Symptoms

Heart failure manifests with shortness of breath, fatigue and excess accumulation of fluid in tissues and organs, explains Iain Squire, professor of cardiovascular medicine at the University of Leicester and chair of the British Society for Heart Failure (BSHF). “Fluid builds up in the legs and ankles causing them to swell, and also builds up in the lungs which makes it hard to breathe. Shortness of breath initially occurs with exercise but later persists at rest. Together with fatigue, which causes patients to feel constantly tired, it lowers the ability to live normally, making simple things like shopping in the supermarket a challenge.”

Risk factors

About 70 per cent of heart failures are caused by coronary artery disease: the build-up of plaque inside the blood vessels that supply the heart. “If plaque blocks the blood flow, a heart attack may occur and damage the cardiac muscle leading to heart failure,” says Professor Squire. “Other risk factors include cardiomyopathy (when the heart walls are stretched, thickened or stiff), high blood pressure and chemotherapy for cancer. Age, too, weakens the cardiac muscle, making people over 65 the most at risk of heart failure.

Treatment

The condition is usually treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) and, in some cases, with pacemakers. Taking regular exercise as part of a heart failure rehabilitation programme is also important.

Phenomenal advances

Professor Squire notes that “the progress in heart failure has been phenomenal, leading to effective treatments and implantable devices that have improved survival rates significantly.” A Healthcare Quality Improvement Partnership audit found that during 2012 and 2013, in-hospital heart failure deaths fell from 11.1 to 9.11 per cent. One-year mortality after hospital discharge also fell, from 26.2 to 24.6 per cent.

The challenges

There remain, however, difficulties, says Professor Squire. Access to treatment is often delayed because heart failure is easy to misdiagnose, for its symptoms are also typical of other diseases. Echocardiography, the gold standard for assessing the heart’s pumping ability, is not useful for those who show heart failure symptoms but have apparently normal cardiac muscle. A test that measures the blood levels of a substance called BNP (B-type natriuretic peptide) can help in these cases but is not available everywhere. Plus, most patients have additional illnesses and are on multiple medications, both of which can affect their tolerability to the drugs they need for their heart failure.

High readmission rates

So although mortality has decreased, survival rates for heart failure are still worse than those of some common cancers. Around 35 per cent of patients with acute heart failure who leave the hospital either die or are readmitted within six to nine months. Professor Squire says the high rates of hospital readmission are a global problem with many reasons, including patients not following their treatment regimen and treatment withdrawal due to the potential for interactions with other therapies. In the UK, the introduction of community heart failure specialist nurses has led to some improvements. A 2012 review study concluded that their work is associated with fewer hospital readmissions and improvements in quality of life.

More is possible

“Heart failure has a marked impact on life quality and expectancy,” says Professor Squire. “While much has been achieved, there’s clearly the potential for further improvement, through early and wider access to diagnostic tests, treatments and specialists, both in hospital and the community.”