Heart Attack Warning: When Your Heart Works Fine but You’re Still at Risk!

WORDS LIM TECK CHOON

FEATURED EXPERT DR RAJA EZMAN FARIDZ RAJA SHARIFF Consultant Cardiologist and Internal Medicine Physician Head of Heart Failure Services Hospital Al-Sultan Abdullah (HASA) Universiti Teknologi MARA (UiTM) and UiTM Sungai Buloh

When we hear about heart failure, we usually think of a heart that’s unable to pump blood effectively.

However, there is a type of heart failure where the heart’s pumping function remains normal. This condition is called heart failure with preserved ejection fraction (HFpEF, pronounced ‘heff peff’).

• In a healthy heart, oxygen-rich blood from the lungs finds its way into the left atrium, which contracts to send the blood into the left ventricle.
• The left ventricle then contracts forcefully to send the oxygen-rich blood out of the heart to the rest of the body.
• In the same manner, oxygen-depleted blood return from the rest of the body to the heart first through the right atrium, which contracts to send the blood into the right ventricle.
• The right ventricle then contracts forcefully to send the blood out of the heart and back to the lungs.

HOW HFpEF COMES TO BE

According to Dr Raja Ezman Faridz Raja Shariff, the main factor that gives rise to HFpEF is the abnormal relaxation of the heart.

1. The heart struggles to relax between contractions (heart beats).
2. This leads to a buildup of pressure inside the heart.
3. As a result, water begins to accumulate in the lungs, lower limbs, and other organs (oedema).
4. Buildup of pressure in the heart also changes the structure of the heart.
5. Often, these structural changes involve thickening of the heart muscles and enlargement of certain chambers of the heart.
6. Over time, the person may experience symptoms of heart failure even when their heart still has normal pumping ability.

Risk Factors for HFpEF

• Increasing age
• Is female
• Has type 2 diabetes
• Is obese
• Has kidney disease
• Has hypertension and/or pulmonary hypertension
• Has coronary artery disease
• At risk of inflammation due to diseases such as certain types of arthritis and rheumatological conditions

Common Possible Symptoms of HFpEF

• Breathlessness, especially with exertion, exercise or lying flat
• Chest discomfort
• Leg swelling

HFpEF IS A COMPLEX AND OFTER UNDERDIAGNOSED CONDITION

“HFpEF is extremely different when compared to the more common type of heart failure, heart failure with reduced ejection fraction,” Dr Ezman says.

He adds that there is evidence to suggest that HFpEF constitutes half of all heart failure cases seen.

“However, it remains severely underdiagnosed and underappreciated even amongst healthcare professionals,” he goes on to say.

This is because, often, healthcare professionals would assume that the affected person is ‘normal’ because tests show that their hearts are pumping blood normally.

Because people with HFpEF tend to have other existing health issues, their symptoms may be attributed to those health issues. For example, Dr Ezman points out that breathlessness may be attributed to the person being obese.

Consequently, people with HFpEF may find themselves visiting multiple healthcare facilities to seek an explanation and treatment for their condition, only to leave disappointed and feeling defeated due to general lack of awareness regarding the condition.

IF LEFT UNTREATED, HFPEF COULD LEAD TO FREQUENT HOSPITALIZATIONS AND DIMINISHED QUALITY OF LIFE

Because of this, Dr Ezman points out that there is a need for greater awareness of this condition among members of the public as well as among healthcare professionals.

TREATMENT OF HFpEF

Treatment Goals

• Improve symptoms and prevent further complications.
• Implement lifestyle changes (diet, exercise, weight control).
• Treat or manage other existing health conditions.

Many people with HFpEF can consult a general cardiologist. However, a heart failure specialist will step in if the patient shows severe symptoms, has organ failure, or is frequently hospitalized.

Diuretics

• Dr Ezman shares that patients are typically given diuretics.
• Diuretics are a class of medications that help to remove excess fluid retention or oedema by increasing urine production and excretion of water and salts from the body.
• “Most patients can stop taking diuretics over time, once they begin taking HFpEF-targeted medications,” Dr Ezman adds.

Dr Ezman reveals that in the recent years, a few classes of medications have been proven useful to treat HFpEF. See the list below.

Sodium-Glucose Transport Protein 2 (SGLT2) Inhibitors

• “Originally used to manage diabetes, these medications improve energy use by heart cells and reducing harmful inflammation and scarring in the heart and blood vessels,” Dr Ezman explains.
• These medications have been shown to also reduce hospital visits and improve patients’ overall heart function.

Mineralocorticoid Receptor Antagonists (MRAs)

• These are a class of medications that block the action of aldosterone, a hormone that regulates sodium and water balance in the body.
• They help to reduce fluid overload, improve heart function, and reduce high blood pressure.

Glucagon-Like Peptide-1 (GLP-1) Receptor Agonist

• This class of medication is used to treat obesity and is now also used to treat HFpEF—a useful approach as many people with HFpEF are also obese.

“We are also beginning to witness the dawn of combined HFpEF and obesity treatment,” says Dr Ezman, citing the use of medications such as GLP-1 receptor agonist that helps tackle both risk factors and disease simultaneously.