Faces of Heart Failure – the Cardiologist

Professor Emer Joyce is a Consultant Heart Function and Transplant Cardiologist,  at the Mater University Hospital Dublin and Clinical Professor of Medicine at University College Dublin (UCD).

A consultant cardiologist is a medical doctor that specialises in the heart and cardiovascular system. If your GP suspects that you may have heart failure or diagnoses heart failure he or she will refer you to a cardiologist for specialist care.

Here Dr Joyce tells us how, with the right treatment and lifestyle changes, it can be possible to turn heart failure into heart success.

Q. As a professional specialising in heart failure what does a typical day look like in your practice?

A. A typical day has a combination of inpatient and outpatient clinical care, administrative tasks, teaching and research tasks, and other academic work such as lectures.

As a Heart Function Cardiologist in the Mater, the National Centre for Heart Transplant and Heart Pump Devices, I see, assess, and treat patients across the entire spectrum of heart failure from early to established and advanced disease, including patients transferred from other hospitals urgently, and those who have had a heart transplant or heart pump.

I also see patients with less common causes of heart muscle disease including genetic causes, those with chemotherapy-related heart problems, and women who have or who are at risk of pregnancy-related heart failure.

Q. There are currently more than 90,000 people in Ireland living with heart failure, do you think this is an underestimate- is there a large number of people who are undiagnosed?

A. This is an underestimate for sure, and is based on 2014 data identifying symptomatic heart failure patients. The same report noted the likelihood of at least another 100,000 undiagnosed. Although the true prevalence is currently unknown in Ireland we are no doubt following international trends, where prevalence is significantly increasing due to more risk factors and an increasingly aging population.

The increase is also due to our success in treating other heart conditions such as heart attack; which can result in decreased heart function. It is also likely that since the pandemic with reduced access to chronic care clinics and elective diagnostics, further patients remain undiagnosed.

Making a diagnosis of heart failure requires a number of key elements including patient awareness of symptoms and timely access to diagnostics (blood test and ultrasound scan primarily) and unfortunately both of these elements are suboptimal in Ireland at present.

Heart failure has traditionally not received the same public awareness and education as other chronic conditions such as heart attack or stroke. The Irish Heart Foundation together with healthcare professionals across the spectrum of heart failure care including primary care, heart failure specialist nurses, cardiologists, and allied health personnel are all working together to change this.

" Heart failure does not mean that your heart has stopped working. It does mean that your heart is not pumping enough blood to meet the demands of your body."

Prof Emer Joyce, Consultant Cardiologist , The Mater University Hospital, Dublin

Q. What is heart failure?

A. One of the biggest challenges for this condition is often around the terminology used. Heart failure does not mean that your heart has stopped working. It does mean that your heart is not pumping enough blood to meet the demands of your body. Another term that would probably be better to use is “Heart inefficiency”. In turn, heart failure treatments aim to restore that efficiency as much as possible.

Q. What causes heart failure?

A. There are multiple causes of and risk factors for developing heart failure. I like to think of them in terms of four different categories or groups namely: Coronary Artery Disease, cardiovascular risk factors, cardiomyopathy or intrinsic heart muscle disease, and other heart problems.

Coronary artery disease: this accounts for more than two-thirds of heart failure cases with a weakened heart muscle – many patients know this as a narrowing or blockage in one or more of the arteries or blood vessels that supply the heart muscle with blood. Especially if these blockages/narrowings have caused a heart attack that can weaken the heart muscle leading to heart failure.  Even if those patients have had stents or a bypass to fix the blockages, the heart failure can still remain.

Cardiovascular risk factors: these are the very common often lifestyle-related factors that can cause heart failure either by leading to coronary artery disease and then heart failure or by themselves causing structural damage to the heart. The most common would be high blood pressure particularly if it is untreated or under treated for a long period of time. Other risk factors such as diabetes, and living with overweight or obesity can also cause heart failure. Smoking and high cholesterol are examples of cardiovascular risk factors which probably don’t cause heart failure on their own, but certainly, cause heart disease and can interact with the other risk factors to make things worse.

Cardiomyopathy or intrinsic heart muscle disease:  this is a relatively common condition where the pumping chamber of the heart, the left ventricle, gets bigger and becomes weaker. This can affect people of all ages and can have many causes. The most common include, a genetic condition, alcohol or other drugs such as cocaine, viral infections, and other medical conditions such as thyroid disease or chemotherapies for cancer.

Other heart problems: any condition that affects the heart can ultimately lead to heart failure and these include,  heart rhythm problems such as an irregular heart beat or arrythmia, valvular heart problems, such as a leaky, narrowed or tight valve and congenital heart disease meaning a heart condition that someone is born with.

Q. How is heart failure diagnosed?

A. Often the most useful test in determining whether or not a patient has heart failure and its cause is a detailed history. Next ,you must examine the patient including, measuring their blood pressure, heart rate and listening with a stethoscope to their heart and lungs. The patient’s tummy and legs may also be checked for any signs of fluid.

Next, your doctor or nurse specialist may order tests including blood tests (a “BNP” test is specific for heart failure and is useful in diagnosis), an ECG, and an ultrasound of the heart. This will look for any structural or functional abnormalities of the heart. In diagnosing heart failure there is one particularly important number which is called the ejection fraction number. Think of this number as the power of your heart engine,  normal is 55 per cent.  However, you can also have heart failure regardless of this number. Following a review of all these tests, the doctor will discuss the results and any further tests that may be needed.

" There are multiple, highly successful treatments for heart failure ,"

Prof Emer Joyce, Consultant Cardiologist , The Mater University Hospital

Q. Is it an easy diagnosis to make?

A. It can be, in a patient with typical risk factors such as high blood pressure, heavy alcohol intake, or a history of heart attack, with typical symptoms, the diagnosis can be straightforward. However, there are two groups in which the diagnosis can be delayed. These are younger people and women.

Due to less awareness and a low index of suspicion,  initial symptoms in younger patients presenting with heart failure (shortness of breath, fatigue) can be commonly misdiagnosed as a chest infection or stress. I would encourage people to know their family history or ask their doctor about whether or not they should be tested for heart failure in these cases.

It is increasingly recognized that women are frequently underdiagnosed with heart conditions, including heart failure. Medical conditions unique to women including pregnancy and pre-eclampsia have also been linked to an increased risk of heart failure.

Q. What are the most common symptoms of heart failure?

A. There are three main common symptoms of heart failure:

Breathlessness, particularly on activity or exertion, such as going up an incline, or a flight of stairs, or perhaps doing housework or lifting something. You may find that you cannot walk as fast or as long as previously. It is important to recognize this as early as possible, as left untreated, this might progress to the point where someone is getting breathless with very little activity or even while lying in bed at night.

Weight gain or swelling, particularly in your ankles/legs or your abdomen. The swelling is caused by excess fluid which the inefficient heart is unable to process.

Fatigue is another cardinal sign – this is fatigue that is different from just being tired at the end of the day or after work – this is more of a complete lack of energy often not tied to activity.

Other symptoms may be present depending on the particular cause of the heart failure or if it has become more advanced – but these are the three cardinal symptoms to look out for.

Q. How is heart failure treated?

A. This is the good news. There are multiple, highly successful treatments for heart failure, including medications, devices, procedures, or surgeries, and in less common cases, heart transplants or pumps, which can greatly improve symptoms, quality of life, life expectancy, and in some cases put heart failure into remission.

Medications are the cornerstone of treatment for all patients. In the last five years, new research has discovered two new medications proven to improve symptoms and outcomes for those with heart failure.

Today there are four proven medications that your doctor will consider prescribing if you are diagnosed with heart failure.

Devices such as defibrillators or special pacemakers may also be needed. Regardless of the cause, type or other treatments used for heart failure, lifestyle interventions remain central to treatment. This means maintaining a healthy weight, not smoking, minimising alcohol intake, eating a balanced healthy diet, regular exercise, looking after your mental health, and maintaining social connections. Self-management is also a key aspect of heart failure treatment and this includes, measuring daily weight and monitoring salt and fluid intake; many patients may need significant input from caregivers to help with the entire regimen.

" All age groups can be affected by heart failure."

Dr Emer Joyce, Consultant Cardiologist , The Mater University Hospital

Q. What age groups are most affected?

A. All age groups can be affected by heart failure. Although older patients may be more likely to have coronary artery disease – one of the most common causes of heart failure, as well as other risk factors, younger patients can also present with heart failure as a result of family history, toxins, viral infections, other medical conditions, congenital heart conditions or pregnancy.

Q. Is it possible to live well with heart failure and how do you do this?

A. Yes it is absolutely possible if you follow your treatment plan, adhere to medication and self-management, and remember to have a healthy lifestyle.

Q. What is the best and worst part of your job?

A. The best part of my job is being able to reassure people about the abundance of treatments available, seeing the heart success stories when people come back to the clinic feeling much better and their test results have significantly improved, and seeing patients with very advanced heart failure literally go back to a full life following a heart transplant.

The worst part of my job is that unfortunately, the nature of this condition/speciality means that, despite being able to offer the very best contemporary care,  in those who are very sick or have advanced heart failure, there are occasionally very sad days.

Q. If you could give one piece of advice to the general public regarding heart failure prevention, what would it be?

A. Know and treat your blood pressure – don’t ignore it – don’t settle for under or half treatment of it, control it properly.

Q. If you could give one, piece of advice to people living with heart failure, what would it be?

A. If you combine fully embracing the medical treatment plan with doing everything you possibly can to live a healthy life such as modifying any risk factors (diet, weight, alcohol, smoking, exercise) you will give yourself the best chance of turning heart failure into heart success.

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