Don’t fail your heart health

Here’s how to recognize and treat the type of heart failure that’s most common in older adults.

Heart failure conjures up the image of your heart suddenly stopping. But it actually means the heart is not pumping as it should. The condition is the leading cause of hospitalization for adults over age 65.

"Heart failure is an abrupt wake-up call for people to address their heart health practices," says Dr. Akshay Suvas Desai, medical director of the Cardiomyopathy and Heart Failure Program at Harvard-affiliated Brigham and Women’s Hospital. "Still, heart failure can be prevented in high-risk individuals, and the outlook for those with heart failure continues to improve."

Left-sided issues

Impairments in pumping action can develop in the entire heart or just one side — left or right. Most heart failure is caused by left-sided problems: the left ventricle (the heart’s largest chamber) is either too weak or too stiff to pump normally.

To figure out what is happening, doctors usually order an echocardiogram to measure the heart’s ejection fraction (EF). EF is a percentage of how much of the blood inside the left ventricle gets pumped out with each contraction.

The left ventricle never pushes out 100% of its blood when it contracts. A normal heart’s EF is 50% to 70%. An EF of 40% to 49% is considered borderline low. Less than 40% is deemed a low or reduced EF. This indicates the left ventricle is too weak to push out enough blood, a problem known as heart failure with reduced ejection fraction (HFrEF).

But when older adults develop heart failure they more often have a normal EF of 50% or greater, called heart failure with preserved ejection fraction (HFpEF). With HFpEF, the left ventricle muscle is too stiff to relax. Ejection fraction is normal, but less blood can enter the chamber in the first place, so less gets pumped out.

What puts you at risk for HFpEF? The usual factors are high blood pressure, coronary artery disease, obesity, and diabetes. Less common causes are inherited or acquired heart muscle diseases.

Similar symptoms

Both types of left-sided heart failure have similar symptoms. At first, you might only notice that you’re more tired or that you can’t walk as fast as you used to. Other symptoms include

• shortness of breath with exertion or when you’re lying flat
• swelling in the legs, ankles, or both
• persistent cough
• waking up in the middle of the night short of breath.

"People may dismiss many of these, especially if they don’t interfere with daily life, but they need checking out even if the symptoms appear minor or come and go," says Dr. Desai.

Treatment options

Treatment for HFpEF continues to evolve, says Dr. Desai. "We are only now developing specific therapies for the condition. But until more is known, prevention strategies are also the best treatments." This includes addressing weight gain with exercise and diet (especially reducing salt intake), quitting smoking, and curbing alcohol intake.

The mainstays of HFpEF drug treatment are to reduce fluid in the body with diuretics ("water pills") and to aggressively lower blood pressure with a variety of medications, including ACE inhibitors, angiotensin-receptor blockers, beta blockers, and calcium-channel blockers.

However, Dr. Desai says, new research shows promising results for two additional drug treatments:

• Angiotensin receptor–neprilysin inhibition therapy uses a medication called Entresto that combines two blood pressure drugs, sacubitril and valsartan.
• A study in the Oct. 14, 2021, issue of The New England Journal of Medicine found that people with diabetes and HFpEF who took the SGLT2 inhibitor empagliflozin (Jardiance) had lower risks for dying from heart problems or being hospitalized for heart failure. SGLT2 inhibitors are showing promise even for heart failure patients without diabetes.