Norma has Type 2 diabetes. She’s 57 years old and admits that she has not made managing her diabetes a priority. She also has high blood pressure and high cholesterol, but she doesn’t like to take drugs, so she doesn’t always take the medicines her doctor has prescribed. Recently, however, Norma has been getting short of breath, especially when she lies down to go to sleep. This scares her, because she thought shortness of breath was only caused by exercise or by overexertion. She visited her health-care team and was shocked — and a bit confused — when she was diagnosed with heart failure. She wasn’t sure what it meant for her heart to “fail,” and she wondered whether this new diagnosis was related to her diabetes. Her health-care team confirmed that heart failure is often related to diabetes, but assured her that both conditions can be successfully managed.
When the heart fails
Normally, the heart pumps oxygen-depleted blood to the lungs and oxygen-rich blood to the rest of the body. (See “The Heart” for a diagram of this organ.) A diagnosis of heart failure (also called congestive heart failure) means that the heart is not pumping blood as effectively as it once was. As a result, the organs and other body parts aren’t getting as much oxygen and other nutrients as they did previously. In addition, some of the fluid that would normally circulate through the blood vessels is “backing up,” causing swelling and edema.
Heart failure happens gradually. As the heart loses strength, it tries to make up for it by beating faster to get more blood moving. Unfortunately, this attempt to compensate causes the muscular walls of the heart to get larger and to stretch, which only makes it weaker and even less efficient at pumping.
As blood flow slows down, blood and fluid build up in parts of the body. If the lower left chamber of the heart, called the left ventricle, is not pumping properly, blood and fluid collect in the lungs and/or heart. This can cause shortness of breath. If the right ventricle is weak, fluid builds up in the legs and feet. In fact, fluid can build up all over the body, including in the face and especially around the eyes. It can also build up in the liver, which also causes shortness of breath as the liver presses against the lungs.
Currently, more than 5 million Americans have heart failure, and a large percentage of those people have diabetes. However, although heart failure is a serious condition, with adequate care and appropriate lifestyle changes, a person who has it can live a full and enjoyable life.
Causes of heart failure
With age, everyone’s heart loses some of its blood-pumping ability, but such age-related changes are not considered heart failure. Heart failure is caused by health conditions that either damage the heart or cause it to have to work too hard. Many of the complications associated with diabetes are causes of heart failure.
According to the American Heart Association, the following are common causes of heart
- Abnormal heart rhythm. If your heart beats irregularly, too fast, or too slow, it may not be able to pump enough blood to meet your body’s needs.
- Abnormal heart valves. Heart valve problems can result from disease, infection, or a birth defect. When your heart valves aren’t working properly, it causes the rest of your heart to work harder.
- Anemia. When your red blood cell count is lower than normal, your heart tries to compensate by increasing your heart rate, and it can become overworked.
- Coronary artery disease. When cholesterol and fatty deposits build up in your arteries, less blood reaches your heart. This damages your heart muscle, and the remaining healthy parts of your heart have to work harder.
- Diabetes. People with diabetes have a high incidence of high blood pressure and coronary artery disease, both of which are linked to heart failure.
- Excessive sodium intake. A high sodium intake can cause fluid retention and raise blood pressure in some people.
- Heart attack(s). A heart attack occurs when the arteries that supply blood to your heart get blocked, and oxygen-rich blood doesn’t get to all parts of your heart. The part of your heart that doesn’t receive oxygen gets damaged, or “dies,” causing the remaining healthy parts of your heart to work harder.
- Heart defects present at birth. If your heart is not formed correctly, the normal parts of your heart have to work harder.
- Heart muscle diseases. Any damage to your heart for any reason increases your risk for heart failure.
- High blood pressure. Uncontrolled high blood pressure greatly increases your risk for heart failure. When the pressure in your blood vessels is too high, your heart has to pump harder to keep your blood circulating. In time, this causes your heart to get larger and weaker.
- Lack of physical activity. Any muscle that isn’t exercised gets weaker, and your heart is no exception.
- Lung disease. When your lungs don’t work properly, your heart has to work harder to get oxygen to the rest of your body.
- Overweight. Being overweight makes your heart work harder.
- Sleep apnea. With sleep apnea, there are times your heart doesn’t get the oxygen it needs because your breathing temporarily stops. This cycle of stopping and abruptly starting to breathe many times per night causes your heart to work harder.
- Thyroid problems. If your thyroid is overactive, your metabolism speeds up, and your heart can get overworked trying to keep up.
- Smoking. Smoking can damage your circulatory system and your lungs and make your heart work harder.
The following symptoms commonly occur with heart failure. A person with heart failure may experience all of them, some of them, or none of them, at least early on.
Shortness of breath. When your blood “backs up,” fluid can leak into your lungs, which causes you to be short of breath. You can also experience shortness of breath if you retain fluid in other parts of your body that press against your lungs. Shortness of breath can occur during activity, at rest, or when sleeping. You may wake up suddenly feeling as if you are suffocating, or just wake up feeling tired, anxious, and restless.
Cough or wheeze. This occurs because of the fluid in your lungs. You may have a dry, hacking cough, or you may cough up white or pink, blood-tinged mucus.
Swelling. Fluid retention, called edema, can occur as blood flow slows down. When this happens, your kidneys become less able to get rid of sodium and water, which causes you to retain yet more fluid. You may experience swelling of your feet, ankles, legs, abdomen, or face, possibly causing shoes or rings to feel tight. You may also experience weight gain because of fluid retention.
Fatigue. Virtually all of your body parts require a steady supply of oxygen and other nutrients from your blood to function properly. When your heart can’t pump enough blood to meet all of your body’s needs, it sends it first to your most vital organs, such as your heart and brain. As a result, you may feel tired all the time and have difficulty performing most activities.
Gastrointestinal problems. When your digestive system receives less blood than normal, your ability to digest food and your appetite can be affected. You may feel full, bloated, or nauseated, which can decrease your appetite. You may also experience constipation or diarrhea.
Mental changes. People with heart failure sometimes experience changes in their ability to remember, learn, pay attention, and react. Such changes may be noticed by other people first.
Increased heart rate. Your heart speeds up, or tries to work harder, to make up for its decreased pumping ability. You may feel like your heart is pounding or speeding.
The goal of treatment is to relieve your symptoms, prevent further heart damage, and improve your quality of life. While certain changes in diet can help limit fluid buildup, most people who have heart failure need to take one or more medicines to control it.
The medicines used for heart failure may improve your heart’s pumping ability, prevent fluid retention, decrease stress on your heart, and decrease the progression of further heart failure. Some of the types of drugs commonly used to treat heart failure include the following:
ACE inhibitors. Angiotensin-converting enzyme, or ACE, inhibitors open your blood vessels by blocking an enzyme that normally narrows them. This allows blood to flow through them more freely to deliver blood and oxygen to all parts of your body; ACE inhibitors also lower blood pressure. They are often prescribed for people with diabetes to protect their kidneys, whether or not a person has high blood pressure or heart failure.
Aldosterone antagonists. These medicines block the action of a hormone known as aldosterone, reducing sodium reabsorption and water retention by the kidneys and therefore leading to decreased blood pressure.
ARBs. Angiotensin receptor blockers, or ARBs, work much like ACE inhibitors except that they block certain chemical receptors that cause blood vessels to narrow. They, too, are sometimes prescribed for people with diabetes to protect the kidneys.
ARNIs. Angiotensin-receptor neprilysin inhibitors, or ARNIs, are a new combination of an ARB and neprilysin inhibitor.
Diuretics. These drugs lower blood pressure by causing the body to increase the amount of fluid lost through urination.
Hydralazine and isosorbide dinitrate. This combination medicine is used specifically for African-Americans with heart failure.
Digoxin. This medicine regulates heartbeat and strengthens the pumping action of the heart.
Beta-blockers. These medicines also regulate heartbeat and treat high blood pressure. They have been shown to protect the heart after a heart attack.
Anticoagulants. This type of drug prevents blood from clotting.
People with heart failure may also be prescribed other medicines to lower blood glucose or cholesterol or to manage any other medical problems a person has. Do not stop taking any of your prescribed medicines or change the amount you take without discussing it first with your health-care provider. Being consistent about taking prescribed medicines is key to managing heart failure.
Certain medicines should be avoided by people with heart failure. The diabetes medicines pioglitazone (brand name Actos) and rosiglitazone (Avandia) can make heart failure worse. If you develop heart failure while taking one of these medicines, your health-care provider will most likely switch you to a different diabetes medicine.
Other medicines to avoid include antacids, because they contain sodium; decongestants, because they can increase heart rate and blood pressure; and nonsteroidal anti-inflammatories, because they can cause fluid retention and increase the risk for kidney failure.
Some nutritional supplements should also be avoided, particularly those that contain ephedra (ma huang) or ephedrine. But all over-the-counter medicines, including vitamins and herbal supplements, should be discussed with your health-care provider since some can interfere with the medicines used to treat heart failure.
Many of the same healthy lifestyle habits that can help control diabetes can also help to manage and prevent progression of heart failure. These include following a healthy diet, engaging in regular physical activity that is appropriate to your level of fitness, being screened for sleep apnea (and treated, if you have it), and making and keeping regular appointments with your health-care providers. Here are a few specifics to keep in mind:
Food choices. Meeting with a registered dietitian is recommended for individualized advice on making healthy food choices. You should not assume that you will have to give up all of your favorite foods, but it is likely that you’ll be advised to cut back on sodium since sodium can contribute to fluid retention. Reading food labels and fast-food and chain restaurant nutrition information (usually available online or by asking at the restaurant) will allow you to assess how much sodium you’re getting in the foods you eat. In general, people with heart failure are advised to consume no more than 2,000 milligrams of sodium per day.
Physical activity. Exercise can help people with heart failure improve their quality of life. However, there is no one-size-fits-all exercise recommendation for people with heart failure. Ideally, your health-care provider should refer you to a cardiac rehabilitation center so you can meet with a professional who can assess your capacity for exercise. Together, you can come up with a plan that fits your medical and personal needs.
Weigh yourself every day. Weighing yourself every day is recommended not primarily for weight control but to check whether you are retaining fluid. A weight gain of 3 or more pounds in one day or 5 or more pounds in one week indicates that you are retaining fluid and that you should call your health-care provider promptly for advice.
When you weigh yourself, use the same scale each time, weigh yourself at about the same time of day, and wear about the same amount of clothes each time. The best time to weigh yourself is when you wake up in the morning, before you have eaten anything but after you have urinated.
Listen to your body. If you are feeling tired, slow down and rest. Some people find that taking an afternoon rest helps them feel better. When traveling, don’t hesitate to request a wheelchair at airports and other venues where such assistance is available. These days, even some grocery stores have mobility scooters available for use by customers. Take advantage of this help if it will help you get where you want to go.
For people with sleep apnea, continuous positive airway pressure (CPAP) therapy is the gold standard for treatment. Using a CPAP device requires wearing a mask while sleeping; the mask is connected to a machine that holds the airway open with gentle air pressure. If you find your mask doesn’t fit or is uncomfortable, talk with your provider about trying other sizes or models. There are several different options, and using the CPAP machine regularly is key to getting sustained benefits.
In some cases, surgery is performed to stop or prevent further damage to the heart and improve its function. There are a number of possible surgical approaches, including the following:
- Coronary artery bypass surgery is done to improve circulation to the heart.
- Valve surgery might be done if your heart failure is due to valvular problems.
- If you have damage or scar tissue in your left ventricle because of a heart attack, the affected area can be surgically removed and your left ventricle reshaped to improve your heart’s pumping action.
- A device called an implantable left ventricular assist device can be surgically implanted to help your heart pump blood through your body. This device is considered a “bridge” to a heart transplantation.
- Heart transplantation is considered when heart failure is severe enough that no other options work.
Knowing that your diabetes puts you at risk of developing heart failure means you can be proactive about preventing it. The following steps can help to lower your risk:
- Control your blood glucose, blood pressure, and blood lipid levels. Talk to your health-care provider about the best ways to do this.
- Moderate your sodium intake by cutting back on processed and restaurant foods that are high in sodium.
- Make regular physical activity a priority. Being active strengthens your heart, helps control blood pressure, and helps prevent weight gain.
- Stop smoking if you smoke.
- If you are being treated for high blood pressure, talk to your doctor about monitoring your blood pressure at home. There are accurate monitors that are easy to use. If you start to see numbers that are above your target range, call your health-care provider for early intervention. For those with diabetes, blood pressure should be lower than 140/90 mm Hg, with lower targets for certain people.
- If you take Actos or Avandia and notice any symptoms of heart failure, contact your health-care provider immediately.
Heart failure sounds scary, and having it probably will increase the amount of time you need to devote to caring for your health. But a lot of people with heart failure are able to work, travel, and lead active lives in spite of it. You can, too, by making your health a priority and learning to manage your diabetes and heart failure as best as possible.