BREATHLESSNESS, HEART FAILURE & VALVE PROBLEMS
Breathlessness, or shortness of breath, could be a sign your heart is struggling to pump blood properly (called heart failure). It could also be a sign a valve is failing (either from leaking or being too narrow) or again that your arteries are narrowing.
There are many reasons that the muscle of the heart can pump less effectively. When the muscle of the heart is affected by a disease it is known as a cardiomyopathy (cardio for heart and myopathy for muscle – a heart muscle problem). The reduction in pumping function of the heart causes a variety of symptoms including shortness of breath, fluid on the lungs, swollen ankles, tiredness and fatigue.
Some causes of cardiomyopathies or heart failure include heart attacks, high blood pressure, hereditary causes that run in families, viruses or failing heart valves.
A problematic heart valve can make a noise when blood crosses it – this is known as a “heart murmur”. If the valve is leaking it is known as “regurgitation” and if it is too narrowed it is called “stenosis”. So aortic stenosis is a narrowing or restriction of the aortic valve.
But lung disease, lack of physical fitness or anaemia are also common causes of breathlessness. Sometimes patients have a combination of problems causing breathing difficulties.
A typical investigation pathway would be a consultation and an ECG. Following this the next most common test to order would be an echocardiogram, which is an ultrasound examination of the heart. It tells us a lot of information about how the muscle of the heart is functioning and pumping and how well the valves are working.
The most common way to express the pumping function of the heart is by means of the ejection fraction (or EF). This is referred to as the percentage of blood the pumping chamber of the heart, the ventricle, is ejecting with every cardiac cycle. A normal ejection fraction would be an EF of 55-75%. Severe heart impairment would be an EF of <35%.
We may order a CT coronary angiogram if we feel the problem could be caused by narrowing of the coronary arteries.
A Cardiac MRI scan is probably the gold standard tests to evaluate the function of the heart and whether there is any scar tissue present in the muscle.
It uses a very powerful magnet, and you are in the tunnel of the scanner for about 30 – 45 minutes. It is quite noisy so headphones are worn. Some patients can get claustrophobic but the modern scanners have bigger tunnels for patients and this is less of a problem than it used to be.
We would then discuss the results and treatment options with you. The cornerstone of treatment for a struggling heart is medication which can be very effective. The most common drugs are ACE-inhibitors and beta-blockers.
Alternatives to ACE-inhibitors are angiotensin receptor blockers and in severe cases there are other drugs such as aldosterone receptor blockers or ARNI’s – angiotensin receptor-neprilysin inhibitors. Interestingly new drugs are been developed in this field and there are some very promising ones now on the market.