About 5 million people in the United States have heart failure, and 300,000 die from it every year. (Compare that with the 570,000 annual deaths caused by every kind of cancer.) Indeed, heart failure—the heart can't pump enough blood through the body—is the most common reason older folks wind up in the hospital, and more than 1 in 4 heart-failure patients must be hospitalized again within a month of being discharged, according to a recent study in the New England Journal of Medicine. That's despite the fact, the American Heart Association contends, that most of these rehospitalizations are preventable. "We can take the failure out of heart failure if we use all of the available treatment strategies to the best of our abilities," says AHA President Clyde Yancy, chief of cardiothoracic transplantation at Baylor University Medical Center in Dallas.
The problem, he says, is that many hospitals and doctors still aren't following the AHA's evidence-based guidelines for treating heart disease, which have been shown to reduce the rate of rehospitalization or death by more than 20 percent in the first two months after patients leave the hospital. The organization says about 460 hospitals in the United States are currently enrolled in its "get with the guidelines" program, whose website allows doctors to enter information about a heart-failure patient and get a recommended course of treatment that might include a combination of medications, dietary restrictions, and possibly an implantable pacemaker. These participating hospitals, however, account for about 275,000 heart-failure patients—just a fraction of those who are hospitalized for treatment.
Thus, the onus may be on patients to ensure that they're getting the best possible care. Here's what you need to know if heart failure is a possibility:
When to get a diagnostic workup. Uncontrolled high blood pressure can lead to heart failure over time. So, too, can a previous heart attack that leaves the heart muscle permanently damaged. Telltale symptoms include shortness of breath, tiredness, and difficulty with physical exertion. You should get these symptoms checked out by a doctor. If your symptoms are severe enough to warrant hospitalization, the AHA recommends the following workup before you're discharged: a thorough medical history, a physical exam, and blood tests to measure certain proteins, electrolytes, and other markers of heart failure. A chest X-ray may also be useful to check for fluid in the lungs, a common heart-failure complication. You might also need an echocardiogram or some other heart imaging test, says Yancy. This will reveal if the inability to push out sufficient blood (called low ejection fraction) is because the heart has become flabby and enlarged or because the muscular walls have stiffened. It will also reveal whether the different parts of the heart that squeeze and relax in sequence have lost their perfectly coordinated rhythm, a condition known as dyssynchrony.
The effective medication strategy. Patients with heart failure whose imaging tests reveal an ejection fraction below 40 percent should be put on heart-failure medications such as ACE inhibitors, beta blockers, and diuretics, according to the AHA guidelines. "These medications have been shown to be absolutely critical, among the most important factors in determining whether patients will die or be rehospitalized in 60 or 90 days," says Gregg Fonarow, a professor of cardiovascular medicine at UCLA School of Medicine who chaired the AHA guideline committee. Along with these medications, African-American patients should be offered hydralazine-nitrate therapy to cut their mortality risk by an additional 43 percent, says Fonarow. "Yet fewer than 1 in 5 African-Americans who qualify for this treatment are actually getting it," he adds. Women, too, are less likely to be given guideline-indicated therapies. What's worse, research on heart-failure treatments in women is still lagging behind research in men, says cardiologist Nieca Goldberg, director of the women's heart center at New York University Medical Center. Currently the AHA guidelines recommend the same medications for women and men, but that, says Goldberg, may be the result of a lack of studies focusing on discerning gender differences.
Who needs cardiac resynchronization therapy. An implantable pacemaker helps reset the heart's electrical system, enabling heart muscles to work in sync. It's indicated, along with medications, for those with severe heart failure—dyssynchrony and an ejection fraction of 35 percent or less, according to the AHA guidelines. Yet a study published last year in the journal Circulation found that only 12 percent of heart-failure patients had the device implanted before they were discharged from the hospital. "I'd estimate that only about one third of patients who need CRT are actually getting it," says study author Adrian Hernandez, an assistant professor of medicine at Duke University School of Medicine. The procedure, which costs $25,000 to $40,000, has been shown to lower a patient's risk of dying from heart failure by one third over several years and to reduce the likelihood of rehospitalization by about half.
Other conditions related to heart failure. A significant number of patients with heart-failure symptoms have no apparent heart abnormality on their imaging scans. These folks often have a stiffening of the heart muscle caused by some underlying condition like uncontrolled high blood pressure, diabetes, chronic kidney disease, or a cardiac arrhythmia like atrial fibrillation. "In this case, the guidelines say to focus primarily on treating these conditions," Yancy says, like getting diabetes or hypertension under control through medication and lifestyle changes.
Dangers of too much sodium. It's always smart to follow a diet plan focusing on whole grains, low-fat protein, and fruits and vegetables. (Consider the heart-healthy DASH plan.) Heart-failure patients also must make every effort to cut down on salt to prevent excess fluid buildup in the lungs, ankles, and abdomen that can make breathing and walking harder. The AHA recommends limiting sodium to no more than 2,000 milligrams a day, which means avoiding such foods as table salt, sports drinks, ketchup, cured meats, and instant and prepared foods, as well as high-sodium medications like Alka-Seltzer. In other words, read all labels for sodium content. This really does take effort: An April study from Emory University found that only one third of heart-failure patients could reduce their sodium intake to 2,000 mg a day even when they tried to follow a low-sodium diet. A good way to tell if you're getting too much salt: Weigh yourself every day, says Fonarow. If you gain more than 2 or 3 pounds from one day to the next, it's probably an indication that your body is retaining too much water. You'll need to cut back on sodium, or, if that doesn't work, he says, you may need a higher dose of diuretics.
A safe level of exercise. Heart-failure patients have to be particularly careful about overexerting themselves. For instance, they should avoid resistance training with heavy weights, says Fonarow. But with a doctor's OK, many can engage in mild cardiovascular activities like walking, swimming, or biking. And some recent studies suggest that regular exercise could reduce heart-failure symptoms like fatigue and shortness of breath, though it's not clear whether exercise actually lowers either death or hospitalization rates.