Why cardiac patients can now take heart
February 10, 2004 | 12:00am
When I graduated from medical school (many moons ago!), there was little that a cardiologist could do for someone who’d had a heart attack other than interpret the electrocardiogram, prescribe a painkiller and a coronary vasodilator, put the patient on prolonged bed rest, and offer tender loving care.
In those days, there were no coronary care units, bypasses, angioplasties, pacemakers and only a handful of drugs with which to treat any kind of heart disease. The death rate from heart attacks, even among patients who made it to the hospital, was high. Patients were kept flat on their backs for at least two weeks, leaving them vulnerable to the formation of blood clots in the legs, which sometimes traveled to the lung artery, causing pulmonary embolism and death.
Although new knowledge and technology have resulted in more effective prevention, more accurate and earlier diagnosis, and better treatment of heart ailments, cardiovascular diseases remain the No. 1 killer in many countries around the world, including the Philippines. But there are exciting advances in every field of medicine every day. And in the field of cardiology, here are some recent highlights in the diagnosis and treatment of common heart conditions:
• New stents keep arteries open. The recent availability of cardiac stents – sleeves inserted into an obstructed artery that has been ballooned open by angioplasty – is a major breakthrough. Whereas older stents closed up within a few months in about 20 to 40 percent of patients, the new ones, coated with a chemical called sirolimus, have been shown to remain open in more than 90 percent of cases. Other coated stents will soon appear on the market. These stents have greatly reduced the need for repeat angioplasty and bypass surgery.
• Irregular heartbeats can be corrected permanently. We used to rely entirely on drugs to suppress cardiac arrhythmias. Their effect was unpredictable, and many had serious side effects even when they did work. We now often can permanently stop or "ablate" these rhythm disturbances with various techniques, including radio waves directed at specific areas of the heart.
• Defibrillators are no longer just for the ER. The leading cause of sudden death in someone whose heart has been damaged by a heart attack is an unexpected life-threatening rhythm disorder called ventricular fibrillation. The heart beats rapidly and irregularly – resembling a bag of worm – and cannot pump its blood. Defibrillators, which shock the heart and restore normal rhythm, have been placed in many public areas. Compact, easy-to-use models for the home are now also available.
Better still, a defibrillator wire can be threaded into the heart of a vulnerable individual. It shocks the heart into normal rhythm as soon as it senses the onset of ventricular fibrillation. You no longer are dependent on having someone who’ll go looking for a defibrillator (and who knows how to use it) and save your life. These implanted devices could save many thousands of lives every year.
• Heart surgery is safer, quicker, less traumatic. Heart surgery doesn’t have to be "open" anymore. Surgeons can now repair or replace heart valves and perform bypass surgery on a beating heart through small incisions in the chest wall. Patients are discharged from the hospital much sooner and suffer fewer complications than after open-heart surgery.
Research is now being conducted using robots to perform these operations. A few already have been done successfully in several hospitals abroad. Don’t misunderstand me: It’s not as if a robot has pushed the surgeon aside and is doing the operation. The doctor inserts robotic "fingers" into the small holes in the chest and manipulates them from the outside.
• Inflammation and the CRP test: a new predictor. Doctors are increasingly convinced that inflammation of the lining of an artery wall, whether in the heart or in the brain, may cause any plaques it contains to rupture and obstruct it. This inflammation may explain why persons with none of the classic risk factors for arteriosclerosis suffer heart attacks in the prime of life.
A blood test now being used fairly widely measures the C-reactive protein (CRP) level, a marker of inflammation in the body. A high CRP is a more reliable predictor of heart attacks and strokes than an elevated level of LDL, the bad cholesterol. When the CRP level is high, many cardiologists now rigorously control all risk factors for vascular disease. Many also make sure that the patients take aspirin for its anti-inflammatory action as well as protection against clot formation. Likewise, they usually prescribe one of the statin drugs, even if the cholesterol level is normal or low. In addition to lowering cholesterol, these medications reduce inflammation. (Incidentally, so does alcohol in moderation.)
• Folic acid supplements reduce risk. Homocysteine, an amino acid (protein) in the blood is another marker of vulnerability to a stroke or fatal heart attack. It can be lowered by folic acid supplements. Ask to be tested for homocysteine as part of your routine physical. If it’s high, be sure to take at least 1 mg of folic acid daily.
• New drugs strengthen weak hearts. When I was a medical student, we only had digitalis to help a weak heart muscle. Though digitalis is still used, there are now varieties of diuretics, beta-blockers and ACE inhibitors that singly or in combination more effectively strengthen a failing heart.
• Statins are the next aspirin. Statins have reaped plenty of glory in the past few years. Millions of people all over the world are taking them to prevent heart attacks – the drug works by blocking an enzyme the liver uses to make cholesterol. A study released in November suggests an intensive regimen of a statin drug could actually arrest artery damage.
Statin drugs also work so well at preventing heart disease in people suffering from diabetes – regardless of their cholesterol levels – that in June 2003, some experts began suggesting some people with diabetes take them. This remarkable pro-statin stance came about after a study involving 6,000 diabetics found that using statins cut the risk of heart problems by about 25 percent, even in those with normal cholesterol. This is key, since some 70 percent of diabetics ultimately die of heart attacks. Overall, study scientists said five years of statin therapy could prevent a major cardiovascular problem, such as angina or a heart attack in 45 out of every 1,000 diabetics. Indeed, doctors around the world are calling the statins "the next aspirin" and they work so well that some even jokingly suggest that they be added to the water supply!
• Improved MRIs provide clearer diagnosis. Magnetic resonance imaging, which gives better views of the heart and coronary arteries, may further reduce the need for invasive cardiac diagnostic procedures.
• Aspirin helps women as well as men. We’ve known for years that aspirin helps prevent the recurrence of heart attacks and strokes in men, as well as initial attacks in men who are still healthy but vulnerable because of various risk factors, such as high cholesterol, hypertension, cigarette smoking and diabetes. But we weren’t certain that aspirin was also protective for women. Recent studies have confirmed that to be a fact.
• The artificial heart is changing lives. These devices are being installed more and more frequently in technologically advanced countries because there are simply not enough human hearts to meet the transplant demand. Artificial hearts are of two types: One totally replaces the heart; the other, called a "left ventricular assist device," is a small auxillary pump inserted into the left ventricle of a failing heart to strengthen its beat.
• Stem cells can heal the human heart. No discussion can be complete without mentioning stem cells. These are immature cells that are capable of transforming themselves into almost any kind of tissue cell. In the field of cardiology, they hold promise in the possibility that these stem cells, when injected into a damaged heart, may stimulate repair of the affected area by producing new heart cells.
In the United States and Europe, a flurry of studies in the past two years have begun to test the ability of stem cells to boost the function of a failing human heart. The initial reports have been encouraging, thus moving heart repair by stem cell therapy out of the "future possibility" into the "presently probable" category.
Indeed, millions of people around the world are getting a new lease on life, thanks to a host of advances in the diagnosis and treatment of heart disease.
In those days, there were no coronary care units, bypasses, angioplasties, pacemakers and only a handful of drugs with which to treat any kind of heart disease. The death rate from heart attacks, even among patients who made it to the hospital, was high. Patients were kept flat on their backs for at least two weeks, leaving them vulnerable to the formation of blood clots in the legs, which sometimes traveled to the lung artery, causing pulmonary embolism and death.
Although new knowledge and technology have resulted in more effective prevention, more accurate and earlier diagnosis, and better treatment of heart ailments, cardiovascular diseases remain the No. 1 killer in many countries around the world, including the Philippines. But there are exciting advances in every field of medicine every day. And in the field of cardiology, here are some recent highlights in the diagnosis and treatment of common heart conditions:
• New stents keep arteries open. The recent availability of cardiac stents – sleeves inserted into an obstructed artery that has been ballooned open by angioplasty – is a major breakthrough. Whereas older stents closed up within a few months in about 20 to 40 percent of patients, the new ones, coated with a chemical called sirolimus, have been shown to remain open in more than 90 percent of cases. Other coated stents will soon appear on the market. These stents have greatly reduced the need for repeat angioplasty and bypass surgery.
• Irregular heartbeats can be corrected permanently. We used to rely entirely on drugs to suppress cardiac arrhythmias. Their effect was unpredictable, and many had serious side effects even when they did work. We now often can permanently stop or "ablate" these rhythm disturbances with various techniques, including radio waves directed at specific areas of the heart.
• Defibrillators are no longer just for the ER. The leading cause of sudden death in someone whose heart has been damaged by a heart attack is an unexpected life-threatening rhythm disorder called ventricular fibrillation. The heart beats rapidly and irregularly – resembling a bag of worm – and cannot pump its blood. Defibrillators, which shock the heart and restore normal rhythm, have been placed in many public areas. Compact, easy-to-use models for the home are now also available.
Better still, a defibrillator wire can be threaded into the heart of a vulnerable individual. It shocks the heart into normal rhythm as soon as it senses the onset of ventricular fibrillation. You no longer are dependent on having someone who’ll go looking for a defibrillator (and who knows how to use it) and save your life. These implanted devices could save many thousands of lives every year.
• Heart surgery is safer, quicker, less traumatic. Heart surgery doesn’t have to be "open" anymore. Surgeons can now repair or replace heart valves and perform bypass surgery on a beating heart through small incisions in the chest wall. Patients are discharged from the hospital much sooner and suffer fewer complications than after open-heart surgery.
Research is now being conducted using robots to perform these operations. A few already have been done successfully in several hospitals abroad. Don’t misunderstand me: It’s not as if a robot has pushed the surgeon aside and is doing the operation. The doctor inserts robotic "fingers" into the small holes in the chest and manipulates them from the outside.
• Inflammation and the CRP test: a new predictor. Doctors are increasingly convinced that inflammation of the lining of an artery wall, whether in the heart or in the brain, may cause any plaques it contains to rupture and obstruct it. This inflammation may explain why persons with none of the classic risk factors for arteriosclerosis suffer heart attacks in the prime of life.
A blood test now being used fairly widely measures the C-reactive protein (CRP) level, a marker of inflammation in the body. A high CRP is a more reliable predictor of heart attacks and strokes than an elevated level of LDL, the bad cholesterol. When the CRP level is high, many cardiologists now rigorously control all risk factors for vascular disease. Many also make sure that the patients take aspirin for its anti-inflammatory action as well as protection against clot formation. Likewise, they usually prescribe one of the statin drugs, even if the cholesterol level is normal or low. In addition to lowering cholesterol, these medications reduce inflammation. (Incidentally, so does alcohol in moderation.)
• Folic acid supplements reduce risk. Homocysteine, an amino acid (protein) in the blood is another marker of vulnerability to a stroke or fatal heart attack. It can be lowered by folic acid supplements. Ask to be tested for homocysteine as part of your routine physical. If it’s high, be sure to take at least 1 mg of folic acid daily.
• New drugs strengthen weak hearts. When I was a medical student, we only had digitalis to help a weak heart muscle. Though digitalis is still used, there are now varieties of diuretics, beta-blockers and ACE inhibitors that singly or in combination more effectively strengthen a failing heart.
• Statins are the next aspirin. Statins have reaped plenty of glory in the past few years. Millions of people all over the world are taking them to prevent heart attacks – the drug works by blocking an enzyme the liver uses to make cholesterol. A study released in November suggests an intensive regimen of a statin drug could actually arrest artery damage.
Statin drugs also work so well at preventing heart disease in people suffering from diabetes – regardless of their cholesterol levels – that in June 2003, some experts began suggesting some people with diabetes take them. This remarkable pro-statin stance came about after a study involving 6,000 diabetics found that using statins cut the risk of heart problems by about 25 percent, even in those with normal cholesterol. This is key, since some 70 percent of diabetics ultimately die of heart attacks. Overall, study scientists said five years of statin therapy could prevent a major cardiovascular problem, such as angina or a heart attack in 45 out of every 1,000 diabetics. Indeed, doctors around the world are calling the statins "the next aspirin" and they work so well that some even jokingly suggest that they be added to the water supply!
• Improved MRIs provide clearer diagnosis. Magnetic resonance imaging, which gives better views of the heart and coronary arteries, may further reduce the need for invasive cardiac diagnostic procedures.
• Aspirin helps women as well as men. We’ve known for years that aspirin helps prevent the recurrence of heart attacks and strokes in men, as well as initial attacks in men who are still healthy but vulnerable because of various risk factors, such as high cholesterol, hypertension, cigarette smoking and diabetes. But we weren’t certain that aspirin was also protective for women. Recent studies have confirmed that to be a fact.
• The artificial heart is changing lives. These devices are being installed more and more frequently in technologically advanced countries because there are simply not enough human hearts to meet the transplant demand. Artificial hearts are of two types: One totally replaces the heart; the other, called a "left ventricular assist device," is a small auxillary pump inserted into the left ventricle of a failing heart to strengthen its beat.
• Stem cells can heal the human heart. No discussion can be complete without mentioning stem cells. These are immature cells that are capable of transforming themselves into almost any kind of tissue cell. In the field of cardiology, they hold promise in the possibility that these stem cells, when injected into a damaged heart, may stimulate repair of the affected area by producing new heart cells.
In the United States and Europe, a flurry of studies in the past two years have begun to test the ability of stem cells to boost the function of a failing human heart. The initial reports have been encouraging, thus moving heart repair by stem cell therapy out of the "future possibility" into the "presently probable" category.
Indeed, millions of people around the world are getting a new lease on life, thanks to a host of advances in the diagnosis and treatment of heart disease.
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