Focus on cardiac failure

What is Cardiac Failure?

Heart failure, commonly referred to as congestive heart failure, is a serious condition that arises when the heart muscle is unable to pump blood as effectively as it should. This inefficiency can stem from various underlying health issues, including narrowed arteries in the heart, known as coronary artery disease, or high blood pressure. Over time, these conditions can weaken the heart or make it stiff, ultimately impairing its ability to fill and pump blood efficiently.

While not all conditions leading to heart failure can be reversed, there are treatments available that can significantly enhance the signs and symptoms associated with this condition, allowing individuals to live longer, healthier lives. Making lifestyle changes is crucial; incorporating regular exercise, reducing sodium intake in your diet, limiting alcohol consumption, quitting smoking, managing stress levels, and achieving a healthy weight can all contribute to an improved quality of life. Additionally, proactive management of conditions that can lead to heart failure, such as coronary artery disease, high blood pressure, diabetes, and obesity, is a key preventive strategy.

The signs and symptoms of cardiac failure

The symptoms of heart failure can vary widely among individuals, but they often include:

• Shortness of breath (dyspnea): This may occur during physical activity or when lying down, indicating that the heart is struggling to manage the body’s oxygen needs.
• Fatigue and weakness: Many individuals with heart failure experience a persistent sense of tiredness and a lack of energy, making everyday activities feel daunting.
• Swelling (edema): Fluid retention can lead to noticeable swelling in the legs, ankles, and feet, which is a common symptom of heart failure.
• Rapid or irregular heartbeat: Patients may notice an increased heart rate or an irregular rhythm, which can be alarming and may require medical attention.
• Reduced ability to exercise: Individuals may find that they are unable to engage in physical activities as they once did, often due to shortness of breath or fatigue.
• Persistent cough or wheezing: Some may experience a cough that produces white or pink blood-tinged phlegm, indicating fluid buildup in the lungs.
• Increased need to urinate at night: Nocturia, or frequent urination during the night, can be a sign of heart failure due to fluid redistribution while lying down.
• Swelling of the abdomen (ascites): Fluid accumulation in the abdominal cavity can occur, leading to discomfort and a feeling of fullness.
• Sudden weight gain: Rapid weight gain due to fluid retention can be a warning sign of worsening heart failure.
• Lack of appetite and nausea: Individuals may experience a decreased desire to eat or feelings of nausea, which can further complicate their health.
• Difficulty concentrating: Cognitive issues, such as decreased alertness or trouble focusing, can arise as the body struggles to manage its blood flow and oxygen supply.
• Severe shortness of breath: A sudden onset of intense shortness of breath, accompanied by coughing up pink, foamy mucus, is a medical emergency.
• Chest pain: If heart failure is triggered by a heart attack, individuals may also experience chest pain.

When to see a doctor

If you suspect that you are experiencing any signs or symptoms of heart failure, it is essential to consult with your doctor promptly. Additionally, seek emergency medical care if you encounter any of the following serious symptoms:

• Chest pain: This could indicate a heart attack or other serious condition.
• Fainting or severe weakness: These symptoms may suggest a significant drop in blood flow to the brain.
• Rapid or irregular heartbeat: If accompanied by shortness of breath, chest pain, or fainting, this could be a sign of a serious issue.
• Sudden, severe shortness of breath: Coupled with coughing up pink, foamy mucus, this indicates a critical situation requiring immediate attention.

Possible causes of cardiac failure

• 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 condition known as atherosclerosis. If these plaques rupture, they can lead to a heart attack, blocking blood flow to a portion of the heart muscle, weakening its pumping ability and potentially causing irreversible 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 cause the heart to become too stiff or weak to pump blood effectively.
• Faulty heart valves: The heart's valves ensure that blood flows in the correct direction. If a valve is damaged due to congenital defects, coronary artery disease, or infections, it can cause the heart to work harder, leading to potential weakening over time. Fortunately, many faulty valves can be repaired or replaced if identified early.
• Damage to the heart muscle (cardiomyopathy): Cardiomyopathy can result from various causes, including diseases, infections, alcohol abuse, and the toxic effects of certain drugs, such as cocaine or some chemotherapy agents. Genetic factors also play a significant role in several types of cardiomyopathy.
• Myocarditis: This is an inflammation of the heart muscle, often caused by viral infections, which can lead to left-sided heart failure.
• Congenital heart defects: Individuals born with heart defects may have improperly formed chambers or valves, forcing the healthy parts of the heart to work harder, potentially leading to heart failure.
• Abnormal heart rhythms (arrhythmias): An irregular heartbeat can either be too fast or too slow, both of which can place additional strain on the heart, ultimately leading to heart failure.
• Other diseases: Chronic conditions such as diabetes, HIV, hyperthyroidism, and conditions that cause excessive iron or protein buildup in the body can also contribute to the development of heart failure. Acute heart failure can result from viral infections, severe infections, allergic reactions, blood clots in the lungs, certain medications, or any illness that affects the entire body.

How to register on the chronic programme

If you have received a diagnosis of Addison’s disease, it is important to have your doctor reach out to our Chronic Medicine Department by calling 0860 11 78 59 to register you in the Chronic Medicine Management Programme. A chronic medicine consultant will work closely with your doctor regarding your treatment plan. Once the necessary diagnostic criteria have been met and relevant blood results submitted, the treatment will be approved. You will be informed whether your treatment falls within the Momentum Medical Scheme formulary or if a co-payment is required. Upon receiving authorization, you can present your prescription to a designated service provider to obtain your medication, and the claim can be processed. A designated service provider (DSP) is a healthcare provider, such as a doctor, pharmacist, or hospital, that is the preferred choice of the medical scheme for members requiring diagnosis, treatment, or care for a Prescribed Minimum Benefit condition. If you choose not to use the DSP and opt for a different provider, you may incur a co-payment. Note that the authorization typically expires after 12 months. If there are no changes in the medication you need, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. The same process applies for any changes or additions to your authorization.

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

Hospitalization

If hospitalization is necessary due to complications related to cardiac failure, you can log in to the Momentum App, utilize the web chat feature on momentummedicalscheme.co.za, 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 monitor your hospital stay.

Treatment plan

Once you are registered in the program, you will gain access to a comprehensive treatment plan. This plan may include coverage for necessary tests, doctor visits, and other benefits deemed medically necessary by your healthcare provider. Our clinical team will review these benefits to ensure their appropriateness and alignment with your treatment needs.

Compliance

• Ensure that you obtain your chronic medication on a monthly basis.
• Take your medication precisely as prescribed by your doctor, adhering to the designated dosage and quantity.
• Do not miss any doses, as this is critical for maintaining compliance and can have serious implications for your overall health and well-being.

Please ensure your claims include the appropriate ICD-10 code

It is crucial for all claims to include the relevant ICD-10 codes (diagnostic codes) to ensure accurate identification and processing of the claim under the Chronic Benefit.

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

• The claims are submitted without the necessary ICD-10 codes.
• You have exceeded the frequency limit on consultations or tests.
• The treatment is deemed not clinically appropriate.

Contact us

You can reach us through the web chat feature on momentummedicalscheme.co.za, email us at [e-mail], send a WhatsApp message, or call us at 0860 11 78 59.

Glossary of terms

Designated service providers: Momentum Medical Scheme operates with a network of designated service providers, including associated general practitioners and specialists, as well as state facilities, to ensure our members receive appropriate diagnosis and treatment for Prescribed Minimum Benefits.

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

ICD-10: This refers to the diagnosis code utilized for medical billing and record-keeping.

Prescribed Minimum Benefits: This is a mandated list of benefits that all medical schemes in South Africa must provide coverage for, as per the Medical Schemes Act 131 of 1998 and its associated regulations. To access these benefits:

• Your medical condition must qualify for coverage and be included in the defined list of Prescribed Minimum Benefit conditions.
• The necessary treatment must align with the defined benefits.
• You must utilize the Scheme’s Designated Service Providers. For more information on Designated Service Providers, please refer to the definition provided on page 2.

If you choose to use non-designated service providers voluntarily, the Scheme will reimburse benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. However, if you utilize non-designated service providers in emergency medical situations, this is considered involuntary, and co-payments will be waived.