Heart failure is on the rise

While the incidence of heart attack and stroke has gone down in recent years, heart failure is more common than ever. The number of people each year who are hospitalized by the condition—in which a damaged heart can't pump enough blood to nourish the rest of the body—has more than doubled over the last three decades, to more than 1.1 million. And they often face a worse prognosis than many cancer patients.

But recent developments, including a new blood test that helps doctors diagnose the disease, have given heart-failure patients some good news.

It's particularly important to understand heart failure if you have any of the main risk factors for the disease: certain heart-valve disorders, diabetes, high blood pressure or cholesterol levels, an overactive thyroid gland, or a previous heart attack. All of those factors can prevent the heart from contracting forcefully enough to expel all the blood in its main pumping chamber, a condition known as systolic heart failure. Or the heart can become overly stiff, preventing the chamber from filling before it contracts. That's diastolic heart failure, a slightly less common form that affects about 40 percent of patients.

The first step toward avoiding heart failure is to make lifestyle changes: stop smoking, limit alcohol intake, lose excess weight, exercise, and eat a heart-healthy diet. Equally important is getting screened regularly for conditions that can damage the heart, and then treating those problems when necessary. People with hypertension who control their blood pressure, for example, can cut their heart-failure risk in half.

If prevention doesn't work, it's best to detect heart failure early. But that's easier said than done, because several common conditions—such as asthma, emphysema, and even anemia—can cause some or all of the same early symptoms or signs. Moreover, those early indications often develop so slowly, over months or even years, that they're easily overlooked or discounted.

As a result, some doctors don't think of the disease until they observe the classic objective signs, including swollen legs or belly, bulging neck veins, liver enlargement, and abnormal heart or lung sounds. But that can be a deadly oversight, because such signs often indicate more advanced disease. Now research shows that a simple blood test, which measures levels of a protein made by heart cells called B-type natriuretic peptide (BNP), can sometimes help to diagnose the disease earlier. And people with indications of possible heart failure should undergo echocardiography, or ultrasound imaging of the heart, after other causes have been ruled out, even if they have none of the disease's classic objective signs.

If tests show that you have heart failure but you don't yet have symptoms, treatment usually starts with an ACE inhibitor such as captopril (Capoten and generic) or enalapril (Vasotec and generic) to reduce the pressure against which the heart pumps. A beta-blocker such as carvedilol (Coreg and generic) or metoprolol (Toprol-XL and generic), which further shields the heart by slowing it down, can also be added if needed. When symptoms appear, your doctor should add a diuretic such as furosemide (Lasix and generic) to eliminate excess fluid, and sometimes low-dose digoxin to strengthen the heart's pump.

Several other treatments, including drugs and surgical interventions, can also help but are often underused, according to our consultants. They include:

• Aldosterone antagonists such as spironolactone (Aldactone and generic). These drugs can help people in the later stages of heart failure by causing the body to pass more urine and preventing the fluid buildup that causes many heart-failure symptoms. But aldosterone antagonists can also elevate blood-potassium levels, which can harm the heart, so physicians must carefully monitor those levels.
• Drugs to dilate the arteries, in African-Americans. The drug Bidil, which combines the two vasodilating drugs hydralazine and isosorbide dinitrate into one pill, appears to boost survival and cut hospitalizations in African-Americans with advanced heart failure. It's still unclear whether the two pills, taken separately, work as well, or whether the drugs benefit other ethnic groups, too.
• Implanted cardiac defibrillators. These devices can save the lives of patients who develop a heart-rhythm abnormality called ventricular fibrillation, which is common in those with heart failure. While it takes just an hour or so to implant a defibrillator, only about a quarter of the candidates suitable for the devices may actually get them.
• Pacemakers. Another option for people with more severe heart failure is a device that makes the two sides of the heart beat together. Known as cardiac resynchronization therapy, it reduced mortality and improved quality of life in a large, randomized clinical trial. But a recent study found that for unknown reasons, this therapy is used less in the Northeast U.S., in patients older than 70, and in African-Americans.
• Ventricular-assist devices. Heart transplantation can keep some patients alive when all other treatments have failed. Surgeons sometimes first implant a pump, called a ventricular-assist device, into such patients as a temporary solution until a donor heart becomes available. But research now shows that the devices by themselves are sometimes sufficient, and might be appropriate even in people who aren't candidates for a transplant.