Tuesday, May 24

Heart failure: A deadly affliction

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Despite its debilitating nature, this is one disease that Malaysians do not know much about – definitely not enough to recognise its symptoms, seek consultation and treatment, and take preventive measures

Dr Cham provides consultation to one of her heart-failure patients at the Heart Failure Clinic.

SINCE its declaration in March 2020, the Covid-19 pandemic has caused severe disruptions not only to the global economic activities, but also to our daily lives and work.

The ongoing battle against the coronavirus has also put a strain on our health check-ups and placed the awareness of other health issues on the back-burner.

But as Covid-19 shows little indication of abatement, it becomes imperative that we must not forget to pay attention to other diseases at the same time.

One of the deadliest health complications striking not only Malaysians, but also the general global population, is heart failure.

It is so major that it afflicts between 300,000 and 600,000 people in Malaysia alone, which is a prevalence of one to two per cent of society.

The hospitalisation rate of patients has also burdened the country’s healthcare system, and while underscored by high recurrences of hospital readmissions, the mortality increases correspondingly.

According to ‘Statistics on Cause of Death in Malaysia, 2020’ from the Department of Statistics, ischemic heart disease was the No 1 cause of death in 2019, said Sarawak Heart Centre’s Department of Cardiology consultant cardiologist Dr Cham Yee Ling.

“The mortality rate for heart failure was reportedly 3.31 per population in Ministry of Health (MoH) hospitals in the same year,” she told thesundaypost in Kuching.

Dr Cham Yee Ling

She said while she did not have the figures for Sarawak, the referrals and admissions for heart failure in the state had picked up significantly over the last 10 years.

“This is in concert with the rising incidence of cardiovascular diseases and also partly due to an increased awareness among healthcare providers and patients, leading to earlier presentation, diagnosis and referrals.

“I would like to mention that the Malaysia Heart Failure Registry, the first such effort in the country, collected data on acute heart failure admissions in 19 Malaysian hospitals.

“The results, upon being published, would finally provide some insights into the local heart failure landscape,” said Dr Cham.

Despite the debilitating nature of heart failure, this is a disease that Malaysians do not know much about – definitely not enough to recognise its symptoms, seek consultation and treatment, as well as take preventive measures.

According to Sarawak Heart Centre’s Department of Cardiology head Dr Ong Tiong Kiam, there are many causes of heart failure.

“The most common is coronary heart disease; that is, blockage of the blood vessels of the heart resulting in damage to the heart muscle due to lack of oxygen.”

Dr Ong Tiong Kiam

He said heart failure could be present when the heart could not pump enough blood into the circulation to meet the needs of other organs in the body.

“This usually occurs when the heart muscle is too weak to pump the blood out.

“However, it can also happen if the heart is too stiff, making it difficult for blood to return to the heart.

“In both situations, the amount of blood that can be pumped into the circulation with every heartbeat is reduced.

“As a consequence, there is not enough pressure and blood flow to deliver oxygen and other nutrients to other organs in the body and to remove their waste products,” he said.

Dr Ong noted that there were many other conditions that could directly affect the heart muscle, causing it to become weak or stiff.
“For instance, the heart has to work extra hard if a person suffers from high blood pressure.

“If the blood pressure remains high and not well controlled over a long period of time, eventually the overworked heart would become exhausted and later, would go into heart failure.

“Sometimes, inflammation of the heart muscle (myocarditis) could be triggered by a viral infection, or by some unknown cause. The heart muscle could also become weak due to toxins – for example, chemotherapy given for cancer,” he said.

Dr Ong pointed out that one of the earliest symptoms of heart failure would be a decrease in effort tolerance.

“In other words, a person with heart failure would become tired or experience shortness of breath more easily, especially after doing some work,” he said.

Dr Ong said when the heart failure became worse, fluid would start to accumulate in the body – resulting in swollen legs or tummy.

“The person might start experiencing shortness of breath even when sitting down or lying on the bed due to fluid in the lungs.

“Decreased blood flow to other organs such as the brain might lead to giddiness or even mental confusion, and decreased blood flow to the kidneys might result in a decrease in urine output,” he said.

Dr Ong said in view of coronary heart disease being the most common cause of heart failure, those at risk of developing coronary heart disease might also be at risk of getting heart failure.

“These include smokers and those suffering from high blood pressure, diabetes or high cholesterol. Some types of heart failure run in the family.

“So, members of the same family might be at risk. Unfortunately, some causes of heart failure are less predictable and, therefore, harder to prevent,” he said.

Dr Ong said it would be hard to predict exactly how long a patient with heart failure would survive as this would depend on the underlying causes of heart failure – whether it was reversible or not, how early the diagnosis had been made, and when did the treatment start.

“Previously, only 50 per cent of patients diagnosed with heart failure would survive up to five years. However, this is highly variable as there are patients with heart failure who have survived for a very long time.

“Nowadays, there are many very good and effective treatments for heart failure including medications, as well as devices that could allow the patients to live longer,” he added.

Asked on how heart failure could be prevented, Dr Ong said this should be achievable by observing a healthy lifestyle and maintaining an ideal body weight.

“Risk factors for coronary heart disease must be adequately addressed. These include quitting smoking and achieving good control of blood pressure, diabetes and cholesterol levels.

“Equally important, the treatment for heart failure once it’s diagnosed must be adhered to strictly because it can potentially reverse (i.e. cure) heart failure if done correctly,” he said.

Meanwhile, with the impact and challenges posed by Covid-19 naturally causing a lot of uncertainties and anxiety amongst the people, Dr Cham advised patients with heart disease to take appropriate precautions and adhere to the standard operating procedures (SOP) set by the Ministry of Health.

“My advice would be the same as for the general population, which is to avoid close contact, practise good hygiene, wear a face mask and specifically, to be aware of misinformation as it can be detrimental to your health,” she said.

She also urged those who had not been vaccinated against Covid-19 to do so as soon as possible.

“There are very little contraindications for getting the vaccine. If you have heart disease or are on certain heart medications like ‘blood thinners’ and are concerned that the vaccine may not be safe for you, please approach your healthcare provider who can perform a pre-vaccination assessment for you,” she advised.

A nurse performs a point-of-care NTproBNP test at the Heart Failure Clinic. NTproBNP is a biomarker for the assessment of heart failure.

Dr Cham also noted that it was not necessary that a person with heart disease would have a higher change of getting infected with Covid-19.

“Heart failure is a significant comorbidity, which confers a higher risk of complications and even death in the event of Covid-19 infection.

“We have seen cases of worsening heart failure co-existing with Covid-19 infection.

“However, as Sarawak Heart Centre is a non-Covid-19 hospital, Covid-19 positive patients who have concomitant heart failure are managed in designated hospitals,” she said.

Dr Cham currently leads the Heart Failure Team at Sarawak Heart Centre, where its role is chiefly the provision of guideline-directed care to high-risk heart failure patients in a multi-disciplinary setting.

“Our objectives are to improve the quality of life of patients, reduce hospital admissions and emergency hospital visits, and ultimately prolong their survival.

“We offer care in a setting where, besides the conventional doctor’s consultations, patients are supported by a nurse who provides medical education, and a pharmacist who provides counselling on medications and troubleshoots any medication-related issues,” she said.

A 2019 group photo of the Heart Failure team conducting a ‘Heart Failure Camp’ for heart failure patients that year. Various educational activities were carried out including lectures, counselling and exercise sessions.

Dr Cham added that this approach would go a long way in fostering a good healthcare provider-patient relationship, which would usually lead to better adherence to and compliance with the treatment plans.

There are currently eight members in the team, consisting of a consulting cardiologist, four medical officers, two nurses and a pharmacist.

“The Heart Failure service is essentially a team effort. Every member of the Department of Cardiology is involved in some capacity,” added Dr Cham.