My favorite patient with heart failure
I have neglected my writing for some time as I attended to some family issues. As the hurricanes appeared to be targeting Cocoa Beach, Florida over a month ago, my mom came as a refugee to visit for a short time. As often happens in life, unexpected things developed such as heart failure.
My mom will be 92 years old this month. When she was 13, she was told that she had a heart murmur (a sign of heart valve issues) and she says she took it easy for about two weeks. Her murmur was likely from her aortic valve as she now has aortic valve stenosis, a narrowing of the valve opening. While the normal aortic valve opens with a diameter similar to the quarter coin, my mom’s aortic valve opens with a size just slightly larger than a pencil eraser.
As aortic valve stenosis progresses and closes off the valve opening, patients progress until their hearts have to work too hard and fail. My mom showed some classic signs of heart failure: difficulty breathing, particularly when lying flat, and a decrease in her ability to exercise. As is typical for many older adults, exercise is usually walking behind a shopping cart, and her decrease in exercise capabilities played out as less shopping. Surprisingly, she did not have swollen ankles, usually an initial sign of developing heart failure.
But there is good even in tragic circumstances. We have had the most exciting adventure as she entered profound heart failure with an unusual presentation, was diagnosed and controlled and managed on drug therapy. I’ll write more about that later.
Heart failure is managed with a number of medications, and fortunately my mom was on many of them.
Blood pressure and fluid control are pillars of heart failure treatment. When blood pressure is elevated, the heart has to work harder to pump against the increased pressure. The body usually responds to heart failure with a series of counterproductive metabolic and hormone responses that stiffen the heart and conserve water; these can worsen heart failure.
So the drugs we see used in heart failure are directed at blood pressure control and diuresis.
- Beta-blockers – usually metoprolol, atenolol or carvedilol – are drugs that decrease blood pressure and protect the heart from structural changes that occur in response to heart failure.
- ACE inhibitors – lisinopril is the most common – inhibit the body from conserving water and encourage the kidneys to remove excess fluid.
- Diuretics such as furosemide prevent or remove excess fluid that can cause ankle swelling or difficulty breathing.
- Other drug classes used in heart failure include angiotensin receptor blockers (ARBs), aldosterone antagonists, digoxin and some newer drugs and combinations.
My mom is not done yet. Her short-term health is marginal as she rests at home carefully monitoring her fluids and supplementing with oxygen as needed. But she is in good spirits, feeling fine and we’re hoping on a new heart valve.
What has surprised mom the most is how good she feels now that her medications have been adjusted and her heart failure somewhat controlled. She has wondered if she was not developing heart failure over the last six months or longer and just not recognizing the symptoms. For example, she cited bouts of “anxiety” that she now believes may have just been the initial feelings that accompany breathing issues.
Heart failure is fairly common and affects over 6 million people in the US.
See your primary care physician if you develop symptoms of heart failure: ankle swelling, difficulty breathing when lying flat, or fatigue and decrease in exercise tolerance. See your pharmacist if you have heart failure and feel that your medications are not helping you as much as you’d like. You might be surprised at how good you can feel. Take good care of yourself.
National Heart Lung and Blood Institute: What is Heart Failure?