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SYMPTOMS
What are the symptoms of heart failure?
When your heart does not pump enough blood around the body, fluid builds up because there is not enough energy to push the fluid through the kidneys into your bladder. The medical word for a build-up of fluid is oedema(pronounced ‘ee-dee-ma’). If the fluid builds up in your lungs, you become breathless, with a wheeze or a cough, and you may produce frothy sputum. If the fluid builds up around your ankles, they will swell up and you will be able to see indentations from your shoes or socks or from pressing your skin with a finger (be careful, it can be painful).
My partner has been diagnosed with heart failure but no one would guess on meeting her. However, she does get breathless atnight. Why is this?
Fluid builds up in her lungs when she lies down and, if she is asleep, her defences are down. She may wake up with a suffocating feeling. This is helped by standing or sitting up, as this will take the pressure off her lungs. Some people open the window, feeling the need to gulp in fresh air, others walk around or go downstairs to make a cup of tea. If you can reassure her that all is well, this will help her to keep calm. She should tell her doctor that this is happening as medication can help to relieve it.
I have heart failure. Am I right to be worried that I will not be able to lead an active life?
Patients with minimal heart failure usually have no limitations to ordinary physical activity. Mild heart failure leads to breathlessness on walking a mile on the flat, one or two flights of stairs or a long incline. Moderate heart failure tends to cause symptoms more readily – walking half a mile on the flat or one flight of stairs leads to needing a rest. Severe heart failure causes breathlessness on minimal effort and even at rest. Everyone is different, so personal issues are usually best discussed with your doctor.
The good news is that we have treatments that can relieve or at least improve any symptoms so that a better exercise ability and quality of life can be enjoyed. People with more severe symptoms have to learn to adapt their lifestyle once all treatments have been tried and they still remain limited. If you are overweight, reducing your weight can help by taking some of the workload off the weakened heart pump.
You will probably be able to go on holiday and travel as usual, but make your plans more carefully to avoid rushing to catch aeroplanes or trains. Discuss with your doctor if you are planning long journeys while you are on water tablets (see the section Treatment below) as these may need adjusting: dehydration can be a problem on long flights.
Sexual activity doesn’t usually present a problem and is not harmful. As in all forms of exercise, breathlessness might limit what you can manage, so take advice if this occurs (see Chapter 8). Some tablets can make you lose your sexual drive and, if this has happened, you should mention this to your doctor rather than accept it. Your doctor may be able to change your medication. Remember, don’t suddenly stop taking your medication as this could be dangerous. People often keep to themselves their worries and anxieties. Don’t do this – most of your problems can be alleviated: don’t be afraid to let the doctor know what’s on your mind.
I had a heart attack recently. My cardiologist tells me that my heart has weakened and that I have now got heart failure. Will the symptoms be noticeable?
Your weight may go up from the retention of fluid (1 kg=1 litre or 1 lb=1 pint). Your doctor will monitor treatment by measuring your weight loss after you have been prescribed diuretics (these are
pills to make you pass more water). There are other symptoms that you might notice:
• feeling tired and washed out;
• swollen ankles (‘I can’t get my usual shoes on’);
• swollen tummy (so your clothing is tight); and • on occasions, you may get a bit confused.
My doctor says I have a hibernating myocardium. What does he mean?
Your heart muscle looks weak and damaged but is capable of getting a lot of its power back; the damage is not irreversible. The heart is literally hibernating. If your heart only appears to be damaged, it may be possible to strengthen it by angioplasty or surgery. If that is possible, your quality of life and length of life will be greatly improved.
The doctor will check your heart to see what its strength is, either with an echocardiogram, perhaps a nuclear (thallium) scan, or a technique known as positron emission tomography (PET for short). See the sectionTests below.
Should I discuss the diagnosis of heart failure with my family?
It is always important with any illness to discuss its effects with close family and friends and, if appropriate, workmates. Having heart failure may limit you because of breathlessness, fatigue and weakness. Your family and friends will be worried about you – by bringing them into the picture they will be able to help and support you.
TESTS
It is important to know the cause of heart failure because, if it is mechanical (such as a leaking valve), you will need a mechanical solution (a new valve). If it is heart muscle failure, you will need tablets. A high blood pressure will need urgent treatment. Investi gations sort this out. Usually you will have an ECG (see Chapter2), a chest X-ray, blood tests and an echocardiogram. These are all discussed below.
The doctor at the hospital told me that I have heart failure. For some reason, he told me to report back for a chest X-ray. Why do I need a chest X-ray for heart failure?
An X-ray picture of your chest will tell him about the size of your heart and its shape; this will help the doctor work out the cause of your heart failure. He will also get a picture of your lungs and can tell whether there is any infection or fluid there.
You will be asked to stand in front of an X-ray plate, and then told to breathe in and hold your breath for a few seconds. As you hold your breath, the picture is taken. Holding your breath will prevent a blurred image occurring. The X-ray dose is very small and not in any way dangerous.
Why do I need blood tests for heart failure?
Your doctor will need to make sure that you are not anaemic, as this can make heart failure worse (see earlier question). Your kidney function will also be checked and any evidence of a congested liver looked for. Blood may also be taken to make sure that your thyroid gland is not under- or overactive. Any evidence of liver damage from alcohol will be monitored. Liver congestion is not unusual in heart failure and improves rapidly with treatment. A test for Brain Naturetic Peptide (BNP) is frequently performed and elevated levels identify heart failure.
My sister is very concerned that she has been given an appointment to have an echocardiogram. What is this?
This is a painless, simple test which tells us about the size of her heart, how well it is working, how strong the muscle is and how the valves are working. It is often used to assess the significance of a heart murmur and the size of a heart attack, to see if any clots are forming and to calculate the efficiency of the heart’s muscle pump.
How is an echocardiogram performed?
The room, in a hospital or at your family doctor’s, is usually darkened to allow the doctor or technician (cardiac physiologist) to see the screen. You may be asked to lie on your back or side (see Figure 5.1). A special type of jelly is put on your chest and a probe applied to the jelly. The probe is moved over your chest. Ultrasound waves (it is not an X-ray being taken) are bounced off your heart and a picture of the heart’s movements and structure made.
You are usually able to see what is happening and the pictures are stored on video or disc which the doctor may show you. It usually takes 20 minutes and is painless,with no side effects.
Doppler ultrasound is also used and this measures the blood flow. It makes a noise like a washing machine.
My doctor wants a special echocardiogram to see if I might benefit from a pacemaker. What is this about?
Anew treatment for heart failure is a special pacemaker which is used when the two heart pumps are out of synchrony, that is, not beating at the same time. A special echo measures the dysyn ¬chrony index. If this is abnormal, it suggests that the heart can be brought back in line with a cardiac re-synchrony pacemaker. The efficiency of the heart will be improved and you will feel better. Sometimes this special pacemaker will be combined with a defibrillator which may prevent you dying suddenly.
I have heard that some echocardiograms are done by the patient swallowing a tube. Is this true and, if so, what is happening here?
Yes, it is true. The reason is that your gullet is situated behind the heart, and a scan from the gullet (or oesophagus, pronounced ‘ee¬sof-a-gus’) gives better pictures than one on the chest, when the probe has to steer round the lungs. This is known as transoesophageal (via your food pipe) echocardiography (TOE or TEE in America). It is done when we need specialised additional information, particularly on valve or clot problems. The tube is not large and is usually passed after you have been given relaxing medication and a local spray anaesthetic to the mouth. Some people do find it unpleasant but it is a very important test to help guide your treatment.
I have an appointment at the hospital for a nuclear scan. This sounds rather dangerous to me. Is it harmful and how is a nuclear scan done?
The radioactive levels are low and not at all dangerous – you won’t glow in the dark! A scanning machine takes pictures of your heart following an injection of a radioactive material (usually thallium or sestamibi) into a vein. If your heart is healthy, the thallium is absorbed and an even picture will be shown. If there is damage to your heart, the thallium will not be taken up well by the bits of your heart that are not working efficiently. If there is scar tissue from a heart attack, there will be a gap or a hole in the picture as no thallium will be taken up. If your heart is made to work hard by an exercise test or by the injection of a stimulant to speed it up, the thallium will not travel well to any areas where there is a poor blood supply (such as in that caused by coronary narrowing). When your heart rests between beats and the demand for blood falls, thallium can reach this area. In this way, the scanner can give a very accurate and useful picture to your doctor. First it shows a deficit, but then shows whether this deficit can be rectified. If the scanner shows a hole in the picture which does not improve, then it is likely that the muscle is dead and cannot be improved.
The hospital has written to me and told me that I need a test called a SPECT. What is this?
This is single photon emission computed tomography. It is a 3-D scanning system. You will lie on a table and the scanner rotates to take pictures from different angles, again helping to identify damaged muscle or muscle suffering from a lack of blood supply. It is a sophisticated test but simple to do – like a standard sestamibi scan but with bells on!
I have had test after test until I feel that I could not be tested further. I now have been summoned for a nuclear scan. When is nuclear scanning specifically helpful?
Nuclear scanning can be very useful for people with angina, after a heart attack and when there is heart failure. It is a means of trying to assess the importance of each narrowing present, and whether any good can be done by treatment. It is more expensive than an exercise test but useful when exercise tests cannot be done (for instance if you have arthritis), or when specific information on your heart muscle is needed that a treadmill exercise test cannot provide.
My wife was told that she is going to have a PET scan. How is PET different from SPECT?
PET is positron emission tomography and this is a very specialised technique involving nuclear scanning, and it accurately tells us about blood flow and whether the heart muscle is hibernating or not. It is a very expensive test,so is used only when really necessary. It can, however, identify where help might be possible when other tests have not been able to show what can done; so, used carefully, it represents value for money.
Reference:
1) http://www.PubMed.com
2) Jackson G. Heart Health, 4th edition, Class Publishing, London. |
