The Case of the Fast-beating Heart: From Heart Failure to Successful Treatment

It's very sweet that after a decade of marriage, Nancy Bowen still likes to rest her head on her husband's chest while they sit at on the sofa watching a movie at home in the evening. It's also fortunate that she is a nurse. One night, these two factors converged with a surprising result. Bowen put her head on her husband John's chest and grew alarmed. "What's going on? Your heart is racing. You're in atrial fibrillation," she remembers exclaiming. This was just the beginning of the surprising things they would learn about John Bowen's heart.

Oddly, Bowen felt fine and was unaware of his racing heart, though many people with atrial fibrillations can feel the palpitations. Once Nancy Bowen explained to her husband that untreated atrial fibrillation can lead to the risk of a stroke, he agreed to let her drive him to the ER at University of Maryland St. Joseph Medical Center, where she once worked as a nursing supervisor.

At the UM SJMC Emergency Department, Ben Vanlandingham, MD, one of the many board-certified emergency physicians who work there, confirmed the diagnosis as atrial fibrillation.

Be Still, My Beating Heart

"When John arrived, his heart rate was 180, which is very fast, so we used medications, including a calcium channel blocker, to slow his heart down," says Dr. Vanlandingham. "A normal heart rate is between 80 and 100 beats per minute. Because John's atrial fibrillation was a new diagnosis, we kept him overnight for observation and further diagnostic tests."

Atrial fibrillation, also known as AFib, is an irregular and often fast heartbeat. It is also called an arrhythmia. AFib may put a person at risk for heart failure because their blood is not moving as well as their body needs. More than 2 million people in the U.S. suffer from AFib, and it is more common in people ages 60 and older. Bowen is 71 years old.

The next day, Bowen's doctors discovered an additional heart issue. His heart was not pumping well, meaning that he had congestive heart failure. "John had an ejection fraction (the percentage of blood leaving the heart each time it contracts) of 20 percent when he was admitted to the ER. Normal is above 50 percent," says Dr. Vanlandingham.

A Rare Symptomless Case

"It was very interesting and unusual that he had no symptoms at all other than the very fast heart rate. He is a healthy weight, doesn't have high blood pressure, and is very active; he told me that he plays a hard game of basketball with his friends several times a week and works out, too," says Dr. Vanlandingham.

Jeremy Pollock, MD, of UM St. Joseph Cardiology Associates, who became Bowen's treating cardiologist, explains that there are two types of heart failure: Most heart failure presents with a reduced ejection fraction, which is known as a weak heart, such as John had; the other type has a preserved ejection fraction, which is known as a thick or stiff heart.

A Range of Causes

"About 60 percent of heart failure is caused by heart disease, hypertension, diabetes, atrial fibrillation, obesity, alcohol or sleep apnea. In the other 40 percent, it can be difficult to find the reason for the patient's weak heart," says Dr. Pollock.

Because the heart isn't pumping blood properly, blood backs up into the lungs, belly, legs and other tissues, explains Dr. Pollock. "The symptoms are shortness of breath, fatigue, trouble sleeping flat, unintended weight gain and swelling in the legs and belly," he says. Bowen recalls that he felt a little fatigue, but he attributed that to his demanding workouts and getting older.

Another risk factor of blood backing up is that it can pool inside a person's heart and form clots, leading to a stroke.

Under the care of Dr. Pollock, Bowen's heart has improved steadily. "We used three classes of medications to treat John, which helped improve his heart function back to normal," says Dr. Pollock. "I follow [congestive heart] failure patients closely. Each visit we ensure they are on the best and optimal doses of medications, which we use to prevent scarring to the heart and retention of fluids by stopping the release of hormones that create these problems."

Expertise Treating Heart Failure

"To treat heart failure, we need to treat the causes of that heart failure. This may include controlling high blood pressure, losing weight, increasing exercise, and/or managing chronic medical diseases such as diabetes, atrial fibrillation or alcohol abuse. Patients should eat a low-salt diet. Patients who have blocked arteries of the heart will need to receive a cardiac stent to open the blockage or undergo open-heart surgery," he says.

The only contributing factors to Bowen's heart failure that Dr. Pollock has been able to identify are his atrial fibrillation and alcohol, both of which can con-tribute to a weak heart. Bowen said that he used to like to drink a couple of glasses of wine every evening, but he says, "Now I only drink one glass of wine a month."

"Dr. Pollock is a very fine physician," says Nancy Bowen. "He's been very attentive. John has a normal heart function now, and we're thrilled."

Results like this are what motivated Dr. Pollock to go into cardiology. "Being a cardiologist means everything to me. It's why I became a physician—to help people get healthy. It's extremely meaningful to help people heal as well as to help them heal themselves through lifestyle modification and healthy choices."

A Common Reason for an ED Visit

For people ages 65 and older, congestive heart failure (CHF) is the leading cause of hospital admissions. "We see a lot of CHF in the emergency department," says Neal Frankel, DO, UM SJMC chief of emergency medicine. "With an older population, it's one of the top five reasons to visit an ED." According to Dr. Frankel, the other four are chest pain, high blood pressure, diabetes and COPD (chronic obstructive pulmonary disease).

The Emergency and Cardiology departments have worked together to create a protocol for patients with a history of congestive heart failure who come to the ED suffering from mild symptoms. The standardized CHF pathway has helped reduce hospitalizations and allows patients who are already under the close care of a cardiologist to recover in the comfort of home. "Those patients will receive a high dose of Lasix that helps them eliminate fluids. Some people can go home if they respond appropriately. Our lab is very efficient, and tests take about an hour," says Dr. Frankel.

"CHF is a clinical diagnosis based on a physical exam, a chest X-ray and lab tests to help guide treatment. If the patient is a new case of CHF or if we have concerns about their lab results, they will be admitted to the hospital," he adds.

Approximately 6 million people in the U.S. suffer from heart failure, and approximately 670,000 new cases are diagnosed every year. Over time, untreated congestive heart failure can cause organ failure.

Getting Back into Proper Rhythm

AFib is another common diagnosis seen in the ED. "The majority of AFib patients we see have chronic AFib and are followed closely by their cardiologists. Our job is to get their heart rates under reasonable control through medication," says Dr. Frankel.

Occasionally, patients with chronic atrial fibrillation who come into the

ED within 24 hours of an episode starting can be treated with cardio-version. "Some patients go in and out of atrial fibrillation very frequently. In rare instances, a patient with a history of atrial fibrillation who is on blood thinners and knows exactly when they went into AFib can undergo cardioversion to restart their heart and restore a normal heartbeat," says Dr. Frankel. "However, they have to be absolutely certain."

Cardioversion can be done using anti-arrhythmic medication or electricity with IV sedation. "Sticky pads are placed on the patient's chest and connected to a defibrillator. A shock of energy is delivered to the heart to reset it," he says.

As a newly diagnosed congestive heart failure patient who did not know when he went into atrial fibrillation, Bowen underwent a cardioversion later during his hospital stay following further testing and treatment with medications.

Bowen's diagnosis of atrial fibrillation and congestive heart failure is an exceptional one. As Dr. Vanlandingham states, "John's wife made an early diagnosis thanks to her training, but if you feel like your heart is racing and beating like crazy for no reason at all, the best thing to do is call 9-1-1."