mood and outlook. Not much is known about how to treat depression differently when heart failure is present
Q. Back on depression . . . it seems like a lot of heart conditions can cause depression? Is it just not doing want you want, or is something else going on? My friend's husband had heart surgery and then bad depression. Someone said it was bad blood chemistry.
A. Depression can accompany many heart conditions. Not enough research has been done in this area to understand the relationship between the depression and various heart illnesses.
Q. A past cancer patient (chemo & radiation) now has severe pain under the L breast. She also has a heart murmur & wonders if the pain is heart or cancer treatment related?
A. The murmur is probably not associated with the pain.
Q. I know heart failure is the term you use, but what is the difference between heart failure and congestive heart failure?
A. The two terms are used synonymously. Because symptoms of fluid retention (congestion) so commonly occur some people add the word congestive to the words heart failure.
However, fluid retention (congestion) is not always seen with heart failure that is why some people eliminate the word congestive. Both mean the same.
Q. I've recently been hearing about the filtering system you use for heart failure. How do you decide who’s a good candidate for this procedure is and how does it work?
A. First, the issue of candidacy. Obviously substantial fluid overload must be present. In addition, there should not be the presence of certain medical conditions where rapid fluid removal can lead to harm. These conditions include cirrhosis, pulmonary hypertension, some forms of kidney disease, etc. These conditions are uncommon and rarely limit ultrafiltration use. Next, to describe the procedure. Two IVs are placed either in the arms or in a large vein in the neck. A small amount of blood is withdrawn by the machine from one IV. The blood goes into the machine and the fluid is discarded into a collection bag. And the blood cells are then returned to the body by the machine through the other IV. This procedure is best used when patients don't respond well to diuretic medications. While it is not fully understood it appears that the ultrafiltration alters the signaling systems between the heart and the kidney, which makes the kidney response to the medications, blunted.
Q. How often do you see CHF associated with MI's or other ischemic heart conditions...or are these 2 separate disease processes?
A. About two thirds of the time heart failure is associated with ischemic cardiomyopathy. The remainder are associated with nonischemic cardiomyopathies. These ratios can obviously change depending upon the group of patients your considering.
Q. Could you expand on why so many have ischemic cardiomyopathy...e.g. how does the congestive lend itself to ischemia?
A. In the Iowa area, coronary artery disease is very common. In other areas of the country it is less common.
Q. Can valve problems lead to heart failure?
A. In the normal heart there are one way valves in-between the chambers of the heart. This allows blood to flow the right way and not flow backwards. Two problems can occur with valves. They can either not open properly (stenosis) or they can close incompletely (regurgitation). Either process puts extra strain on the heart and over time can result in dilated cardiomyopathy.
Q. What kind of medications slow or prevent the onset of heart failure and what are the side effects of those medications?
A. The major problem with heart failure is maladaption of the various organ systems in the body to the heart's pumping abnormalities. This maladaption is the result of abnormalities in the normal chemical signaling systems. Most of the medications that are used, which slow the disease progression or actually reverse the illness are designed to help normalize these abnormal signaling systems. Examples include: 1. Beta blockers which help normalize the sympathetic nervous system. 2. ACE- inhibitors that help normalize the renin system. 3. Spironalactone, which help, normalizes the aldosterone system. Unfortunately several signaling systems are unaffected by these medications. In the past a variety of medications have been tested which block other signaling systems and have been found to not be either safe or not be effective.
Q. It has been said to avoid aspirin after heart failure. I thought that would thin the blood and make it easier to circulate. Where am I mistaken?
A. There is some evidence that suggests that aspirin adversely affects the actions of ACE-inhibitors, which are one of the major medications used in heart failure. The notion that aspirin "thins the blood" is actually a mis-statement. It actually inhibits platelet function making blood less likely to clot.
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