(February 20, 2009 - Insidermedicine) Watch Dr. Ann Bolger, MD, discuss what she would do if she had shortness of breath at all times, except when upright. 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 talk with Dr. Ann Bolger; who is the William Watt Kerr Professor of Clinical Medicine at the University of California San Francisco.
If I had shortness of breath at all times, except when upright...
Dr. Bolger: Shortness of breath that is particularly noticeable when you are lying down if very worrisome for heart involvement. There are lots of things that can cause shortness of breath, but things that get better when you sit up imply that the load on the heart when you are lying down is too great. Almost immediately you would need to see your healthcare provider and even just in the office getting a good history and physical examination, listening for the presence of fluid in the lungs, looking for signs of fluid overload in the body that they can hear signs of in the neck or hear signs of in the heart; they'll get a preliminary idea. They may also want to do a chest x-ray to see if this shortness of breath seems to be associated with fluid that is getting out into the lung tissues.
At the end of that they may have a fairly good idea that it is coming from the heart. And if it is, they certainly will send you for an echocardiogram. And that is an ultrasound examination of the heart, that shows not only the walls of the heart and how strong the muscle is but also how big the chamber sizes are and whether they are enlarged. In addition it will show the heart valves and sometimes a valve problem can be what causes shortness of breath. Let's take one scenario of many, that when you do this ultrasound test, we see that it is not your heart is too weak (in the sense of how it can pump) but in fact its too thick and it is actually unable to relax. And that is called Diastolic dysfunction. Diastole is the phase of the heart cycle when the heart fills. When you can't get blood into the heart easily because of this extra stiffness, then you can't get blood out of the lungs. And that makes you short of breath. You get most short of breath when you lie down and all the blood that lives in our legs during the time when we are upright redistributes into the central circulation and then suddenly you are very short of breath and you have to sit up to breathe
What is the difference between systolic and diastolic heart failure?
Dr. Bolger: When we talk about systolic heart failure we are focusing on the phase when the heart is contracting, and making itself smaller in order to eject the blood into the body. There are a lot of things that can interfere with the muscles' ability to form these tight little bundles and shrink the size of the heart down so that blood is ejected. One of those things is a heart attack; a heart attack may be very subtle or very small. Other things include diabetic disease, high blood pressure over many years, and viral infections. All of these things can affect the muscle and its ability to be strong. A heart that isn't strong enough will also have problems relaxing, so its diastolic relaxing function won't be normal either. But the predominant problem in those hearts is that it can't squeeze.
What does the evaluation consist of?
Dr. Bolger: There are a lot of things that are going to be important in this conversation. We really would need to know how long this has been going on and you need to really scratch you head and think back to when was the last time you really felt normal. And it may be that even when you were in high school playing sports, or as a child you had episodes where you were short of breath before, maybe you have had episodes of syncope (fainting). These would all point to a primary muscle problem that is perhaps runs in your family, or perhaps you were born with. Similarly it could be a heart valve problem that you were born with. Sometimes we don't detect those, believe it or not, until people are in their adult years.
The other thing that we would really like to get to would be your family members. Have other people had problems with their heart health. One thing that is very powerful in this regard with diastolic heart failure is high blood pressure. High blood pressure can absolutely run in families. There is a genetic predisposition that can make lifestyle problems, like salt intake, so much worse. So we need to understand that as well. Because some of the problems that cause diastolic heart failures can be associated with heart arrhythmias, the history of any kind of fainting is very important, or unexplained loss of consciousness. Those can be a telling signs.
Beyond that you are going to get a lot of questions and you shouldn't be offended it you are asked about elicit substance abuse. Cocaine and methamphetamine for instance have notorious associations with this kind of heart problem. And people need to ask you those questions. Similarly for HIV status and diabetes. Have you been tested? Another thing is tobacco. It really doesn't help anybody to say "...I only smoke a cigarette now and then..." when you are actually smoking 1/2 a pack a day. Fess up and we can get to the bottom of this quicker. Something is wrong if you are short of breath as the heart is built to do this, so we need to get to the bottom of it and get the right therapies in place immediately.
What diagnostic tests are ordered?
Dr. Bolger: Usually at the end of a complete echo Doppler study, which is completely noninvasive, it involves putting gel on the chest and taking images, we know an awful lot about how the heart is functioning. What we don't know is what caused the heart to be thick or stiff, or both. In order to get to the bottom of that there are some blood tests that would probably be done. Some of those look for congenital or genetic muscle problems and can be done straightforwardly. Other things are very simple like screening for diabetes. Sometimes people don't realize they have it. Same thing for kidney dysfunction. Kidney dysfunction can be relatively quiet but it is all part of the syndrome of high blood pressure and its long-term effects on the body. So we would absolutely be looking for that.
Sometimes we have to do more elaborate blood tests looking for less common markers in the body of infiltrative diseases. Diseases where proteins or other diseases start growing into the heart muscle where they shouldn't be, so there are some blood tests for that. A lot of times we also are very concerned that part of this stiffness may be actually blockages in the arteries. It’s not uncommon to use angiography or cardiac catheterization to look at the arteries that take the blood to the heart to see if there are any cholesterol blockages. At the same time and during the same procedure they would also put a catheter in the right ventricular side of the heart where the chamber that pumps the blood to the lungs. Because sometimes it is not really the muscle alone that is the problem, but the blood vessels inside the lungs have started to scar down. We can look to see if the resistance is very high in the blood circulation to the lungs, and that's a big clue.
What is the management of diastolic dysfunction?
Dr. Bolger: When someone is diagnosed with diastolic dysfunction as a cause for their shortness of breath, assuming that we haven't come up with a specific syndrome that is one of these unusual muscle problems, maybe it is just from a lifetime of poorly treated high blood pressure. That is probably the number one thing that we see. What do we do for a patient like that? Well there are a number of things.
First off if high blood pressure is what got you into this mess, you have to control permanently forever. Getting the best blood pressure regimen that you can and staying on it; taking it every day. Which is not that easy to do, but it is really the goal. Exactly what pills you take varies with the individual. Usually it takes about three months to go through and individualize the agents. You have to take these pills for the rest of your life, so they can't have any side effects for you. Similarly during that time you are going to have to change your diet. This is because for almost anybody with high blood pressure you are going to have to learn to eat a very low salt diet. Which again is not necessarily an easy thing to do, if you have never met that challenge before. You need to be reeducated about what you eat which is probably going to impact your family choices as well. The good news is that it is good for everyone involved, so that is not the worse thing.
I think that the other medicines that we often use, some of them are very powerful; one class of drugs that we use is called beta-blockers. And what beta-blockers have as an effects in part is not only some control of the blood pressure but importantly they slow the heart rate down. And that can be a very important thing, because if the heart does not fill very easily, if you give it enough time because the heart is slowed down, then it will actually get the blood out of the lungs and that feeling of shortness of breath will be much improved.
Are there any surgical procedures for diastolic heart failure?
Dr. Bolger: Unless there is something specific that has contributed to it, there really isn't any role for surgery to play. But there are people who have had for example a valve that has been stuck shut, like aortic stenosis or aortic coarctation. Those are very specific entities and the diastolic dysfunction is secondary to that. So you do want to go in and do the surgery that corrects the primary problem and then it will get better over time.
If I had shortness of breath and was diagnosed with diastolic heart failure...
Dr. Bolger: If I was short of breath and I had been told that I probably had diastolic heart failure, I would absolutely want to make sure that I had had a thorough echocardiogram and Doppler study. To make sure that this is only about the muscle and it is not about a bad valve or some other problem. I would want to know how big my heart had gotten to be. I'd want to basically take a real careful look at my family history and my own personal history to try to look for the subtle signs of congenital or genetic abnormalities. And then I would really want to work closely with someone who understands the role of controlling blood pressure and heart rate with an eye to something that I could tolerate going forward indefinitely. Because even if the medicines make you feel a little strange or they upset your stomach a little bit that can be enough to keep you from taking them every day. And that’s really not okay. I would want someone who is also interested in my family members because if I have this, perhaps my children or my grandchildren might have a problem going forward in there adult lives as well. I think we need to look at all these things in the context of our shared genetic pool and also our shared habits. Maybe its all that good cooking I do that has gotten us into this mess.