Congestive heart failure (CHF) is the inability of the heart to pump blood to meet the requirements of the body. CHF is classified into two groups based on ejection fraction. Ejection fraction (EF) is the percentage of blood ejected by the heart with each heartbeat. Normal EF is greater than 55%. CHF with reduced EF includes patients with EF less than 40% while patients with CHF with preserved EF have EF greater than 50%. CHF is an enormous global problem affecting more than 60 million people worldwide. CHF is the number one reason for hospitalization in the US and associated with frequent hospitalization, high healthcare use and cost. Symptoms of CHF include shortness of breath, trouble breathing with exertion or laying flat in bed, severe exercise intolerance, easy fatigability, and swelling. In 2021, a universal definition of CHF stated that CHF is a clinical syndrome with symptoms caused by a structural heart problem plus either an elevation in the blood of natriuretic peptides or objective evidence of congestion (by physical examination or chest X-ray). Natriuretic peptides are released when the heart is stretched or stressed, as in CHF. There are two natriuretic peptides; BNP and pro-BNP. CHF is present when BNP is greater than 35pg/ml or pro-BNP is greater than 125 pg/ml.
CHF with preserved EF affects half of all CHF patients. It affects women more than men and it is increasing in prevalence compared to CHF with reduced EF. CHF with preserved EF is associated with and may be caused by hypertension, obesity, diabetes, heart artery disease, sleep apnea, kidney dysfunction and advanced age. Treating CHF preserved EF is difficult and frequent hospitalizations often result. A recent guideline recommends SGLT2 inhibitors as first line therapy. These medications, Jardiance and Farxiga, relieve congestion and promote weight loss. In addition, diuretics such as furosemide (Lasix) and spironolactone help in the treatment of fluid overload. The next line of recommended medications include Entresto, valsartan or losartan. Beyond medication, what else can be done? Recent information postulates that CHF preserved EF is an exercise deficiency and a social isolation problem. Addressing those issues could go a long way to treating the disease.
CHF preserved EF is a syndrome of exercise deficiency.
An intriguing article hypothesizes a spectrum of shortness of breath with exertion. At one end is the patient with CHF preserved EF. With exercise, such as climbing the stairs, there is insufficient cardiac output to meet the demands of the muscles, pressure goes up in the heart, and breathlessness ensues. The same series of events happens with an elite athlete. The difference is the workload; the CHF patient just walks up the stairs, the athlete has run 26 miles. The athlete has larger cardiac chambers, more heart muscle mass and a compliant heart that can handle high volumes and work loads. The patient with CHF preserved EF has a small, stiff, less compliant heart that cannot handle increased volumes with exertion. Normal aging results in a smaller heart size, higher filling pressures during exertion and a greater potential for CHF. Being sedentary over the course of a lifetime exacerbates the effects of aging. For adults who sit many hours each day the cumulative effects of a sedentary lifestyle plus the effects of aging plus other factors (for example, high blood pressure, smoking, diabetes) combine to cause CHF preserved EF. On the other hand, adults who have spent a lifetime exercising regularly can stave off the cardiac stiffness that occurs with age and can avoid CHF. Fortunately, for patients with CHF preserved EF the adverse cardiac effects can be reversed with physical training. For this reason, the American Heart Association recommends structured exercise for patients with CHF preserved EF. Structured exercise, or cardiac rehab, has been shown to reduce hospitalizations and reduce cardiac events. Not all those with CHF preserved EF fall into the category of exercise deficiency; it is reserved for the subset of patients with habitually low levels of physical exertion.
CHF preserved EF is a syndrome of social isolation and loneliness.
Social factors are a well-known contributor to heart disease. A recent study followed more than 400,000 people for more than 12 years to see if social isolation or loneliness were associated with CHF. Social isolation was defined as objectively being alone or having few social connections. Loneliness was defined as a painful feeling resulting from a desire for more social connections. Those with social isolation or loneliness were more likely to be men and to have unhealthy lifestyles (smoking, diabetes, obesity, physical inactivity). The study found that both social isolation and loneliness increased the risk for CHF by 15-20%.
So, if you have CHF, or are at risk for CHF, grab a friend, talk a walk, eat, sleep, repeat.
No comments:
Post a Comment