Disheartening prognosis: although heart attacks are decreasing, deaths from heart failure are increasing

Insight on the News, July 15, 2002 by Joyce Howard Price

Congestive heart failure (CHF) is one of the major causes of illness and disability in the United States and is the leading cause of hospitalization in people older than 65, according to the 1999 Harvard Medical School Family Health Guide. The condition afflicts nearly 5 million Americans, and the numbers are increasing, especially among the elderly.

Between 1979 and 1998, the number of deaths from heart failure more than doubled, from 25,074 to 50,228, according to the National Center for Health Statistics. Of those, deaths from CHF climbed from fewer than 20,000 to nearly 47,000.

While nearly 900,000 Americans died from heart disease or stroke in 2000, according to the National Center for Health Statistics, almost 62 million Americans--about one in five--is living with the often debilitating consequences of these diseases, notes Robert Bonow, president-elect of the American Heart Association (AHA). "The population is aging, so as we get better at treating heart attacks and have survival at younger ages, a large number of Americans are living with damaged hearts" that incrementally lose effectiveness as the person gets along in years.

CHF can be caused by prolonged high blood pressure; atherosclerosis, or a narrowing of blood vessels from high-fat, high-cholesterol diets; a primary disease of the heart muscle (cardiomyopathy); a disease of the heart valves, which control blood flow; a congenital heart defect; and, of course, damage from heart attacks. But heart failure is not necessarily as ominous as its name suggests. The term does not mean a patient's heart stops pumping as it does in cardiac arrest. Rather, it means the heart is not pumping all the blood it should, so it is not working effectively.

When the heart cannot pump enough blood, the body retains salt and water, and blood volume increases. The result is a backup of blood into the lungs and other tissues. Early symptoms include difficulty in breathing--especially when lying down--and easy fatigue. When blood backs up in veins, fluid starts to leak out of veins, causing swelling. Older people with CHF often display acute confusion. Plus, CHF can make a patient more vulnerable to serious infections.

Treatments have improved significantly during the last decade. The prognosis of a patient depends on the severity of the underlying medical condition and how fast he or she gets treated.

Robert F. Smith, 74, of Los Angeles has been living with CHF for seven years. As he has found out, it can develop in people with no previous history of heart disease. "I never had a heart attack but, seven years ago, I started getting shortness of breath," says Smith, an ex-smoker.

He takes a variety of prescription drugs to treat his heart disease, emphysema and high blood pressure, which was diagnosed more recently. "And I'm on oxygen therapy 24 hours a day," he says.

Heart failure in the elderly more often is triggered or worsened by related medical problems than it is in younger patients. A large and growing population of patients in their 70s and older have symptoms such as shortness of breath, fatigue, cough, confusion and swollen ankles and feet, which they may or may not recognize are effects of an ailing heart.

"We've reduced mortality from heart attacks from 20 percent to 5 or 6 percent," says Jay Cohn, a professor of medicine at the University of Minnesota Medical School and founder of the Heart Failure Society. "But heart damage is progressive. Over a course of years, the heart damage [suffered by a heart-attack survivor] may progress to heart failure."

Other factors doctors see as contributing to a continued plateauing of deaths from heart disease include the increase in obesity, the public's resistance to exercise and a refusal by many teen-agers and young adults to heed antismoking messages. According to published reports, the number of American men weighing more than 300 pounds has climbed by 50 percent since 1998 to one in 80 men. The number of women weighing more than 300 pounds has risen 67 percent in the last four years to one in 200. Obesity is a risk factor for diabetes, which is a major risk factor for heart disease. Diabetics are four to five times more likely to suffer heart disease than nondiabetics.

Research published earlier this year found that poor physical fitness is an even better predictor of death than other well-established risk factors, including smoking, high blood pressure, heart disease, diabetes or high cholesterol. A study conducted by doctors in the Veterans Affairs Palo Alto Health Care System in California found that the least-fit patients gained the most in terms of improved survival because of regular exercise. But the researchers acknowledge that getting Americans to exercise is a hard sell. Some 40 percent of the population does not exercise.

For years, U.S. surgeons general have called smoking the "most preventable" cause of death in this country. The good news is that just 23 percent of the U.S. population now smokes--down from 47 percent in the 1960s. The bad news is that one-third of high-school seniors do so, according to a national report released in April. New research from the University of Massachusetts found that adolescents can become addicted to smoking in just a few weeks.