FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

HAVING "A BIG HEART" DOESN'T NECESSARILY MEAN YOU'RE GENEROUS

Question: I'm 65 years old and have an enlarged heart. Heart troubles run through my entire family. Many have had heart surgery and don't seem to be any better. I've heard that many heart surgeries aren't necessary. I don't smoke or drink alcohol. Is walking daily, taking 400 mg. of vitamin E daily and a baby aspirin daily good enough therapy for my enlarged heart?

Answer: Heart disease is the leading cause of death in our country. Two-thirds of us will ultimately die from it, and therefore, you have good reason to be concerned. As you obviously know, your family history of heart disease does increase your risk, but there are other risk factors as well. Age, tobacco use, sedentary lifestyle, diabetes, high cholesterol, high blood pressure, and drinking more than two alcoholic drinks per day all increase one's chances of dying from heart disease.

Just knowing that you have an enlarged heart doesn't enable me to determine your overall risk for premature demise due to heart disease. Instead, it just tells me you have a symptom that might have several different origins. The possible causes include: high blood pressure or existing heart disease. Given what you've told me in your letter, either of these seems likely in your case. High blood pressure is, by the way, a common cause of enlarged heart because the heart of a person with this condition must work extra hard to maintain the elevated pressure.

In general, any factor -- like exercise or high blood pressure -- which subjects your heart to even a mild increase in workload strengthens the heart muscle. The heart grows stronger not by growing more muscle fibers but by "bulking-up" the existing fibers. Often this increased strength is desirable; it is one of the goals of athletic training. However, in a person with an existing heart problem, this growth in the heart muscle can cause problems. This is because the small blood vessels (capillaries) that feed the heart muscle don't enlarge or increase in number sufficiently to supply the amount of blood the muscle needs for adequate nourishment. This puts the individual at risk for a heart attack, particularly during vigorous activity.

Besides the group of conditions that increase heart muscle size, there is another cause of enlarged heart. The volume of the heart chambers can become greater than normal and, thereby, make the entire heart larger. All of the conditions that produce this type of enlargement significantly increase the risk of death from heart disease.

All of the "good health" measures you mentioned are clearly a good idea, but I don't think they are the only treatments you should consider. Talk to your doctor about the cause of your enlarged heart. He or she will need to do several tests to clarify the exact nature of your condition. An electrocardiogram (EKG), a stress test and an echocardiogram, at the very least, would be required. Often a cardiac catheterization is also needed. Your doctor may or may not recommend surgery as a treatment for you. IF he or she does, then you should not consent to it until you have a clear understanding of the anticipated benefits from surgery when compared to non-surgical treatments.

We in the United States have a much higher rate of heart surgery than any other part of the world. There is no doubt that some of these surgeries failed to give the anticipated improvement in the quality or length of life and could, therefore, be considered unnecessary. The dilemma, however, is that we doctors don't have a foolproof way for determining who will benefit from any given procedure. Therefore, ask lots of questions! You may even want a second opinion. Remember, the ultimate decision is yours, not your doctor's.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701. Past columns are available online at http://www.FamilyMedicineNews.org.