Dr. Patricia Yarberry Allen is a collaborative physician who writes a weekly “Medical Monday” column for Women’s Voices for Change. (Search our archives for her posts, calling on the expertise of medical specialists, on topics from angiography to vulvar melanoma.)
This week’s post addresses the concerns of a 53-year old woman who has suffered heart failure. Dr. Allen has asked cardiologist Dr. James Blake, Clinical Assistant Professor of Medicine at Weill Cornell Medical College in New York City, to describe the diagnosis and treatment of early congestive heart failure, especially in women.
Dear Dr. Pat,
I am 53 years old and have been overweight for most of my life. Everyone in my family is overweight. I developed high blood pressure in my late 30s and then diabetes in my late 40s. I take a drug for my blood pressure, a drug for my high cholesterol and two drugs by mouth for my diabetes. My sugars are under good control. In desperation, I began to exercise in order to lose some weight and hopefully cut back on my drugs. I began with a walking program and increased my miles weekly. I thought I was doing all the right things. I bought good shoes. I stretched before and after. I was watching my food intake much more carefully and was slowly taking some pounds off. After a month I began to jog and slowly worked up to three miles a day. Then for a few days I noticed that I was getting out of breath more than usual during the jogging and sweating more. I also had some chest tightness but I thought it was just that I was still not in decent physical condition. I was really tired after the jogging so much so that I had to lie down. The last day that I went out to jog I had severe chest pain with shortness of breath and sweating. I knew this was serious. I called an ambulance and sure enough I had suffered a major heart attack. I saw a cardiologist for the first time after the heart attack. He said I was lucky to have survived. I had too much blockage in other arteries for a stent and so I was sent to a heart surgery center in my state for open heart surgery which went well. However, I am not myself. The heart team told me that I have some mild heart failure due to the size and location of the heart damage. My parents both died in their 70s of heart failure and it was awful to watch. Is treatment for this any different now (they died 20 years ago)? I am losing weight and taking even more medications and am really hoping for a longer life than my parents had. What can you tell me about heart failure and women? Should I have seen a doctor for clearance before beginning my own exercise program?
Susan
Dr Pat Responds:
Dear Susan,
Your story is not as unusual as you may think. We are focused here at womensvoicesforchange.org on prevention: encouraging women at forty to change unhealthy habits and to do the hard things that can decrease the risk of early onset of serious diseases. If you had been encouraged to do more than the cursory “lose weight Susan” when you were forty, your health outcome really may have been much different. Health care providers need to have a sense of urgency in their conversations with patients whose family history is rife with obesity, diabetes, hypertension and early death from congestive heart failure. If you could relive your early forties, knowing now what you didn’t know at that time, I am certain that you would have decreased the calories, given up the fast foods along with the foods filled with trans fats, fructose and sugars, and all those other foods with empty calories. You would have chosen to exercise daily at that time, before your coronary arteries were damaged. And, yes, with your history you should have had a careful cardiac evaluation before beginning any exercise program. But, you can’t go back and change a decade of bad habits. However you are fortunate that the diagnosis and treatment of early congestive heart failure has changed and with continued weight loss and improvement in glucose control and a heart healthy diet, your life with congestive heart failure should be much longer with a much improved quality of life than that experienced by your parents. We have asked Dr. James Blake, a practicing cardiologist affiliated with Weill Cornell-New York Presbyterian Hospital and a member of our Medical Advisory Board to explain this very complex subject to you and to our readers. I asked him to give us everything an intelligent reader needs to know to understand congestive heart failure. Don’t be dismayed by the inclusion of physiology, pharmacology and anatomy in this important post. Read it again and take notes. Dr. Blake’s erudite explanation of congestive heart failure is a post worth sharing.
Dr. Pat
Dr. Blake Responds:
Susan, the treatment for congestive heart failure, or CHF, has been revolutionized since your parents’ time, offering patients like yourself a life that is both longer and with better quality of life. In the not so distant past, a diagnosis of CHF implied a five-year survival of only 50 percent. Contemporary studies have significantly improved these dismal statistics. To reap the full benefits of modern therapeutic changes requires a clear understanding of the type and cause of your CHF along with a physician with a high level of expertise in using all the appropriate available medical options.
Most people and many physicians would have trouble defining congestive heart failure. The function of the heart is to pump enough oxygenated blood to meet the body’s needs, while also filling up the partly emptied heart with more blood at a normal pressure prior to each contraction. Most people are familiar with the blood pressure, which is the circulatory pressure generated when the heart contracts. But there is a separate pressure, namely the amount of pressure required to fill the relaxed heart with enough blood to be pumped during the subsequent heartbeat. This “filling pressure” (like the force required to fill a balloon) in an efficient heart is very low. If the heart is unable to meet the metabolic needs of the body at a normal filling pressure, the elevation of pressure backs up the blood draining to the heart from the pulmonary veins causing increased lung fluid or lung “congestion” and eventually extra body fluid or edema. Inadequate forward flow from the heart may produce weakness and fatigue. While these symptoms are unpleasant, it is the lung congestion that produces shortness of breath interfering with activity. When the congestion is severe, it may necessitate frequent hospitalizations with a very diminished quality of life.
The improvement in outcomes could not come at a better time as CHF has reached epidemic proportions. It is the single most expensive condition funded by Medicare. Hypertension and obesity, especially when accompanied by abnormalities in blood sugar control, including diabetes and prediabetes (called glucose intolerance), are conditions that impact nearly half of all Americans. In your situation these are the factors increasing the likelihood of CHF.
