Preventing heart failure: Disciplined lifestyle vs. medication

A simple and practical plan to suit the individual would suffice

For conditions that eventually result in heart failure, we can give treatment; we can give you three different medicines for three different conditions – high blood pressure, diabetes, and cholesterol – but if you exercise and eat healthy, that will solve all three problems at one go – without medication

By Fathima Riznaz Hafi

A healthy lifestyle, which includes exercise, a good diet, and adequate sleep, has always been the mantra in prevention of heart disease, as it has been for prevention of just about any other disease. However, this requires immense discipline, which many people do not have. The general tendency is, not to invest in good health habits, but instead, when signs of trouble start to surface, to invest in medication, to prevent further deterioration. This may be the easier option. But is it the better option?

Parkway Hospitals Singapore Cardiologist Dr. Lim Choon Pin, during a recent press meet in Colombo, said it is far better to practise some discipline and maintain good health, that is, take preventive measures, than seek cure through numerous amounts of medication and treatment, after the damage is done.

Lifestyle

“Lifestyle is important. Overall, for most people, exercise is very beneficial – it not only protects your heart; it controls blood pressure, diabetes, and cholesterol. High blood pressure, cholesterol, diabetes and smoking – these are the four main causes of blocked heart arteries and then blocked heart arteries lead to heart failure. 

“If you have these, we give you three different medicines. But if you exercise and eat healthy, it will solve all three problems at the same time – without medication! It is, however, easier said than done. It requires a lot of discipline to really live such a healthy lifestyle. We have a lot of excuses,” Dr. Lim said.  

People avoid exercise thinking they have to go to great lengths to be fit. Contrary to popular belief, vigorous training or high intensity workouts are not mandatory to achieve fitness. A simple and practical plan to suit the individual would suffice. “We recommend moderate intensity exercise. Different people like to do different things, and you can simply choose what’s best for you, be it jogging, brisk walking, or swimming,” he explained. 

Heart patients and fear of exercise 

There is however, a fear among patients on the safety of exercise especially for those with a weak heart or other conditions. The fear stems from cases of patients dying after exercise. The exercise factor is confusing for patients because the medical experts say it’s good for the body and then when the patients exercise they die – Dr. Lim was therefore asked about what should be done about this and if it is unsafe to exercise with heart ailments.

“When you exercise you have more adrenaline in your body; so if someone has blocked arteries, the adrenaline can cause a sudden heart attack. If someone has an abnormal heart rhythm, the adrenaline may also trigger this abnormal heartbeat. Or if they have an abnormal heart muscle, the adrenaline can trigger off the attack or cardiac arrest,” he explained, adding, “That doesn’t mean you shouldn’t exercise. The intensity just needs to be adjusted.” 

“Exercise is good if you don’t have a severe heart issue, and it helps to prevent blockages in the heart arteries; but if somebody has underlying heart problems, then the exercise may not be suitable for them. Those who have risk factors – diabetes, cholesterol, blood pressure, and smokers – may have to go for some check-ups before they start on exercise. 

“These patients should be evaluated; we should ‘risk-stratify’ them – assess them to see if they are suitable for exercise, or whether they should adjust their exercises. This is why we recommend that they go for heart screening. Those who experience chest discomfort or breathlessness and are worried about whether it is safe to exercise, should go for this health screening. If they go for the screening, and we detect some abnormality, we can tell them to adjust the exercise intensity and suggest the type of sports that they should be doing.” 

Quality of sleep

Dr. Choon stressed that sleep quality is also very important as sleep is when our body regenerates. “For people who lack sleep, their body is in a heightened state of stress. There is a lot of high adrenaline levels in their body. It stresses the heart, increases blocked arteries, increases blood pressure, and increases risk of heart rhythm problems. Sleep is important – not just quantity (above six hours per day is essential) but also quality of sleep,” he explained.  

Modifiable and non-modifiable risk factors

Dr. Lim noted, however, that an unhealthy lifestyle is not always the cause of a heart ailment. It could be the result of a genetic disposition, in which case nothing could be done to prevent its onset. 

“There are things we can prevent and things we cannot do anything about. What we’ve mentioned so far are modifiable risk factors – things that you can do something about. But then there are the non-modifiable risk factors – such as your age – as you grow older, cholesterol will go higher, blood pressure goes higher, sugar goes haywire, and also there is risk of blockage as you grow older. Then of course, there’s genes as well; you can’t do anything about it. You can blame your father, blame your mother, but at the end of it, you are still stuck with the genes. A family history of blocked heart arteries increases the risk of blocked arteries yourself. And a sedentary lifestyle makes it worse – the less exercise you engage in, the higher the chances of developing heart diseases.” 

Medication

In the absence of a good lifestyle, or due to a genetic disposition, eventually a person’s heart health starts to deteriorate, especially with ageing. The person then turns to medication and this type of medication is usually for lifelong use. The doctor was asked if there are risks that come with long-term medication, and if the medication can be halted after the condition is brought under control. 

“These medications tend to be long-term. A lot of patients ask if they can stop. The reason we put patients on medication is lifestyle and diet no longer controls it. So when you take these medications it only helps enhance your body’s clearance of all this cholesterol; it brings it down. But the moment you stop the medicine, it goes back to your original level which is a bad level, and that’s why most people require the medication lifelong. Like for high blood pressure, diabetes, and cholesterol – these medicines don’t cure you – they don’t get rid of the diabetes – they only control it; they bring down the sugar; the moment you stop the medicine, you are back to your own self, you’re surviving on your own organs; the level comes back up to usual again; so most patients are on these medicines lifelong.”

The doctor was asked, in patients whose cholesterol is at a danger level, when they take the medicine for some time and bring it down to a safe level, can’t they just maintain that through a healthy lifestyle and diet? He replied, “Not unless you change your lifestyle drastically. Let’s say you didn’t exercise before and now you exercise five times a week; you were eating unhealthily in the past, and you have changed your diet completely, maybe your cholesterol has come down and yes you can cut down on the medicine. But the reality is, most people will not change their lifestyle; and most people, if I tell them, “Let’s monitor for six months,” they really won’t do anything for those six months. Six months later, you don’t change your lifestyle, you get the same results. So that’s why most people are stuck on medicine – it’s because they don’t change their lifestyle drastically enough to make a difference.” 

Adverse effects of long-term medication

It is said that long-term use of medication can cause severe side effects and also damage to important organs, especially the kidneys. The doctor was asked if this information was correct. “These medicines have been around for a long, long time; the long-term safety is well-established. We have patients on decades and decades of cholesterol, diabetes, blood pressure medicine, that shows that it is quite safe. Our randomised controlled studies also show that these are quite safe.”

As for the risk of damage to the organs, Dr. Lim advised regular check-ups so the doctors can monitor it, but noted that the damage is usually not caused by the medicine. “Your doctors will check on your kidney function, liver function, make sure that everything is okay. If the liver or kidney is not so good, we may have to adjust the medication; but usually it’s not because of the medication. Let’s say you don’t take blood pressure pills – having high blood pressure will damage the kidney much faster than if you took the medicines. The medicines actually help to protect your body against all this long-term damage. So overall, the benefits strongly outweigh the risks of all these medicines. They are meant for long-term use.” 

When the only solution is surgery

When heart health deteriorates, in most cases, medication can help control the condition but in more severe cases, such as when these patients reach advanced, end-stage heart failure, surgery is the only solution.

Dr. Lim explained what happens after damage has set in and what options there are to treat the patients. “Within the heart we have artery diseases, valve problems, blocked arteries, heart rhythm problems, and heart failure. When it reaches heart failure, the heart becomes weak, the pumping function of the heart becomes inefficient and cannot meet the body’s demands. When that happens, the patient feels more and more sick; they feel breathless, they experience leg swelling, abdominal swelling, and they develop a lot of water retention problems; then even with activities we usually do, like walking, exercising, climbing stairs, they feel breathless. This is my area of specialty.”

He said that when it comes to the advanced stage, when the patient’s heart is weak, more drastic measures have to be considered, such as heart transplants. However, it is very difficult to find a donor. Many countries have a shortage of heart donors. Some countries don’t even have a heart donation or heart transplant program. There are also other downsides to heart transplants, such as infections and the body’s system rejecting the new heart. 

It is still the gold standard, but in the absence of a heart transplant, there is the ventricular assist device, which is an artificial heart pump that runs on batteries. 

“This device is inserted via an open heart surgery; we put the pump in at the tip of the heart. It sucks the blood from the heart and pumps the blood to the rest of the body, thus taking over the function of the heart. The battery-operated device enables the patient to walk, run, and travel, as opposed to when the heart was very weak, and they were frequently hospitalised, and breathless. We put these pumps so they can have a good quality of life. Some of them, after this surgery, they walk faster than me! More importantly, it keeps them alive,” he explained.

The chance of survival of someone with advanced heart failure is less than 50% in one year. With the pump inserted, the average lifespan will be five years and beyond. “This is a lifesaving surgery; a lifesaving pump. It’s not experimental; it’s actually the standard of care in most guidelines, and certainly we do quite a fair bit of it in Singapore. We’ve been doing this since 2009; around 15-20 patients per year.”   

Though there is now state-of-the-art treatment available for heart failure, Dr. Lim reiterated that drastic measures and costly treatment can be avoided by simply following a healthy lifestyle, and if genetically predisposed, to go for regular screening so early intervention can take place. He spoke of how easily heart failure can be avoided, with some self-discipline. “For conditions that eventually result in heart failure, we can give treatment; we can give you three different medicines for three different conditions – high blood pressure, diabetes, and cholesterol – but if you exercise and eat healthy, that will solve all three problems at one go – without medication!” he stressed.