In this article:
- Following the blood through the heart
- Looking at various diseases that affect the heart
- Figuring out when your heart is failing and how
- Eliminating bad habits
Heart disease is the leading cause of death throughout the world.
It involves the muscles of the heart and the blood vessels that provide nutrition to those muscles. Various forms of heart disease include angina (chest pain caused by a decreased blood supply to the heart), heart failure (when your heart isn’t able to pump enough blood to maintain an adequate flow to and from the body tissues), and heart attack (death of heart muscle tissue due to loss of blood supply).
High blood pressure plays a major role in the development of heart disease.
High blood pressure without other risk factors such as diabetes, smoking, and lack of exercise is rare. But these risk factors, when mixed in with high blood pressure, can increase the chance of a fatal heart attack as much as 15 to 20 times.
In fact, people with untreated high blood pressure may live 10 to 20 years less than people without high blood pressure.
When the blood pressure is controlled consistently, however, a person’s life span isn’t shortened. It’s been said that gambling is a great way of getting nothing for something, and you can gamble away your life if you don’t control your blood pressure — this is guaranteed.
You must make up your mind to get something for something. Take the trouble to measure your blood pressure properly (see article 2 to find out how) and to follow the recommendations in Part III, and we guarantee that you’ll not only live longer but also increase the quality of your life — free of much of the medical misery that people develop as they get older. This article tells you what you need to know about high blood pressure and your heart. It provides a foundation for moving into Part III.
If you read this whole article, you’ll have an excellent understanding of how important blood pressure control is, especially for your heart. The other articles in Part ll help you understand how high blood pressure affects your kidneys and your brain. Even though we discuss the heart, kidneys, and brain in three separate articles, remember that uncontrolled high blood pressure doesn’t just cause the development of heart disease, but also kidney disease and a brain attack as well.
Introducing the Mighty Pump
What a piece of work the heart is! An organ that’s mostly muscle, the heart is about the size of a clenched fist and weighs about 101⁄2 ounces. This little muscle is responsible for supplying blood and oxygen (which are usually 15 or more times heavier than the heart itself) to all parts of the body.
Your heart is in your chest cavity behind your breastbone and between your lungs. It’s divided into four chambers — the left and right atria and the left and right ventricles. Here’s how the chambers work together:
- The right atrium receives blood through the vena cava (veins) and pushes it into the right ventricle.
- The right ventricle squeezes down and sends the blood into the pulmonary arteries to the lungs, where the blood picks up oxygen.
- Pulmonary veins carry the blood back to the left atrium, which sends it down to the left ventricle.
- The left ventricle squeezes the blood into the aorta, a major artery that sends the blood to every cell and organ.
- Valves that close, blocking backward flow, prevent the blood from going backwards (from the left side of the heart to the lungs, from the right side of the heart to the veins, and from the ventricles to the atria).
This amazing pump pushes 11⁄2 gallons of blood forward every minute. Every hour, it sends 90 gallons around the body, enough to fill a car’s 15-gallon gas tank six times. During a fairly restful day, your heart pumps 2,160 gallons of blood. And when you’re working or playing energetically, the number gets much higher.
The combination of the heart, the blood vessels that carry the blood, and the blood itself is the cardiovascular system.
When the blood pressure rises, the heart must work harder to push the blood through. It wasn’t meant to struggle so hard, and eventually it may fail because the heart muscles are just too tired and weak to work properly.
Blocking Blood Flow to the Heart Muscle
Just like any other organ of the body, your heart muscle must receive oxygen, glucose (blood sugar), and other nutrients in order to work. These nutrients are the food of the heart muscles. When arteriosclerosis (hardening of the arteries) occurs, the bloodstream that carries these nutrients is partially obstructed. The heart muscle then becomes partially starved, which can cause pain. If the obstruction remains about the same, the pain is stable. But a complete obstruction causes a heart attack.
Figure above shows the location of the major arteries that provide blood supply to the heart muscles.
- The right coronary artery supplies blood to the right side of the heart.
- The left main coronary artery supplies the left side of the heart. It, in turn, divides into the following:
- The left anterior descending artery that supplies the front of the left side
- The left circumflex artery that curves around to the back
- Both the left and right coronary arteries arise as the left ventricle continues into the aorta.
Click here for more pictures of the coronary arteries
Beware of left ventricular hypertrophy
Under the influence of high blood pressure, heart muscle becomes hypertrophic, that is, it begins to thicken just like any muscle that constantly does more work. About 20 percent of people with high blood pressure have left ventricular hypertrophy, a severe version of this condition, which can lead to heart attacks or heart failure (both of which we cover later in this article). As the muscle gets thicker, it loses its elasticity, leading to reduced blood flow into and out of the heart. The heart begins to enlarge, leading to the need for more blood for the heart tissue, which it can’t provide.
Symptoms may include shortness of breath, chest pain, and irregular heartbeats. Your doctor can diagnose left ventricular hypertrophy with an electrocardiogram (EKG - US, ECG -UK).
Treatment is with blood-pressure-lowering drugs, especially losartan (see article 13).
Examining arteriosclerosis
In arteriosclerosis, deposits of cholesterol and formation of a plaque (consisting of inflammatory cells and fibrous tissue) cause an artery to narrow, blocking the flow of blood. (See below for: “The formation of a plaque” for more information.) When the blood flow is blocked, the heart has to pump harder, leading to hypertrophy (thickening of the heart muscles). (See above: “Beware of left ventricular hypertrophy” for details about one kind of hypertrophy.)
High blood pressure can increase the development of fatty deposits in the walls of the arteries, leading to:
- Atherosclerosis: A form of arteriosclerosis in the medium- to large-size arteries
- Arteriolosclerosis: Arteriosclerosis in the small arteries
- Coronary atherosclerosis: A form of arteriosclerosis involving the arteries to the muscle of the heart
As the coronary arteries (the ones that feed the heart muscle) become more and more blocked, the heart muscle may become hungry for nutrients or even die, a condition called coronary artery disease (also known as coronary heart disease and atherosclerotic heart disease).
According to the National Institutes of Health, one of every five deaths (460,000 total) in the United States each year is a lethal heart attack as a result of atherosclerosis of the coronary arteries. In addition to these deaths, another 650,000 people have heart attacks but don’t die, making a total of about 1.1 million people affected by atherosclerosis each year. About 12.5 million people in the United States have chest pain associated with coronary atherosclerosis, a heart attack, or some other form of coronary. Due to the greater prevalence of high blood pressure among the African American population, this group has a higher rate of coronary heart disease than any other ethnic group in the United States.
Coronary artery disease has been found in the arteries of people as young as age 20 or younger who die of other causes, and it is extensive in older people who die of other causes. However, not everyone has it. People who don’t have risk factors such as uncontrolled high blood pressure, cigarette smoking, dia- betes, a sedentary lifestyle, and high cholesterol levels rarely have problems with coronary artery disease. Although a family history of coronary artery disease is another risk factor (and one that you can do nothing about), its effect is minimized when the individual avoids or controls the other risk factors.
Coronary artery disease may cause sudden death as its first sign in as many as 25 percent of the patients. Another 20 percent die as a result of a fatal irregularity in their heartbeat before they reach the hospital. The remaining 55 percent may undergo a procedure that tries to open the blocked artery or arteries. (See the “Opting for surgery” section coming up later in this article.)
Managing stable heart pain
A large group of patients with coronary artery disease have angina pectoris (Latin for pain in the chest), a relatively stable form of chest pain that doesn’t get worse over time. Commonly known as angina, the disease affects 8.9 mil- lion people in the United States. It results from blockage of an artery, but it can also occur when the coronary artery squeezes down (after a meal, for example, when blood is diverted to the intestine, thus causing a decrease in blood supply to the heart). Some diseases (such as hyperthyroidism — where an overactive thyroid gland increases the demands on the body’s metabolism) can cause angina even in the absence of coronary atherosclerosis.
In the following sections, we discuss the symptoms, testing, diagnosis, and treatment of stable heart pain.
Identifying the symptoms
Some of the characteristic symptoms of coronary artery disease include the following:
- Chest pain begins with activity and is relieved with rest. The person most often feels the pain in the front of the chest on the left side and radiating down the left arm. Even less activity can bring on the pain after a meal or during excitement. Strong emotions can bring on pain even without activity.
- Symptomatic pain in the chest may be absent. However, according to coronary artery disease patients, symptomatic discomfort in the chest area can include burning, squeezing, pressing, aching, or indigestion.
- The area of discomfort is most often behind the middle of the chest, and it tends to be in the same area for an individual each time he has it. Other places may include the right side of the chest, the left shoulder, and sometimes the right shoulder. It can also be in the jaw. The discom- fort often radiates from one of those sites back to the chest.
- Discomfort may last no longer than a few minutes, especially if the patient rests as soon as it starts. It doesn’t last longer than 30 minutes.
- Nitroglycerin often reduces or stops the pain, and this same response helps to make the diagnosis.
The formation of plaque
When high blood pressure, smoking, diabetes, or increased levels of cholesterol (especially low-density lipoprotein [LDL] cholesterol) damage the inner lining of the arteries, a plaque (obstruction) begins to form. The following figure shows the parts of a normal artery before and after plaque develops.
After damage occurs, the following steps take place:
- Fat begins to accumulate within the intima, the innermost part of the artery wall.
- The chemicals that normally prevent changes to the fat can’t reach it — the fat begins to change to a more damaging form.
- White blood cells enter the intima, transform into macrophages (large cells), and begin gobbling up the changed fat, turning the cells into foam cells. Note: Macrophages normally remove waste products, harmful microorganisms, and foreign material from the bloodstream.
- Calcium also deposits in the walls of plaque. It’s responsible for the calcification in arteries that is visible in X-rays.
- This accumulation of foam cells and calcium is now plaque. It grows and begins to stick out into the lumen (the hollow part) of the artery.
- Blood flow to the heart muscle is reduced when 80 percent of the lumen is blocked.
- Blood platelets can accumulate to form clots on the irregular surface of plaque. The clot can stay at that position (reducing the opening of the lumen even more) or break off and lodge in a smaller artery (completely closing off blood flow beyond it).
Testing and making a diagnosis
The doctor may use certain blood tests to characterize the type and extent of the heart disease. These include the following:
- Cardiac enzymes: Blood chemicals that are in higher amounts when the heart damage is acute
- C-reactive protein: A chemical in the blood that indicates you’re responding to injury or infection High levels indicate an increased risk of a heart attack or brain attack.
- Fibrinogen: A protein that promotes blood clots and is present in higher amounts in higher risk patients
- Homocysteine: A chemical that indicates increased danger of brain attack, heart attack, or blockage of blood vessels to the legs
- Low-density cholesterol: A form of fat in the blood that increases atherosclerosis
The blood levels of these chemicals and the patient’s description of symp- toms usually lead the doctor to diagnose angina. But the classic diagnostic tool for this condition is a stress test. The patient walks on a treadmill or bikes on a stable bike up to 12 minutes at increasing speeds and increasing slopes while a continuous electrocardiogram (ECG or EKG — a recording of the electrical impulses in the heart) is performed.
This test is accurate only if the patient achieves a certain level of activity and heart rate and sustains the activity long enough. The doctor looks for specific changes on the graph paper especially if chest pain occurs during the EKG. When a stress test indicates angina pectoris, other tests that require an intravenous line or even less invasive measures can further characterize the severity of the coronary artery disease. These include the following:
- Coronary angiogram: This test is the gold standard for the diagnosis of angina pectoris, and it’s ordered when the preceding tests indicate an abnormality. To find the areas of narrowing, the doctor places a catheter in the individual coronary arteries and injects a dye that’s visible on an X-ray. Coronary angiography is only for patients who exhibit the following:
- Stable or unstable angina is present, and medical treatment with pills is unsuccessful.
- Symptoms don’t point to a diagnosis of coronary artery disease.
- Coronary artery surgery has been performed, but symptoms return.
- Heart has severe abnormal rhythm disturbances that may be caused by coronary artery disease.
- Echocardiography: Using sound to bounce off the walls of the heart, this test shows areas that don’t contract with the rest of the heart muscle. A device that sends a sound wave to the heart muscle is held over your heart, producing a picture of the moving heart muscle. This is truly noninvasive to your body.
- Myocardial perfusion scan: This test shows where the myocardium (heart muscle) is and isn’t receiving normal blood flow. After a radioactive tracer is injected through an IV, and an instrument similar to a Geiger counter for detecting radioactivity locates the tracer in the heart. When no radioactivity is observed, no perfusion (blood delivery) is occurring.
- Radionuclide angiography: This test measures the ejection fraction (the amount of blood that’s pushed out of the heart with each beat divided by the amount of blood within the left ventricle when it’s completely full) and the motion of the heart wall to identify which areas may have lost their blood supply and are probably dead tissue.
The ejection fraction should rise with exercise, but when coronary artery disease is present, it may fall. (See below: “Ejection fraction, what’s your function?” for more information.) A radioactive substance that attaches to red blood cells is injected into your blood through an IV. The radioactivity is counted as it goes through your heart.Chapter 5: Defending Your Heart After a coronary angiogram clearly points to obstructive coronary artery disease, the doctor determines a treatment plan.
Treating with medication
Three major forms of treatment are available for coronary artery obstruction, and each has its advantages and disadvantages. One treatment option for patients with stable, uncomplicated angina pectoris is medication. This option is usually best for patients who aren’t interested in exertion. However, if the patient wants to perform energetic activities or has unstable angina, then two surgical procedures — percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) — are the treatments of choice. (we discuss them in the following section.)
Before prescribing drugs, the doctor wants to eliminate contributing factors. (See “Avoiding the Risk Factors” later in this article.) If blood pressure is high, it must be brought under control. If the patient smokes, he must stop. Diabetes needs to be controlled, and elevated cholesterol need to be treated.
Strenuous activity may provoke pain, which may have to be eliminated as well. A number of drugs have successfully reduced pain and increased the time that such patients can exercise without it recurring. For example:
- Beta blockers, a class of drugs in pill form that include propranolol, metoprolol, and atenolol, decrease the heart’s oxygen requirements, thereby decreasing pain. Note: Beta blockers actually prolong the life of angina sufferers.
- Calcium channel-blocking agents, another class of drugs such as verapamil and diltiazem, reduce the heart’s oxygen needs by reducing blood pressure and heart rate. They are in pill form.
- Drugs that dilate the blood vessels or prevent the blood’s platelets from forming a clot (such as aspirin) can reduce pain and prevent further clotting. These are available in pill form.
- Long-acting nitrates such as isosorbide dinitrate and isosorbide mononitrate decrease the frequency of pain attacks. In addition to pills, they’re available as a patch that’s worn during the day; the medication is absorbed through the skin.
- Nitroglycerin has been successful for years. It opens up the arteries directly and lowers the blood pressure so the heart doesn’t have to work as hard. Nitroglycerin is placed under the tongue at the first sign of pain and usually works in minutes.
Opting for surgery
As we mention earlier in this section, two surgical procedures that treat coronary artery obstruction include PTCA and CABG.
Studies of patients who were randomly given PTCA or CABG show similar results. For a single blocked blood vessel, the two operations have equal rates of success. Note: This similarity is also true for multiple vessels as long as the patient isn’t diabetic and the obstructed blood vessels can be entered. In the latter case, however, bypass surgery is the treatment of choice.
For PTCA you are awake. Your groin area is cleaned and numbed. A tiny incision allows the cardiologist to find an artery so he can place a guide wire and a tube up to the blockage in the coronary artery. The doctor observes the blocked artery by injecting dye through the tube and taking an X-ray. He then inflates a balloon at that end of the tube to widen the area of blockage and stretch it out. This step may be repeated, and the tube and balloon are then removed. After the blockage is open, the doctor may also place a stent (an open tubular structure made of metal) at that location to act like a scaffold and keep the artery open. By using certain drugs on the stent, the blockage remains open much longer. You may be in the hospital a day and return to work the next week. Some recent research suggests that drug-coated stents may cause death earlier than non-drug-coated stents.
Above picture of a coronary artery: insertion of a stent into a coronary artery. When a coronary artery becomes narrowed or blocked, a stent with a deflated balloon is inserted into the artery through a catheter. The balloon is inflated, thereby expanding the stent and widening the artery. Finally, the balloon is removed, and the expanded stent is left in the artery to hold the artery open, thus re-establishing the flow of oxygen-rich blood to the heart.
For CABG, you’re under general anesthesia and a large incision is made to open the chest. The flow of blood is diverted from the heart to a heart-lung machine, which provides blood to the rest of the body while the heart is still. The surgeon attaches a healthy blood vessel (from the leg or the inside of the chest) onto both sides of the blocked artery. The blood then flows freely through that blood vessel. The surgery takes up to six hours because two to four arteries are repaired. You’re usually in the intensive care unit for a couple of days, out of the hospital by a week after surgery, and back to work in 6 to 12 weeks.
PTCA has a number of advantages over CAGB:
- PTCA is a simpler surgery and doesn’t require anesthesia.
- The chest isn’t opened up.
- The heart isn’t bypassed during surgery.
- Convalescence is relatively short, and the usual discharge occurs after 24 hours.
However, in general, CAGB lasts longer and provides a more complete reopening of blood flow. In addition, two newer procedures make your stay in the hospital much shorter following CAGB:
Using beating-heart surgery, the surgeon stills only the area of the heart that he’s operating on. This improvement results in much less overall trauma, which shortens the hospital stay.
The surgeon uses much smaller incisions in the chest, making this surgery minimally invasive, especially when only one artery needs opening.
Disadvantages and complications accompany each procedure:
- PTCA can’t be performed when an artery is completely closed. Also, PTCA isn’t effective when many separate lesions are present. This problem may be the reason PTCA isn’t the treatment of choice for diabetics with coronary artery disease, where multiple arteries are affected. These patients do much better with CABG.
- CABG can have complications (an acute heart attack, a stroke, an infection in the body’s surgical site, and even death on the operating table), especially in patients more than 70 years old and patients with other diseases such as kidney disease and diabetes (check out the later section “Controlling diabetes”). In these patients, CABG is only performed when symptoms are most severe (for example, unremitting chest pain).
Treating a heart attack
A myocardial infarction (MI) is a heart attack where heart muscle tissue dies because it lacks a supply of blood. It can cause immediate death in 25 percent of the people who have one, and another 20 percent never reach the hospital alive. For those who do make it to the hospital, however, excellent treatment is available.
The symptoms that suggest that an individual is having a heart attack include the following:
- Development of severe pain in the front of the chest that lasts for more than 30 minutes with radiation down the left arm
- Unexplained shock or a severe fall in blood pressure, sometimes accompanied by vomiting and even unconsciousness
- A feeling of impending doom with sweating and a rapid heartbeat
Call 911 (in US) or 999 (in UK) for an ambulance ride to the nearest hospital, and call your doctor for follow-up.
The doctor will ask whether you’ve had a recent change in your pattern of chest pain and whether you’re experiencing sweating, dizziness, nausea, and weakness.
In addition:
- Your blood pressure may be low.
- You may appear pale
- Your heart rhythm may be irregular.
- Your heart may reveal soft sounds that mean the muscle isn’t functioning properly.
On examination, your chest may have rales, the sound of fluid in the lungs as a result of some heart failure (see the next section for more information).
The doctor does lab studies, which may show the following:
- Elevations of heart enzymes, chemicals (usually found only in the heart) that leak into the blood when the heart muscle is damaged.
- Electrocardiographic changes that suggest a heart attack.
- Changes in the movement of the heart wall; the wall doesn’t move at all, or it may flop outward when it should be moving in to squeeze out blood.
See the earlier section “Testing and making a diagnosis” for more on each of these studies.
One of the biggest advances in the treatment of heart attacks is the availability of thrombolytic therapy, intravascular drugs that dissolve the clot that’s obstructing the coronary artery, thereby allowing blood to flow back into the obstructed area. This treatment decreases the size of the damage and often saves the patient. Note: A possible side effect of thrombolytic therapy is the danger of bleeding in undesired areas such as the brain — especially when the blood pressure isn’t controlled.
Doctors can use several different agents for thrombolytic therapy, and the choice depends on your doctor’s experience with each of them. But the success of this treatment depends on how quickly the patient gets to the doctor after the onset — the earlier, the better. The reopening may be as much as 80 percent, and it accompanies an end to the pain and an improved EKG reading.
After the initial therapy, the heart attack patient remains in the coronary care unit for a couple of days and gradually returns to normal activity.
If the blood vessel closes again (this happens in 10 percent of cases), the patient must have PTCA or CABG to reopen the artery permanently. (we describe these two procedures in the previous section.) Sometimes the doctor chooses immediate PTCA over thrombolytic therapy, especially in the severely sick patient with a heart attack and shock.
Studies have shown that several drugs can significantly reduce the chance of a future heart attack when they’re prescribed early. For example:
- Aspirin to prevent more clots
- Beta blockers to extend the life of the patient
- Nitroglycerine as the treatment of choice when pain occurs
Developing Heart Failure
Heart failure is clearly more prevalent today compared to 25 years ago. The reason for the increase isn’t clear, but uncontrolled high blood pressure is certainly one contributing factor.
When high blood pressure is present, your heart is forced to pump against more resistance. To sustain its output, the heart gets bigger and thicker, just like the muscles of a weight lifter. But heart muscle can only thicken so much. After a while, it’s too large to pump effectively, and heart failure begins.
If you suffer from heart failure, you may experience pain in the front of the chest, the jaw, the left arm, or the shoulder. We describe this pain (angina) earlier in this article in the “Managing stable heart pain” section. This pain comes from the high oxygen requirement of the thick heart muscle plus the decreased blood supply coming through the arteries that supply the heart.
Your doctor can tell that your heart is developing problems because he hears the changes in your heart sounds through his stethoscope. Also, with his hand on the front of your chest, he can feel your heart thumping against the chest wall. As your heart fails, that thumping moves away from the center of your chest, indicating that your heart is getting larger.
In this section, we discuss the signs and symptoms of heart failure as well as the many options for its treatment after your doctor has made a definite diagnosis. 8182 Part II: Considering the Medical Consequences
Noticing the tell-tale signs
The most common symptom of heart failure is dyspnea (difficulty breathing). At first, breathing is only difficult during exercise. As heart failure increases, however, the individual has difficulty breathing when she’s resting, too. Note: People without heart failure may get short of breath with exercise, too, but only after exercising at least a few minutes or so. People whose hearts are failing have difficulty breathing at the onset of exercising.
Dyspnea develops when the blood vessels of the failing heart become congested with blood — sometimes even leaking into the lung tissue. The lungs, ordinarily light and filled with air, become much heavier. The diaphragm and other muscles of respiration have a much harder time pushing air out and pulling it in. As they become fatigued, the person experiences shortness of breath.
The patient is unable to lie down flat without raising his head because more blood pools in the lungs, making breathing even more difficult. As a result, the patient may need to sleep on several pillows. If his head falls off the pillows, he may have orthopnea, a coughing spell that improves when the patient sits up or raises his head.
Sometimes a severe coughing spell and shortness of breath that can’t be relieved just by sitting up or raising the head can awaken the patient. This can be a terrifying experience because the patient can’t catch his breath. This paroxysmal nocturnal dyspnea is associated with an abundance of fluid in the lung tissue.
Symptoms as severe as paroxysmal nocturnal dyspnea require a call to 911 (US) or 999 (UK)and emergency room treatment.
Other less specific signs and symptoms of heart failure include:
- Fatigue and weakness
- Confused mental state due to poor blood flow to the brain
Severe shortness of breath, mental confusion, severe fatigue, or the new onset of chest pain requires a visit to your doctor.
Understanding what the doctor looks for
The following list presents some of the signs and symptoms that the doctor looks for when she suspects that heart failure is present. But you, too, can recognize many of these if you or a loved one has heart failure:
- Swollen legs: The legs swell because of edema (water in the tissues; you can see a dent when the finger pushes into the skin).
- Large liver: A tender, large liver fills with fluid.
- Jaundice: Yellow eyes and yellow skin characterize this condition. The yellowing is a result of severe liver damage due to fluid in the liver.
- Off-beat heart sounds: Your doctor hears abnormal heart sounds with her stethoscope.
- Rales: These crackling sounds in the lungs indicate the presence of fluid in the lung tissue.
- Swollen abdomen: The abdomen swells because of fluid in the abdomi- nal cavity.
- Decreased urine flow: Due to diminished blood flow to the kidneys, the body’s normal production of urine decreases.
- Cold and pale limbs: Arms and legs are cold and pale because of poor blood flow.
As you can tell, this is a description of a very sick individual. Patients may have one or more of these symptoms. You don’t want this to be what you see in the mirror some day! Start following the recommendations in Part III right away to lower your blood pressure and decrease your chances of developing heart failure.
A chest X-ray and an EKG can help your doctor see the severity of the heart failure. These standard tests are ordered for most types of heart disease including heart failure.
- Chest X-ray: This test indicates the size of the heart and the presence and extent of fluid in the lungs. Often the veins in the chest are visible in the X-ray because the backed-up blood enlarges these veins.
- Electrocardiogram: This test may indicate an enlarged heart, but often other testing shows more.
Ejection fraction, what’s your function?
Assessing the ejection fraction is one of the best ways to measure your heart function. The ejection fraction is the resulting ratio when the stroke volume (amount of blood that’s pushed out of the heart with each beat) is divided by the end diastolic volume (amount of blood within the large chamber of the heart, the left ventricle, when it’s completely full). If the ejection fraction is low (for example less than 50 percent), a significant fraction of the blood in the left ventricle is left inside the heart with each beat, suggesting an inefficient (failing) heart.
These volumes can be determined by an ultrasound study that uses the different echo properties of blood and heart tissue to produce a picture of the heart at rest (end diastolic volume) or when pumping (end systolic volume). The amount of blood at rest minus the amount after pumping, divided by the amount at rest, gives the ejection fraction. Alternately, an X-ray study can provide the same information.
Measurements while the patient is exercising may be even more helpful because this is the time when the heart is being maximally stressed. Although unstressed values may be normal, the patient may show evidence of significant heart failure when the heart is stressed.
Treating heart failure
After heart failure is diagnosed, your doctor gives you the information and the drugs you need to manage the condition. This complicated process can’t be discussed in detail here. See this article for detailed technical information about heart failure and treatment: Heart failure
However, like all illness, successful treatment depends on your willingness to follow the doctor’s recommendations. Some of your doctor’s instructions and treatments may include the following:
- Significant reduction in salt intake, not just to lower blood pressure but even more importantly to prevent water retention associated with increased salt (see article 10 for more information on limiting your salt intake)
- Use of certain medications including
- A drug from the category of ACE inhibitors (see article 13) to help lower blood pressure and reduce salt and water retention early in the development of heart failure
- Diuretics to eliminate salt and water through the kidneys
- Vasodilators to open the arteries
- Digitalis, a drug that increases the heart muscle’s ability to contract
- Restriction of activity to give the heart a rest
- Weight loss to reduce the work of the heart (we discuss weight loss in article 9)
- Reduction of fluid intake to no more than 48 ounces daily.
Avoiding the Risk Factors
Uncontrolled high blood pressure makes both heart failure and heart attacks much more difficult to manage, so controlling the high blood pressure is an early step toward managing these complications.
Some risk factors that contribute to high blood pressure can’t be avoided (like family history of early heart disease). But doing everything possible to avoid or eliminate other risk factors helps to prevent heart failure and heart attacks — two complications of high blood pressure — and minimize their impact if they do occur. In the following sections, I point out how prevalent these risk factors remain, how much of a role they continue to play in the occurrence of heart failure and heart attacks, and their prognoses when they do occur.
Curbing high cholesterol
Half of the United States adult population has abnormally high cholesterol levels. These statistics are similar for the United Kingdom, Australia, and New Zealand. For a breakdown of the various ethnic populations, the rates are:
- Caucasian: 52 percent of men and 49 percent of women
- African American: 45 percent of men and 46 percent of women
- Hispanic: 53 percent of men and 48 percent of women
- Native American: 38 percent of men and 37 percent of women
Given these numbers, it’s astonishing that doctors don’t see far more patients with complications, especially heart attacks in association with high blood pressure.
High cholesterol is treatable. The dietary changes I recommend in article 9 along with the exercise recommendations of article 12 can take care of most cases. In addition, cholesterol that doesn’t respond to diet and exercise is easily managed by statins, a powerful group of cholesterol-lowering drugs.
Find out the level of your cholesterol and bring it down. The lower your cholesterol, the better.
Cutting tobacco use
In many ways, tobacco use is a greater problem than high cholesterol. The most important reason is that you’re addicted to cigarettes, but you’re not addicted to fat. Breaking the smoking habit is difficult but definitely worth the effort.
About a quarter of the United States population is addicted to cigarette smoking. The ethnic breakdown is:
- Caucasian: 26 percent of men and 24 percent of women
- African American: 29 percent of men and 21 percent of women
- Hispanic: 25 percent of men and 13 percent of women
- Native American: 42 percent of men and 38 percent of women
Just how many men and women continue to commit slow suicide is astonishing. Even more astonishing is the rate of cigarette smoking among young people who are very much aware of the statistics that relate cigarettes not only to heart disease, but also to emphysema, lung cancer, and many other cancers.
In article 11, we provide everything researchers know about how to stop smoking — one of the most difficult tasks you may ever face. In terms of the benefits to your health, though, nothing you do can be of greater value.
Controlling diabetes
Today more than 21 million Americans have diabetes. That’s 5 million (more than 30 percent) more than in 2002. Heart attacks remain the most frequent cause of death among diabetics, and they’re responsible for two-thirds of all deaths among diabetics. They also tend to be more complicated than a heart attack in a non-diabetic. For example, the extensive nature of the atherosclerotic plaque (areas of obstruction in blood vessels) in diabetics results in a poor response to PTCA surgery and the need for CABG (a more invasive surgery) when angina or a heart attack occurs. (See the earlier section “Opting for surgery” for more details about PTCA and CABG.)
The prognosis is less pessimistic when the diabetes is under control. This means keeping the blood glucose as close to the normal range as possible (between 80 and 120 milligrams of glucose per deciliter of blood [mg/dL]) and keeping the hemoglobin A1c (a test for long-term diabetic control) less than 7 percent of the total hemoglobin.
Diabetes is the diagnosis when the blood glucose is 126 mg/dL on two or more occasions in the fasting state or 200 mg/dL in a random blood glucose check on two or more occasions. However, the patient already has impaired fasting glucose (impaired glucose tolerance) at 100 to 126 in the fasting state or 140 to 200 at random. The increased risk of heart disease associated with the blood glucose is present at these lower levels of blood glucose as well. The number of people with these conditions isn’t small either. The United States statistics for just impaired fasting glucose are as follows:
- Caucasian: 9 percent of men and 5 percent of women
- African American: 3 percent of men and 5 percent of women
- Hispanic: 12 percent of men and 7 percent of women
The solution is to keep your weight down, get plenty of exercise, avoid fats, and keep your blood glucose under 100 fasting or 140 random. These steps keep your heart risk at a minimum.
Stepping up physical activity
Lack of physical activity is clearly a risk factor for heart disease, as much as tobacco smoking. Because many people do work that requires little physical activity, they need to exercise during their leisure time. However, this proactive approach isn’t happening. The following percentages show the populations that don’t exercise regularly:
- Caucasian: 33 percent of men and 39 percent of women
- African American: 46 percent of men and 57 percent of women
- Hispanic: 50 percent of men and 57 percent of women
Anyone who says that Americans are on the move hasn’t looked at these numbers! Article 12 tells you how to get going and keep going. The farther you walk, the longer you live. It’s as simple as that. Walk and protect your heart from high blood pressure.
Continued in this article: Protect the kidneys from high blood pressure