The High Blood Pressure/Heart Failure Link: A New Concern for Older Americans

Congestive heart failure is the only cardiovascular disease that is increasing in prevalence and mortality. The clinical, economic, and social costs associated with this illness are staggering. Congestive heart failure results in multiple hospitalizations per patient, and its prognosis is poor. Congestive heart failure is straining our health care facilities, draining the Medicare budget, and most important, robbing many older citizens of the ability to enjoy their final years of life.

In this article, Dr. Claude Lenfant, Director of the National Heart, Lung, and Blood Institute, discusses the causes of congestive heart failure, why rates for this disease are rising, how this upward trend is affecting the Nation, and what can be done to combat this trend.

AI urge everyone who is concerned about the quality of life of older people to support the National High Blood Pressure Education Program's efforts to bring renewed national attention to high blood pressure control and its role in preventing congestive heart failure and the devastation this disease exacts on older Americans and on the health care system. Claude Lenfant, M.D. Director, NHLBI Dr. Lenfant also shares findings from the latest research, which indicate that the primary precursor of heart failure is uncontrolled hypertension. Dr. Lenfant stresses the need to bring renewed attention to high blood pressure control and the absolute necessity of changing the idea that blood pressure control is not crucial for the elderly.

Years ago, it was known as "dropsy," an apt name for a condition characterized by severe fatigue and weighty swelling, especially in the lower body. Many people may remember someone who was said to suffer from dropsyCan aunt, uncle, or elderly neighbor who could hardly get from the bed to a chair, who propped up on pillows to breathe, or whose swollen ankles literally draped over the tops of shoes.

A disease of the past? Hardly. This condition, now known as congestive heart failure (CHF), is a growing and serious public health concern. CHF is, in fact, the only cardiovascular disorder that is increasing in prevalence and mortality.

Currently, more than 4.7 million Americans suffer from congestive heart failure, and each year CHF is listed as the primary or secondary cause of death of 250,000 people. 1 Congestive heart failure is present in 2 percent of persons age 40 to 69, in more than 5 percent of persons age 60 to 69, and in 10 percent of persons age 70 and over. In addition, national surveys show that the prevalence of CHF increased substantially in all ages between two periods: 1976 to 1980 and 1988 to 1991 (figure 1).

Consequently, profound clinical, economic, and social costs are associated with this illness. Since 1970, hospitalization rates due to congestive heart failure have quadrupled (figure 2), and more than 6 million hospital days are attributed to CHF annually. 2 CHF is the most prevalent discharge diagnosis among patients age 65 and older, and it is the most expensive item ($12 million) in the Medicare budget. 3 And, because of its effect on energy and mobility, this disease prevents many older people from fully enjoying their final years.

What causes heart failure?
Ironically, death and disability attributed to CHF are increasing at the same time that significant progress is being achieved with other cardiovascular diseases, such as stroke and heart attack. To understand why, it is necessary to examine the process of congestive heart failure.

Heart failure does not mean that the heart stops; instead, it means that the heart fails to pump blood effectively and therefore fails to adequately deliver oxygen to the body's cells. This inability to pump blood is caused by damage to the heart muscle. The damage preceding CHF can be caused by a heart attack, uncontrolled hypertension, atherosclerosis, valve deformities, or lung disease.

When the heart pumps ineffectively, blood backs up into the lungs (which makes breathing difficult) or gathers in the veins leading back to the heart (which causes severe swelling). Eventually, the pressure from the swelling or the oxygen deprivation damages vital organs, including the heart itself.

Once CHF develops, the prognosis is not favorable. As the disease progresses, most patients are hospitalized several times and their quality of life steadily diminishes. Only half survive more than 5 years following a definitive diagnosis of CHF. 4 A common consequence is sudden death, which occurs five times more often among people with CHF.

Who is at risk?
The aging process itself increases the risk of CHF, and most predisposing conditions (such as heart attack, hypertension, diabetes, obesity, and elevated high density lipoprotein cholesterol) also occur more commonly as people age. Therefore, it is reasonable to expect the prevalence of CHF to continue to increase with life expectancy. The number of people at risk of heart failure also is increasing as a result of medical science's successes in other areas. Improved medical and surgical treatments now avert premature death from various cardiovascular diseases, such as heart attack and stroke. However, those procedures do not alleviate cardiac damage or cure the predisposing condition. Therefore, many patients who survive heart attack, stroke, and other disorders eventually develop heart failure.

Symptoms of Congestive Heart Failure

• Fatigue and weakness.
• Shortness of breath, all the time or during mild activity.
• Swelling, especially in the legs or ankles
• Rapid heartbeat.
• A dry, hacking cough or wheezing.
• Waking up suddenly with a feeling of suffocation.
• Trouble sleeping unless propped up on several pillows.
• Weight gain (from fluid retention) of several pounds in less than a week, sometimes in a 24-hour period.
• Tenderness in the abdominal area; clothing tight at the waist.
  

How can heart failure be prevented?
Recent research indicates that one common risk factor: uncontrolled hypertension is the primary precursor of congestive heart failure. Eighteen-year follow-up data on subjects from the Framingham Heart Study show that hypertension preceded the development of CHF in 91 percent of CHF cases. Data further indicate that uncontrolled hypertension increases the risk of CHF twofold among men and threefold among women and that the risk of CHF increases with the severity of hypertension. 5

Fortunately, heart failure caused by uncontrolled hypertension can be prevented, because hypertension itself can be prevented or controlled. Data from clinical trials conducted in the United States and other countries show that controlling high blood pressure can reduce the incidence of CHF by as much as 55 percent. 6

Three national surveys confirm that hypertension is not an inevitable part of aging. In fact, data show a reduction in the hypertension rate during the past 20 years among African American and white adults, ages 60 to 74.7 A person's blood pressure is considered high if it is equal to or exceeds 140/90 mmHg.

There is a substantial body of knowledge concerning ways to prevent and control high blood pressure. In addition to healthy lifestyle changes, a number of medications are successfully used to maintain normal blood pressure levels.

High Blood Pressure: Just How Common Is It?
According to the Joint Commission on the Detection, Evaluation and Treatment of High Blood Pressure--an expert panel convened by the National High Blood Pressure Education Program to develop blood pressure clinical guidelines--a person's blood pressure is considered high if the diastolic measurement meets or exceeds 90 mmHg or if the systolic measurement meets or exceeds 140 mmHg or higher.

Based on those criteria, more than half of Americans over the age of 60 have high blood pressure.

A national survey conducted between 1988 and 1991 (National Health and Nutrition Examination Survey [NHANES] III, phase 1) revealed that 50.0 percent of white women and 51.1 percent of white men ages 60 to 74 years old have high blood pressure. Among blacks the rates are much higher: 71.1 percent of black men and 73.9 percent of black women in that same age group suffer from hypertension. 8

Unfortunately, the prevalence of high blood pressure is still too high, and the rate of control is far too low, especially among older people. Data show that only 19 percent of women and 16 percent of men above the age of 70 have their blood pressure controlled to below 140/90 mmHg. 8 That level of control confirms the need for additional measures to convince clinicians and patients of the importance of treating high blood pressure and maintaining long-term control of the condition. How can congestive heart failure be treated?

Because of various drawbacks associated with medications and the overall poor outcome for established CHF, prevention remains the greatest hope for addressing this disease.
Medications, selected according to the individual patient's condition, are the mainstay of CHF treatment. Four types of medications are generally prescribed for CHF:

• digitalis strengthens the heartbeat so the heart can pump more blood with each beat;
• diuretics help the kidneys rid the body of excess fluid and reduce blood volume by removing salt and water from the blood;
• vasodilators, such as ACE inhibitors, relax the blood vessels so the heart can pump blood more easily; and
• potassium supplements replace potassium excreted with excess fluid when diuretics are prescribed. (Low potassium also can cause heart arrhythmias and is necessary for digitalis to work correctly.)

However, because of various drawbacks associated with medications and the overall poor outcome for established CHF, prevention remains the greatest hope for addressing this disease.

What is being done to address this problem?
The National Heart, Lung, and Blood Institute (NHLBI) and the National High Blood Pressure Education Program (NHBPEP) are committed to improving blood pressure prevention and control and applying their resources to the prevention and treatment of CHF. In March 1996, the NHBPEP Coordinating Committee issued a national call to action to elicit its member organizations' support of activities designed to publicize the link between high blood pressure and CHF and implement immediate steps to address this public health concern. I urge everyone who is concerned about the quality of life of older people to support the NHBPEP's efforts to bring renewed national attention to high blood pressure control and its role in preventing congestive heart failure and the devastation this disease exacts on older Americans and on the health care system.

The 45 professional and voluntary organizations and U.S. Federal agencies that comprise the NHBPEP Coordinating Committee have responded to this request by signing pledges to create action plans within their individual organizations. Since the call for action was presented, NHBPEP Coordinating Committee members have begun submitting articles to their organization's journals and newsletters, creating presentations for annual scientific meetings, developing continuing medical education courses focusing on the topic of high blood pressure and congestive heart failure, and developing contact with media outlets to draw attention to this public health problem.

At the same time, the NHBPEP has been developing a network of agencies targeting older Americans through their community outreach efforts. The network, with a combined membership of more than 4 million older Americans, will highlight the need to work with health care providers to improve the management and control of hypertension. Creating a community focus on this problem will facilitate further pooling of ideas and resources, making it more likely that we can effect a substantial change in the impact of congestive heart failure among older Americans.

The NHLBI also supports a wide range of basic, clinical, and epidemiologic research to better understand the causes and improve the prevention, diagnosis, and treatment of CHF. The studies include investigations of what happens in CHF, how this condition can be better diagnosed, and drug therapies that may improve the prognosis of patients with CHF. Other studies are trying to prevent the loss of heart muscle cells, which causes the heart to lose its ability to pump blood effectively. In animal studies, researchers have begun grafting healthy cells into failing hearts, and results thus far are promising. The grafted cells, even cells from muscles other than the heart, appear to thrive and function normally. Other studies are developing drugs with multiple actions to treat CHFC for example, a drug that might improve the heart's pumping ability, open clogged arteries, and prevent tissue damage from free radicals, which are a byproduct of the body's metabolic processes. Other investigations are being conducted to improve heart transplantations for CHF patients. In some cases, a heart transplant is the only viable treatment for CHF, so new technologies are being explored to prevent rejection of the heart by the CHF patient's immune system.

Better devices to help damaged hearts function also are being developed. A small mechanical device called a left ventricular assist device (LVAD) already is in use to help patients who are awaiting a heart transplant. Researchers are finding that in some patients, the heart improves so much after using a LVAD for several months that a transplant is no longer needed.

The NHLBI also has designated improvements in hypertension control in its Healthy People 2000 objectives. Specifically, the NHLBI is committed to increasing to at least 50 percent the proportion of people with high blood pressure whose blood pressure is under control.

How you can become involved.
Hopefully readers have begun to ask themselves what they can do or what their organization can do to promote high blood pressure control and prevent congestive heart failure. Individuals in contact with an older person or persons in their private or professional lives can spread the word about the link between high blood pressure and heart failure.

For example, you can help older people obtain regular blood pressure screenings and explain the importance of going to the doctor to establish a blood pressure management plan. You also can help them adhere to that plan. Above all, you can emphasize that no one should allow hypertension to remain untreated, even if he or she is experiencing no adverse symptoms. And you can carefully monitor your blood pressure and your family's blood pressure to lessen your and your family's risks of developing congestive heart failure.

For additional information about congestive heart failure and high blood pressure, contact the NHLBI Information Center by calling (301) 251-1222 or by writing to P.O. Box 30105, Bethesda, MD 20824-0105. Messages concerning high blood pressure can be heard by calling (800) 575-WELL. This toll-free service also allows callers to request written materials. The NHLBI also provides information through its World Wide Web site at http:www.nhlbi.nih.gov/nhlbi.html or through a Gopher Browser at gopher.nhlbi.gov.

Myths about Cardiovascular Disease

• High blood pressure and heart disease are a natural part of aging.
  Although high blood pressure and heart disease are more common among older people, they are not an inevitable part of growing older. These health problems can be prevented by modifying one's lifestyle before they develop. Being physically active, maintaining a healthy weight, and eating a diet that is low in saturated fat and sodium can help prevent high blood pressure, high blood cholesterol, diabetes, and other disorders that subsequently lead to heart disease.
  
  Another important step to maintaining lifelong cardiovascular health is to have regular screening for these diseases, and if they develop, to work with your physician to adhere to a proper treatment plan. Blood cholesterol levels can be reduced, and high blood pressure and diabetes can be controlled.
  
  
• Medicines for high blood pressure only make you feel worse.
  There are a number of medications that are effective in controlling high blood pressure. If one medication makes you feel bad, you should go back to your doctor so that he or she can adjust your dosage or prescribe another medication. Also, some medications produce initial side effects that diminish with use. Always communicate honestly with your physician and do not adjust or stop your medications on your own. Remember that even though high blood pressure may have few symptoms itself, uncontrolled high blood pressure results in stroke, heart attack, and heart failure.
  
  
• High blood pressure, heart attack, and stroke are less of a risk than cancer or AIDS.
  Coronary heart disease kills more Americans each year than any other disease, including all forms of cancer and AIDS. In 1993, cardiovascular disease claimed 954,138 lives, accounting for more than 42 percent of all deaths. In comparison, 530,870 people died of cancer and 38,500 died of AIDS. 9
  
  
• When blood pressure becomes lower, it is not necessary to continue taking the medication.
  Blood pressure medications control but do not cure hypertension. Therefore, most people must continue to take the medications over the long term. Sometimes improvements in diet, weight, and activity level, stopping smoking, or other lifestyle changes will permit the doctor to adjust the medication level.
  
  
• If a heart attack is not fatal, you'll eventually recover completely.
  Having a heart attack increases the chance of death or illness two to nine times. About two-thirds of heart attack patients do not make a complete recovery; however, about 88 percent under the age of 65 can return to their normal work. 9 It is important to be aware that having a heart attack increases your risks of a second heart attack, angina, heart failure, and stroke.
  
  
• Hypertension is a type of blood pressure that is caused by tension or stress.
  Stress is a contributing factor to hypertension/high blood pressure, but the two are the same disease. High blood pressure is just a more common name for this condition.

References

1. U.S. Department of Health and Human Services. Data Fact Sheet: Congestive Heart Failure. Congestive Heart Failure in the United States: A New Epidemic. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute, 1996.
2. National Center for Health Statistics. National Hospital Discharge Survey: Annual Summary 1993. Vital and Health Statistics 13(122):43, 1995.
3. Carter BL, Roccella EJ. Preventing CHF is goal of National High Blood Pressure Education Program call to action. American Journal of Health Systems Pharmacies Jun(53):1381-1384, 1996.
4. Dunbar SB, Dracup K. Agency for health care policy and research: Clinical practice guidelines for heart failure. Journal of Cardiovascular Nursing 10(2):85-88, 1996.
5. Levy D, Larson MG, Vasan R, Kannel W, Ho KKL. The progression from hypertension to congestive heart failure. Journal of the American Medical Association 275(20):1557-1562, 1996.
6. Joint National Committee. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Archives of Internal Medicine 153:154-183, 1993.
7. Burt VL, Cutler, JA, Higgins M, Horan MJ, Labarthe D, Whelton P, Brown C, Roccella EJ. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult U.S. population: data from the Health Examination Surveys, 1960 to 1991. Hypertension 26(1): 60-69, 1995.
8. Burt VL, Whelton P, Roccella EJ, Brown C, Cutler J, Higgins M, Horan MJ, Labarthe D. Prevalence of hypertension in the U.S. adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 25(3):305-313, 1995.
9. American Heart Association. Heart and Stroke Facts: 1996 Statistical Supplement. Dallas, TX: American Heart Association National Center, 1996.