Guest: Dr. Michael Zile. – Cardiology
Host: Dr. Pamela Morris – Cardiology
Dr. Pamela Morris: Hi, I am Dr. Pamela Morris and you are listening to heart sounds. I am here today with Dr. Michael Zile, who is the Charles Ezra Daniel Endowed professor of cardiology at the Medical University of South Carolina in Charleston. He is also the director of the Medical Intensive Care Unit at the Ralph H. Johnson VA Medical Center. Good morning Dr. Zile.
Dr. Michael Zile: Good morning Pam.
Dr. Pamela Morris: We are talking today about congestive heart failure. Dr. Zile, how does a person know that they have heart failure?
Dr. Michael Zile: Pam, that’s a really important question because it’s almost always the patient who alerts the doctor that something is wrong with them and helps the physician make the diagnosis of heart failure. The patients who develop heart failure often develop a complex of symptoms, which includes shortness of breath, particularly when they are active, but sometimes even when they are at rest. They also develop swelling predominantly in their feet, and they develop fatigue so that they tire easily with any kind of activity.
Dr. Pamela Morris: Why would someone develop these symptoms?
Dr. Michael Zile: People develop heart failure primarily because the heart doesn’t function correctly, i.e. the heart fails to function normally and that’s where the term heart failure comes from; a failure of the function of the heart.
Dr. Pamela Morris: What is the function of the heart?
Dr. Michael Zile: Good question. The heart really does two very simple and specific things. First, the heart develops force and contracts, so that it ejects a volume of blood which goes from the heart to the vital tissues. So, it goes to the brain so that you can think properly; it goes to the muscles, so you can exercise properly; it goes to the liver and the stomach, so that you can digest your food properly. That developing force, contracting and ejecting blood occurs in what’s called systole. Systole is just a Greek word that means ?contraction?. So, when the heart functions normally in systole, it ejects the sufficient amount of blood per minute to supply the needs of the body. When the heart doesn’t function normally in systole, then it doesn’t eject the sufficient amount of blood and that’s often measured by physicians as the fraction of blood which is ejected per beat or you will here your doctor use the term ejection fraction. So, there are abnormalities in systolic function, and then are there abnormalities in the second job of the heart. The second job of the heart is, after it ejects then it has to fill back up with blood. So, it has to relax and then fill, and do it at very low filling pressures, and that portion of the heart cycle is called diastole; another Greek word that just means ?filling?. So, when the heart functions normally in diastole, it relaxes quickly and completely, and it fills rapidly and completely, and it does that at very low pressures. When the heart functions abnormally in diastole, it relaxes slowly, it fills slowly and incompletely, and it fills with very high filling pressures, and it’s those filling pressures that cause the development of symptoms. So, when we talk about heart function, we are talking about contraction or systole and relaxation filling or diastole, and the heart can fail to function in either portions of the heart cycle or both.
Dr. Pamela Morris: You mentioned earlier that some of the symptoms of heart failure might be shortness of breath or swelling of the ankles, and I know, I often time see the patients who come for a variety of reasons saying that ?oh! I have been on an airplane and my feet swell or when I have been on my feet all day, they swell at the end of the day? or perhaps they are physically inactive and any time they try to climb the stairs; how would a physician who sees the patient with those types of complaints, how would they know the difference between heart failure and too many red cells.
Dr. Michael Zile: This is the real challenge for the physician and the patient, because what you?re alluding to is the fact that the signs and the symptoms that, I said, indicate the presence of heart failure, can be caused by other things. So, for example, when people develop abnormalities in the veins in their legs; for example women who develop varicose veins for example; those varicose veins will cause the development of extra fluid in the legs and cause swollen legs. The other thing you indicated is people who gain a lot of weight or who are very inactive, particularly as they get older and they do less exercise, they develop deconditioning. So, when they try to exercise, they get short of breath right away just because they are deconditioned. So, the question then becomes, how does the physician and the patient determine what’s an abnormality in the veins, what’s an abnormality in conditioning versus what’s an abnormality in the function of the heart. The answer to that are in part the kinds of studies which a physician would do in his office. So, he would examine the patient and listen to the heart tones or listen to the lung sounds. He would look at an electrocardiogram. He would look at specific blood tests. He might look at images of the heart like what’s called an echocardiogram or a sound wave test of the heart similar to what happens when women get pregnant and you have an ultrasound or sound wave of the baby. Well, this is a sound wave or ultrasound of the heart, and by looking at the structures of the heart and the function of the heart, we can tell whether it’s functioning normally in systole or normally in diastole or abnormal. When a physician finds abnormalities on a physical examination, on a blood test, on an EKG, and on an echocardiogram, that’s how we make the distinction between venous insufficiency that is abnormal vein function in the legs or deconditioning or heart failure.
Dr. Pamela Morris: Well, it’s sounds then Dr. Zile as if it’s very important for a patient with those symptoms such as shortness of breath or swelling in their legs to see their physician to be sure if this represents other problems or heart failure. Now, the term heart failure is very frightening to people. A failure of a vital body organ can be very frightening.
Dr. Michael Zile: It is frightening. It’s not only frightening for the patient, but it also frightening for the physician and for very good reasons. If one were to look at what happens to people after they develop heart failure, we need to look two specific things. One is, does heart failure shorten a patient’s lifespan, and furthermore does heart failure cause significant suffering an even suffering to the point of having to be hospitalized, and the answer to both of those questions is ?yes?, but let me give you the details. Once, somebody develops symptoms and signs of heart failure, almost 30% of those patients will die within a year and as many as 50% of those patients will be dead in five years. So, that mortality rate, i.e. the rate of dying or put in the opposite direction, the rate of survival is significantly altered by the presence of heart failure. In addition, once somebody develops heart failure and is admitted to the hospital with this, the chances are at least 50% that they will be readmitted to the hospital within six months after the first hospitalization. You can imagine, therefore that the amount of suffering that the patient has and the patient’s family has is pretty significant once they develop heart failure. So, it’s important to make the diagnosis as early as possible and then to begin effective therapy as early as possible.
Dr. Pamela Morris: That’s very important because those statistics are truly scary to a patient. Is there something that you can do to manage the suffering associated with heart failure?
Dr. Michael Zile: You bet you can. This involves a clear and well developed partnership between the patient and the healthcare givers, which means the physician, the healthcare professionals that work with the physicians including dietitians and exercise physiologist, and let me call you what that means; that means that a patient has to become an active participant in their own healthcare. So, they first have to look at their weight and say are they overweight or not? If they are overweight, they need to clearly lose weight. We have to look at their diet; is their diet appropriate or not appropriate? One of the most important things in dieting in patients with heart failure is sodium or salt control. So, the patient has to get control of sodium and salt intake. Third is exercise, are the patients inactive or active? No matter what activity they participate in at the moment, at the time they develop heart failure they can help control the symptoms of heart failure and extend their life with an exercise program, and then lastly are the things that physicians can do for the patients in terms of treatment, and those treatment include a specific list of drugs or medications that can either reverse the abnormal functions of the heart or at least modify the abnormal functions of the heart or at least reduce the rate of development of abnormalities or the progression of those abnormalities. So, in summary, this is a partnership between the patient and the physician. There are great number of things the physician can do for the patient. There are great numbers of things that the patient can do for himself or herself.
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