Focus on cardiac failure

What is heart failure?

Heart failure, often referred to as congestive heart failure, is a serious condition that arises when the heart muscle is unable to pump blood effectively throughout the body. This inefficiency can result from various underlying health issues, such as coronary artery disease, where the arteries supplying blood to the heart become narrowed, or high blood pressure, which can cause the heart to become too weak or stiff over time. As a result, the heart struggles to fill and pump blood efficiently. While not all conditions that lead to heart failure are reversible, there are treatments available that can significantly alleviate the symptoms and enhance the patient's quality of life. Additionally, adopting lifestyle changes can play a crucial role in managing heart failure. Engaging in regular exercise, reducing salt intake, limiting alcohol consumption, quitting smoking, managing stress levels, and achieving a healthy weight are all beneficial strategies. Furthermore, controlling risk factors such as coronary artery disease, high blood pressure, diabetes, and obesity is essential for preventing heart failure.

The signs and symptoms of cardiac failure

Individuals experiencing heart failure may notice a variety of signs and symptoms, which can significantly impact their daily lives. Common symptoms include:

• Shortness of breath (dyspnea): This may occur during physical exertion or even while lying down, making it difficult to breathe comfortably.
• Fatigue and weakness: Many people with heart failure feel unusually tired and weak, which can limit their ability to perform everyday activities.
• Swelling (edema): Fluid retention can lead to noticeable swelling in the legs, ankles, and feet, which may be uncomfortable.
• Rapid or irregular heartbeat: Individuals may experience a racing or erratic heartbeat, which can be alarming.
• Reduced ability to exercise: As heart failure progresses, physical activity may become increasingly challenging.
• Persistent cough or wheezing: Some may develop a chronic cough, often accompanied by white or pink blood-tinged phlegm.
• Increased need to urinate at night: Nocturia, or frequent urination during the night, is a common complaint.
• Swelling of the abdomen (ascites): This can occur as a result of fluid buildup, leading to discomfort.
• Sudden weight gain: Rapid weight gain due to fluid retention can be a warning sign.
• Lack of appetite and nausea: Many individuals with heart failure experience a decreased desire to eat and may feel nauseous.
• Difficulty concentrating: Cognitive issues, such as trouble focusing or decreased alertness, may arise.
• Severe shortness of breath: A sudden and intense feeling of breathlessness, particularly when accompanied by coughing up pink, foamy mucus, is a medical emergency.
• Chest pain: If heart failure is due to a heart attack, individuals may experience chest pain.

When to see a doctor

If you suspect that you are exhibiting signs or symptoms of heart failure, it is crucial to consult with your healthcare provider promptly. Additionally, you should seek emergency medical attention if you experience any of the following alarming symptoms:

• Chest pain: This can be indicative of a serious cardiac event.
• Fainting or severe weakness: These symptoms may suggest that your heart is struggling to function properly.
• Rapid or irregular heartbeat: If accompanied by shortness of breath, chest pain, or fainting, this warrants immediate medical evaluation.
• Severe shortness of breath: Sudden and intense difficulty breathing, especially when combined with coughing up pink, foamy mucus, is a critical situation that requires urgent care.

Possible causes of cardiac failure

Heart failure can arise from several underlying conditions, including:

• Coronary artery disease and heart attack: This is the most prevalent form of heart disease and the leading cause of heart failure. Over time, the arteries that supply blood to the heart muscle can become narrowed due to a buildup of fatty deposits, a process known as atherosclerosis. If these plaques rupture, a blood clot may form, obstructing blood flow to a portion of the heart muscle, which can weaken the heart's pumping ability and potentially cause lasting damage.
• High blood pressure (hypertension): Elevated blood pressure forces the heart to work harder to circulate blood, which can lead to thickening of the heart muscle. Over time, this can result in the heart becoming too stiff or weak to pump blood effectively.
• Faulty heart valves: The heart's valves are essential for ensuring blood flows in the correct direction. If a valve is damaged due to a heart defect, coronary artery disease, or infection, the heart must exert extra effort to maintain proper blood flow, which can lead to weakening over time. Fortunately, many faulty valves can be repaired or replaced if identified early.
• Damage to the heart muscle (cardiomyopathy): This condition can result from various causes, including diseases, infections, alcohol misuse, and the toxic effects of certain drugs, such as cocaine or some chemotherapy agents.
• Genetic factors: Several types of cardiomyopathy, including dilated, hypertrophic, arrhythmogenic right ventricular, left ventricular noncompaction, and restrictive cardiomyopathy, have a genetic component, making family history an important consideration.
• Myocarditis: This refers to inflammation of the heart muscle, most often caused by viral infections, which can lead to left-sided heart failure.
• Congenital heart defects: If an individual is born with structural issues in the heart or its valves, the healthy parts of the heart may need to work harder to pump blood, potentially leading to heart failure.
• Abnormal heart rhythms (arrhythmias): Irregular heartbeats can cause the heart to beat too quickly, increasing its workload and potentially leading to heart failure over time. Conversely, a slow heartbeat may prevent the heart from adequately supplying blood to the body.
• Other diseases: Chronic conditions such as diabetes, HIV, hyperthyroidism, hypothyroidism, and disorders involving iron or protein buildup can also contribute to heart failure. Acute heart failure may be triggered by factors such as viral infections affecting the heart muscle, severe infections, allergic reactions, blood clots in the lungs, certain medications, or any illness that impacts the entire body.

How to register on the chronic programme

If you have been diagnosed with heart failure, it is important to ask your healthcare provider to reach out to our Chronic Medicine Department at 0860 11 78 59 to initiate your registration in the Chronic Medicine Management Programme. This program is designed to provide ongoing support and management for individuals living with chronic conditions.

Once your registration is complete, a chronic medicine consultant will collaborate with your doctor regarding your treatment plan. After the necessary diagnostic criteria are met and your blood test results are submitted, your treatment will be approved. We will inform you whether your prescribed treatment falls within the Momentum Medical Scheme formulary or if a co-payment will be required.

Once you receive authorization, you can take your prescription to your designated service provider to obtain your medication, and the claim will be submitted on your behalf. A designated service provider (DSP) is a healthcare professional, such as a doctor or pharmacist, that the medical scheme recommends as the first choice for diagnosis, treatment, or care for a Prescribed Minimum Benefit condition. If you choose to use a different provider voluntarily, a co-payment may apply.

It is essential to note that authorizations typically expire after 12 months. If there are no changes in the medication you require, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. The same procedure applies if there are any modifications or additions to your treatment plan.

For more information about your chronic benefits and where to obtain chronic medication and treatment, please click here.

Hospitalization

If you require hospitalization due to complications from heart failure, it is important to log in to the Momentum App or contact us through the web chat feature on momentummedicalscheme.co.za. You can also email us at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59 to request pre-authorization. A case manager will be assigned to follow up on your hospital stay and ensure that you receive the necessary care.

Treatment plan

Upon registration in the program, you will gain access to a comprehensive treatment plan that may include coverage for necessary tests, doctor visits, and other medically essential services as determined by your healthcare provider. Our clinical team will review these services to ensure their appropriateness and necessity.

Compliance

To effectively manage your condition, it is crucial to adhere to a few key compliance measures. First, ensure that you obtain your chronic medication on a monthly basis. Second, take your medication exactly as prescribed by your doctor, paying close attention to the dosage and quantity. Finally, it is vital not to miss doses, as this can have serious implications for your health and overall well-being.

Please make sure your claims have the appropriate ICD-10 code

For all claims to be processed correctly, they must include the appropriate ICD-10 codes (diagnostic codes). This ensures that we can accurately identify and pay for the claim from the Chronic Benefit.

We may pay claims from your Day-to-day Benefits if:

• The claims are submitted without the relevant ICD-10 codes.
• You have exceeded the frequency limit on consultations or tests.
• The treatment is deemed clinically inappropriate.

Contact us

If you have any questions or need assistance, you can reach out to us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message, or call us at 0860 11 78 59.

Glossary of terms

Designated service providers: Momentum Medical Scheme collaborates with a network of designated service providers, including associated general practitioners and specialists, as well as state facilities, to diagnose and treat our members for Prescribed Minimum Benefits.

A formulary: This is a list of medications covered under your health plan, from which your doctor can prescribe the appropriate medication for your chronic condition.

ICD-10: This refers to the diagnosis code used for identifying medical conditions.

Prescribed Minimum Benefits: This is a mandated list of benefits that all medical schemes in South Africa are required to cover as per the Medical Schemes Act 131 of 1998 and its regulations. To access these benefits, your medical condition must qualify and be part of the defined list of Prescribed Minimum Benefit conditions. Additionally, the treatment required must align with the defined benefits, and you must utilize the Scheme’s Designated Service Providers. For more information on Designated Service Providers, see the definition on page 2.

If you opt to use non-designated service providers voluntarily, the Scheme will cover benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. However, if you use non-designated service providers in the case of an emergency medical condition, it is considered involuntary, and co-payments will be waived.

If your medical condition and treatment do not meet the criteria for accessing these benefits, we will process claims according to the benefits available under your chosen plan option.