(February 9, 2009 - Insidermedicine) In this video, Dr. Ann Bolger, MD, discuss what she would do if she had shortness of breath and was diagnosed with cardiomyopathy. Dr. Bolger is the William Watt Kerr Professor of Clinical Medicine at University of California San Francisco.
At the American Heart Association's Scientific Sessions in New Orleans, we had a chance to catch up with Dr. Ann Bolger, MD, who is the William Watt Kerr Professor of Clinical Medicine at University of California San Francisco.
If I had shortness of breath…
Dr. Bolger: When someone becomes short of breath, something is wrong, and there’s no question about it. We all get short of breath walking up steep stairs or running with groceries to catch the bus. That may be that we should be on the treadmill more or do more walking so that we are more fit.
Real shortness of breath, particularly that gets better when you sit up, is almost always a real problem. It can come from the lungs, but until proven otherwise, you want to make sure it’s not coming from the heart, because shortness of breath is a major symptom of heart failure, and we’re in the middle of a heart failure epidemic in this country. It’s going to be one of the most common things that people have to deal with in their cardiovascular health.
There’s a lot of things you can do about it, so you don’t want to delay making that diagnosis. What I would really expect a patient to do is go right to their health care provider. You need to get a good history taken. When are you short of breath? What brings it on? Maybe this is asthma, maybe it turns out that even though you never had an allergy or an asthmatic problem before, now you do. Or maybe those cigarettes that you were smoking are catching up with you now. There are a lot of things, but they will also ask and look for signs of heart problems, and if the heart seems to be enlarged on physical examination, there are signs of fluid in the lungs, all of these start pointing to the heart as the cause.
Electrocardiogram may show that you have an irregular heart rhythm, such as atrial fibrillation, which is also extremely common. A chest x-ray may confirm this fluid. At that point, really the very next step needs to be an echocardiogram. Echocardiography uses ultrasound to make a picture of the heart muscle, the values, and even the great vessels that come off the heart. Those are very powerful because those can show us if the heart is enlarged, and by the heart here I really mean the left ventricle, even though it can happen to other chambers as well. How is the muscle contracting? How able is it to change its volume and squeeze down so that blood goes out to the body?
In cardiomyopathy, which is a disease of the muscle of the heart, that squeezing ability of the muscle may be very impaired, and it may get impaired and the heart may get enlarged without really a lot of symptoms early on. One of our goals is to find people as early as we can because what’s happening if we let this go, and go, and go, is that the heart is actually changing its shape and changing its scaffolding. We call that remodeling, and we don’t want the heart to permanently remodel, we want it to be able to be at an early enough stage that when we get the treatments going it can come back closer to normal function.
An echocardiogram would be absolutely critical. There may be things that they see or things that they learn in the history or the physical that make them say, “You know what, maybe this is really coronary artery disease, and this person has been having little heart attacks without knowing it.” That’s not uncommon in people with diabetes, smokers, hypertension.
They may choose to do some sort of stress evaluation, have you on a treadmill and walking, they look at your ECG. They may do a nuclear medicine study to see if there is a part of your blood muscle that doesn’t get enough blood supply, or they may actually ask you to undergo a coronary angiography where we look for cholesterol blockages in the arteries that might explain what has happened to this muscle so that now your heart is enlarged and not able to be beat properly.
The good news is that if they find things like this we have a lot of tools to deal with it. Some are medical, some are interventional and there are an awful lot of things that we can do. It’s always an art form to say, “Well this muscle doesn’t move, is it never going to move again, or is it just hibernating? If we go through a procedure can we make it stronger, or is it permanently damaged? These kinds of questions really take a tradeoff between different testing. We have different ways of looking at the function of the heart muscle.
When the heart is significantly damaged you’re going to have to have some evaluation of how strong and viable the muscle is underneath. If they don’t find coronary artery disease, you’re talking about a primary problem of the heart muscle and that’s the myopathy. At that point you have to scratch your head about what causes it.
If you look over the whole world, probably one of the most common causes is parasitic disease, a disease called Chagas. It’s a very common cause of heart failure in parts of the world where that parasite is viable. We don’t see so much of that in the United States and in my practice.
One of the common causes is hypertension that has been poorly controlled the patient’s whole life. I also have an intercity practice and I would say that alcohol, methamphetamine and cocaine are extremely common causes of this. Alcohol cardiomyopathy is a really important disease to recognize because some patients just with abstaining from alcohol, have very good improvement. Not all of them unfortunately do, but sometimes we can really make a big difference.
What are the risks of Cardiomyopahty
Dr. Bolger: Cardiomyopathy is really the most dangerous when it’s causing the shortness of breath. What that basically says is that the heart isn’t even able to let the blood out of the lungs. At the same time it’s probably not pumping blood very efficiently to the body so you could also have kidney problems. You might also have problems with profusion of other critical organs like the brain.
So during those phases, that’s a very dangerous situation to find yourself in. The other thing is that a heart that is stretched out and failing, because it can’t beat properly, is prone to arrhythmias. Arrhythmias are usually the cause of the sudden cardiovascular death that patients experience. So getting things diagnosed, so that we can start therapy and we have methods to prevent arrhythmic sudden death, we can use implantable defibrillators. There are any number of tools that we can use medically to try and get the heart size down to try and improve not only how you feel and how much work you can do but decrease the risk of having one of these arrhythmic events.
The other part of starting to live with heart failure is a broad look at everything else that impacts your health. If you have heart failure, you absolutely can’t smoke and you can’t be around someone that does. It interferes with your oxygen carrying capacity and is a terrible stress on your system. You have to keep walking, but you can’t overstress the heart in ways that aren’t necessarily advantageous. If your hobby has always been bench pressing 200 pounds, this is not the time to continue with that habit. On the other hand, if you love going out and walking for 45 minutes every morning and you can do that in the limits of your shortness of breath, definitely you should continue.
Learning just to be complaint with the medications and learning how to manage yourself, it turns out heart failure management is really a give and taken between the healthcare provider and the patient. Things like having a scale at home. If your weight goes up two or three pounds, don’t let it go up to ten pounds, because that’s all fluid building up in your body. At two or three pounds make the call, call your nurse practitioner, whoever you’re teamed up with, and they’ll say, “You know what, I think you better take a little bit more of this medication or a little bit more of that medication.” Keep it under control because there’s always going to be fluctuations, and learning to manage your heart failure with some autonomy is also very helpful and gives people back a sense of control.
Dr. Bolger: If I were short of breath and received the news that this was a cardiomyopathy, of course I would be very interested to find out how I got into this situation and what I could do proactively to manage my symptoms. I would really want to be sure that it was not something that was genetic, because some of theses syndromes can be, and I’d want to make sure that no family member was also at risk for this.
I would really want to have an understanding of how bad it is. There are stages of heart failure in cardiomyopathy, and the worst stage, especially if symptoms and progression doesn’t stop with good treatment, you may end up needing a heart transplant. Trying to learn about what are the considerations, what other experiences people have had, what things I could do now to prepare myself and my health to go through such an overwhelming kind of procedure would be high on my list and I would feel very good to know that those kinds of options, if I ever got to that point, might be available.
Similarly, I would want to be at a centre where they have some of the newest technologies. There are biventricular pacemakers, where we put in pacemakers that effect both the left ventricle and the right ventricle and change the timing. Sometimes people have a very good response to that. These are not done by everybody and I would want to make sure that the care that I was receiving could be done in collaboration with a centre that could do some of the advanced modalities.