Breathlessness & Heart Failure

Breathlessness is an extremely common complaint, and it can sometimes be caused by heart failure. Many people experience shortness of breath at times during their life, but this does not necessarily mean that the cause is heart failure. A simple chest infection can cause breathlessness, and it is therefore extremely important to determine what the cause of breathlessness is in a patient.

What is Heart Failure?

The term heart failure sounds daunting to most people, and understandably so. There are some extremely good treatments for heart failure, which will be covered later. Heart failure is a condition in which the pumping action of the heart is impaired. There can be differing degrees of impairment to the hearts pumping function.

Heart failure can affect the left ventricle, the right ventricle, or both ventricles. Heart failure can be a problem with the contracting function of the heart, which we refer to as the systolic function, or it can be a problem with the relaxing function of the heart, termed diastolic function. Most commonly when we talk about heart failure is in reference to the left ventricle which pumps the oxygenated blood around the body and to the vital organs, and the contracting (systolic) function.

We commonly measure the efficiency of the pumping action of the heart using a test called an echocardiogram, or echo. This is a test that is not painful, and uses ultrasound technology which is the same type of imaging that is used to carry out scans during pregnancy. A  specialised probe is gently moved over the left side of the chest wall in multiple different positions to get a good view of the whole heart. From this, the ejection fraction can be determined. This is the percentage of blood that is pushed out of the ventricle when it contracts, and is also referred to as the ‘left ventricular ejection fraction’ or LVEF. The ejection fraction of the right ventricle can also be assessed. A normal left ventricular ejection fraction is around 55-60%.

The relaxing function, or diastolic function, can also be assessed at the same time during an echocardiogram. Diastolic heart failure can result in the same symptoms as systolic heart failure. Diastolic heart failure becomes more common with advancing age. A very common cause of impaired relaxing function of the heart is due to years of untreated high blood pressure, although there are other causes. This can make the heart ‘stiff’ and impair the relaxing function.

What are the symptoms of heart failure?

Some patients do not have any symptoms at all, and it is picked up by chance when they are having investigations for something completely different. More commonly, patients present with shortness of breath when they are exerting themselves and sometimes at rest. Shortness of breath is sometimes described as being worse when laying down which can result in waking from sleep. Other symptoms include swollen feet/ankles/legs/abdomen, or feeling unusually tired and weak.

What causes heart failure?

There are a number of different causes for heart failure. It can happen very gradually over a number of years in some patients, and very suddenly in some cases. Some of the more common causes of heart failure are:

  • A heart attack – A heart attack can cause damage to the heart muscle, which impairs its ability to pump. Heart failure can result many years down the line, and also at the time of the heart attack.
  • High blood pressure – Years of high blood pressure can put pressure on the heart. It can also cause the heart muscle to thicken, which makes it less efficient at pumping and in some cases less efficient at relaxing.
  • Cardiomyopathy – A cardiomyopathy is a disease of the heart muscle. There are many different causes of cardiomyopathy, some of which can be inherited through the family, and some that can be caused by other things, like a virus or some rare cases during pregnancy.
  • Heart rhythm problems – When the heart goes out of its normal rhythm, it is a less efficient pump. Some heart rhythm problems can result in the heart beating very quickly for very long periods of time. The heart is a muscle, and similar in some ways to the muscles in the rest of your body. If you went to the gym and tried to do 200 press-ups, the muscle gets tired. In the same way, if the heart is being made to work extremely hard by beating very quickly for a long time, the muscle gets tired.
  • Heart valve problems – The heart has 4 valves; 2 on the left and 2 on the right side of the heart. These valves can sometimes have problems with them that you are born with, but can also develop over the years. Generally a heart valve that starts to cause heart failure is either too narrow/tight, preventing blood from flowing through the valve easily, or leaky and lets blood flow back the wrong way. A narrow/tight heart valve and a leaky heart valve can put additional strain on the heart which causes the pumping action to weaken.
  • Some cancer treatments – Some cancer treatments, while being very effective at treating the cancer, can also cause damage to the heart muscle. This is not the case with all cancer treatments.
  • Excessive alcohol consumption – Drinking alcohol to excess can be toxic to the heart and impair the pumping action. Treatment and stopping drinking can help to reverse this. The recommended weekly allowance for alcohol is 14 units per week.
  • Anaemia – This is not an especially common cause of heart failure. Anaemia is when the level of haemoglobin is low. Haemoglobin carries the oxygen around the body, and if there isn’t enough haemoglobin this can put strain on the heart and result in heart failure.
  • Thyroid disease – This is an uncommon cause of heart failure, and treatment of the thyroid problem, along with heart failure treatment can often reverse this.

How is heart failure diagnosed?

The diagnosis is made with multiple pieces of information and several tests. One of the most important parts of making a diagnosis occurs when the doctor takes a medical history from you, asking you about your symptoms, family history, and will examine you. Following this you might need to have some investigations, which can include:

  • Blood tests
  • Electrocardiogram (ECG) – This is a recording of the electrical activity of the heart. A number of electrode stickers are attached to the limbs and chest, and a recording is made. It usually takes no more than around 5 minutes, and is not painful.
  • Echocardiogram – This is an ultrasound scan of the heart. The pumping action of the heart can be studied, along with the heart valve function.
  • Lung Function Tests – Breathlessness can be caused by many different things. Some causes can be due to problems with the lungs rather than the heart. Lung function tests are is a test to assess your breathing and measure lots of different parameters.
  • Chest X-ray – A chest x-ray is a very simple test to look at the lungs. It can be used to see if there is any fluid that has built up in the lungs, which can be caused by heart failure. It can also help to identify different causes of breathlessness.
  • CT Coronary angiogram or formal Coronary Angiogram – Disease in the coronary arteries, which supply the heart muscle with blood, can become narrow. This can result in insufficient blood supply to the heart muscle, and can cause heart failure.
  • Cardiac MRI scan – This is a highly detailed scan of the heart. It does not use any radiation, as is the case for CT scans. This test is sometimes used to look at the heart muscle in great detail, and can be particularly useful for diagnosing different cardiomyopathies which can cause heart failure.

What are the treatments for heart failure?

Treatments for heart failure have improved significantly over the years. We now have a wide variety of therapies that can be used to treat patients. Treatments include:

  • Medications to help reduce the fluid build up caused by heart failure, and medications which can help to improve the pumping action of the heart.
  • Treating the cause – This may be the avoidance of alcohol, treating anaemia or thyroid problems, heart valve surgery, opening blocked or narrow coronary arteries which is sometimes done with stents and sometimes coronary artery bypass surgery.
  • Pacemakers and implantable defibrillators – Specialised pacemakers can improve the coordination of the electrics in the heart, which helps to improve the pumping action of the heart. Some patients require an implantable cardioverter defibrillator (ICD). These tend to be used for patients with quite severely impaired heart function as there can be a risk of dangerous heart rhythm problems if the heart muscle is very weak. The ICD is able to detect dangerous heart rhythms and try to correct the rhythm back to normal.

What can I do to help my heart failure?

Aside from the medication and various different therapies, patients can do a lot to help themselves. This include:

  • Maintaining a healthy diet and body weight
  • Watching the amount of fluid that you drink in a day, and not drinking too much
  • Keeping you blood pressure controlled. Some patient purchase a blood pressure monitor to keep an eye on things at home.
  • Stopping smoking
  • Taking regular exercise. This might include walking, swimming or cycling. It is generally not recommended to go to the gym and do significant weight training for patients with heart failure.
  • Limiting the amount of alcohol that you drink. The guidance is to adhere to no more than 14 units of alcohol per week. If the heart failure was caused by alcohol excess, it is usually recommended to stop drinking completely.