India is changing. Patients are living longer, medical treatment has advanced, and more of them are surviving significant heart surgery than ever before. However, a silent and emerging problem has emerged along the way, which is Advanced Heart Failure. It was once a rare and end-stage disease, but it's now becoming one of the most severe and life-threatening health problems in the country.
The Severity Of The Issue
Consider the numbers, and that's how serious this is. An estimated 2 to 3 lakh Indians (between 200,000 and 3,00,000) develop advanced heart failure every year. Of these, almost 50,000 patients are in a critical condition and urgently need either a heart transplant or an artificial heart support device to survive.
This is no small number. For they are growing, due to the ageing population, the increasing number of people suffering lifestyle diseases and the increasing number of patients that have already had heart surgery and must live longer with damaged hearts.
What is Advanced Heart Failure?
A basic understanding of the function of the heart is important for advanced heart failure. The heart is simply a pump. Its purpose is to keep pumping blood (with oxygen and nutrients) throughout the body. This is done by squeezing its muscular walls in a rhythmic fashion.
This muscle (the myocardium, also known as the heart muscle) is extremely damaged in advanced heart failure. It develops weakness and stiffness and will not squeeze as well. This leads to a decreased supply of blood to the body.
This injury may involve the left side of the heart, the right side of the heart or both. The left side is more important because it has to pump blood to all parts of the body.
A doctor's important measurement of the pumping efficiency of the heart is called the Ejection Fraction (EF). Imagine that a healthy heart squeezes and does about 55 to 70% of the job of pumping the blood in it out of the heart. In severe heart failure, this falls precipitously, and sometimes to as low as 25%, meaning that the heart is operating at a reduced efficiency. This is detected with an easy, non-invasive test called an echocardiogram (ultrasound of the heart).
It's important to remember that age and gender do not discriminate against anyone when it comes to heart failure. It can affect newborns, young adults, middle-aged people and the elderly. Males and females are equally affected.
Why Does It Get Worse?
It's not caused by just one thing. There are multiple pathways that can lead to advanced heart failure:
Idiopathic Cardiomyopathy: This is the most common cause. The term "idiopathic" just means that the cause cannot be identified; that is, the heart muscle becomes weak and stops working for no known reason. It may occur in people of any age, ranging from a baby to people in their forties and fifties. It's one of the most frustrating causes, partly because there is no obvious trigger to deal with.
Ischaemic Cardiomyopathy: Ischaemic means that the blood supply is reduced. This form of heart failure occurs as a result of a heart attack or the cumulative damage resulting from other treatments such as angioplasty (PTCA), a tiny balloon and stent are used to open a blocked artery, or bypass surgery, where additional paths are made to allow blood to flow around blocked arteries. However, following these steps, the blood-starved heart muscle may still be permanently damaged from the original event.
Heavy alcohol use is also a known cause of damage to the heart muscle. Chronic heavy drinking is well known to cause damage to the heart muscle. Alcohol gradually causes poisoning of the heart muscle over the years, and causes heart muscle to become weaker over time.
Cancer Treatment and Heart Damage — While some cancer treatments are effective in saving lives, they can also be poisonous to the heart muscle. Years after cancer, patients might find themselves with heart failure due to their cancer treatment.
Congenital Heart Disease in Adults — Some people are born with structural defects in their hearts (congenital heart disease) and have repair surgeries while children. These patients, when they become adults, can develop progressive heart failure because of the chronic stress.
Signs To Look Out For
This is where awareness can make a real difference in life. Advanced heart failure doesn't always hit you out of nowhere. It can develop over time, and the initial symptoms can be mistaken for tiredness, ageing or overall illness.
Warning signs you should never ignore:
Leg, ankle or facial swelling – When the heart isn’t working well, fluid backs up and pools in the body tissues, resulting in swelling.
Fatigue: The patient becomes easily fatigued, even with minor exertion such as walking a few steps or going up a few stairs. This is because the body is not receiving enough oxygen-carrying blood to its organs and muscles.
Trouble breathing when lying flat at night (also referred to as orthopnoea) - This is when somebody wakes up in the middle of the night struggling to breathe and must sit up or prop themselves up with pillows to be able to breathe comfortably. It's a traditional and significant red flag.
Abdominal distention or bloating: fluid may collect in the belly, making it very distended or bloated.
Dizziness or sudden loss of consciousness: This happens when the brain is not receiving adequate blood supply, and is a medical emergency.
Fluid within the lungs: In severe cases, fluid builds up within the lungs themselves, and breathing becomes very difficult, and patients may experience a chronic wet cough.
When Is a Heart Transplant Needed?
Not every heart failure patient needs a transplant. Most patients are managed effectively with medications, lifestyle changes, and device-based therapies. However, when the condition progresses to a point where the Ejection Fraction drops below 25%, and the patient is no longer responding to medicines or intravenous treatments, two advanced interventions come into consideration:
Heart Transplant: This is the surgical replacement of the failing heart with a healthy heart from a brain-dead donor. It is a complex procedure, but for the right patient, it is life-transforming.
LVAD (Left Ventricular Assist Device): Also referred to as an artificial heart pump, this is a mechanical device surgically implanted inside the chest. It works alongside the heart, taking over the pumping function that the weakened heart can no longer perform. Some patients receive an LVAD as a bridge while waiting for a transplant; others receive it as a long-term solution.
Both options are reserved for the most critically ill patients, but for those who qualify, they offer a genuine second chance at life.
India's Progress in Heart Transplantation
The good news is that India has made significant strides in this field. Since 2012, approximately 1,200 heart transplants have been successfully performed across the country, with an impressive 90% success rate, figures that are comparable to international standards.
The primary requirement post-surgery is a lifelong commitment to immunosuppressant medications, drugs that prevent the body's immune system from attacking and rejecting the new heart.
It is worth noting that currently, 90% of heart transplants in India are performed in South India, reflecting the concentration of advanced cardiac infrastructure and expertise in that region.
