When Your Heart Fails You Will Not Walk Alone by Dr Lin Weiqin
The Straits Times 26 August 2019
Heart failure is a growing epidemic but a multidisciplinary team will help patients manage the condition
I first met Peter, 61, when he was admitted to hospital last year.
He had undergone cardiac bypass surgery more than five years ago after being diagnosed with multiple blockages in his heart arteries.
Having been healthy till that point, he was shocked that he had to undergo surgery.
Traumatised by it, he developed a fear of going to hospital. He decided to skip the follow-up visits as he felt fine after surgery. He also stopped taking his medications after a while.
Peter started feeling things were amiss a few months prior to that admission. He developed shortness of breath on minimal exertion and felt tired most of the time.
Sleeping became a problem as he could not lie flat without feeling breathless. Eventually, his abdomen and lower limbs swelled, causing him great distress.
He finally decided to go to hospital though, by then, it was apparent he had developed heart failure. It was caused by his underlying coronary heart disease, which was not managed with medications.
Heart failure is a condition where the heart is unable to pump efficiently enough to supply blood to the vital organs of the body. Only 50 per cent of those diagnosed with heart failure remain alive five years after the initial diagnosis.
In Singapore, some 4.5 per cent of the population currently live with heart failure. It is a growing epidemic and one of the most common causes of hospital admissions here.
To date, there is no single test that allows doctors to make the diagnosis of heart failure in isolation. Doctors have to integrate the information obtained from a patient's clinical history, the physical assessment and specialised investigations, to come to a diagnosis of heart failure.
Common complaints of heart failure patients include fatigue, shortness of breath on exertion, shortness of breath on lying flat, abdominal swelling and lower limb swelling. These are signs of what is commonly known as "water retention".
On examining these patients, doctors are often able to find swollen neck veins, abnormal heart sounds and fluid sound in the lungs.
At this point, they will send most patients for specialised cardiac investigations to support the diagnosis of heart failure and look for the underlying cause.
Peter underwent an echocardiogram, which revealed that the left heart had severely impaired pumping function.
Echocardiogram, or ultrasound examination of the heart, is one of the most important tests for doctors to assess patients with heart failure. It gives valuable information about the patient's heart structure and function, which will guide subsequent investigations and management.
Peter also went for a repeat coronary angiogram, an invasive test allowing doctors to look at the blood flow in his heart arteries.
Unfortunately for Peter, the, angiogram revealed that his arteries had developed such severe blockages that it was no longer possible to perform stenting procedures to restore blood flow and his heart function.
The only option at this stage would be medical therapy and close follow-ups with the multidisciplinary heart failure team.
Peter met a dietitian, a physiotherapist and a pharmacist, who empowered him with the self-care knowledge to manage his condition at home.
Having realised the gravity of his heart condition, he promised he would keep to his medications and subsequent appointments at the clinic.
Since his first hospital admission five years ago, heart failure management has been boosted by the discovery of new drugs.
A new class of drugs called angiotensin receptor-neprilysin inhibitor has been shown to be superior to conventional treatment in reducing the morbidity and mortality in patients with very poor heart function.
In patients with heart failure and diabetes, a new class of diabetes drug, the sodium-glucose co-transporter 2 inhibitors, has also been shown to improve heart failure outcomes.
Peter was prescribed these two new drugs and he faithfully adhered to his clinic appointments after his discharge.
However, he remained symptomatic, unable to complete his day-to-day tasks without feeling short of breath.
So I sent him for an electrocardiogram or ECG, which showed that he was suitable for cardiac resynchronisation therapy: This involves implanting a special cardiac pacemaker in him to coordinate his heart chamber contraction and improve heart function. Peter had this done in March this year.
When I saw him a month later at the clinic, he reported that he was eating and sleeping better.
I congratulated him on his improvement, but we remained realistic about his condition.
I told him that should his symptoms worsen again, he might eventually require a left ventricular assist device or LVAD, a permanent pump implanted in the heart to improve blood delivery to the rest of the body.
Peter and his wife smiled at me. "We will continue to celebrate every good day and take everything else as they come," he said. I found it hard to disagree with that.
Dr Lin Weiqin is a consultant with the Department of Cardiology at National University Heart Centre, Singapore.