Heart Failure. Interview with Dr. Nazzaro.

There are approximately 600,000 patients suffering from heart failure (or heart failure) in Italy. It is a disease that ranks among the leading causes of death and hospitalisation, particularly in patients over 65 years of age, and its prevalence is estimated to double with each decade of age, reaching around 10% after the age of 65 (source: Report 2023 PNE by Agenas). Hospital admissions for heart failure are associated with a 20-30% mortality within the first year.

Heart failure is a serious and chronic condition. Although older people are more likely to develop it, it can occur at any age and for a variety of reasons. We discuss this with Dr. Marco Stefano Nazzaro, an interventional cardiologist surgeon, expert in the treatment of ischaemic heart disease and heart failure therapy.

Dr. Nazzaro, what are the risk factors for heart failure?

Certainly, an unhealthy diet and a sedentary lifestyle can lead to coronary artery disease, which is the primary cause of heart failure. Alcohol consumption, drug use, and smoking play significant roles. These are all controllable risk factors associated with hypertension and diabetes. The presence of sleep apnea in obese and diabetic individuals over 65 further increases the risk of heart failure. In summary, coexisting ischemic, hypertensive, or diabetic heart disease can cause profound changes in the heart's contractile capabilities and the patient's hemodynamics. Added to these are other causes such as viral infections, genetic factors, and valvular conditions which, though less common, often represent an emergency.

What are the symptoms of heart failure?

Several indicators of the disease can be identified, primarily shortness of breath, or as some may describe it, a feeling of air hunger. This is accompanied by the inability to complete daily activities without needing to rest. This can happen during physical exertion, such as walking or climbing a flight of stairs. For example, if you were able to climb that flight of stairs a month ago without difficulty but cannot now, something has changed. A dry cough or shortness of breath when lying down are additional warning signs. Lying down may cause a sensation of air hunger, requiring one to get up or sit up to breathe normally during the night, a condition known as paroxysmal nocturnal dyspnea. Chest pain or discomfort is also very common. It is important not to ignore swollen ankles or the aforementioned symptoms, as these are signs of advanced heart failure. Another symptom to consider is the feeling of fullness after eating very little. This may indicate fluid accumulation in the abdomen (ascites). Additionally, if you feel nauseous after eating, it could indicate insufficient blood flow. For older patients, we also look for signs of confusion, memory difficulties, or trouble concentrating.

Dr. Nazzaro, what are the treatment options for heart failure?

The primary treatment for heart failure is the careful management of risk factors combined with targeted therapy. If heart failure is caused by coronary artery disease, myocardial revascularization is the ideal therapy but should be combined with lifestyle changes. The improvement is evident on an echocardiogram, with symptoms disappearing and the heart's ejection fraction improving from 30% to 50%. Returning to the example of the flight of stairs, the patient will be able to climb it without shortness of breath. Targeted drug therapy can increase survival rates by up to 70% and improve quality of life.

It is important to distinguish between two different types of heart failure. The first type we discussed is systolic heart failure, but there is also diastolic heart failure, where the heart muscle is stiff and not efficient even with normal contraction. This can be caused by hypertension, diabetes, or storage diseases. In this case, the treatment involves addressing the underlying cause: treating hypertension, managing diabetes, increasing physical activity, and aiming for weight loss. The goal of treatment is to correct an otherwise unfavorable trajectory, optimizing therapy in the long term. New drugs used in the last 10 years have changed the prognosis for these patients and improved their quality of life. However, I emphasize that this is a delicate and personalized therapy, which is adjusted and regulated based on the patient's response. It cannot be managed with occasional cardiology visits. If the trajectory is not altered, these patients will end up with repeated hospital admissions, the so-called “revolving door,” with less symptom control, as often seen in women.

Dr. Nazzaro, how does heart failure differ between men and women?

There is a fundamental difference in the disease's pathophysiology between men and women. While the primary cause in men is ischemic heart disease with obstructive coronary artery disease, in women, the damage is more often at the microcirculation level. In women, the diagnosis is delayed due to atypical symptoms that mislead the general practitioner. More pronounced fatigue, reduced exercise tolerance, more severe shortness of breath, and precordial palpitations are common and characteristic symptoms in women with heart failure, but they can be confusing compared to the typical chest pain. Women generally have a higher degree of comorbidities and polypharmacy. The delay in diagnosis is accompanied by suboptimal therapy, as evidenced by the fact that women receive fewer invasive treatments like pacemakers, implantable defibrillators, and others than men. The delayed diagnosis and difficulty in risk stratification also result in fewer referrals for heart transplantation for female patients. Unfortunately, women are at greater risk of therapeutic failure.

When is it appropriate to see a cardiologist for cardiac prevention?

Generally, most patients first consult their general practitioner (GP), who, after an examination, refers them to a cardiologist for specialized care if they suspect a problem. This is the first step. Without synergy between the patient, general practitioner, and specialist, everything becomes more complicated. The cardiologist determines the necessary tests, both instrumental and laboratory, and sets up the therapy and frequency of visits. Some very effective medications require a dedicated therapeutic plan and continuous monitoring of their effects on the patient.

How is heart failure diagnosed?

Cardiological examination and electrocardiogram are helpful, but it is the echocardiogram that is the main tool for assessing the efficiency of the heart directly with the ejection fraction and indirectly with other more specific parameters. If there are symptoms of heart failure and the echocardiogram is abnormal, one must distinguish between heart failure with reduced ejection fraction and heart failure with normal ejection fraction. Returning to gender differences, heart failure with preserved ejection fraction is more common in women.  Blood tests help us a lot in this case. The two parts of the heart, left and right, are responsible for different forms of heart failure, with similar symptoms but requiring different therapies. The echocardiogram also allows us to investigate the presence of valvular diseases that may cause the symptoms of heart failure and require a different type of treatment. In recent years, valve diseases leading to heart failure are increasingly being treated using percutaneous catheters and without the need for a scalpel. After carrying out the necessary examinations such as electrocardiogram, echocardiogram or more advanced examinations such as MRI and CT scan of the heart, the results are analysed together with the information obtained from the blood tests and we can thus determine whether the patient is suffering from or is at risk of heart failure. The goal in treating patients with heart failure is to improve, as well as prolong, their quality of life. Nothing can be done without the synergy of efforts between the people involved who revolve around the patient: family doctor, cardiologist, dietician, physiotherapist and above all the family members themselves.

Learn more about the cardiology services at UPMC Salvator Mundi International Hospital.

If you suspect you are suffering from acute heart failure or a heart attack, call 118 or go to the nearest emergency room.