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Moderate Symptoms (Class III)

Moderate Symptoms (Class III)

What are moderate symptoms?

Symptoms and functional impairment are obvious. Symptoms such as shortness of breath and fatigue may be quite limiting, and can occur even with less than ordinary physical activity. Walking even short distances will be limited by symptoms, requiring more frequent periods of rest or less overall activity performed. However, there are no symptoms when at rest. For example, a person was able to easily walk around an entire big box store and take just one short period of rest six months ago, but now can only walk half the number of aisles without needing to sit and rest. Sometimes they cannot do more than this. People with this degree of impairment may begin to think about getting a handicap permit.

Fluid retention may become more problematic in patients with dilated cardiomyopathy (DCM) due to decreased efficiency of heart function. Higher doses of diuretics could be required. Sometimes hospitalization is needed to improve symptoms. Some people with moderate symptoms may still look healthy. As a result, their family and friends may not understand that they have real limitations. Some people with moderate symptoms might be helped by a ventricular assist device (an implantable heart pump) or heart transplant.

Many people with moderate symptoms might find it hard to work a full-time schedule depending on the type of job. If someone has a job where they sit most of the day, or a job where not much exertion is required, they may be able to continue working. It is not unusual for people with moderate or Class III symptoms to file for disability.

What are the treatments?

In general, the more severe the symptoms and impairment, the more complicated the treatment. Treatment is recommended when you have reduced heart muscle function. Reduced heart muscle function is measured by ejection fraction, or the percentage of blood pumped from the heart with each beat. A normal ejection fraction indicating normal heart contraction is 50% or more. If an individual has Class III heart failure symptoms, it is very likely that their ejection fraction is less than 40%. Drugs are the primary treatment. Essential drugs are those classified as beta blockers; the other essential class of drugs are ACE-inhibitors or ARBs.

Both classes of drugs work to block the activated hormonal and neural systems. They have been studied in thousands of patients and have been shown to improve the survival rate of people with DCM. In some people, these drugs may decrease the size of the heart and improve heart muscle function. An echocardiogram should be performed after a minimum of six months of optimal drug therapy to determine if medications are improving the ejection fraction and/or heart size.

If a person has signs of fluid retention, they may benefit from diuretics, which help the kidneys eliminate excess fluid from the body. If they were previously on diuretics but have worsening fluid retention, the dose may need to be increased to improve symptoms. There may now be indications for additional drugs that, when taken with most of current medications, will improve life expectancy and symptoms even further. These drugs may include spironolactone, hydralazine-nitrate, and sacubitril/valsartan (Entresto®).

If a person’s ejection fraction is 30% or less, and they have been on optimal drug therapy, they may be a candidate for an implantable cardiac defibrillator (ICD) to help prevent sudden cardiac death. This prophylactic, or preventive therapy, is an elective therapy; some people do not want this therapy, nor are the best candidates for it. Patients should discuss this option with their cardiologist.

If a person’s ejection fraction is 35% or less, and they have certain abnormalities on their ECG (e.g., bundle branch block), they may be a candidate for cardiac resynchronized therapy (CRT), which requires the implantation of a special pacemaker. This therapy helps people with DCM live longer and may improve heart muscle function.

Will symptoms get worse over time?

This is hard to predict. For some people with DCM, symptoms will stay the same or improve slightly. While for others, symptoms may worsen with time. Occasionally, there are other people who may have an improvement in their symptoms to such a degree that they no longer have symptoms. What is predictable is that the chances of symptoms getting worse, and/or a person dying sooner, are much higher for people who do not take the essential medications.

Are there activities that should be avoided?

Stay as active as possible. Regular exercise, such as walking at a pace or distance that does not cause limiting symptoms, is beneficial. Activities that cause marked limitation symptoms should probably be avoided or done in a manner that symptoms are less severe. A person may need to rest more often, do activities slower, or use aids, such as a motorized chair, that help them exert less effort. Commonly, people with Class III symptoms request handicap permits.

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