Dear Dr. Roach • My husband was diagnosed with congestive heart failure a year ago. His ejection fraction was 15-20. Now it is 25-30, but he’s worse! For the past few months, he’s been admitted to the hospital at least once a week. It started with an overload of 13 liters; he came home, and within a few days was unable to keep his blood pressure up and was readmitted for dehydration. They loaded him up on fluids, sent him home a few days later, and he was overloaded again. His kidneys get “insulted” every time he gets dehydrated. How do you find the balance? This flip-flopping every week is so old. — D.E.
Answer • Congestive heart failure is not a single disease; it’s a syndrome of inadequate blood flow from the heart to meet demand. It has many different causes, but the most common are longstanding high blood pressure, heart attacks and dilated cardiomyopathy, which itself often is caused by a virus but can be caused by alcohol or some chemotherapies.
One measurement of heart failure is the ejection fraction, the amount of blood pumped out by the left ventricle with every beat. That’s normally between 50 percent and 75 percent or so, but because the heart can dilate (enlarge), an ejection fraction of 15 percent might cause only mild symptoms or might be incompatible with life. Further, medications that improve the ejection fraction can make symptoms worse in some people.
When the heart is as precarious as your husband’s, it is very difficult to manage fluid. Too little fluid, and the heart can’t provide enough blood for critical organs — in which case, the kidneys frequently are damaged. Too much fluid, and the heart fails and the lungs become congested, as can the abdominal cavity.
Heart failure this severe deserves an expert. General internists like myself can manage many people with heart failure, but a cardiologist, or even a cardiologist with special expertise in heart failure, can make a big difference. Careful management of medications might help him a lot. Unfortunately, some people will require more drastic treatments, such as a left-ventricular-assist device or a heart transplant. Not everyone is a good candidate for these therapies.
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