Understanding Heart Failure Treatment

Purpose of this Article

To understand what happens in heart failure
To know the essential medicines for heart failure
To show the effects of exercise on the heart

Heart Failure (HF) is a condition when the heart cannot pump enough blood to meet the demands of the whole body. HF affects 6.3 to 13.3% of the population. 1 million get hospitalized for heart failure each year. It is a significant cause of death. I see a patient with a heart failure-related complaint every day when I worked in the ER. If someone has atherosclerotic heart disease, metabolic syndrome, takes a chemotherapy drug that weakens the heart, hypertension, obese or diabetic, then they are in Class A Hear Failure! Just check out this article. That is why this article is relevant.

There are many reasons for heart failure. The most common cause is ischemic heart failure from coronary artery disease. The heart muscles cannot get enough oxygen to do their work. Aging also stiffens the heart and makes it more sensitive to heart failure.

Right_side_heart_failure — Normal Heart Left, Heart Failure Right

What happens in heart failure?

In heart failure, the heart muscles cannot pump enough blood to meet the oxygen demand of the whole body. Different mechanisms then compensate in an attempt to meet the demand.

The sensors located in several blood vessels detect the lesser volume of circulating blood and activates the hormone system (renin-angiotensin-aldosterone system, RAAS). The net effect is the reabsorption of more sodium and water in the kidneys leading to an increase in the blood volume.
The blood vessels constrict, allowing the blood in the arteries to go further. Just imagine your thumb on the end of a water hose. The smaller you make the opening, the farther away you can make the water go. The heart also beats faster to make up for the lower amount of blood coming out.

Is the compensation good enough?

Not really. The cardiac output improves but still can not meet the demand, and the maladaptation creates additional problems. The problems are:

The resulting smaller blood vessels increase the resistance to the heart. The faster the heart rate makes the heart work harder. When the heart has to work harder to contract against higher opposition, then it needs more oxygen. But the ischemic heart is not getting enough blood in the first place! It is similar to beating a tired horse to make it run faster.
The increased blood volume may be suitable for a healthy heart, but for a failing heart, it leads to a backup of fluids. Although the chamber of the heart looks big in the picture, it is still an inefficient heart.
The net effect is that all of the attempted compensation just resulted in more stress to the heart and further lowering of the cardiac output.
The heart enters a vicious cycle of poor performance, dysfunctional compensation with further deterioration. Left on its own, the heart will continue to fail and ultimately affects the other organs leading to multi-system organ failure and death.

So how is Heart Failure Treated?

To prevent the vicious cycle, drugs like the angiotensin-converting enzyme inhibitors (ACEI) and the angiotensin receptor blockers (ARBs)are recommended. The ARBs like losartan are given if ACEIs like lisinopril cannot be tolerated by the patient. The ACEIs and ARBs prevent the salt/sodium/water reabsorption.

Beta-blockers like metoprolol are also offered. Beta-blockers prevent the heart from beating faster and also relaxes the blood vessels.

These classes of drugs have been proven to prolong the life of heart failure patients. They are included in the 2013 American College of Cardiology/American Heart Association Guideline for the Management of Heart Failure.

Guidelines are far-reaching because significant physician associations like the American College of Physicians, health insurance companies, textbooks, reviewers for recertification test for internists, and clinicians locally and internationally use them as the accepted “Standard of Care.” Guidelines are not carved in stone. Patient treatment is always individualized, depending on their situation and their goals.

The emphasis on this article is on some of the medications recommended for heart failure.

The figure below is from the ACC/AHA guideline and summarizes the recommendation.

AHA Heart Failure Stages and Therapy

What are the Treatment Goals for Heart Failure?

The Goals are contained within the Therapy box for each Heart Failure stage. The goals for Stages B, C, and D are mainly to prevent and control symptoms, improve Health-Related Quality of Life, HRQOL, prevent hospitalizations and deaths. Notice the absence of the words cure, reversal, or anything to that effect in the treatment goals. So far, there are no drugs available that can completely reverse a failing heart.

Medications in heart failure are only useful if the patient is in a stable condition. If a heart failure patient eats more salt, drinks more fluid than recommended, becomes sick with an infection, forgets to take their medicines or received the wrong dose, or had another cardiac event, an acute worsening of the heart failure can happen. They usually present as having edema fluid in the legs, shortness of breath, and lead to an emergency room visit and hospitalization. They can become Stage C or D quickly.

What about Exercise?

Included in the 2013 ACC/AHA guidelines are the recommendations for Activity, Exercise Prescription, and Cardiac Rehabilitation.

7.3.1.6. Activity, Exercise Prescription, and Cardiac Rehabilitation: Recommendations

Class I

Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status.^404–407(Level of Evidence: A)

Level of Evidence: A means multiple populations and studies were evaluated to come to that recommendation. Exercise, particularly cardiac rehabilitation, has many benefits, including an 11% decrease in all-cause and cardiovascular disease (CVD) mortality. CVD mortality includes heart attacks, hypertension, diseases of the aorta, strokes, and peripheral vascular disease.

photo-1536922246289-88c42f957773 — Jumping repeatedly on plyometric boxes will surely raise the heart rate

Is there anything to avoid heart failure?

Yes! A study published in January 2018 in the Journal Circulation, Reversing the Cardiac Effects of Sedentary Aging in the Middle Age. The authors reported that;

In previously sedentary healthy middle-aged adults, 2 years of exercise training improved maximal oxygen uptake and decreased cardiac stiffness. Regular exercise training may provide protection against the future risk of heart failure with a preserved ejection fraction by preventing the increase in cardiac stiffness attributable to sedentary aging.

What is unique to this study is that it is the most extensive prospective study about the effect of exercise on the heart (2 years).

Both study and control groups started as sedentary individuals.

The control group did yoga, balance, and stretching 3 times a week for 2 years.

The exercise group did the following:

4 minutes of exercise at a 95% peak heart rate followed by 3 minutes of active recovery at 60%–75% peak heart rate, repeated 4 times, at least once a week.
A moderate exercise performed on 1 day of the week was spent as a fun activity such as tennis, aerobic dancing, walking, or biking.
One or two other sessions were performed each week at a moderate intensity. The participant should break a sweat, be short of breath, and still be able to carry on a conversation — the “talk test.”
One or two days of weekly strength training sessions using weights or exercise machines were done on a separate day, or after an endurance session.

Goodcalculators.com can calculate your target heart rate.

Sounds Intense, Man!

The 4 x 4 minutes of high-intensity exercise at 95% maximum sounds intimidating, and it is, but it can be done. I tried it myself doing jump squats, jump lunges, burpees, and push-ups and lived to write this article. I look forward to doing it at least 3 times a week on top of resistance training.

While 21 minutes of high-intensity work out may sound a lot. The heart works 1,440 minutes each day, and it needs to be working well until old age. 21 minutes spent on the heart is only 1.45% of the amount of time the heart works in 24 hours.

People in the Stage A Heart Failure group, the ones with atherosclerotic heart disease, metabolic syndrome, takes a chemotherapy drug that weakens the heart, hypertensive, obese, or diabetic, have the best chance of avoiding heart failure with exercise.

Exercise improves the whole body and improves insulin resistance and can lower blood pressure and help to lose weight. Furthermore, sweating with exercise removes toxins and heavy metals that may not be removed by the kidneys or the liver.

Ischemic heart failure therapy is decades away from being perfect. Exercise, as proven by many studies, is well known to increase the most important measure of health.

Physical Activity Correlates with Life Span

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Don’t Get Sick.

References

2013 ACCF/AHA Guideline for the Management of Heart Failure. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Levine et al. Reversing the Cardiac Effects of Sedentary Aging in Middle Age—A Randomized Controlled Trial. Implications For Heart Failure Prevention. Circulation. 2018;137:1549–1560

Image Credits

Heart Failure Manu5 – http://www.scientificanimations.com/wiki-images/

Working out with Plyometric boxes Meghan Holmes @yellowteapot

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