IT is an unfortunate fact that we Asians have it worse than the Europeans and Americans when it comes to matters of the heart.
No, not love affairs, but that hardworking fist-sized organ that can never ever take a break as long as we live.
Our heart has one task, and one task alone: pumping blood to and from the lungs, where it gets oxygenated, to the rest of our body.
If it should falter in its task, that would mean the death of us, quite literally.
So, it is quite bad news that Asians not only get heart failure at a younger age compared to Europeans and Americans, but they also seem to develop a more severe version of it.
This, according to Prof Dr Chee Kok Han, is what the Asian Sudden Cardiac Death in Heart Failure (Asian-HF) Prospective Observational Study found.
The study followed around 5,000 heart failure patients from 11 Asian countries, including Malaysia.
The Universiti Malaya Medical Centre (UMMC) consultant cardiologist says: “Based on the Asian Heart Failure registry, it is very, very obvious that we are getting heart failure at a much younger age.
“For example, in this registry, our average age group for heart failure is around 60 years old; compared with the US, they are up to about 75 years old as their average age for heart failure patients (and the average age for European patients is 70).
“So, the Asian patient like us, who has heart failure, is actually much younger.”
He adds: “And beyond that, Asian patients are also having a more severe form of heart failure.”
He explains that heart failure patients are divided into classes, based on the severity of their disease. Class I and II are the less severe cases, while class III and IV are the more severe ones.
“If you look at Asians, one-third (35%) of them have much more severe heart failure (class III and IV), compared with the Europeans, where only one-quarter (26%) of them have severe heart failure,” he says.
The reason for this disparity in age and severity is unknown, although Prof Chee notes that the higher rates of high blood pressure and diabetes in the South-East Asian region might be contributing factors, as they are risk factors for heart failure.
Other risk factors include coronary artery disease, a heart attack, faulty heart valves, damage to the heart muscle (cardiomyopathy), inflammation of the heart muscles (myocarditis), congenital heart defects and abnormal heart rhythms (cardiac arrhythmias).
Recognising the symptoms
Heart failure is basically the decreasing capacity of the heart to efficiently pump blood throughout the body.
No blood means no oxygen and nutrients, and no getting rid of waste products within our cells.
Prof Chee compares a heart that is failing to a car with problems that is still being driven.
“Of course, the heart will continue going downhill unless something is done.”
The worrying thing is that heart failure is quite a common condition, probably more common than most of us think.
According to Prof Chee, one in five people over the age of 40 will develop heart failure within their lifetimes.
There is no cure for this condition, although it can be treated to slow its progress.
He says: “Heart failure causes two to three times as many deaths as advanced cancers like bowel or breast cancer.”
According to the latest Health Ministry’s Health Facts, which is based on data from 2016, diseases of the circulatory system – which includes heart failure – are the number one (22.6%) and two (26.4%) causes of death in Malaysian public and private hospitals respectively.
The important thing, Prof Chee says, is for people to recognise the symptoms of heart failure quickly, so that they can be treated as soon as possible for a better outcome.
“The most common one is shortness of breath.
“They may have problems walking a short distance – they may be panting and may need to hold onto something while they stop to catch their breath.”
For example, healthy people will probably pant after walking up five flights of stairs, but heart failure patients might start to pant after even 10 steps.
Another common symptom is a chronic, or long-term, cough.
“This cough can go on for weeks or months, and the moment they lie down flat, they start coughing, they start making wheezing noises,” he says, explaining that this is due to water retention in the lungs caused by the inefficient pumping of the heart.
Those experiencing these symptoms are also likely to need three or four pillows to prop them up in bed, otherwise, they are unable to sleep due to breathlessness – a condition called orthopnoea.
Other symptoms include swelling or oedema in the legs, feeling very weak or tired, and a rapid heartbeat.
A diagnosis of heart failure will be based on the patient’s symptoms and medical history, as well as physical examination and the appropriate tests and imaging.
Prof Chee notes that it is not necessary to undergo many sophisticated tests to diagnose heart failure.
“A simple X-ray will tell the doctor a lot of things.” he says, including whether the patient’s heart is larger than normal. “An enlarged heart will tell you that this patient is most likely to have possible heart failure.”
However, he adds that the main test to diagnose heart failure is an echocardiogram – essentially, an ultrasound of the heart.
“With this echocardiography, we can actually do measurements, which will tell us whether this patient has heart failure or not,” he says.
“What we measure is called the left ventricular systolic function. For most of us with a normal heart function, our percentage would be from 60% to 85%.
“But the moment the patient has anything less than 40%, then it is most likely this patient has heart failure.”
Managing the condition
According to Prof Chee, there are many options for treatment, which would also depend on the cause of the heart failure.
“The purpose of treating heart failure is: number one, definitely to prolong their life; number two, to improve their quality of life, so that they don’t need to sit in a bed the whole day and become pessimistic; and lastly, we also want to cut down on patients coming into the hospital – we don’t want them to be hospitalised,” he says.
He explains: “These are a few different ways of how we treat heart failure: we have exercises, we need to change our lifestyles, and there is medication, devices and surgery.”
He notes that there are many medications available to treat heart failure, “and these medications have been shown to actually improve the outcome, improve their chance of survival”.
There are also devices that can be put in the heart to help it function better, he adds.
“We can do surgery in some cases,” he says, giving the examples of a heart transplant and replacing faulty heart valves.
Patients themselves also need to implement healthy lifestyle changes like becoming more physically active, cutting down on alcohol intake, eating a balanced and healthy diet, quitting smoking and reducing stress.
In addition, Prof Chee says that they need to take care of their water intake, cut down on salt and do cardiac rehabilitation.
“The problem is that you and I always have this misconception that we should drink as much as possible – water is harmless. But not in a heart failure patient.”
Because the heart is less efficient in pumping, water is retained in the body, especially in the lungs and legs, where it can cause breathlessness and oedema respectively.
“We usually limit patients to less than two litres a day, and this includes your coffee, your sup ayam – everything liquid,” he says.
Cutting down on salt helps to decrease water retention as salt causes the body to retain water.
Meanwhile, UMMC rehabilitation physician Dr Anwar Suhaimi says that cardiac rehabilitation is fairly new in Malaysia, so many people might not be aware of it.
He explains: “There is no cure for heart failure, but we can, and want to, assist the patient to control the symptoms.
“So, instead of letting the symptoms of heart failure ruin or control a person’s life, we teach them how to overcome them.”
He adds that there are many ways to do this, which includes helping patients to manage their medications, recognising their symptoms and getting active.
As each patient is different, they are assessed individually, then prescribed the appropriate exercises.
Two main areas cardiac rehabilitation can help in are overcoming the physical and psychological limitations of breathlessness, and helping patients regain as much of their ability to do their usual activities as possible.
Dr Anwar adds that almost all tertiary public hospitals in Malaysia will have a rehabilitation physician, and certain ones will also have dedicated cardiac rehabilitation teams like UMMC.
Prof Chee and Dr Anwar were speaking at the Heart Failure Media Workshop organised by pharmaceutical company Novartis Malaysia in conjunction with their Keep It Pumping campaign.