I have been told that I have heart failure but was also informed that I will not need treatment for some time; why not? And, if I have to have treatment in the future, what might it consist of?
First of all, the tests will decide on the cause of your heart failure. A high blood pressure, coronary artery disease, severe lung damage, excess alcohol and problems with the valves are all possible causes. A leaking valve may be repaired or replaced; a narrow valve can be replaced or stretched by a large balloon, and a big scar from a heart attack, which causes the muscle to stretch (aneurysm, pronounced ‘ann-ure-ism’), can be cut out. Most of the time the problem is likely to involve the muscle pump and your treatment then is with tablets.
DRUGS FOR HEART FAILURE
Diuretics (water pills)
Amiloride
Bendroflumethiazide
Bumetanide
Furosemide
Spironolactone
Angiotensin converting enzyme inhibitors
Captopril
Cilazapril
Enalapril
Fosinopril
Lisinopril
Perindopril
Quinapril
Ramipril
Trandolapril
Digoxin
Nitrates
Isosorbide dinitrate
Isosorbide mononitrate
Beta-blockers
Bisoprolol
Carvedilol
Metoprolol
Angiotensin II antagonists
Candesartan
Irbesartan
Losartan
Valsartan
Sinus node slowers
Ivabradine
I have had an unpleasant jolt, having a heart attack. I suppose that I ignored the advice and warnings. Now I am determined not to lose control again. My doctor says it’s heart failure. What can I do to help myself with my heart problem?
The main thing is to guard against increasing the fluid build-up in your body (in your lungs or legs particularly). Therefore:
• try to lose weight;
• keep as active as you can;
• avoid salty foods or adding salt at the table;
• weigh yourself every day to check to see if you have put on weight which might be due to increased fluid;
• take your medicine as directed;
• keep in touch with your support nurse for advice.
If you find it harder to breathe, your ankles puff up, or you feel generally washed out, go and see your doctor. Don’t let the fluid build up too much as it alters the absorption of some medications making treatment more difficult.
Medication
I have been prescribed diuretics. What are these?
Diuretics are commonly known as water tablets. They act to stimulate the kidney to get rid of the excess fluid which causes breathlessness and swollen ankles. Some tablets, such as furosemide and bumetanide, act quickly: you will notice that you need to go to the toilet a lot over the first four hours or so after you have taken the tablet. This occurs every time you take the tablets but is usually over with by six hours. You need to plan when to take the tablets, so that you are not caught short. Some, the thiazides, are milder and gentler than others and these help to spread the passing of water over a 10–12 hour period.
Most diuretics flush potassium out of the body and this may need to be replaced by tablets. Blood tests will help the doctor keep an eye on the chemicals in your blood. Doctors measure the ‘urea and electrolytes’ levels in a blood sample; these levels monitor your kidney function, potassium and sodium (you can remember them as ‘electric lights’). In addition, as estimated glomerular filtration rate (eGFR) is now routinely calculated to monitor kidney function more precisely.
How will I know if the diuretics are working?
You will be able to breathe better and your ankles will be less swollen. Your weight will go down as the fluid is urinated out. If your weight goes up, you will need more water pills but, if it drops too low, you may need them reducing, as you may have got rid of too much fluid. We try to use the lowest doses possible.
Sometimes the tablets don’t work and the drugs have to be temporarily given by an injection in a vein. This usually needs specialised treatment in a hospital. Once the fluid levels have been controlled, the tablets will be started again and this usually keeps the fluid at bay.
My doctor tells me that I need digoxin to help my heart. Why?
Digoxin is a tablet which in some people helps regulate an irregular heartbeat and makes the heart more efficient. It is also used to strengthen the heart muscle, giving it more pumping power. If the drug builds up too much in your blood, it can cause loss of appetite and nausea. Your doctor may check the level of digoxin in the blood with a blood test and adjust the dose to get the best effect without side effects.
My doctor has taken me off water tablets and put me on ACE inhibitors, which don’t agree with me at all – they just make me cough all the time. Why?
ACE inhibitors stands for angiotensin-converting enzyme inhibitors. These are very important medicines that, in some people, increase their ability to exercise, as well as reducing breath – lessness and fatigue. People will feel better on this medication and their life can be prolonged. Side effects are not common but occasionally people get a dry hacking cough. This is more common in women and Chinese people. If your cough is a problem (and is not due to fluid), ACE inhibitors can be switched to AII antagonists which have similar effects without producing the cough. Research studies show they are very effective drugs and may improve treatment by being prescribed in addition to ACE inhibitors as well as an alternative if ACE inhibitors cannot be tolerated. Studies with candesartan and valsartan have given impressive results, which are probably applicable to the other AII drugs.
Generally, doctors try to get everyone with heart failure to take ACE inhibitors if at all possible. ACE inhibitors are prescribed with diuretics and have the advantage of retaining the potassium that the diuretics wash out. They are quite often prescribed with diuretics and digoxin.
Commonly used ACE inhibitors are captopril, enalapril, lisinopril, ramipril and perindopril. It is likely that more people will be on ACE inhibitors or AII drugs either alone, or in combination, as the research suggests patients with mild failure do not develop a more severe condition and overall wellbeing is improved.
My wife has heart failure and gets very breathless. She was prescribed nitrates at her last visit to the doctor. What are these for?
Nitrate tablets (isosorbide mononitrate or dinitrate) are sometimes used to help breathlessness, particularly if heart failure and angina occur together. Although the treatment is effective, headaches can be a limiting side effect.
I have been prescribed warfarin. I thought this was rat poison! Why am I taking it?
Warfarin is a blood-thinning medicine and is used to prevent clot formation if your heartbeat is irregular or if the echocardiogram shows something that might mean you may develop clots. It may kill rats but for you it helps prevent a stroke. Warfarin reacts with many medicines and alcohol, so make sure you get a list of these drugs from your doctor. Regular sensible alcohol intake should not be harmful as the reaction between warfarin and alcohol will be constant, but drinking in bouts, or heavily, is dangerous as it may not only disturb the warfarin control but further damage the heart. Heart failure caused by alcohol means that you will have to stop drinking alcohol completely – the heart may improve as a result.
The effects of warfarin need to be monitored with regular blood tests. The INR (International Normalised Ratio) is a test for measuring the thinness of blood – normal is 1. On warfarin, the INR should be between 2.0 and 3.0. In some people the INR varies a lot for no obvious reason and blood tests have to be frequent for accurate monitoring. When the blood is stable, the test may be monthly or less frequent. Machines are available to allow you to test and monitor yourself at home.
Should I be taking aspirin? I have heard a lot about it in the media recently.
Aspirin may be used instead of warfarin, particularly in milder cases of heart failure or when the heart rhythm is regular (normal sinus rhythm, not atrial fibrillation). The dose is 75 mg daily.
Aspirin can upset the stomach so you may prefer to take the soluble form in a glass of water or with food. Coated aspirin (such as Nu-seals) is available and may help protect the stomach if regular soluble aspirin upsets you. Clopidogrel 75 mg daily is an alternative.
Can I take other medicines while I am on any of these heart failure tablets?
Other medicines may be used for specific problems. Ask your doctor or chemist if there is any chance of a reaction. Do not take arthritis pills without first discussing them with your doctor, as they can interact with heart failure medication. Some antacids contain salt so ask the chemist about the choices available.
Should I be taking beta-blockers?
In the past, the response would have been a firm no. Now research has shown that, once the failure has been controlled, beta-blockers may improve both symptoms and length of survival. Dosage is very low to start with, and under hospital supervision. When starting betablockers, you may not feel as good at first but, after a week or two, you should gradually feel better.
I have heart failure – can you tell me which drugs I should be taking and why?
Yes. Your doctor may prescribe one of these or a combination.
• Diuretics (water pills) – These reduce fluid and relieve breathlessness and ankle swelling.
• ACE inhibitors – Used to improve the heart’s pumping efficacy and improve life expectancy.
• Warfarin – Used in atrial fibrillation and some other irregular heartbeats to reduce clots.
• Digoxin – Used to help control atrial fibrillation and, in some severe cases in normal sinus rhythm, to improve symptoms.
• Beta-blockers – Used to improve symptoms and length of survival.
• AII antagonists – Used in cases where ACE inhibitors cause a cough, and in combination.
• Statins – Used to reduce cholesterol when coronary disease is also present.
I recently read about spironolactone. Will this be given to me?
Spironolactone is an old diuretic (water pill). In a study of more severe cases, when it was added to diuretics, such as furosemide and ACE inhibitors, further improvement was noted. A problem arose in that the ACE inhibitors were used in lower doses than usually recommended, so we are unclear as to the exact benefit. If ACE inhibitors cannot be used or increased in dose because of side effects, spironolactone should certainly be considered.
My doctor placed me on eplerenone because I developed heart failure after a heart attack. How does it work?
It works like spironolactone, antagonising a hormone call aldosterone which becomes elevated in heart failure causing fluid retention. It helps prevent potassium loss, so like spironolactone needs to be carefully monitored with blood tests if used with ACE inhibitors or AII antagonists. It has been shown to improve length of survival when started 3–14 days after a heart attack when there is evidence of heart failure. Spironolactone can cause swollen breasts in men which may be tender and eplerenone avoids this.
Can I help monitor my heart failure at home?
The easiest way is to weigh you at the same time of day with no clothes on. The best time is first thing before breakfast. If you gain 1 kg, that is, 1 litre of fluid (2 pints), this points to the need to increase your diuretics. If you gain weight 2 days on the run, ask your doctor for advice. If you have been given a weight plan already, follow the instructions regarding extra diuretics (water pills). Your weight should return to the baseline – if it does not, visit your doctor.
Transplant
I have been diagnosed as having heart failure. Will I be able to have a heart transplant?
If your heart muscle is very weak and your activity remains very limited in spite of optimal medical treatment, transplantation is the best option available to give you a better quality and length of life. You must be aged less than 60 years and you will need to be mentally strong and have support and help available. Some people will not be suitable because of other serious illnesses or problems.
What does a heart transplant involve?
If you have been placed on a waiting list, you must be available within 2–3 hours of being called because the donor heart can only be transplanted within 6 hours of the death of the donor. You will usually be given a beeper or mobile phone. The donor heart should be of the same blood group and match yours, as well as matching your immune system. The race and sex of the donor and recipient do not matter but the size of the heart should be similar to yours, although it does not need to be exactly the same.
The operation is performed on the bypass machine. The diseased heart is removed by separating it from all the vessels connected to it but the back walls of the right and left atria are left in place. The new heart is then stitched onto the vessels and the atria, and the bypass is discontinued to allow the new heart to take over.
After the transplant, which is a straightforward procedure, you will stay in hospital for 2–3 weeks whilst drugs are used to suppress rejection of the new heart. Biopsies via a small catheter are taken from the heart to look for signs of rejection. This is a simple, painless procedure performed under a local anaesthetic and uses a vein in the neck.
You will remain on drugs always to keep rejection at bay, and you need to watch your lifestyle carefully: hardening of the arteries in the new heart is a particular problem and is checked for at regularintervals by your transplant doctor. A transplant that is successful will transform your life. After 1 year, 8 out of 10 patients will still be alive, and 6 out of 10 will live beyond 5 years.
I’ve heard about an operation to reduce the size of the heart by cutting out a piece of heart muscle. It is claimed to help heart failure. Should I consider this before a transplant?
This is a debated operation. In many of the cases, a new mitral valve is also put in, so that it is difficult to sort out which part of the operation has been successful. It must remain a part of a careful evaluation programme before it is widely used. We need to know the risk of death at the time of the operation and if the operation works – for how long and what evidence there is for improved quality of life. It is still in its early phase of evaluation when caution should replace over-enthusiasm.
This was an idea for surgery for the failing heart. A large muscle taken from a patient’s back was loosened and then wrapped around the heart. A pacemaker was used to stimulate the muscle to squeeze the heart and give it more power. Initial enthusiasm has been replaced with disappointment as any benefit did not last long.
Is an artificial heart another option for me?
It may be a short-term help, if the heart is severely inflamed by a virus, when it might buy time for recovery. It might also buy time for a transplant donor to be found. At present, it does not offer a longterm solution, but it acts as a bridge to definitive therapy.
Can pacemakers be used to treat heart failure?
Pacemakers are usually used if there is an electrical fault with the heart. However, a special pacing technique has been developed for heart failure, which can be used even if the electrical connections are intact.
It is used in more severe cases but is not suitable for everyone. Results have been very encouraging and it is certainly a treatment to consider. It is called resynchronisation therapy.
My cardiologist has advised a defibrillator as well as a pacemaker. Why both?
It is one combined unit. The pacemaker improves the heart’s efficiency and the defibrillator stops dangerous, life-threatening changes in heart rhythm by giving the heart a shock. It is recommended when heart failure is more severe or when dangerous rhythms have already occurred. It is inserted by cardiologists who specialise in electrical events affecting the heart, and regular followup checks are needed.
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