Introduction

The heart has four chambers–two atria and two ventricles, divided by a septum that separates the heart into the left and right. Cardiomegaly, which also refers to enlargement of the heart, may involve any of the four chambers or the entire heart. An enlarged heart can be present at birth ( congenital ) or manifested by other conditions that affect the functions of the heart, such as cardiomyopathy and coronary artery disease.¹

Some of the common causes that lead to an enlarged heart are high blood pressure, heart attack, heart valve diseases, and  bacterial endocarditis. These conditions ultimately reduce the heart’s ability to pump blood efficiently, leading to enlargement of the heart. In high blood pressure patients, the heart is forced to work harder to overcome the high pressure in order to pump blood throughout the body. Coronary artery disease, such as heart attack, and inflammation of the heart damages the heart muscles, and to compensate for the damage, the heart enlarges so it is able to continuously pump blood throughout the body.^2,3,4 

Most patients with enlarged hearts do not present with symptoms and may only present symptoms during exertion. Some of the symptoms related to an enlarged heart are:

• Shortness of breath
• Fatigue
• Chest pain
• Palpitations
• Lightheadedness
• Swollen ankles, feet and legs

Since these symptoms are non-specific, a detailed history taken upon admission is required to accurately diagnose patients. An enlarged heart can only be seen via imaging, usually a chest X-ray. Once cardiomegaly is visualised on the X-ray, further tests, such as an electrocardiogram (ECG), can be used to assess the heart’s function and to determine the valves’ structures and function. Other tests include cardiac MRI, , coronary angiogram, and stress test.¹

There is no specific treatment for having an enlarged heart. Patients are usually advised on lifestyle modifications to decrease risk factors. However, patients often get medical treatment for the underlying disease or condition that causes the heart enlargement. Some of the underlying risk factors that require treatment are high blood pressure, dyslipidaemia, diabetes mellitus, arrhythmias, anaemia, and obstructive sleep apnoea. Examples of common heart medications are angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blocker (ARB) inhibitors to lower blood pressure, antiarrhythmics to correct heart rhythms, beta-blockers to lower blood pressure and improve heart function, and anticoagulants to prevent blood clots. A standard heart failure treatment guideline is also used for patients with enlarged hearts associated with heart failure. Surgical interventions may be needed in cases of valve disease or pacemaker implantation.¹

Patient education and self-management strategies

Monitoring symptoms

Patients who are at risk of cardiomegaly, especially those with a family history and without specific symptoms, should attend regular health checkups for early detection and treatment. Regular checkup is also important to ensure symptoms are not worsening and there are no other further complications, for example heart failure. Patients who experience heart discomfort and sudden onset of symptoms such as chest pain, shortness of breath, irregular heartbeat, fainting should seek medical attention promptly as it could also be a heart attack. While an enlarged heart is not an emergency, an underlying condition that exacerbates the condition can be life-threatening if not treated promptly.

Understanding triggers

It is important to understand the triggering factors that are causing the symptoms. and to avoid them. Having an unhealthy diet and nutritional intake could lead to obesity, which is a major risk factor for cardiovascular diseases that could cause heart enlargement.⁵ Another possible trigger is smoking–it reduces the amount of oxygen in the blood and increases the blood pressure, which could also cause heart enlargement.⁶ Similarly, alcohol consumption has been negatively linked to various heart diseases and conditions, and patients who are at risk for cardiomegaly or are diagnosed with cardiomegaly should reduce alcohol intake as much as possible.⁷

Medication adherence

Patients are usually prescribed one or more medications for their underlying disease or conditions; hence, it is important to adhere to these prescribed medications in order to get the symptoms under control and to prevent worsening of the condition. Poor adherence to specific heart failure medications can lead to hospitalisation and death. There are many causes of non-adherence, either intentional or non-intentional. It could be due to the side effects of the treatment that are making patients uncomfortable or feeling unwell upon taking, or it could just be the patients have forgotten to take the medications on time. Therefore, patients should be able to discuss openly as to why they are not adhering to the medications prescribed so a relevant intervention can take place. Having a good adherence to medications reduces hospitalisation events and costs related to it, improves survival rate, and overall improves patients’ physical function and quality of life.^8,9

Lifestyle modification

Lifestyle modifications include smoking cessation, healthy dietary intake, reduction in alcohol intake, weight management, physical activity, and stress management. These modifiable risk factors directly affect the heart’s health and can significantly reduce the risk of cardiovascular diseases.^1,11

Smoking cessation 

Smoking cessation can be done cold-turkey, or patients can attend stop smoking service that provides support and help from professionals. It is important to understand that the harmful effects of cigarettes are not only limited to the active smokers but to the surrounding people.– are the second-hand smoke exposure who also possess similar risks to the active smokers. Therefore, patients with a family, especially young children, should be motivated to quit smoking for their own health and the wellbeing of the family.

Balanced diet

A heart-healthy and balanced diet includes reduced unhealthy fats, lower calories, low sodium, high levels of magnesium, potassium, and calcium, and is rich in omega-3 fatty acids, antioxidants, and fibre. The European Society of Cardiology (ESC) Guidelines recommend the Mediterranean diet that is packed with fruits and vegetables, wholegrains, legumes, fish, and olive oil. The Mediterranean lifestyle also include the vitamin D supplement if you have little to no exposure to sunlight, especially during the winter, when the daytime is shorter. Vitamin D deficiency has been reported to increase the risk of cardiovascular diseases.¹² 

Alcohol consumption

A high amount of alcohol consumption has been linked to increased risks of cardiovascular diseases. Drinking a large amount of alcohol at once, also called binge-drinking, in particular, does not only have harmful effects on heart health and general health; there is also a risk of alcohol poisoning and falling. Statistically, alcohol drinkers pose a 14% higher risk for haemorrhagic stroke compared to non-smokers. Therefore, patients are advised to reduce alcohol consumption, especially if they are showing symptoms. One to two drinks per day is considered safe; however, it is worth noting that daily consumption can lead to alcohol dependence and addiction.¹³ 

Physical Activity

Regular physical activity, such as brisk walking, swimming, cycling, yoga, and pilates, helps to maintain a healthy weight as well as reduce the cardiovascular risks. It is recommended to do at least 150 minutes of moderate exercises per week or 75 minutes of intense exercises per week for optimal cardiovascular health. Moderate exercises are generally more comfortable and slow-paced, like walking or gardening, while intense exercises, like running and swimming, increase your heart rate and breathing. Patients should always pick the exercises that they feel confident doing without overstraining the body.

Stress management 

Stress management correlates with all the other lifestyle modifications–eating healthy and regular exercises help to relieve stress. Patients should first identify the cause of the stress, and the management is to tackle the root cause. There are several stress management techniques, such as meditation and deep breathing exercises, that are meant to be relaxing, or patients can always seek professional help from therapists or counsellors. Having a good support network, either family or friends or both, is also helpful in stress management. 

Summary

Enlarged heart is a condition rather than a disease that is usually the result from another condition or diseases like coronary artery diseases, cardiomyopathy, or it can be congenital. While there is no specific treatment for an enlarged heart, there are usually medications prescribed for the underlying condition or disease. It is crucial that patients understand the adherence to these medications to prevent exacerbation of the condition and worsening of the symptoms. All diagnosed patients are advised on their lifestyle modifications, involving their eating habits, physical activity, and weight management. Patients are usually also advised against binge drinking of alcohol, smoking, tobacco, and other uses of recreational drugs. These modifications vary from one patient to another and are individualised depending on the patient’s current medical condition.