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

Congestive Heart Failure – 3

            Last week’s column dealt with how to treat early congestive heart failure before severe damage has been done to a heart, but there are a large number of people who have developed severe heart failure.  The example of this type of person is described in the next paragraph. 

            The gentleman was a 67 year old farmer/rancher who had run a 6,000 acre operation since he took it over from his father 30 years ago.  He had his first heart attack at age 52 and bypass surgery was done soon thereafter.  But the heart attack that he had left his heart with much less muscle than it had before as a significant piece of his heart muscle had died.  When a heart attack occurs and a piece of heart muscle dies, that doesn’t grow back.  The rest of the heart muscle must go on through life carrying the full load day in day out.  After this gentleman’s heart attack he really hadn’t slowed down one bit.

            After his heart attack at age 52, he did stop smoking and he did start taking a cholesterol medicine, but admitted that he sometimes ran out and often forgot it.  He took a blood pressure pill, but he didn’t know if it really controlled his blood pressure.  His weight was heavier than he needed and his sleep pattern almost certainly represented sleep apnea based on what his wife described.  She said he stopped breathing many times at night and he snored so loudly she couldn’t stay in the room sometimes.

            He came to the emergency room in the early morning hours extremely short of breath with frothing at the mouth.  His wife indicated that he had been short of breath all the previous day, but “seemed to be all right” when he went to bed.  Soon thereafter he woke up very short of breath with frothing at the mouth and was brought on to the emergency room.

            Once in the emergency room, a condition known as pulmonary edema was diagnosed immediately.  Pulmonary edema is the end result of severe heart failure.  In this condition, the heart is simply not strong enough to pump the blood out of the lungs.  Therefore, the blood backs up in the lungs, takes up the air space, and the person virtually can’t breathe.  If not addressed immediately, this is a fatal condition.  Treatment in this extreme situation requires the immediate use of morphine.  The morphine both relieves the person’s anxieties and at the same time it relaxes the venous system of the body to take up the extra blood that is backed up in the lungs.  It also lowers the blood pressure so that the heart doesn’t have to work so hard and can catch up.

            The second immediate step that had to be instituted was the use of a water pill, but given intravenously.  A product called furosemide (Lasix) can be injected intravenously to let a large amount of fluid come out through the kidneys as quickly as possible.  After the immediate problem was dealt with through these two steps, an x-ray was taken confirming that his heart was very, very enlarged and weakened.  His condition qualified as “dilated cardiomyopathy.”  This was the result of the heart attack that he had 15 years before and inadequately treated high blood pressure over the subsequent years.

            Reviewing his medications, it was seen that he was indeed on a product called an ACE inhibitor, but the dose had never really been adjusted to get his blood pressure down into the normal range.  The addition of another family of blood pressure pills called angiotensin receptor blockers was necessary at this point to take the load off of his weakened heart and allow it to rest. 

            In the past, the great American concept has always been to make things work harder and better.  However, medications and steps to make a failing heart work harder have been unsuccessful and lead to a greater mortality than those patients who were not so treated.  A modern philosophy on how to deal with severe heart failure is to give the heart less work to do and this has been shown to improve mortality and well being.  The single most important step in giving the heart less work to do is to get the blood pressure down into the low normal range.  This person will never be equal to what he could do in the past and trying to achieve that has thus far been destined to failure and disappointment.  Instead the person must readjust his lifestyle toward less stress and less physical work.  They must realize that they no longer have a Ford 250 engine running their body, but instead are going to get by on a little Volkswagen motor that will work just fine provided they don’t overload it.

            The treatment for this gentleman long term was to continue the medication called an ACE inhibitor, continue the medication called an angiotensin receptor blocker, and add the beta-blocker product called carvedilol to his protocol.  In addition, he would need a water pill long term to keep him from accumulating swelling in his ankles, which backs up into his lungs as when he was admitted.  A potassium pill will be required to keep his potassium from getting too low from the water pill.  A statin drug to keep his cholesterol down and an Aspirin per day are also essential long-term medications.  Lastly the patient needs to restrict fluids so that he doesn’t reaccumulate all of the water that was in his ankles and eventually in his lungs as when he was admitted to the hospital.

            Okay.  So now he is on 7 pills instead of 3, but this is what it takes to care for somebody whose heart has been overloaded too much too long.  Severe heart failure like this carries a very high mortality, but can be improved with the medications mentioned.  The healthcare providers at your local clinics are well aware of these problems and how difficult they are to deal with.  They can be a significant help.