Introduction

Shortness of breath, medically termed dyspnea or dyspnoea, is a common and often distressing symptom experienced by patients with heart disease. This condition arises from the interplay between the cardiovascular and respiratory systems, both of which are crucial in maintaining the body’s oxygen supply. For patients with diagnosis of heart conditions, breathing difficulties can signal underlying or worsening heart problems. As heart disease progresses, the lungs and muscles receive less oxygen, leading to the sensation of being “out of breath.” This article explores the causes of shortness of breath in heart patients, examines potential treatments, and reviews the latest research findings on managing this condition. Heart disease and shortness of breath are commonly seen together.  

Causes of Dyspnea in Heart Disease

Breathlessness in heart disease stems primarily from the heart’s inability to pump efficiently, leading to inadequate oxygen delivery to tissues. This often happens due to various heart conditions, including heart failure, coronary artery disease, and valvular heart diseases. Understanding the root causes helps in developing effective interventions.

1.Heart Failure and trouble breathing

Heart failure is one of the leading causes of shortness of breath in heart patients. It occurs when the heart’s ability to pump blood is impaired, resulting in fluid buildup in the lungs (pulmonary 0edema). The accumulation of fluid in the lungs causes congestion, reducing the lungs’ capacity to exchange oxygen and carbon dioxide, which leads to difficulty breathing. This can be both a chronic condition or an acute scenario. If sudden onset of breathlessness occurs in a patient with known heart failure, this often requires an emergency treatment with intravenous diuretics. Managing breathlessness in heart failure may require a complex and multidisciplinary approach. 

A study published in The Lancet in 2016 showed that patients with heart failure experience numerous symptoms have an impact on their quality of life, including dyspnea, lethargy, poor exercise tolerance, and fluid retention. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868779/pdf/nihms767438.pdf)

One of the tests to diagnose or exclude heart failure is called an echocardiogram, which is an ultrasound of the heart. This test can be performed at all our private clinics, including at Sarum Road Hospital in Winchester, Candover Clinic in Basingstoke, Clare Park Hospital in Farnham and Luxmedica clinic in London.

2.Coronary Artery Disease

Coronary artery disease, also known as ischaemic heart disease, is furring up or blockage of coronary arteries due to fatty deposits buildup, which restricts blood flow to the heart muscles. This reduces the oxygen supply to the heart, making it harder for the heart to meet the body’s oxygen demands. As a result, patients often experience breathing problems with heart conditions like coronary artery disease, particularly during physical exertion. Physical exertion means that the heart muscle needs more blood flow to be delivered. 

A clinical study from the Journal of the American College of Cardiology (JACC), which was published in 2017, demonstrated that patients with significant coronary artery stenosis often experience breathlessness as a sign of heart problems, especially during physical activity. (https://www.jacc.org/doi/epdf/10.1016/j.jacc.2017.08.017)

Dr Bart Olechowski is a consultant interventional cardiologist, which means that he specialises in diagnosis and treatment of angina and heart attacks, which are presentation of coronary artery disease. Dr Bart and his team perform invasive procedures including coronary angiograms and stenting at Heart Centre in Basingstoke.

3.Valvular Heart Disease

In patients with valvular heart disease, the heart valves do not function properly, leading to disrupted blood flow. This can be caused by either leaky valves or narrowed valves. Conditions like aortic stenosis (narrow aortic valve) or mitral regurgitation (leaky mitral valve) can cause the heart to work harder to pump blood, ultimately leading to heart failure. 

A 2017 study from a medical journal, Circulation highlighted that individuals with severe aortic stenosis were more likely to have trouble breathing and heart health issues. Progressive narrowing of the aortic heart valve causes development of left ventricular hypertrophy (thickening of the heart muscle) and its subsequent decompensation, which ultimately can lead to heart failure.

Echocardiogram, explained by Dr Bart in details in one of our videos, https://drbart.co.uk/videos/, can diagnose heart valve problems.

4.Arrhythmias

Arrhythmias, or abnormal heart beats, disrupt the heart’s normal pumping function, impairing blood circulation. Both tachycardia (fast heart beat) and bradycardia (slow heart beat) can compromise the heart’s efficiency, leading to breathing problems. 

Patients with atrial fibrillation, also known in non medical jargon as irregular heart beat is a common type of arrhythmia. Patients with atrial fibrillation are more likely to experience respiratory symptoms in heart patients, including breathlessness.

A test, that can be performed by our private practice called Holter monitoring can diagnose or exclude important heart beat issues. This separate page on our website explains Holter monitoring in details, https://drbart.co.uk/tests-and-procedures/holter-monitoring/. 

Breathing problems with heart conditions

Shortness of breath in heart patients is a manifestation of the complex relationship between the cardiovascular and respiratory systems. The heart and lungs work together to oxygenate the blood and remove carbon dioxide from the body. When the heart`s main pumping chamber, called left ventricle function declines, the lungs struggle to compensate, leading to breathlessness signs of heart problems. This initially can occur on exertion and occasionally in an end stage phase at rest too.

1.Pulmonary Hypertension

In some cases, heart disease can lead to pulmonary hypertension, a condition where the blood pressure in the lungs’ arteries is elevated. Pulmonary hypertension can lead to dilatation of the right sided chambers of the heart. Pulmonary hypertension makes it harder for the heart to pump blood through the lungs and as a result worsening symptoms of dyspnea, lack of breath.

Clinical symptoms of patients with pulmonary hypertension are usually characterized by nonspecific symptoms of exercise-induced dyspnea, ankle swelling and lethargy. The most common cause of pulmonary hypertension is left heart disease, mainly left ventricular dysfunction. This phenomenon has been well described in an article published in 2020 in an American Heart Association journal, called Hypertension. (https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.119.14330) Pulmonary hypertension is a well recognised condition causing breathing problems with heart conditions.

2.Cardiomyopathy

In patients with a weakened heart muscle, which in medical jargon is called cardiomyopathy, the heart’s ability to pump blood is reduced. This results in decreased oxygen delivery to the body’s tissues, triggering difficulty breathing. Difficulty breathing and heart health are very closely linked. 

3.Pericarditis

The sac surrounding the heart is called pericardium. Pericardium can sometimes become inflamed which is known as pericarditis. Pericarditis and especially, an accumulation of additional fluid (pericardial fluid), in the heart sac can also lead to dyspnea. This inflammation restricts the heart’s movement, reducing its pumping efficiency and possibly leading to fluid accumulation around the lungs as well. 

A specific type of pericarditis called constrictive pericarditis, can lead to dyspnea too. A clinical review published in 2020 in JACC journal, describes pericarditis in details. (https://www.jacc.org/doi/epdf/10.1016/j.jacc.2019.11.021) 

Recognizing Breathlessness as a Sign of Heart Problems

For many heart patients, shortness of breath may be the first indication of a more serious cardiac issue, also referred as decompensation. Identifying and addressing these symptoms early by medical professional is important to prevent further deterioration and possible complications.

1.Dyspnea During Physical Activity

Patients with coronary artery disease or reduced pumping function of the heart often first notice dyspnea during physical exertion. Patients, who experience unexplained breathlessness when walking or climbing stairs for instance, should seek medical evaluation, as this can be an early sign of underlying heart disease .

2.Orthopnea and Paroxysmal Nocturnal Dyspnea (PND)

Different type of breathlessness is lack of breath while lying down (orthopnea) or during the night (paroxysmal nocturnal dyspnea, PND). These symptoms occur due to fluid redistribution in the body when lying flat, which overwhelms the heart’s ability to pump effectively. For some patients with a diagnosis of heart failure this can be quite a debilitating phenomenon. 

Managing Breathlessness in Heart Failure

Effectively managing shortness of breath in heart patients requires a multidisciplinary approach, including medications, lifestyle modifications, and, in some cases, advanced pacemakers or even surgical interventions.

1.Medications

Several medications can provide dyspnea treatment for cardiac patients by improving heart function and reducing fluid overload.

• Diuretics: Often referred to us `water tablets`. These medications help reduce fluid buildup in the lungs and other parts of the body, alleviating breathing problems in heart failure. This article published in 2019 in the European Journal of Heart Failure summarises how to use diuretics in patients with heart failure. (https://onlinelibrary.wiley.com/doi/10.1002/ejhf.1369) 
• ACE Inhibitors/ARBs: These medications showed to improve heart function in clinical studies and are one of the four pillars currently used in treatment of heart failure. The doses are dependent on individual patient`s blood pressure and kidney function. 
• Beta-blockers: Beta-blockers slow the heart rate and reduce blood pressure, improving the heart’s efficiency. Clinical studies confirmed their benefit for patients. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837435/) 
• Other: in addition to the above several other medications play an important role including, Dapagliflozin, Empagliflozin, Spironolactone, Eplerenone and Sacubitril/Valsartan.

2.Lifestyle Changes

Lifestyle interventions, which into a long term healthy habits can also play a significant role in managing breathlessness in heart patients:

• Weight Management: Excess weight places extra strain on the heart and lungs. Obesity significantly increases risk of Atrial Fibrillation as described in an article published in JAHA journal in 2023. (https://www.ahajournals.org/doi/10.1161/JAHA.123.032277) 
• Exercise: Engaging in light to moderate aerobic exercise can strengthen the heart muscle and improve overall cardiovascular health. More information about the benefits of exercise on heart health are included in our previous blog post `Tips for a healthy heart`. (https://drbart.co.uk/tips-for-a-healthy-heart/)
• Smoking Cessation: Smoking damages both the heart and lungs, exacerbating breathing problems. Undoubtedly smoking is one of the major risk factors for coronary artery disease and lung disease.

3.Surgical Interventions

In patients with advanced heart problems, surgical options may be necessary to manage lack of breath and improve patients survival and well being:

• Coronary artery bypass grafting (CABG): This surgery can improve blood flow to the heart, alleviating shortness of breath in patients with coronary artery disease.
• Valve Repair or Replacement: Patients with severe valvular heart disease may benefit from valve repair or replacement surgery, which can reduce breathlessness. This can nowadays be performed either via a traditional open heart surgery or key hole strategies. 
• Left Ventricular Assist Devices (LVADs): In patients with advanced heart failure who are not candidates for a heart transplant, an LVAD can help the heart pump more effectively, reducing dyspnea. LVADs are implantable mechanical pumps that help the weakened heart pump blood more effectively. Initially used as a bridge to heart transplantation, LVADs are now also used as a long-term solution for patients who are not candidates for transplant. 

Dyspnea Treatment for Cardiac Patients

Treatment for dyspnea in heart patients depends on the underlying cause. In addition to the interventions discussed above, addressing contributing factors like anemia or chronic lung disease is crucial. 

Conclusion

Shortness of breath is a common and concerning symptom in patients with heart disease, but it is manageable with the right interventions. Understanding the underlying causes of lack of breath—such as heart failure, coronary artery disease, or valvular heart disease—is essential for developing effective treatments. Through a combination of medications, lifestyle changes, and, in some cases, surgical interventions, dyspnea treatment for cardiac patients can be significantly improved. Dr Bart regularly consults patient with breathing difficulties in his clinics.  Early recognition and management are key to preventing more severe complications and improving the quality of life for heart patients.