Gettysburg Medical News
The Clinical View
16 May 2007
by Phillip Hoffsten, M.D. 

Congestive Heart Failure – 2

            Last week’s column was devoted to congestive heart failure and questions that were asked on Dr. Rick Holm’s television program entitled “On Call.”  This program appears at 7 p.m. on Thursday evenings and is well worth the listening.

            But the column last week really only covered certain basics.  There were many questions asked about how to treat congestive heart failure and I didn’t address any of those.  Heart failure really comes in graded forms.  There are those individuals who have mild early impairment of their heart function and there are those who have very severe, late stage heart failure.  This week’s column will be devoted to how to treat the person in the early stages of heart failure.  The most important aspect of care for this person is prevention of the progression of the disease process that leads to severe and fatal heart failure. 

            Not to belabor a point, by far the most common cause of progressive heart failure is high blood pressure (hypertension.).  A heart is like anything else in this world.  When it is asked to work too hard too long, it wears out.  Pumping against a high blood pressure over years of time wears a heart out early and is the leading cause of heart failure.  The high blood pressure that I am talking about is not that which comes from short periods of heavy exertion.  A weight lifter may have a blood pressure of 400/200 at the peak of a difficult lift, but as soon as he puts that barbell down, the conditioned athlete will again have a blood pressure of 120/70 the rest of the day.  The mom worried about a sick child or the dad worried about a business deal has a high blood pressure all day long.  Granted it is not 400/200, but is higher than normal and considered over hours and days will wear a heart out.  In the lady described below, this is the problem that we addressed most specifically.

            An excellent example of a person with mild heart failure is provided by a 58 year old housewife who came to the clinic at her family’s insistence because she was “tired all the time” and short of breath with any exertion.  She hadn’t really sought medical attention since the birth of her third child at age 36 and she took no medications.  In her mind, there was “nothing wrong with her.”  Pap smears, mammograms, cholesterols, blood pressures, those were the things other people could worry about and she wasn’t going to take any medicine.  She acknowledged that she worried about her husband’s health and her children’s personal relationships with a divorce going on between her youngest son and his wife.  She acknowledged that she was very concerned about her grandchildren and how they weren’t being raised right.  In summary, she seemed a very intense and tense lady. 

            Her weight was not excessive and she was not a smoker.  She acknowledged that she didn’t exercise or walk on purpose.  She could do her own housework, but acknowledged that after she had vacuumed the large living room she would have to rest briefly because she would be short of breath and tired.

            On physical examination, her blood pressure was 170/100 and her pulse was 86 beats per minute, somewhat fast for an individual in the resting state.  Her ankles had very slight swelling and her heart had abnormal sounds, suggesting that it was struggling.  Her chest film showed that her heart size was slightly enlarged.  Note that an enlarged heart on chest film is an indication of a weakened heart muscle.  Her electrocardiogram showed that the heart muscle in spite of being weakened was in fact enlarged and thickened, consistent with a heart that had been asked to work too hard too long. 

            Then came the hard part.  I apprised her of what was wrong and what she could expect if she continued her present ways.  A predicted 50 percent mortality in the next 5 years was not exactly what she had in mind at age 58.

            So she wanted to know what she could do to change that.  I reviewed her diet and it was not excessive or particularly unbalanced.  She probably ate more salt than benefitted her and fewer fresh vegetables than would benefit her, but changing her diet wasn’t going to be enough.  We reviewed her sleep pattern and as one might expect she was very regular in that regard.  She got 7 to 8 hours of sleep a night and did not seem to have a sleep disturbance such as sleep apnea.  More exercise was not going to do anything for her if her blood pressure remained that high.  At that point, the conversation degenerated to what medications might be helpful and she really was against the idea of taking medication because it “wasn’t natural.’  I pointed out to her that what she was doing might be interpreted as natural, but it sure wasn’t what she wanted.  I am not sure this “natural thing” is quite as good as it is cracked up to be.

            So I explained to her that there are medications that would not cause her significant side effects and would definitely improve the function of her heart.  It also would definitely improve the likelihood for a longer more functional life.  The first step was to start a family of medications called “angiotensin receptor blockers.”  These medications very clearly will lower blood pressures, give the heart less work to do, and decrease the overgrown size of an enlarged heart.  Their side effect profile is not different than that of a placebo nothing pill.  In the interest of starting one medication at a time, becoming acclimated to that, and noting any side effects that might occur, she was started on one of these medications.  In 6 week’s time, her blood pressure was down to 135/90 and she was still very suspicious because she said she didn’t feel a bit different.  I pointed out to her that one of the sad aspects of taking a preventive medication is that she would never know what did not happen to her.  Not getting a stroke or not getting a heart attack is not something we are usually thankful for day to day.  But it sure is something people hate when it happens to them.  We need to be appreciative of what does not happen to us.

            Acknowledging that the medication she was taking did not cause side effects and helped to correct her blood pressure, it was now time for a second medication.  On the average, people in the United States with high blood pressure require 3 different classes of blood pressure medicine in order to adequately control a blood pressure at 120/80 or less.  Finding 3 medications that don’t cause side effects is not an easy task, but it can be done.  The second medication she was started on was called a beta-blocker.  There is now one beta-blocker on the market which is clearly superior to the others, although a bit more expensive than most people like.  The second medication she was started on was called carvedilol and in another 6 weeks her blood pressure was down to 125/80.  Fortunately again there were no side effects that developed and she again complained that she really didn’t feel any different.  And then I queried whether vacuuming the living room was still as hard as it used to be and she grudgingly acknowledged that she didn’t have to rest afterwards and didn’t get as short of breath as she had before.  I indicated to her that she can expect further benefits in the future, but still will never really appreciate what did not happen to her.

            This lady was a reluctant customer, but at least she did come to seek healthcare.  Trying to get the guys into the office or get them to buy into these ideas is nowhere near as easy as it was for this lady.  The healthcare providers at your local clinics are the backbone of treatment for this huge group of people in the United States and there is clear and definite evidence that effectively treating blood pressure with medication prevents progressive heart failure, saves lives, and leads to a higher quality of life.

            Next week I will consider the tougher problem of severe heart failure.