A COMPREHENSIVE OUTLOOK ON THE ADVANCED TREATMENT OPTIONS FOR HEART FAILURE

Heart Attack, Heart Block and Heart Failure are three different types of Cardiac problems that people often get confused about. Heart Attack occurs when heart-muscle gets damaged due to the sudden cut off in the blood-supply to the walls of the heart. The presence of fat-accumulation in layers of these coronary arteries that could have occurred over years (called atherosclerosis) creates rapid blood-clot formation resulting into a Heart Attack. Consequently patients may suffer with anginal chest pain, sudden breathlessness and may end up in shock and even death. Heart Block refers to the electrical disturbances resulting in abnormal heart rhythms, often manifests as giddiness and syncope. Serious situations require minor surgeries involving permanent pacemaker fixation. The Heart Failure, also known as congestive heart failure, is the weak pumping action of the heart muscles that can result as a sequel of various other diseases (diabetes, hypertension, viral infections, cardiomyopathy, radiation, valvular heart diseases, congenital heart diseases etc.) or following a coronary artery disease or due to unknown causes (idiopathic). In most instances there can be multiple factors operating in the same patient. Cardiomyopathy is a medical term doctors use to describe the pathological affection of heart muscle.

Symptoms:  

As the heart isn’t pumping enough blood to meet your body’s needs there can be fatigue and weakness, shortness of breath (dyspnea) on exerting or whenever patient lies down. Other symptoms like rapid or irregular heartbeat, reduced ability to exercise, persistent cough or wheezing with white or pink blood-tinged phlegm can all point to a poorly pumping heart (heart failure). As a result of poor heart pumping, fluid may build up in the legs, lungs, and in other tissues throughout the body and lead to swelling (edema) in legs, ankles and feet. There can be compounding co-existent medical problems like anemia, electrolyte abnormalities, diabetes mellitus, hypertension, coronary artery disease, thyroid problems, bronchial asthma, arrythmias, renal dysfunction and stroke.

Tests:

Simple tests like ECG, Chest X-ray, 2D-ECHO, blood sugars, thyroid profile, hemogram, serum electrolytes and serum creatinine are adequate in the initial stages to assess and help in prescribing the medications. Coronary angiogram and Cardiac MRI may be advised in some patients. Cardiac MRI is evolving as an important tool for the study of diseases of heart muscle and if the cardiologist advises one should go for it despite the cost and limited availability in the city.

Intensive Care Therapy in acute stage: When patient is severely breathless, grossly swollen, confused and panting, he needs to be hospitalized in intensive care unit, administered oxygen and intravenous drugs that pump out all excess fluid out of the body via urine and those which may improve muscle contraction). Some patients need a mechanical ventilator and mechanical pumps to supporting the respiratory distress and falling blood pressure. The patients need monitoring, frequent evaluation and efficient nursing care.

Chronic Therapy is needed after initial stabilization. Patients have to take a good number of medications which can confuse him and his attendants. It is helpful if a responsible attendant understands about the medications and takes responsibility for medication-compliance. Some drugs need titration to optimal doses after multiple visits to the physicians. There is a possibility that Patients can harm themselves if the instructions about medications are grossly deviated on their own. The drugs generally include diuretics (those take out the excess of fluid from the body and relieve work-load of the heart), vasodilators, ACE inhibitors, ARBs, beta-blockers, aldosterone antagonists (all these fight out the harmful effects of various chemicals generated in heart failure patients).

Sometimes drugs like digoxin, warfarin, amiodarone and statins are used at the discretion of the physician. Despite these multiple drugs the response may not be satisfactory in some patients. Research in this direction is in full swing. Newer drugs like Ivabradine and Sacubitril / Valsartan Complex were recently studied in large trials with promising results. Their potential to improve patient’s symptoms is widely realized and is now adopted into the current practice. No doubt they are very expensive and beyond the reach of most patients on long term basis” said Dr. AN Patnaik, Consultant Cardiologist, STAR Hospitals.

Besides the regular Heart Failure therapies, some patients may have to undergo other cardiac procedures/surgeries simultaneously like Coronary Bypass Surgery, Coronary Angioplasty, Valve Repair or Replacements, TAVI, Ventricular Reduction Surgeries etc., which will help in preventing the worsening of an early heart failure. These procedures are undertaken in advanced cardiac centers after several diagnostic tests. The procedures which are considered to be more specific for the management of heart failure are as follows

CRT-Therapy:

In this modality, a device (containing a mini-computer and a battery), that looks like a pace-maker, is fixed over the chest of the patient under the skin layers by a minor surgery. This device sends electrical impulses to both the lower chambers through the wires that connect with the device and help them to beat in a synchronized pattern. This can improve the pumping efficiency of heart to some extent. This is an expensive device costing about 8 lakhs and it may not suit everyone. Once implanted, there is need for periodic check-up of the device function along with other tests.

Cardiac Transplantation

The surgery involves the transplantation of heart from the person who is just expired to the patient with completely damaged heart. The donor in such situations is the unfortunate person who had suffered with irreversible brain injury (generally after a fatal motor vehicle accident) with a normal heart (called brain dead). The other organs of the donor are maintained on supports and medication till the heart is taken out. The donor’s family members must agree voluntarily and the medical team should act as fast as possible to get best results. At times the donor may be in a different city. The transport of the heart is done by best available air service without wasting a single minute. Once the implantation is done the patient is kept on special medicines for the acceptance of the donor heart by the patient for as many years as possible. The drugs that prevent the rejection of transplanted heart have several side-effects including increased incidence for infections and cancers. The trained cardiologists can help out the patients when such problems arise. Initial cost may be as much as 5 to 30 lakhs. Only with generosity of the donors families and high level coordination of all team members of the transplant team this program can be successful.

Ventricular Assist Devices

These complex devices are fixed by surgeons to assist/support either one or both ventricles to improve the blood circulation. The pump is generally fixed in upper abdomen. It pulls blood from the left ventricle and delivers into the aorta. A control system is outside the body that runs on battery. They can be either used temporarily till the transplant is done [bridge to transplant] or at times as the permanent solution through the life-span of the patient. In a few instances the necessity to assist the circulation may be for a temporary period. These devices need to be charged almost continuously and maintenance calls for the special training of paramedics, family members and the patient. These devices cost 20 to 90 lakhs at the time of implantation depending on the model used. Unfortunately the cost of these new therapies is a big limitation to most patients with heart failure and the community and state have to support them.

Heart-failure Clinics/ Rehabilitation

For the delivery of comprehensive heart failure treatment services from prevention, diagnosis, treatment, surgery and rehabilitation, all big hospitals should create ‘Heart Clinics’ and a Heat failure treatment team. A good rehabilitation center should be created with well qualified professionals who can advice on diet, exercises, activities and all other needs on long term basis.

Here’s the list of necessary steps to prevent the onset or further deterioration of the situation by progressing to advanced stages.

1. Low salt diet

1. Fluid restriction
2. Physician prescribed exercises/activities
3. Body-weight monitoring
4. Continuation of medicines for Hypertension, Diabetes and Coronary Artery disease
5. Register in transplant program
6. Periodic check-ups

Patients should not feel helpless when the diagnosis of heart failure is made. Presently many effective medications and state-of-the-art technologies and facilities to perform cardiac transplantation are available in most cities in India. Our Star Hospital at Hyderabad is well-equipped for offering all the above modalities and has expert doctors and personnel to guide the patient’s treatment at any stage of the Heart Failure.

Book Appointment: Dr. AN Patnaik, Consultant Cardiologist, STAR Hospitals.