Without any possible hesitation, heart failure (HF) is one of the main public health concerns in France. This pathology is, in our country, at the origin of more than 200 deaths on average per day (
2016 figures), more than the number of people who died due to the Covid-19 epidemic (176 deaths per day on average
according to figures from Vidal) but it is not inevitable.
Indeed, we know better how to act to reduce the risk of its symptoms appearing or worsening. This article has a dual role: on the one hand, to explain what CI is, its origin and its symptoms. And on the other hand remember that, even if drug management is still improving, there will be a decline in the number of patients concerned only by the awareness of the need to change hygieno-dietetic habits. Either be more active and adopt new eating habits.
What are we really talking about?
Heart failure (HF) is defined as the inability of the heart muscle to normally perform its role of propelling blood through the body. It is linked to a functional and / or structural abnormality of the heart.
The symptoms usually observed are difficulty in breathing, an increase in volume of the lower limbs and fatigue, all of which are linked to an abnormal retention of water and salt and / or an inadequate water intake compared to the needs of other organs (muscles , brain, kidney, digestive tract…). The diagnosis is made following the presence of these symptoms and the observation of abnormalities on the cardiac ultrasound.
Many factors contribute to the onset of heart failure © J. Zoll, A. Charlot & F. Sauer (via The Conversation)
We distinguish three major CI groups according to the “ejection fraction”, which is the percentage of blood that the heart can evacuate with each beat, measured on ultrasound: when the percentage is less than 40%, when it is between 40% and 50% and when it is greater than 50%. Normal ejection fraction values are greater than 50%.
In developed countries, the main causes of HF are pathologies of the arteries of the heart (called coronary arteries) and high blood pressure. Both, as well as the intensity of the symptoms when HF onset, can be prevented by suitable hygiene and dietetic measures. The main risk factors on which it is possible to play are high blood pressure, smoking, excess “bad” cholesterol, diabetes, physical inactivity and overweight.
In France, this disease still carries significant morbidity (number of patients or cases in a population at a given time) and mortality. Based on the causes of death declared by CépiDc (Center for Epidemiology on Medical Causes of Death) at the latest available date (2016), the number attributable to the CI is 78,033 for 12 months. According to the
data from Public Health France, 2.3% of the French population would be affected and this figure rises to 10% beyond 70 years.
How to prevent heart failure
Nordic walking is an increasingly popular physical activity in France © Regional Committee EPGV Center-Val de Loire
The national health strategy (SNS) 2018-2022 and the
National public health plan “Priority prevention” affirm the priority of prevention. Regular physical activity of moderate intensity (equivalent to walking on flat ground at 5 km / h or cycling on flat ground at 15 km / h) up to 30 minutes per day is recommended by the
World Health Organization (WHO) and can effectively prevent the development of high blood pressure, diabetes, dyslipidemia and overweight.
Regarding diet, it is recommended to follow a Mediterranean-style diet favoring:
- Unsaturated fatty acids (olive oil, rapeseed oil and walnuts in particular),
- A minimum intake of five fruits and vegetables per day,
- Regular contributions (on active days), but not systematic, preferably whole and organic cereals (bread, wheat, bulgur, rye, etc.),
- Moderate intake of meat, preferably white (three times a week) and fish (at least once a week),
- Limited salt intake (less than 5 grams per day),
- Low intakes in added sugars (soda, fruit juice, industrial desserts, etc.), with less than 25 grams of added sugar per day,
- Moderate alcohol consumption, and only during the meal (one glass per day, 5 days a week).
A recent study of New England Journal of Medicine objective a 30% reduction in cardiovascular mortality in healthy subjects who followed a Mediterranean diet.
All of these are listed on the WHO website. Moreover, the
13ᵉ WHO general program of work (2019-2023) has for priority measures the reduction of salt / sodium intake and the elimination of fatty acids trans saturated industrial.
Before switching to a pharmaceutical treatment, adapting your habits has an important preventive effect © J. Zoll, A. Charlot & F. Sauer (via The Conversation)
The benefit of simple medical vigilance
Regular and personalized medical follow-up is recommended in order to assess the general state of health and to detect cardiovascular risk factors, which are most often silent in the initial phase. A visit to a cardiologist is recommended from the age of 40, especially in the event of resuming sports activity.
Blood pressure less than 140 mmHg (systolic blood pressure) over 90 mmHg (diastolic blood pressure) is preferable, in order to limit the constraints on the heart for the expulsion of blood in the body. Regular blood pressure measurements in the arm and at rest allow the early detection of this pathology. Likewise, monitoring of the level of sugar in the blood (glycemia) may be necessary, as chronic hyperglycemia may be the cause of an energy imbalance in the heart.
Stopping smoking is one of the most effective actions in the prevention of cardiovascular disease such as pulmonary pathologies.
Cholesterol control is also popular, distinguishing between “bad” cholesterol (LDL-c) and “good” cholesterol (HDL-c). The first, capable of infiltrating the walls of the arteries, can generate the creation of lipid plaques and inflammation on the surface. This process, called atherosclerosis, causes a narrowing of the lumen of the arteries which can be the cause of a myocardial infarction (the heart does not receive enough blood).
As the atheroma enlarges, the arterial wall ruptures and releases blood clots which lead to the narrowing of the artery © Manu5 / Wikimedia CC BY-SA 4.0
All of the above measures are recommended for lowering LDL-cholesterol. To date, there is no drug treatment to effectively prevent the formation of atherosclerosis.
For arterial hypertension, hyperglycemia or LDL-c levels, if three months of well-followed hygieno-dietetic measures (physical activity and diet) do not allow a return to normal of biological values, pharmacological treatment may be necessary. considered. With of course the maintenance of hygienic-dietetic measures.
What are the possible treatments ?
The treatment of HF is based on the respect of hygieno-dietetic measures and the establishment of a drug treatment. The large therapeutic arsenal makes it possible to limit symptoms on a daily basis and reduce mortality.
These treatments have the function of relieving the constraints imposed on the heart (high heart rate, high blood pressure, evacuation of excess water and salt in the body) and, in some cases, to treat the triggering factor. There are:
- Beta blockers (to regulate the heart rate),
- Converting enzyme inhibitors (angiotensin II), whether or not associated with a neprilysin inhibitor (against hypertension),
- Mineralocorticoid antagonists and other diuretics (in case of excess water and salt),
- And a very promising latest addition: glifozins (oral antidiabetics).
They can be prescribed when the ejection fraction of the blood out of the heart is less than 40%, not systematically otherwise.
Heart transplant © Cardio-Vascular Research Foundation / Institut de France
In cases of severe and / or advanced HF, drugs to supplement contractile function may be considered, or even the implementation of temporary or permanent mechanical cardiac assistance, as well as a heart transplant.
A new drug in the arsenal: glifozins
The European Society of Cardiology (ESC) put forward these oral antidiabetics in August 2021. Indeed, two studies,
DAPA-HF and
EMPEROR-REDUCED, carried out on 8,474 patients, compared the effectiveness of glifozins in addition to conventional treatment: they observed a decrease in cardiovascular mortality of 14% compared to conventional treatment. A 25% drop in the combined criterion of first hospitalization is also noted.
The molecules used include dapaglifozin and empaglifozin, inhibitors of the glucose transporter (SGLT2) in the kidneys. The role of this transporter is to reabsorb 90% of the glucose extracted by them. Reason for its indication in diabetes (to increase the evacuation of glucose through the urine, and therefore lower blood sugar).
Diabetes monitoring and treatment tools © StevePB / Pixnio
These molecules are the first class oforal antidiabetics capable of improving glycemic control while promoting weight loss. Recent studies have shown a clear benefit on the morbidity and mortality in HF, even in the absence of pre-existing diabetes. Although the reasons for this are not yet clearly established, it seems that their improvement in the “strength” of the heart plays an important role. Better maintenance of blood sugar levels and weight loss may also be involved in these beneficial effects.
A major public health issue
HF, and cardiovascular disease more broadly, remains a major public health problem. Several plans which include hygiene and diet recommendations (sport and diet) have been put in place by the public authorities in order to improve prevention. Unfortunately, they remain insufficiently applied … The fault in particular of our way of life and habits that are difficult to change.
The agrifood industry does not make life easier for users, by marketing a majority of products with too much added sugar. In this context, the effectiveness of treatment with dapaglifozin reinforces the importance of the harmful role of excessive intake of added sugar (especially glucose), and therefore of the benefit of controlling blood sugar and energy intake to the heart. in order to improve its function, even in the absence of type 2 diabetes.
This analysis was written by Joffrey Zoll, lecturer and hospital practitioner in physiology, Anouk Charlot, doctoral student in physiology and François Sauer, intern in cardiology (all three at the University of Strasbourg).
The original article was published on the website of The Conversation.
