Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and welcome to my podcast and videocast station and welcome to the Healthy Heart Network. Today I'd like to talk a little bit about cardiac failure and in particular how we recognise and think about cardiac failure for the individual. Well, from a historical perspective, cardiac failure has been recognised for thousands of years. The documentation of patients or individuals swelling and being short of breath has been recorded by the Babylonians, by the Egyptians and by the Greeks. So we have been observing the process of people retaining fluid and suffering the consequences of that for thousands of years. dropsy was used or applied to that symptom complex of retaining fluid and associated shortness of breath. The features were observed more and more and became recognised more broadly in the 18th century but it wasn't until the end of the 19th century when two physicians called Blackwell Sorry, Black All and Bright started to develop and advance our understanding of the process of fluid retention or dropsy. Their recognition was that there was two things that could lead to that situation. The first being problems with the heart. The second being problems with the kidneys. Both situations leading to an imbalance. of fluid within the body. They also recognised that salt and water were central to this process. From that time on, there were efforts to try and control the condition by using removal of fluid to help the symptoms. This was done by two main ways. One was by altering secretions and making people excrete or release more fluid. either through diaphoresis, which is making them sweat, or through losing fluid through their bowels using purgatives. The other way that fluid was removed from the body was by direct means. So some patients would undergo a process of bleeding where literally blood would be taken from the veins. Some underwent leaching and some underwent lancing. This really went on for a good number of years, and in fact it wasn't until in the post-war era that we started to look towards mercurial agents as potential diuretics. These agents, although they had some efficacy or some effect, weren't really... able to do the job that was required and interestingly it was subsequent to World War II towards the end of the 1940s and into the 1950s where the current modern diuretic agents were developed and started to be used. These are agents that hold salt in the urine and take salt and water from the body allowing the kidneys and the urine to be the source. of release of the extra fluid which has been collected as part of that process of dropsy or cardiac failure or even altered renal function. I'm going to stick to the cardiac failure component of it. The renal failure leading to swelling and edema is a different story altogether. In the modern day, in my practice, in my rooms, the patients who come to see me who have features of cardiac failure will tend to describe shortness of breath mainly on exertion. Often they'll notice climbing hills or climbing stairs or carrying their groceries as the thing that will trigger their awareness that they're more short of breath than usual. They may describe fatigue or lethargy or lack of motivation to do things because of that shortness of breath. It's pretty common for these same patients to also recognise some swelling, and they may certainly recognise swelling in their legs, and if it's worse, they may even recognise swelling in their tummies. There are two particular situations that we do see with shortness of breath in the setting of cardiac failure, and these are position-related changes. Most commonly, when patients are sitting upright or standing upright, fluid that is within the body tends by gravity to be drawn to their legs or the lower extremities. This means that the lungs, relative to the fluid balance that's in the body, remain free or relatively free of the extra fluid that's been accumulated. One of the situations that gets described by patients with some regularity is a condition that we call orthopnea. Orthopnea. And what this simply means is that when the patient lays down flat or lays most of the way down flat, they become short of breath. This is relatively easy to understand. It simply means that there is excess fluid within the circulation. That that excess fluid is by gravity being held in the lower extremities when the person lays down flat. That fluid then moves toward the chest and leads to congestion within the lungs. Sitting back upright will improve that situation almost immediately. We call that orthopnea. And that's a simple shift of fluid due to excess fluid being within the circulation. The other condition that we sometimes have reported is a condition called paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea. So this is shortness of breath that comes somewhat out of the blue in the middle of the night. What patients will describe is that they go to bed without any problems. In fact, they don't have orthopnea. So this condition is a precursor to orthopnea. These patients will go to bed, relatively comfortable, they'll have several hours of sleep, but then be interrupted with shortness of breath, a feeling of suffocation. This clearly provokes anxiety and fear. These patients will sit up, get out of bed, And the historical reports, the clinical reports that we read about as training doctors is that these patients will open a window and get fresh air to help relieve their symptom. Well, what's happening with paroxysmal nocturnal dyspnea is there's still fluid overload within the body, but that fluid overload is mainly held within the tissues, not within the circulation. If it's held within the tissues... Then as the patient lays down and rests overnight, the fluid that is in, say, the legs, the lower extremities, moves out of the tissues into the circulation. The circulatory volume increases. That circulatory volume as it increases can then flow back to the chest, cause congestion, cause shortness of breath, cause the features of cardiac failure. and wake this person up in the middle of the night. These patients really do get some relief by standing up, going to a window and getting some fresh air, by altering their posture, their position, that fluid starts to shift away from their lungs, and that brings relief in terms of their breathing. So when I see patients in my rooms, when other cardiologists and doctors are seeing, patients with features of cardiac failure, how do we think about classifying those individuals with regard to the impact their breathing is having on them? Well, we use a simple scale, which is pretty broadly used and really quite convenient in a clinical setting, doctors talking to doctors, so we get an understanding of exactly what a patient's able to do. We talk about a thing called the New York Heart Association Classification of Cardiac Failure and it has four stages. There'll be a little table at the bottom to explain this in more detail or we might well provide a link for it. But very simply, the first stage is really only negligible symptoms of shortness of breath on activities of daily living, maybe some shortness of breath if pushing really hard or undertaking. greater than usual at the levels of activity. The fourth level is shortness of breath at rest or with minimal activity significant symptoms. The two levels in between are minimal symptoms with activities of daily living and marked symptoms in association with activities of daily living. So our four classifications. So that's how we think about cardiac failure. It's been observed for thousands of years. We've evolved, fortunately, beyond giving people appearance, agents, laxatives and purgatives. We've progressed beyond using leeches. We've now got a range of... diuretic agents that hold salt and water and take those out through the kidneys to help us balance the congestion within the circulation. I've told you about how people present with cardiac failure including positional issues which is laying down and being woken up from sleep and I've also touched on the New York Heart Association classification. I hope that gives you a little bit of background on how we observe and think about cardiac failure. Of course, if you have any queries or questions, as always, feel free to drop us a note. If you've got any suggestions for further topics, please also drop us a line. As always, I'd like to wish you the very best. Take care and bye for now. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.