By Pam McGrath
Just a few hundred years ago, the heart and its function were a bit of a mystery. And when the heart malfunctioned, treatment options were few and often ineffective. Today’s cardiologists offer their patients treatments that can lead to recovery.
To date, an Egyptian man named Nebiri, also known as Chief of Stables, is the oldest-known case of heart failure. Thanks to a German pathologist’s examination of 3,500-year-old mummified remains, it’s believed Nebiri died of pulmonary edema caused by heart failure.
In Nebiri’s day, physicians practicing medicine in Egypt, Greece, China and India recorded symptoms of heart failure that are similar to those we recognize today—but they didn’t have an accurate understanding of how the heart functioned and malfunctioned. It was then understood that the heart served as a pump, contracting as it worked. But it was believed that the body’s arteries were filled with air and its veins with blood. The heart’s job was to pump air throughout the body, thereby distributing heat. It wasn’t until the 17th century, when an English physician named William Harvey began studying the heart, that the organ’s true functions were more fully understood. Harvey’s work correctly identified the heart’s functions in relation to the body’s circulatory system.
And his observation that a dilated ventricle could cause the heart to fail was the first glimmer of an understanding of heart failure. In the late 18th century, William Withering, another British physician, noted that a patient with dropsy—what we now call edema—greatly improved after taking a traditional herbal remedy whose active ingredient came from the foxglove plant (of the genus Digitalis). Withering’s work led to the development of a drug called digoxin or digitalis, which was used to treat heart failure into the 1980s.
When breakthrough medical tools—including X-ray technology, the stethoscope and electrocardiography—were developed in the 19th century, they proved effective in furthering heart-failure research. By the early 1900s, physicians knew that diuretics could reduce fluid buildup in the body—a contributing factor in heart failure. In the 1940s to 1960s, heart specialists refined techniques in cardiac catheterization—a procedure to clear blocked arteries—and other heart surgeries. The first human heart transplant happened in 1967.
Then in the 1970s, says Gregory Ewald, MD, Washington University cardiologist at Barnes-Jewish Hospital, medical science gained further insight into heart failure, its causes, effects and treatment. Ewald also is director of the cardiovascular division’s section of heart failure and cardiac transplantation at Washington University School of Medicine. It was in that decade, Ewald notes, that medicine developed an important understanding of the ways pre-existing conditions can cause heart dysfunction. “And when the heart isn’t working effectively, the body may try to compensate. That effort may work for a while but, ultimately,” Ewald says, “the result is heart failure.”
Causes and symptoms of heart failure
Contemporary medicine has defined a number of conditions that can cause the heart to fail. Among them are:
- coronary artery disease and heart attack
- high blood pressure
- faulty heart valves
- damage to and inflammation of the heart muscle
- congenital heart defects
- abnormal heart rhythms
- other diseases, including diabetes, HIV and an over- or underactive thyroid
“Any of these can result in a heart that doesn’t efficiently supply blood to the body,” says Ewald. “That inefficiency produces a variety of symptoms that signal heart failure.”
The symptoms of heart failure include:
- shortness of breath during activity or when lying down
- exercise intolerance
- fatigue and weakness
- swelling in the legs, ankles and feet
- chest pain (when caused by a heart attack)
- rapid or irregular heartbeat
“Sometimes people think their allergies are acting up or that they have pneumonia or bronchitis, because those conditions can cause symptoms that are similar to those of heart failure,” says Ewald. “Fortunately, we can offer patients a number of tests that provide a definitive diagnosis.”
Diagnosis and treatment
To learn about the heart’s health and ability to function, a cardiologist may order one or more tests. An ultrasound can be used to reveal the heart’s activities and show blood flow patterns. An angiogram or cardiac catheterization can help a specialist understand how blood is flowing through the heart, arteries and veins. A cardiac MRI produces detailed images of the beating heart. And a blood test can reveal an elevated level of natriuretic peptide, an indication of heart failure.
“At the Washington University Heart Failure Center at Barnes-Jewish Hospital, our method of diagnosing encompasses a constellation of factors in addition to testing, including how the person appears during a physical exam and the overall medical history,” says Ewald. “We now recognize that some cardiomyopathies—chronic diseases of the heart muscle—are genetic in nature, so we also take a thorough family medical history.”
Ewald admits that if a newly diagnosed patient Googles the term “heart failure,” the results can be scary. He notes that some research shows that in a large population of people with heart failure, the five-year mortality rate approaches 30%-50%. The American Heart Association estimated the prevalence of heart failure in the United States to be 6 million individuals in 2021, with approximately 960,000 new cases diagnosed each year. “The really good news, however, is that over the past 30 to 40 years, excellent studies have defined medication therapies that can significantly improve heart function for some.”
Heart failure can cause some people to have a low ejection fraction, which means the heart is not pumping an adequate amount of blood out of its lower chambers. Treatment guidelines for this condition include use of a combination of drugs, as well as a diuretic to help prevent edema. “As heart failure specialists, my colleagues and I focus on determining what is best for the individual. That means adjusting dosages until we are sure the medications are effective,” Ewald says. And, when some of the standard drugs aren’t safe or effective for a particular patient, “we develop a drug regimen they can tolerate.”
Washington University cardiologists participate in the Heart Failure Clinical Network, a national, multidisciplinary community of investigators engaged in clinical research aimed at understanding and treating the condition. Ewald notes that his team’s association with this network helps offer patients the possibility of enrolling in ongoing trials of new drugs, some of which may prove more effective than those in current use. “This option gives our patients a distinct advantage over many other heart-failure programs.”
For some people with heart failure, medical management is not enough to protect them from the effects of irregular heartbeats called cardiac arrhythmias. In these cases, implantable devices can help. Ewald says a pacemaker is one such option. This small, battery-operated device is implanted in the chest, where it helps the heart maintain a regular rhythm. Other implantable devices include the cardiac defibrillator, which monitors heart rate and delivers an electrical shock to restore a heartbeat to normal in the case of tachycardia—a heart rate of more than 100 beats a minute.
Another option is a recently developed implantable device that can be used to continually track the heart’s rhythms. “The device sends readings via Bluetooth technology to our Heart Failure Center, allowing us to remotely keep constant watch while people go about their daily lives,” says Ewald. For those with severe heart failure, a left ventricular assist device, or LVAD, can be implanted. This small, rotary pump is attached to the heart to help move blood from the lower left heart chamber to the rest of the body.
“Implanting an LVAD is an open-heart procedure,” Ewald says. “However, for patients whose conditions aren’t improved with medications or heart-pacing devices, LVADs can provide support.” In some cases, an LVAD sustains life during the wait for heart transplantation. And for those who are ineligible for transplant, Ewald says, “this device can extend their lives, sometimes for many years.”
Washington University cardiologists have enrolled a large number of their patients in clinical trials for LVADs, pacemakers and implantable defibrillators. “Trials like these are another opportunity for us to offer our patients access to the latest technological advances for heart failure treatment,” Ewald says.
In some cases, the best option is heart transplantation. “The surgical techniques for heart transplantation are well established,” Ewald says. And in recent years, significant advances have been made in managing potential rejection of the new heart and other post-transplant complications. Ewald notes that, thanks to surgical and post-surgical expertise, the Washington University and Barnes-Jewish Transplant Center offers survival rates that surpass national statistics.
People with heart failure can also do a lot to help themselves, Ewald says, by changing aspects of their lifestyles. “If they smoke, they need to stop. If they don’t exercise, they need to start.” From 2003 to 2007, Washington University researchers participated in the largest exercise trial to date, called HF-ACTION, which enrolled more than 2,000 people with heart failure in the U.S., Canada and France. “We found that regular exercise positively impacts heart-failure symptoms—plus, people feel better and their quality of life improves,” Ewald says. In fact, he notes, these findings influenced the Centers for Medicare and Medicaid Services to offer insurance coverage for cardiac rehabilitation to patients with heart failure.
Life after heart failure
Ewald says he and his colleagues at the Heart Failure Center find it deeply rewarding to help people who, at risk of dying from heart failure, make a full recovery after having an LVAD implanted or receiving a heart transplant. “These are the people who tell us about the grandkids who have been born since they underwent their procedures—children they otherwise never would have met,” he says.
Equally rewarding is watching people improve after taking one of the latest drug therapies. “The implantable devices and heart transplantation are the ‘cool’ treatments that receive a lot of attention,” says Ewald. “But many more lives are impacted by medical management. Today’s advanced drug therapy can improve heart function so dramatically that patients seemingly destined to receive a heart transplant never reach that point. Instead, they lead active, fulfilling lives by taking four pills a day.”