Transforming heart health: Awareness saves lives

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Given that Heart Awareness Month is one of its key campaign events, the foundation aims to make a significant impact on heart-disease awareness and through the campaign strategy also aims to reduce the burden of cardiovascular disease (CVD).

Sunday, 29 September, is World Heart Day (WHD), and the foundation’s Heart Awareness Month (HAM) campaign will culminate on this day. The HSFSA will align with the World Heart Federation's global theme, highlighting the need for continued collaboration and collective action to make a lasting impact.

Taking a comprehensive look at the cardiovascular-disease statistics pertaining to the mortality and morbidity rates in the South African context, it is alarming that South Africa is still facing a crisis of CVD burden.

Statistics South Africa in 2020, highlighted mortality trends, indicating that Diabetes Mellitus, hypertensive disease, cerebrovascular disease and heart disease were marked in the top 10 leading natural causes of death in South Africa. These conditions added up to an estimated 17% of all reported deaths in 2020.

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Chief executive officer, Pamela Naidoo, together with key stakeholders have realised that the South African public does not fully understand the complexity of CVD. She continues to state that “there are many medical conditions that constitute the cluster of CVDs”. As a starting point Naidoo conceptualised the focus on heart failure given the many misconceptions about what exactly is heart failure.

Consequently, for 2024, Heart Awareness Month's primary theme is on heart failure and its key risk factors. Over a four-week period, each week will have an exclusive but related theme on heart failure.

Week One: What is heart failure?

Heart failure, or congestive heart failure, is a serious condition, in which the quantity of blood pumped by the heart each minute (cardiac output) is insufficient to meet the body’s normal requirement for oxygen and nutrients.

This does not mean, however, that the heart is about to fail or stop completely. During heart failure, the heart is not capable of coping with its workload. When the heart does not pump efficiently, the heart has to beat faster and gradually enlarge to cope with the workload causing the heart to weaken and the amount of blood pumped to the body to be restricted.

The circulation becomes sluggish causing excess fluid to be retained in the body. When this happens a person's blood cannot deliver enough oxygen and nutrients to the rest of their body to allow it to work normally.

Heart failure can damage the liver or kidneys and may lead to other conditions including pulmonary hypertension or other heart conditions, such as an irregular heartbeat, heart valve disease, and sudden cardiac arrest.

Heart failure may happen suddenly with severe symptoms (known as acute heart failure) or symptoms may appear slowly and gradually worsen (known as chronic heart failure). If not treated, heart failure (HF) can be life-threatening. If treated however, many individuals live with HF for years.

Types of heart failure may be divided into two categories: Left-sided heart failure and right-sided heart failure.

Left-sided heart failure is when the power of the left heart chamber is reduced causing the left chamber to work harder to pump the same amount of blood. The left chamber is responsible for pumping blood throughout the body. There are two types:

• Heart failure with reduced ejection fraction, also called systolic heart failure. The left heart chamber does not have enough force to push enough blood into circulation.
• Heart failure with preserved ejection fraction, also called diastolic heart failure. The left heart chamber does not relax normally because the muscle has become stiffer and thus the filling of the chamber with blood is impaired.
  The term ejection fraction describes the heart chambers’ strength and ability to empty with each beat. Specific left-sided heart-failure symptoms may include fluid build-up in the lungs, causing shortness of breath, bluish color of fingers and lips, sleepiness or trouble concentrating and an inability to sleep lying flat.

Right sided heart failure affects the lower-right heart chamber and is responsible for pumping blood to the lungs. Some particular symptoms may include fluid build-up and swelling in the abdomen, legs and feet or a pain in the abdomen area.

Generally symptoms of heart failure may include:

• Shortness of breath with activity or when lying down
• Wheezing
• A cough that doesn't go away or a cough that brings up white or pink mucus with spots of blood
• Swelling in the abdomen, legs, ankles and feet
• Weight gain from fluid retention
• Fatigue, weakness or dizziness
• Rapid or irregular heartbeat
• Nausea and loss of appetite
• Increased need to urinate at night
• Palpitations

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Week Two: The causes of heart failure

When considering the different types of heart failure (HF), we note that HF may be caused by a weakened, damaged or stiffened heart. If the heart is damaged or weakened, the heart chambers may stretch and get bigger, which means that the heart can't pump the blood out of the heart at the rate it is supposed to. If the main pumping chambers of the heart are stiff or rigid, they can't fill with enough blood between beats.

The heart is vulnerable to many factors that may lead to the heart muscle being damaged, weakened or rigid. These risk factors include advancing age, sex, inherited cardiomyopathies, hypertension, diabetes mellitus, obesity, certain infections, consumption of alcohol, drugs or tobacco products and selected chemotherapy medicines.

The following conditions may cause damage or weaken the heart and lead to heart failure:

• Coronary artery disease and heart attack: Coronary artery disease is the most common cause of heart failure due to atherosclerosis taking place in the arteries supplying the heart muscle. This reduces blood flow and can lead to heart attack, which in turn damages the heart tissue.
• Hypertension/high blood pressure: Hypertension causes the heart to work harder to pump blood throughout the body. Over time, the extra work can make the heart muscle too rigid or too weak to properly pump blood.
• Heart valve disease: The valves of the heart ensure the blood flows in one direction. Heart valve disease or damage may cause the heart to work harder to pump the blood. This may weaken the heart over time. Treating some heart-valve conditions may reverse heart failure or improve heart function.
• Myocarditis: Myocarditis is most commonly caused by a virus, which is characterised by inflammation of the heart muscle, and can lead to left-sided heart failure.
• Congenital heart disorders: The heart, chambers or valves which haven't formed properly, may cause other parts of the heart to work harder to pump blood.
• Arrhythmias: Irregular heart rhythms may cause the heart to beat too fast, slow, or inconsistently, creating extra work for the heart.
• Other diseases or causes: Some long-term diseases like diabetes, thyroid disorders, or chemical imbalances may contribute to chronic heart failure. Some acute conditions are: Allergic reactions, any illness that affects the whole body, blood clots in the lungs, severe infections, and use of certain medicines. It is also important to note that the causes of HF differ across countries. In tropical countries for example, parasites can lodge in the heart leading to HF.

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Week Three: Management of heart failure and living with heart failure

When treating and managing heart failure the goal is to help patients live longer, prevent hospital admissions, decrease symptoms and improve quality of life. Heart failure is to a large extent not curable but manageable.

It is, however, possible that in the event that a disease or condition that has led to heart failure is treated, like valvular disorders, it may reverse the heart failure, depending on the damage that has already been sustained.

Management of heart failure may include: medication, devices, surgery, behaviour modifications, management and monitoring.

• Medication: Medication treatments are patient specific and may be used to achieve the following: To remove extra sodium and fluid from your body, to relax your blood vessels, to slow your heart rate, and to make your heart beat stronger and pump more blood.
• Devices: Sometimes a doctor, depending on the condition, may advise a medical device to be inserted surgically to treat heart failure.
• Surgery: A person with heart failure may also need heart surgery to repair any congenital heart defects or damage to their heart. If a person’s heart failure has progressed and become life-threatening and other treatments have not worked, the person may need a heart transplant, if all other criteria have been met.
• Behaviour modifications: Behavior changes are essential for a cardiac-rehabilitation programme to be successful. It may include dietary changes (low salt, low sugar, low fat), reaching and maintaining a healthy weight, regular exercise, managing stress, getting enough sleep, avoiding alcohol, tobacco products, or any other illicit drugs.
• Management and monitoring: When people are diagnosed with heart failure, they will need to follow a treatment or management plan for the rest of their lives. Heart failure will indefinitely progress, but adhering to the management plan it may improve and lengthen the person’s quality of life. Regular monitoring of the condition is essential. One may be able to detect and treat new or worsening symptoms before it leads to more damage.

Week Four: Diabetes Type 2 and other risk factors for heart failure

Heart Failure (HF) is a common complication of diabetes, affecting between 9% and 22% of individuals with diabetes, particularly those over 60 years old, with incidence rates on the rise.

The prevalence of diabetes has risen by 30% globally in the past decade, increasing the burden of HF on the healthcare system. HF may develop in individuals with diabetes even without hypertension, coronary heart disease, or valvular heart disease, making it a major cardiovascular complication in this vulnerable population.

According to the American Diabetes Association, having a glycated hemoglobin A1C of more than 7% was tied to a greater chance of developing later stages of HF. Each 1% increase in glycated hemoglobin A1c increases the risk of HF by 30% in Type 1 diabetes (T1DM) and by 8% in Type 2 diabetes (T2DM).

The epidemiologic association between HF and diabetes is well-known, with longitudinal observational studies showing a two- to fourfold increased risk of HF among men and women with diabetes or pre-diabetes compared to those without diabetes.

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Heart failure risks

A systematic review by Ohkuma et al. (2019) of 47 cohort studies found that both Type 1 Diabetes Mellitus (T1DM) and Type 2 Diabetes Mellitus (T2DM) are significantly higher risk factors for heart failure (HF) in women compared to men, with T1DM associated with a 47% higher excess risk and T2DM with a 9% higher risk. Effective diabetes management may reduce HF incidence and progression, thereby impacting quality of life and lifespan.

The other risk factors for HF include coronary artery disease, high blood pressure, obesity, metabolic syndrome, hyperactive thyroid problems, aging, smoking, alcohol or drug abuse, and certain types of radiation and chemotherapy. Unhealthy behaviours like eating food that are high in fat, cholesterol and sodium; physical inactivity; smoking tobacco and electronic vaping devices; and alcohol consumption can increase the risk of HF.

According to the American Heart Association, hypertension, obesity, diabetes, and smoking are responsible for 52% of HF incidences. Hypertension control reduces HF risk, with effective treatment reducing HF events. A meta-analysis by Thomopoulos et al. (2016), found that controlling blood pressure within normal ranges can result in a 40% reduction in HF.

Men and women both experience HF, but men tend to develop it at a younger age, while women tend to have worse symptoms. Research has found that individuals of African origin have an estimated 19% higher risk of developing HF than those of European origin. Hispanic individuals carry multiple HF risk factors and healthcare disparities, which suggests elevated HF risk in this population.

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Healthy eating tips

Shonisani Nephalama, the HSFSA's nutrition science team head states that healthy eating patterns, including the Mediterranean diet, whole grain, and plant-based diets, as well as Dietary Approaches to Stop Hypertension (DASH) diets, are inversely associated with incident hypertension and may offer protection against HF.

She also encourages the public to look out for The Heart and Stroke Foundation South Africa's heart mark logo on food products which is an indication that the foundation has endorsed the product as being a healthy food choice.

Throughout the month of September, the foundation’s healthcare practitioners have many activities planned in community-based settings in the provinces of KZN, Western Cape, and Gauteng, and will also provide health talks and health-risk assessments.

The foundation emphasises the crucial importance of understanding your risk for CVDs. Regular cardiovascular screening is vital to knowing one's key health indicators: blood pressure, blood glucose levels, blood cholesterol levels, and BMI.

By monitoring these numbers, people can significantly reduce their chances of developing heart attacks, strokes, and other CVDs.

Juandre Watson, the Health Promotion and Health Risk Assessment team lead at the foundation, urges all South Africans to know their numbers, be informed about matters relating to their health, and to adopt healthy lifestyle behaviours.

This year, the global theme for World Heart Day is, 'Use Heart For Action' and the theme is driven by the World Heart Federation (WHF), of which the HSFSA is a proud member.

The 'Use Heart For Action' theme goes beyond mere awareness, emphasising purposeful efforts to drive meaningful change.