Health articles

What is it?

Congenital heart disease is a structural problem of the heart or great vessels present from birth. Most children born with it now reach adulthood, and adults with the condition outnumber children. Common types include holes in the heart (ASD, VSD), valve narrowing, bicuspid aortic valve, coarctation of the aorta, tetralogy of Fallot, and more complex defects such as transposition of the great arteries or single-ventricle hearts.

Symptoms in adults

• Breathlessness and tiring faster than people your age
• Palpitations, irregular heartbeat, dizziness or fainting
• Swollen legs
• Bluish lips and nails (cyanosis)
• High blood pressure in the arms with weak pulses in the legs (coarctation)
• Stroke at a young age

Some people have no symptoms for years and are found only through a heart murmur or an incidental echo.

Why diagnosis and follow-up matter

Repair in childhood is often not a cure for life. A heart repaired in childhood still needs lifelong follow-up. Late diagnosis can mean permanent damage to the heart or lungs.

Risks if untreated or not followed

• Arrhythmia and, sometimes, cardiac arrest
• Heart failure
• High pressure in the lung vessels
• Infection of the valves or heart lining (endocarditis)
• Stroke, and enlargement or tear of the aorta
• Risks to mother and baby in pregnancy

Diagnosis and care

Full congenital echocardiography, ECG, sometimes cardiac MRI or CT, exercise testing, Holter monitoring and, in some cases, catheterisation. Follow-up is best with a doctor experienced in adult congenital heart disease. Dental hygiene, pre-pregnancy counselling and advice on the type and intensity of exercise are part of care.

What happens?

The heart gets its blood from the coronary arteries. Over years, cholesterol and fat build up in the artery walls as plaque (atherosclerosis), narrowing them. When the narrowing is severe, the heart muscle does not get enough blood during effort and causes chest pressure or pain (angina). If a plaque suddenly ruptures, a clot forms on it and blocks the artery completely. This is a heart attack: part of the heart muscle is cut off from blood and, if not reopened quickly, is permanently damaged.

Symptoms

• Pressure, heaviness or burning in the centre of the chest, which may spread to the left arm, jaw, neck or back
• Shortness of breath, cold sweat, nausea or dizziness
• In women, older people and people with diabetes, sometimes only unusual fatigue, breathlessness or indigestion-like discomfort

Who is at risk?

High blood pressure, diabetes, high LDL cholesterol, smoking (including hookah), obesity, inactivity, a family history of early heart disease and older age. The more risk factors, the higher the risk.

Diagnosis

History and examination, ECG, blood tests (including troponin in acute pain), echocardiography, exercise testing, CT angiography and, when needed, coronary angiography.

Treatment and prevention

Controlling blood pressure, sugar and cholesterol, quitting tobacco, regular exercise and a healthy diet are the foundation. Medicines such as statins and antiplatelet drugs lower the risk of heart attack. In severe narrowing or a heart attack, the artery may need to be opened with angioplasty and a stent, or with bypass surgery. Your doctor decides based on your individual situation.

What is a hole in the heart?

Walls inside the heart keep oxygen-rich and oxygen-poor blood apart. A gap in this wall is called a hole in the heart. ASD is a hole between the two upper chambers (atria), VSD is between the two lower chambers (ventricles), and PFO is a small flap that should close after birth but stays open in about one in four people; in most of them it causes no problem.

Why is it sometimes found only in adulthood?

Small holes can cause no symptoms for years. Larger holes gradually increase the blood flow through the right side of the heart and the lungs.

Symptoms and risks

• Breathlessness and early tiredness on effort
• Palpitations and arrhythmia, especially atrial fibrillation
• Enlargement of the right side of the heart and, in advanced cases, high pressure in the lung vessels
• Stroke: a small clot from a vein can cross the hole and reach the brain (in PFO and ASD)

Diagnosis

Echocardiography is the main test. Sometimes a bubble study or a transoesophageal echo is needed. The ECG may also show clues.

Treatment

A small hole without symptoms usually needs only follow-up. A large ASD, or one that has enlarged the heart, is closed with a device through a vein (no open surgery) or with surgery. PFO closure is considered only in selected patients, for example after a stroke with no other cause. If you plan a pregnancy, get assessed first.

What do heart valves do?

The heart has four valves (aortic, mitral, tricuspid and pulmonary) that work like one-way doors. A valve that does not open well is stenotic (narrowed) and forces the heart to work harder. A valve that does not close well leaks (regurgitation) and lets blood flow backwards.

Causes

Calcification with age, rheumatic fever in childhood, a bicuspid aortic valve or other congenital problems, valve infection (endocarditis) and enlargement of the heart.

Symptoms

• Breathlessness on effort or when lying flat
• Chest pain or pressure, dizziness or fainting
• Palpitations, swollen legs, fatigue

Why not ignore it?

Severe aortic stenosis with symptoms can lead to fainting, heart failure and sudden death. Mitral valve disease can cause atrial fibrillation and stroke. Early diagnosis means treatment at the right time.

Diagnosis and treatment

Listening to the heart and echocardiography are the key tools. Mild cases are followed with periodic echo. Medicines relieve symptoms. In severe cases the valve is repaired or replaced, by surgery or by less invasive procedures. The type and timing of treatment are decided by your doctor.

Palpitations are not always a disease

Feeling a fast or irregular heartbeat can be due to anxiety, poor sleep, coffee, fever, anaemia or an overactive thyroid. But sometimes it signals an arrhythmia, a disturbance of the heart’s electrical system.

Common types

Premature beats (PAC and PVC), which are often harmless; a fast regular rhythm that starts and stops suddenly (SVT); atrial fibrillation; a very slow heart rate; and dangerous ventricular arrhythmias.

Diagnosis and treatment

ECG, echo, blood and thyroid tests and, most importantly, Holter monitoring (24 hours or longer), which catches a transient arrhythmia. Treatment depends on the type: avoiding triggers, medicines and, in selected cases, specialised procedures such as ablation or a pacemaker.

What happens?

In atrial fibrillation (AF) the upper chambers of the heart quiver instead of contracting regularly. Blood does not move well through them and can form clots. If a clot travels to the brain, it causes a stroke. People with AF have several times the usual risk of stroke.

Symptoms

Irregular palpitations, fatigue, breathlessness, dizziness. But sometimes there are no symptoms and the first sign is the stroke itself. That is why checking the pulse and an ECG matter after age 65, or with high blood pressure or diabetes.

Prevention and treatment

Your doctor decides whether you need an anticoagulant based on your age and other conditions (such as high blood pressure, diabetes or heart failure). Rate or rhythm control, treating blood pressure and sleep apnoea, and reducing alcohol also matter. Do not stop an anticoagulant without medical advice.

What does it mean?

Heart failure does not mean the heart has stopped. It means the heart cannot deliver enough blood to the body or cannot clear blood well from the lungs and legs. Causes include blocked heart arteries and a previous heart attack, high blood pressure, valve disease, weak heart muscle, arrhythmia and congenital heart disease.

Symptoms

• Breathlessness on effort, lying flat or at night
• Swelling of the legs and ankles
• Sudden weight gain (for example 2 kg in a few days)
• Fatigue, night cough and reduced exercise capacity

Diagnosis and treatment

Echocardiography (to measure EF), ECG, the BNP blood test and a search for the cause. Treatment today is effective: several drug classes that reduce hospital stays and deaths, salt and fluid advice from your doctor, daily weighing, suitable physical activity and treatment of the cause. Some patients benefit from implanted devices.

Why is it dangerous?

High blood pressure usually has no symptoms, but for years it strains the walls of the arteries, the heart, brain, kidneys and eyes. The result can be stroke, heart attack, heart failure, kidney failure and eye damage.

What number is high?

If blood pressure is repeatedly above about 140/90 (above 130/80 in some guidelines), it needs assessment and treatment. For an accurate reading, measure at home over several days under standard conditions: seated, after a few minutes of rest, with a properly sized cuff.

Control

• Less salt, weight loss, regular exercise, stopping tobacco and limiting alcohol
• Take medicines regularly. Even if you feel well, do not stop them without advice
• In young people or resistant hypertension, a cause (such as kidney or hormonal problems or aortic narrowing) should be looked for