A fading heart

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Heart failure is often not diagnosed until it’s too late. Discover how to spot the signs years before, so that your doctor can apply the brakes.

When we think about cardiovascular catastrophes, heart attack and stroke leap to mind. We're less likely to think of heart failure, though it affects more than 2.5 million women and is the leading reason for hospitalisation and a major cause of death in women over 65. The term "heart failure" evokes an image of a suddenly silent heart, but the condition is better described as a gradual decline in the heart's ability to pump and circulate blood.

Like other muscles in the body, the heart weakens over the years. For most people, the effects are subtle: colour fades from the cheeks; hands grow cold; you begin to nod off earlier in the evening. But for the 1% of people over 65 who develop heart failure, a decline in the supply of oxygenated blood to organs and tissues can eventually jeopardise the lungs, kidneys, and liver.

Today, we know that practising healthy habits earlier in life can often prevent heart failure. And thanks to improved treatments aimed at preserving heart function, women with heart failure can expect to survive longer than in past generations.

Causes of heart failure

Heart failure usually doesn't have a single cause. Instead, several factors or conditions act in concert to erode heart function. The problem may originate in either the right ventricle, which pumps blood into the lungs, where it picks up oxygen, or the left ventricle, which pumps oxygen-rich blood to the body's tissues. In either case, the heart can't do the work needed to supply adequate blood to all parts of the body.

The ventricle may be too stiff to relax enough between contractions and thus unable to fill completely (diastolic failure), or - more commonly - it may not contract strongly enough to expel most of the blood it holds (systolic failure).

Like coronary artery disease, heart failure may take a slightly different course in women than in men. The landmark Framingham Heart Study has followed the development of heart failure in three generations of men and women and catalogued the risk factors. The researchers found that any of the conditions listed below can set the stage for heart failure, but some are more likely culprits in women:

Hypertension

As blood pressure rises, the heart has to work harder, putting its muscle tissue under strain. Hypertension raises the risk of heart failure two to three times, and it's a stronger risk factor in women than in men. In a 1996 Framingham report, nearly 60% of women with heart failure had a history of high blood pressure, compared to only 40% of men.

Diabetes

Diabetes doesn't cause heart failure directly, but it promotes coronary artery disease and hypertension, especially in women. A 1993 report from the Framingham Heart Study indicated that diabetic women, aged 35 to 64, were twice as likely to develop heart failure than diabetic men the same age.

Valvular abnormalities

Heart valves that have structural defects, whether present at birth or resulting from disease, may fail to open and close properly. As with hypertension, the heart may pump harder to compensate. Over time, this can result in heart failure.

Myocardial damage

With age, the heart finds it more difficult to compensate for past damage to its muscle tissue. This damage may result from conditions present at birth (such as congenital cardiomyopathy or abnormalities in the formation of the heart chambers) or it may be due to infections or other conditions encountered in youth or adulthood.

A heart attack, for example, can permanently damage the heart muscle. About 25% of people who survive a heart attack develop heart failure within the next year.

Coronary artery disease (CAD)

As blood vessels narrow because of cholesterol build-up, blood flow to the heart muscle tissue (myocardium) decreases, gradually causing the tissue to deteriorate. CAD is a major source of heart failure, but it's more likely to be the chief cause in men than in women.

Severe lung disease

Conditions like chronic obstructive pulmonary disease and pulmonary fibrosis reduce the amount of oxygen in the blood, forcing the heart to work harder. Eventually, the right side of the heart can weaken and become enlarged, a usually fatal condition known as cor pulmonale.

Obesity

Probably because it raises the risk of CAD, obesity is also an independent risk factor for heart failure. In the Framingham study, obese women had a 50% greater risk of heart failure than women of normal weight.

Certain forms of chemotherapy

The chemotherapy drugs known as anthracyclines - for example, doxorubicin, which is used to treat breast and other forms of cancer - are toxic to the heart muscle tissue. Cancer survivors who were treated with these drugs have a higher risk for heart failure.

Peripartum cardiomyopathy

Rarely, for unexplained reasons, some women suffer heart failure in the month before giving birth or within a few months afterward. The condition can be reversed if it's treated promptly, but it's likely to recur in future pregnancies. A woman is at greater risk of this condition if she's over age 35, is African American, or has pregnancy-related diabetes.

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