Are You at Risk for Heart Failure?

Notes from Dr. Norman Blumenstock
U.S. News & World Report discusses the relationship between sleep apnea and heart failure.

Why it’s better to protect your pump while it’s healthy.

Heart failure is most prevalent in older adults and affects nearly 5 million Americans.

Heart failure – a weakened heart muscle that can’t pump properly – is every bit as serious as it sounds. You’d expect heart disease and damaging heart attacks to put you at higher risk, and they do. High blood pressure and diabetes are also major contributors. But more surprisingly, sleep apnea has a role in heart failure risk, as do drugs such as amphetamines and cocaine. Here’s what it’s like to live with heart failure and what you can do to prevent it.

Heart Failure: Stage D

Lawrence Lamotte, 70, a Southern California retiree, has advanced heart failure. In 2006, soon after experiencing pressure in his chest “like an accordion squeezing,” he underwent triple bypass surgery, which likely saved his life. But with a heart that was no longer strong enough to sustain circulation on its own, his quality of life plummeted.

“I had special medication with an IV and a computer, and I had to carry it around with me at all times,” he recalls. He felt lightheaded and dizzy and kept having falls. He was still very sick and getting progressively worse.

In a healthy heart, the right and left ventricles – the two lower chambers – work together to circulate oxygen-rich blood throughout the body. With heart failure, one or both ventricles can’t do their job. It’s called “congestive” heart failure as fluid builds up in the lungs, causing a frightening sense of suffocation, or leaks into other parts of the body.

[See: The Facts on Heart Disease.]

Hallmarks of Heart Failure

Rather than coming on all at once, heart failure tends to develop slowly and insidiously. Fatigue is one of the first warning signs.

A drastic change in exercise tolerance is another, says David Friedman, a cardiologist with the North Shore Long Island Jewish Health System. Patients describe “more shortness of breath with the same number of city blocks, or now they’re short of breath after walking just a half block.”

Swelling, especially in the legs and feet, is a key complaint, with people sometimes putting on 2 or 3 pounds of fluid weight in a day, or 5 or more pounds in a week. “Their shoes don’t fit. Their ankles are swollen,” says Sharon Curry, facilitator for heart failure patient care at St. John’s Hospital in Springfield, Illinois. “Sometimes they have abdominal swelling.”

And then there’s the pillow sign. “I ask patients, ‘How many pillows do you need to sleep on to breathe?” Friedman says. If they can’t lie down comfortably without piling on pillows, or they resort to sleeping in a reclining chair instead of bed, it could be due to fluid collecting in their lungs.

[See: U.S. News Best Heart-Healthy Diets.]

Cardiac Causes

Major heart conditions put people at higher risk for heart failure: heart attack, coronary artery disease, cardiomyopathy (heart muscle disease), cardiomegaly (enlarged heart) and inflammatory heart disease, along with heart valve abnormalities and murmurs that can worsen over the years. Some 20 to 30 percent of people with heart murmurs don’t even realize it, Friedman says.

Family history is another risk factor for heart failure, which affects nearly 5 million Americans, according to the Heart Failure Society of America. The prognosis is often grim, with the five-year survival rate after diagnosis less than 50 percent. “Heart failure is the dark side of living longer [with] heart disease,” Friedman says. “Now a person’s first heart attack isn’t their last one.”

While age in itself is not necessarily a risk factor, heart failure is more prevalent in older adults. However, people can be diagnosed in their 30s and 40s.

Sleep and Drug Connection

Sleep apnea, pauses in breathing during sleep, doesn’t just leave you tired – it can lead to heart failure if untreated, Curry says. At St. John’s Prairie Heart Institute, “even though patients say they don’t snore or have problems [where] ​they’re not sleeping at night, we’ll do a sleep study to confirm that,” she says. Patients found to have apnea are put on a CPAP device to make sure they get enough oxygen during sleep.

Even among perfectly healthy people, “anyone who ingests or imbibes cardiac toxins – cocaine, methamphetamines – is at risk for heart failure,” says Teresa De Marco, ​director of the Advanced Heart Failure Evaluation and Therapies Program at UCSF Medical Center. And “alcohol is a toxin to the heart.”

Certain classes of cancer drugs can also contribute, she says, so oncologists evaluate a patient’s heart failure risk before using those treatments.

[Read: Why a Sleep Apnea Diagnosis May Save Your Life.]

Stages of Sickness

Heart failure is classified into four stages. Patient in stage D, like Lamotte, require intensive treatments such as mechanical pumps, continuous IV infusions of cardiac drugs and eventually, heart transplant or hospice care.

Patients in stage B or stage C heart failure have structural heart disease, with or without symptoms. “Some people live long and very well with heart failure,” Curry says, “and other people’s symptoms are so severe that it greatly limits their daily lives.”

During hospital readmissions, Curry says, patients often require IV and oral diuretics “to pull all the extra fluid out of their lungs and tissues. We give them medications to help their heart muscle pump and squeeze to the best of its ability. They might need blood pressure support. Some people are so critically ill they have to be admitted into the intensive care unit.”

With some conditions, De Marco says, such as inflammatory or alcohol-induced heart disease, heart function can sometimes be normalized and heart failure reversed, but it’s not usually about a cure. In systolic-type heart failure, she says, “some of the best medicines for disease progression can slow disease progression, reverse some abnormalities, can improve quality of life” and improve life expectancy and side effects.

De Marco, who is also medical director of heart transplantation at UCSF, says it’s at stage A, when patients are only at risk of developing heart failure, where health care providers “can really make a major impact” by closely following and “aggressively attacking” risk factors such as diabetes and high blood pressure.

Protect Your Pump

Anything you do that’s good for your heart will help protect you from heart failure, Curry says. And clearly, making lifestyle changes beats waiting for heart failure to change your whole life.

Because salt causes people to retain fluid, cutting dietary salt is a standard instruction for heart failure patients. In his case, Lamotte says, sodium is even more restricted: “None. Salt-free diet. It was hard in the beginning; I’m used to it now.” That doesn’t only apply to people with heart failure – because of its strong link to high blood pressure, healthy adults are strongly encouraged to watch their salt intake.

Smoking is also a thing of the past for Lamotte, who hasn’t had a cigarette since 2006. “You’d be crazy to go back to smoking once they’ve got you together,” he says.

Everyone “should keep their blood pressure under control,” Curry says. “They should maintain a healthy weight. They should follow a 1,500 milligram-per-day sodium diet. They should be screened for possible sleep apnea. That’s what you can do to avoid heart failure if you’re a young, healthy 40-year-old.”

Pump Replacement

In 2012, Lamotte underwent another surgery, this time to implant a left ventricular assist device – a mechanical heart pump. That’s helped, but it means going about his day “wearing” the external controller, monitor and battery pack. His outlook remains positive and matter of fact. “I do my church duties,” he says, like serving communion to the sick and shut-in. But he had to stop singing in the choir: “You’ve got to carry those long, long notes sometimes. But I keep cheering them on.”

In his case, the LVAD is considered a temporary measure, a bridge, Lamotte says: “I’m on the list – I’m just waiting for a heart transplant.”

As De Marco says, “There are an awful lot of people out there with heart failure – and once they have heart failure, they’re on a path which may not be good going forward. So it’s really important to prevent heart failure. It’s important to treat it, but let’s try to prevent it first.”

[Read: Life on an Organ Transplant Waiting List.]