Cindy from Kerrville, Tx asks:

Im an 88 year old female with recurring headaches caused by nitroglycerin, my other symptoms inlcude fatigue and difficulty breathing. My doctor said an operation is all that can be done? Do I have other options?

Dr. Jaski's answer:

There are many causes for shortness of breath including a leaky mitral valve. Normally, the mitral valve allows blood into the left ventricle when it is filling and should close when the heart is contracting. When the mitral valve has a severe leak, increased fluid pressure behind the heart can cause the lungs to become distended with fluid--a condition called pulmonary edema.  Reduced forward heart delivery of blood to the body can contribute to symptoms of fatigue. A definitive therapy for severe conditions could include surgery to repair or replace the leaky valve when a patient's general condition would permit this. Medical management through diuretics (medicines that increase the excretion of salt and water by the kidneys) may decrease fluid overload of the lungs and improve shortness of breath. Medicines that dilate blood vessels can also reduce an increased fluid pressure. A diet low in intake of sodium can reduce the fluid pressures within the circulation and also help.  A decision for surgery should be thought about carefully due to increased risks associated with older age.

Anonymous asks:

My father is suffering from shortness of breath and also wakes so much in the night, i.e. 5 times an hour. Walking from the house to the car and then a short walk to a shop is too much for him. The General Practitioner states the fluid in his lungs is the cause of the shortness of breath. Would oxygen or a nebulizer help?

Dr. Jaski's answer:

Congestive heart failure has many symptoms, but the most dominant, shortness of breath, can be caused by fluid buildup in the lungs. Although inhaled oxygen might temporarily help symptoms of difficulty breathing at night, it might be better to try to get to the root causes. Fluid congestion at night can often be improved over time by reducing sodium intake in the diet or increasing the doses of diuretics.  Medicines that dilate blood vessels can also reduce vascular pressures that contribute to fluid buildup in the lungs. Your father's doctor could also answer whether there are any treatable conditions that could fundamentally improve your father's heart function as a pump such as excessive high blood pressure, blocked heart arteries, or impaired heart valves.  

Cindy from Marysville, WA asks:

My 93 year old grandmother has CHF and has a pacemaker.  She has been spitting up frothy white sputum for years.  She is currently in a nursing facility recovering from weakness related to an intestinal bleeding issue.  While in the nursing facility she has developed a cough (unrelated to an upper respiratory infection).  They are giving her Albuterol treatments every 4 hours.  The past 2 days she has been hallucinating off an on.  Is it possible that her CHF is causing her oxygen saturation to drop such that it is causing her mental status to change? 

Dr. Jaski's answer:

Your grandmother could experience symptoms of dizziness if her heart failure led to a frequently low  blood pressure or oxygen saturation in her blood. With advanced heart failure, memory or analytical thinking may be impaired. In general, when elderly individuals have hallucinations, causes besides heart failure that could affect brain function should be considered.

Debopom from India asks:

What is the recomended treatment stradegy for a patient with pneumonia and heart failure?

Dr. Jaski's answer:

Both pneumonia and heart failure are common conditions that can result in shortness of breath. By definition, pneumonia is an inflammation that results in filling of the air spaces of the lungs—usually due to infection. Heart failure can also result in congestion of the lung air spaces by salt and water displaced from the circulation because of a high fluid pressure “backed up” behind the left ventricle. On a chest x-ray, different distributions of opacification of the lungs can help distinguish the two conditions. Pneumonia is usually associated with fever. Heart failure may be associated with other findings of fluid retention including elevation of a heart failure blood test.  Nevertheless, especially in patients with a history of heart disease, distinguishing between the two conditions can be difficult including the possibility that both could be present at the same time. Whereas pneumonia usually requires antibiotics to improve, heart failure with lung congestion may need therapies to increase the removal of excess salt and water from the body.

Aishah asks:

My 74 year old grandmother was recently diagnosed with heart failure. Doctors claim she has just 29% of her hearts life left. She is diabetic and has high blood pressure as well. She recently became very ill when fluids filled up in her lungs leading to breathing issues and an increased heart rate. While in the hospital she had to receive cardioversions twice to reduce her heart rate.

Kindly advise me on what precautionary measures we can take and what we can expect for her future health.

Dr. Jaski's answer:

Several important points emerged from your question. First, I would define ejection fraction as the amount of blood ejected by the heart with each beat as a fraction of what it starts with at the beginning of a beat. For example, if the heart has a 100ml of blood at the beginning and ejects 60ml leaving 40ml, that would be an ejection fraction of 60%. If the heart were to flatten like a pancake when it contracted, the ejection fraction would then be 100%, but that never happens. Normally the heart ejects about 2/3 of the blood it starts with at the beginning of a beat. So if your grandmother has an ejection fraction of 29%--that is seriously decreased but it's not 29% of 100%, but 29% of a normal range of 55-75%.

Secondly, your mother was given a diagnosis of "Heart Failure", I like to use the analogy of a car--this would be like a mechanic saying you have "engine trouble". The question is why? For example is there a problem with her heart arteries ("fuel lines")? Is her heart muscle weak despite an adequate blood supply ("bad cylinders")? Does she have a problem with the electrical activation of her heart (" a problem with the distributor"). The answer to these questions may lead to specific therapies that could help her.

Lastly, In general, there are recommendations that should come from her doctor and medical team, including medication, diet and exercise. Please look at the sections in our website specific to these topics which may help.

Gregory K. from Oklahoma asks:

Hello Dr. Jaski, I was once a patient of yours and I have since relocated out of state. My question is, can cardiomyopathy and/or conjestive heart failure (CHF) be a result of untreated sleep apnea? It is a question of mine since I have both of these at such a young age.

Dr. Jaski's answer:

Hi Greg,

As you know, sleep apnea is a relatively common condition typically associated with periodic obstruction of breathing by the tongue during sleep. Frequently it is suspected when someone is noted to be a loud snorer and has fatigue during the day due to ineffective rest at night. It is more common in individuals who are overweight--the condition can be improved by weight loss. It is often treated by having someone wear a special mask at night that provides continuous positive airway pressure (CPAP) to prevent or relieve the tendency to airway obstruction.

It has been increasingly recognized that untreated sleep apnea can exacerbate the findings of heart failure if someone is prone to the condition. Blood pressure is elevated during episodes of obstructive breathing at night. Other hormonal systems are activated as well that lead to the progression of heart failure. Ironically, heart failure itself can complicate things by making disordered breathing more likely. In general, if you have a suspicion for sleep apnea, it is best to be evaluated, especially if you have a history of heart failure. Whether sleep-apnea by itself can cause heart failure or cardiomyopathy without other risk factors is currently uncertain, but a topic of ongoing clinical research.

Anonymous asks:

My father had a mitral valve replaced 30 years ago and today underwent an angiogram to see what’s going on with his heart. His mitral valve is still working well and his arteries are clear however he has been told that he has another badly leaking valve and will not be offered surgery to correct it as his heart is too weak. He is already taking high doses of diuretics to help alleviate the buildup of fluids around his lungs and abdomen. As surgery has been ruled out what other treatments could be offered to help his condition?

Dr. Jaski's answer:

A leaky heart valve that regulates the direction of the flow in or out of the left ventricle (atrial or aortic) can by itself lead the heart to weaken. The heart is working “overtime”. If the hearts impaired condition is too advanced it is possible that the surgery to repair or replace would be too risky.

In those cases medications including diuretics and others can still help. Other factors including your father’s age at this time may also be relevant.

Nicole from Phoenix, Az asks:

Can a patient with heart failure expirience a cough and facial periorbital edema from the disease process? or would these symptoms be unrelated?

Dr. Jaski's answer:

There are 2 aspects to your question. Cough is a symptom that has many causes including congestion of the lungs associated with heart failure. When this is the cause, cough often improves with an increase in  the dose of diuretics- less commonly, a dry cough especially at night may be a side effect of a class of heart failure medications called angiotensin-converting enzyme inhibitors (for example, lisinopril, enalapril, captopril).

     Fluid retention associated with heart failure usually is seen in the locations of the body most affected by gravity: the ankles, calves, or possibly abdomen. Although facial swelling may be seen with heart failure, other causes should in general be considered (such low protein states or facial inflammation). If this symptom persists, you should bring this up with your doctor.

Meredith from Daytona, Ohio asks:

My father is 69 years old, and has weighted 375 lbs. at 6'8" most of his adult life. He has had diabetes since he was 50 years old and  Congestive Heart Failure for sometime.  On July 1st, 2011 he had valve replacement surgery of his mitral and aortic valves.  What is strange, is that other than fluid buildup in his abdomen and lower extremities, he was never short of breath befoe surgery. Now he is.He cannot lay flat at all or is gasping for air.  And he is still gaining fluid weight.  If the valves were not the underlying cause, or only one underlying cause of the CHF, what else could be going on? He is severly anemic, 8.0 hemo..they could  not find a reason for this without a bone marrow test as nothing else appears as an obvious cause... should we be pursuing the anemia solution to attack the CHF?

Dr. Jaski's answer:

      Shortness of breath while lying flat, orthopnea, is a common finding of congestive heart failure associated with high fluid pressures behind the left ventricle.  Whereas standing tends to keep excess fluid in the extremities by gravity--lying down can allow this fluid to return to the central circulation including the lungs.  Surgically repairing a mitral and aortic valve may help with the reduction of pressure by pumping blood out of the lungs by the left ventricle, but paradoxically, especially when repairing a leaking mitral valve, previously present cardiac remodeling or hypertrophy may be unmasked by the removal of the “pop off” valve when the heart ejects blood.This impaired state will reduce the efficiency at which the blood pumps out of the ventricle. So, even though the valves have been repaired the ventricle itself may not be able to work as a proper pump to push the blood into the vascular system.  Even in the absence of heart failure, peripheral edema can be caused by obesity and stretched venous valves. Additionally, severe anemia contributes to the feeling of being short of breath due to lack of oxygen especially in combination with your father’s obesity.  At this time, if possible, your father may do best to take heart failure medication, correct his anemia, and lose weight.