Health – Caring for our hearts

We have some unfortunate terms in medicine and one of them is “heart failure”. It really suggests a terminal event when in fact it is eminently treatable and has been for centuries. In fact, a remedy was discovered in 1775 when William Withering investigated a folk remedy derived from foxglove and found it effective for “dropsy” (aka fluid retention). 

We’ve come a long way since then and now diligent treatment of heart failure makes a massive difference to quality of life.

We tend to take our hearts for granted. Ticking away from early pregnancy to death, they dutifully pump blood around the body with astonishing efficiency and consistency. The heart is a large complex muscle, consisting of a high-pressure side (the left ventricle) that supplies blood to the whole body, including the brain. We want our blood pressure to be enough to supply all our organs but not too high in the long term.

The right side of the heart has to pump blood only a few centimetres to the lungs, so it has a much lower pressure.

The efficiency of the heart muscle can be impaired on either side, with different approaches to treatment, but for this article we’ll concentrate on the high-pressure left ventricle.

Heart failure means the muscle isn’t pumping as well as it should. Until the advent of echocardiography we had to infer this from symptoms and signs, but now echo scans can tell us accurately how much blood is being pumped out with each beat (known as ejection fraction or EF). A good output is 50 to 70 percent of the contents of the left ventricle. This may not sound very impressive, but some blood has to remain in the heart to “prime the pump” and maintain pressure. 

Once the EF falls below 50 per cent, and especially down around 30 per cent, patients can experience shortness of breath, fatigue, leg swelling, wheezing and reduced exercise tolerance. For sufferers, life expectancy is reduced significantly. 

Despite William Withering’s early discovery of digitalis, for many years our treatment options were limited to that drug and fluid pills. But progress has been made in our understanding of the physiology of heart failure and its treatment.

The cornerstone of modern therapy is known as the “four pillars”. There is strong evidence for the introduction of four different medications for heart failure, as quickly as possible and to the maximum doses tolerated. All cause mortality is improved by about 60 percent when on this combo, as compared to no treatment at all.  

This compelling evidence obliges doctors to rethink their management of heart failure. We realise this requires time, effort and expense for the patient, but it is worth it for a better, longer life.