Heart Conditions: Therapies - Medical Essentials
CORONARY HEART DISEASE
The H2G2 website describes medical essentials and treatments including:
DIAGNOSTIC TESTS: An initial diagnosis can be made by having an ECG, (Electrocardiograph). This simply involves having a series of electrodes attached to the chest and lower legs. The electrodes pick up the electrical impulses from heart activity and from blood flow which then produces a printout showing the trace patterns. A normal trace pattern shows in the form of a graph with even peaks and troughs showing different impulses produced at each stage of the cardiac cycle. Any abnormalities can be seen fairly quickly by the doctor and further tests and treatment then arranged.
If an actual heart attack is suspected, as well as showing up on the ECG, blood tests are taken which measure certain enzymes that are released by the heart muscle during an attack. These are Troponin I and Troponin T tests. There should be little or no Troponin in the blood if there is no damage to the heart muscle itself. Troponin is released into the blood stream and is measured up to six hours after the initial onset of the attack.
For heart attack one of the most useful tools is an ANGIOGRAM. This is normally done as a day patient and involves a tube being inserted into the main artery in the groin through which a fine wire/tube is fed up the artery to the heart. A dye is injected and this allows the arteries to show up clearly on a video/x-ray. The resulting pictures will show the cardiologist where and how severe the blockage of blood flow is, and will then lead on to whether a full by-pass operation is required or a procedure known as angioplasty with a stent (more on this under Surgery in our ‘Treatments’ section).
An exercise stress test can also be carried out. This involves the patient being wired to a heart monitoring machine and a blood pressure monitor and then
the patient starts by walking on a treadmill. The treadmill is adjusted for different levels of severity mimicking walking uphill and possibly jogging. The
test can last for up to 20 minutes after which the printed results are studied to see what abnormalities, if any, are present. This test is carried out with qualified staff present in case it triggers an angina attack or worse.
For patients unable to have either an angiogram or carry out a stress test, an echocardiogram can be used in a number of ways see how your heart is functioning.
The angiogram is the only test that involves what medics term invasive diagnostics. All three of the above procedures are relatively safe and routine these days.
Surgery, drug treatments and lifestyle changes can all be essentials in dealing with coronary heart disease.
HEART FAILURE
The therapeutic goals are to:
- Treat the underlying cause of your heart failure
- Improve your symptoms (typically including poor energy, breathlessness and swollen ankles) and improve your quality of life
- Stop your heart failure from getting worse
- Prolong your life span
Your doctor will treat any identifiable diseases or conditions (such as coronary artery disease, high blood pressure, or diabetes) causing your heart failure.
The treatments for heart failure include:
Lifestyle changes (see our Self-Help section)
Medications
Specialized care for those in the most advanced stage of heart failure
Lifestyle Changes: There are things that you can do to help with your treatment. Your doctor will recommend that you:
Follow a diet low in salt. Salt can cause extra fluid to build up in your body, making your heart failure worse.
Limit the amount of fluids that you drink.
Weigh yourself every day, and let your doctor know right away if you have a sudden weight gain. This could mean you have extra fluid building up in your body.
Exercise as directed to help build your fitness level and ability to be more active.
Your doctor will also tell you to:
Lose weight if you are overweight.
Quit smoking if you smoke.
Limit the amount of alcohol that you drink.
Medicines: Your doctor will prescribe medicines to help improve your heart function and symptoms. The main medicines are:
Diuretics (water or fluid pills) to help reduce fluid buildup in your lungs and swelling in your feet and ankles.
ACE inhibitors to lower blood pressure and reduce the strain on your heart. These medicines also may reduce the risk of a future heart attack.
Beta blockers to slow your heart rate and lower your blood pressure to decrease the workload on your heart.
Digoxin to make the heart beat stronger and pump more blood.
As heart failure progresses, lifestyle changes and regular medicines may not be enough to control worsening symptoms. Many people with severe heart failure must be treated in the hospital from time to time. In the hospital, your doctor may prescribe new or special medicines. You will continue to take your regular medicines during this treatment.
Your doctor will also order extra oxygen if you continue to have trouble breathing. The extra oxygen can be given in the hospital and at home.
Persons with very severe heart failure may be considered for a:
- Mechanical heart pump
- Heart transplant
A mechanical heart pump is a special device placed inside the body to help pump blood to the rest of the body. There are different kinds of mechanical heart pumps. Some stay in the body for a short period of time, while others can stay in the body for a long time. Many people with a mechanical heart pump will also be considered for a heart transplant.
A heart transplant is surgery to replace a heart failure patient’s heart with a healthy heart from someone who has recently died. A transplant is indicated in some people when all other treatments fail to control symptoms.
HIGH BLOOD PRESSURE (HYPERTENSION)
Much of what you need to do can be found in our Self-Help section.
If your blood pressure requires medical treatment, you will probably have to take medicine on a regular basis. If so, never stop taking it without consulting your GP, even if you feel fine. The result of doing so could be very bad indeed.
Sometimes blood pressure control is not straightforward. Many people require more than one drug on a regular basis to get their blood pressure under good control.
Your GP may wish to seek the advice of an expert in hypertension if your blood pressure seems particularly difficult to control.
By treating hypertension well, complications can be avoided and average life expectancy will remain almost normal. Without treatment, life expectancy may well be reduced due to the risk of developing complications such as heart failure or stroke.
ATRIAL FIBRILLATION increases the risk of stroke. Because blood doesn’t flow as smoothly in the atria during AF small clots may form along the atrial walls and these can fall off and be carried to the brain where they obstruct blood flow and cause a stroke. This risk also increases with age and if other risk factors for stroke are present such as diabetes or high blood pressure. For this reason, coumadin or warfarin is used as an anticoagulant, sometimes called a “blood thinner”. This greatly reduces the risk of stroke. There is a very small increased risk of bleeding as long as the coumadin level is carefully monitored. For people who can’t use coumadin, aspirin also reduces the risk of stroke but not as much as coumadin.
AF is caused by many factors, however in most people it seems to be initiated by muscle cells located in the veins which connect the lungs to the heart. The pulmonary veins bring the oxygen rich blood back to the heart to be pumped out to the body. (Trivia fans note: these are the only veins – as opposed to arteries – in the body to carry oxygenated blood!) . The four pulmonary veins attach to the back of the left atrium. Muscle cells in the pulmonary veins are electrically active cells and some may begin firing off electrical impulses very rapidly. These impulses go to the left atrium and may initiate atrial fibrillation. We earlier described the healthy electrics of the heart as being like an undisturbed swimming pool. The rapidly firing muscle cells in AF are like dropping one stone after another at speed into the water. The speed of firing causes a disorganized chaos of waves. This chaotic electrical activity disrupts the heart’s pumping and blood flow systems.
Doctors have debated for years whether it is best to treat AF by controlling the heart rate with medications and using coumadin to prevent stroke, or to use
medicines to try to convert the AF back to a normal rhythm. There is agreement that heart rate control is very important and that the use of coumadin is important for at least four to six weeks after the onset of AF. If AF has been present for less than 48 hours it is usually safe to try to convert the heart back to a normal rhythm. This is called a cardioversion and can be done using medication or by using an electric shock to convert the rhythm back to normal. Once AF has been present for 48 hours the risk of stroke with cardioversion goes up and coumadin must be used for three or four weeks first.
Unfortunately, the drugs used to convert and prevent AF have a variety of possible side effects some of which may be serious. Also, AF will recur in about half of people with AF within two years despite being on drug therapy.
Some people do well with AF as long as the heart rate is controlled and they take coumadin. They do not have symptoms and are able to function well with their normal activities. Other people do not tolerate AF well and have moderate or severe symptoms. For this group treatment can be difficult when the medications fail to maintain a normal rhythm. It is this group that may benefit from:
Ablation Therapy - The first type of ablation therapy is called AV node ablation. A catheter is used to cauterize and eliminate the electrical connection (AV node) between the atria and the ventricles or bottom chambers of the heart. The ventricles are the main pumping chambers. A pacemaker is then implanted. After AV node ablation, the electrical impulses from the atria can no longer reach the ventricles and the ventricular rate is now controlled by the pacemaker. This therapy has worked well for many people. However, it doesn’t cure the atrial fibrillation or reduce the risk of stroke. Patients still need to take coumadin and many become “pacemaker dependent” so that they have a dangerously slow heart rate without the pacemaker.
The newest type of ablation therapy involves making thin scars in the left atrium around the pulmonary veins where they attach to the back of the left atrium. Scars do no conduct electricity and act as insulators, electrically isolating the pulmonary veins from the left atrium. This prevents the rapidly firing cells in the pulmonary veins from exciting the atrial muscle and AF is prevented. If we refer back to our swimming pool example, this is about preventing the stones from hitting the water. This procedure can be done using several different approaches. Tools have been developed to perform atrial fibrillation ablation during open heart procedures for patients requiring other surgery such as coronary bypass. AF ablation can also be done surgically using a minimally invasive technique performed for AF alone. Finally AF ablation can be done using catheters introduced to the heart through veins in the leg. All of these procedures carry a small risk of serious side effects but are between 70% and 90% effective in curing AF. For patients who have very symptomatic AF and for whom drug therapy has failed, AFablation may be the right choice. See SURGERY AND OTHER PROCEDURES below to learn more about this in simple terms.
DRUG TREATMENTS
Medication advice: Avoid confusion. Give your medication a chance to do its job for you. Take the right things at the right times. You’d be surprised how many people don’t and suffer the consequences. It helps to write down what you take and when you take it. You need to use heart and blood pressure medications properly. Consider buying a medication tray with sections for each day and time of day. Fill it with the right medications and you can be sure that you took what you should when you should.
There are many different drugs for treating heart disease, but they all belong to a few main types/categories. Most heart drugs change how the heart or circulation works. Drugs can be used to treat:
Angina
Heart attack
High blood pressure
Disorders of heart rhythms
Heart failure
Some drugs can be used to treat more than one condition. Others are used to prevent coronary heart disease. We’ll start with a summary and then go into some detail:
Angina – The main drugs used to prevent or treat angina are beta-blockers, calcium blockers, nitrates and potassium channel activators.
Heart Attack – Also known as myocardial infarction or coronary thrombosis. The drugs used are generally given in hospital and not self-administered. Aspirin is used to reduce the risk of blood clots, and hospitals will administer clot busting enzymes called thrombolytics.
High Blood Pressure – A wide range of drugs are used including ACE inhibitors, beta blockers, calcium channel blockers and diuretics.
ACE inhibitors stop the production of a hormone called angiotensin II that makes the blood vessels narrow. As a result, the vessels expand, improving blood flow. Tension in the circulation is also lowered by the kidneys filtering more fluid from the blood vessels into urine. This also helps reduce blood pressure. If your blood pressure is not easily controlled on simple medication, your doctor will probably use a medicine of this type.
Angiotensin-II receptor antagonists work in a similar way to ACE inhibitors. But instead of stopping the production of angiotensin II, they block its action. This allows the blood vessels to expand, improving blood flow and reducing blood pressure.
Beta-blockers block the effect of the hormone adrenaline and the sympathetic nervous system on the body. This relaxes the heart so that it beats more slowly, lowering the blood pressure.
Alpha-blockers cause the blood vessels to relax and widen. Combining them with beta-blockers has a greater effect on the resistance in the circulation.
Calcium-channel blockers reduce muscle tension in the arteries, expanding them and creating more room for the blood flow. In addition, they slightly relax the heart muscle so it beats more slowly, reducing blood pressure.
Diuretics help the body get rid of excess salt and fluids via the kidneys. In certain cases, they relax blood vessels, reducing the strain on your circulation.
FOR ALL HEART PROBLEMS, more information on the drugs in use and what’s likely to be available can be found by contacting or looking at the website for the British Heart Foundation (see Useful Organisations) or through our First Resources organisations. We cannot possibly be comprehensive here, but the following begins to detail some of the main streams of drug treatment. Among the most common are:
BETA-BLOCKERS (e.g. Atenonol) – These block the actions of hormones such as adrenaline that make the heart beat harder and faster. They are very effective in preventing angina but work too slowly in relieving chest pain from an angina attack. They are also very effective in lowering blood pressure therefore reducing the risk of further heart attacks. Some types of beta-blockers can help control abnormal heart rhythms and heart failure.
Beta blockers are usually taken in small doses alongside ACE inhibitors (see below) and diuretics (drugs that help your body get rid of extra fluid). They are not suitable for people with respiratory problems such as asthma, or for people with diabetes.
ACE (Angiotensin Converting Enzyme) INHIBITORS are commonly used to treat heart failure and high blood pressure. They block the activity of a hormone called angiotensin II, which narrows blood vessels. This stops the heart having to work so hard and improves the flow of blood around the body.
Your blood pressure will be monitored while you are taking ACE inhibitors, and regular blood tests are needed to check the kidneys are working properly. Around one in ten people have kidney problems as a result of taking ACE inhibitors.
You should not stop taking ACE inhibitors without consulting you doctor first. If you do, your symptoms are likely to get suddenly worse. The most common side effects of ACE inhibitors are a dry cough, dizziness and fainting.
ANGIOTENSIN II RECEPTOR ANTAGONISTS work in a similar way to ACE inhibitors. They are used to lower your blood pressure by limiting angiotensin, a hormone produced by the body that regulates blood pressure.
Angiotensin II receptor antagonists have fewer side effects than ACE inhibitors – most commonly mild dizziness – so they may be prescribed for people who have a strong reaction to ACE inhibitors.
CARDIAC GLYCOSIDES (such as digoxin) strengthen and slow the heartbeat. By making the heart muscles contract (squeeze together) more strongly, blood is pushed around the body with more force. Cardiac glycosides are usually only taken in addition to other medication, such as ACE inhibitors and diuretics.
ANTI-ARRHYTHMIC DRUGS control the rhythm of your heart. They are most effective when exactly the right level is in your bloodstream, so it’s important to take them correctly.
CALCIUM CHANNEL BLOCKERS (e.g. Amlodopine) – These drugs reduce the amount of calcium entering the muscle cells of the arteries causing them to relax and widen resulting in a better blood flow to the heart and reducing the work the heart has to do. Calcium Channel Blockers are sometimes used to treat angina, often together with other drugs. They are also used to reduce high blood pressure.
NITRATES (e.g. Isosorbide Mononitrate) – Nitrates relax the muscles in the walls of arteries including the coronary arteries and make them wider. They are very useful in relieving angina pain and in preventing predictable attacks for example, prior to physical exertion. Isosorbide mononitrate is a slow release nitrate that works over a period of time but does not give immediate relief from angina pain. Glyceryl Trinitrate tablets or GTN spray is the normal method of relieving angina pain. The tablet is placed under the tongue and dissolves quickly. You do not swallow them as this makes them ineffective. The GTN spray is also sprayed under the tongue.
POTASSIUM CHANNEL ACTIVATORS (e.g. Nicorandil)- These have a similar effect to nitrates as they relax the walls of the arteries and so improve blood flow to the heart. Unlike Nitrates they do not appear to become less effective with continued use.
STATINS (e.g. Atorvastatin) – Blood Lipids is the name given to the fatty deposits in the blood including HDL and LDL Cholesterol. Statins are very
effective in reducing these levels which if left lead to the furring up of the
arteries. These are used if lifestyle and diet changes do not lower the cholesterol naturally.
ASPIRIN/ANTI-PLATELET/ANTI-COAGULANTS – These are used to prevent blood clots and reduces stickiness of blood platelets. Drugs include aspirin, clopidrogel, coumadin (warfarin) and several others.
Anticoagulants stop the blood clotting. They may cause bleeding or make bleeding from cuts or during your period worse, so your GP may advise
regular blood tests. It is a good idea to carry a card with you stating that you are taking anticoagulants.
Warfarin is an import and often essential anti-coagulant that is in common use but has to be monitored with regular blood tests. Other medicines starting to be used may do the same job without the need for monitoring in the form of regular blood tests.
HORMONE REPLACEMENT THERAPY (HRT) was used for some years to prevent coronary heart disease and heart attack in women who had gone through menopause. Current evidence shows that HRT does not necessarily reduce the risk of heart attack and some women may have an increased risk of heart attack and stroke in the first year or two after starting treatment.
IN GENERAL: Coronary heart disease cannot be cured, but the condition can often be managed with medication and lifestyle changes to stop it getting worse.
Regular use of appropriate drugs can improve the function of the heart and reduce the symptoms of coronary heart disease. It may take some time to get the right combination and amount of medication, as many of the drugs have side effects. Your GP or specialist will discuss this with you.
We’ve said it before but we’ll say it again: Please remember to never stop taking any medication for your heart without first speaking to your doctor.
SURGERY AND OTHER PROCEDURES
If the blood vessels are very narrow, or if symptoms cannot be controlled with drugs, then surgery may be needed to open up or replace blocked arteries. Taking our information mostly from about.com:
A CORONARY ANGIOPLASTY operation is the most common treatment for coronary heart disease. An angioplasty opens up a blocked or narrowed coronary artery, allowing the blood supply to flow freely. A catheter (flexible
tube) is inserted through the upper leg, groin or upper arm and threaded
through to the coronary artery using a thin wire. A device like a small balloon is inserted into the artery and inflated until the artery is wide enough to allow a good blood supply. A STENT (a very fine wire gauze tube) is also inserted to keep the artery open. More than one stent can be used. The balloon is then deflated and taken out.
CORONARY ARTERY BYPASS
This is the most common kind of heart surgery. You may also hear it called coronary artery bypass graft surgery (CABG), coronary artery bypass (CAB), coronary bypass, or bypass surgery.
The surgery involves sewing a section of vein from the leg or arteries from the chest or another part of the body to bypass a part of a diseased coronary artery. This creates a new route for blood to flow, so that the heart muscle will get the oxygen-rich blood it needs to work properly. It may take 2-3 months or more to recover from, but can have extremely good (not to mention life-saving) results.
During bypass surgery, the breastbone (sternum) is divided, the heart is stopped, and blood is sent through a heart-lung machine. Unlike other kinds of heart surgery, the chambers of the heart are not opened during bypass surgery.
When you hear the words single bypass, double bypass, triple bypass, or quadruple bypass, it refers to the number of arteries that are bypassed. The number of bypasses does not necessarily indicate how severe the heart condition is.
VALVE REPAIR OR REPLACEMENT
Blood is pumped through your heart in only one direction. Heart valves play key roles in this one-way blood flow, opening and closing with each heartbeat. Pressure changes behind and in front of the valves allow them to open their flap-like "doors" (called cusps or leaflets) at just the right time, then close them tightly to prevent a backflow of blood.
Two of the most common kinds of valve problems that require surgery are:
Stenosis, which means the leaflets do not open wide enough and only a small amount of blood can flow through the valve. Stenosis occurs when the leaflets thicken, stiffen, or fuse together. Surgery can either open the valve that is there or replace it with a new one.
Regurgitation, which is also called insufficiency or incompetence, means that the valve does not close properly and blood leaks backward instead of moving
in the proper forward direction. Surgery is needed to either tighten or replace the valve.
Surgical repair of a valve involves the surgeon rebuilding the valve so that it will work properly. Valve replacement means that the valve is replaced with a biological valve (made of animal or human tissue) or a mechanical valve (made from materials such as plastic, carbon, or metal).
ARRHYTHMIA SURGERY
As we’ve discussed, any irregularity in your heart’s natural rhythm is called an arrhythmia. Arrhythmias are usually treated first with medicines. Other treatments may include:
- Electrical cardioversion, where the cardiologist or surgeon uses paddles to "shock" the heart back into a normal rhythm.
- Catheter ablation, where the cardiologist uses a special tool to destroy (ablate) the cells that are causing the arrhythmia. This is done in the cardiac catheterization laboratory (the cath lab).
- Pacing and rhythm-control devices, including PACEMAKERS and implantable cardioverter defibrillators (ICDs).Patients can have these devices implanted while in the operating room or the cath lab.
When these treatments do not work, surgery may be needed. One type of surgery is called MAZE SURGERY. In Maze surgery, surgeons create a "maze" of new electrical pathways to let electrical impulses travel easily through the heart. Maze surgery is used most often to treat Atrial fibrillation, the most common type of arrhythmia.
ANEURYSM REPAIR
An aneurysm is a balloon-like bulge in a blood vessel or in the wall of the heart. An aneurysm occurs when the wall of a blood vessel or the heart becomes weakened. Pressure from the blood forces it to bulge outward, forming what you might think of as a blister. An aneurysm can often be repaired before it bursts.
Surgery involves replacing the weakened section of blood vessel or heart with a patch or artificial tube (called a graft).
Aneurysms in the wall of the heart occur most often in the lower-left chamber (called the left ventricle). These aneurysms are called left ventricular aneurysms, and they may develop after a heart attack. (A heart attack can weaken the wall of the left ventricle.) If a left ventricular aneurysm leads to an irregular heartbeat or to heart failure, the surgeon may perform open heart surgery to remove the damaged part of the wall.
TRANSMYOCARDIAL LASER REVASCULARIZATION (TMLR)
Angina is the pain you feel when a diseased vessel in your heart (called a coronary artery) can no longer deliver enough blood to a part of the heart to meet its need for oxygen. Transmyocardial laser revascularization (TMLR) is a procedure that uses lasers to make channels in the heart muscle, in an attempt to allow blood to flow from a heart chamber directly into the heart
muscle. If the blood flow is increased, more oxygen can reach the heart. This procedure is only done as a last resort. For example, TMLR may be done in patients who have had many coronary artery bypass operations and cannot have another bypass operation.
CAROTID ENDARTERECTOMY
Carotid artery disease is a disease that affects the vessels leading to the head and brain. Like the heart, the brain’s cells need a constant supply of oxygen-rich blood. This blood supply is delivered to the brain by the 2 large carotid arteries in the front of your neck and by 2 smaller vertebral arteries at the back of your neck. The right and left vertebral arteries come together at the base of the brain to form what is called the basilar artery. A stroke most often occurs when fatty plaque blocks the carotid arteries and the brain does not get enough oxygen.
Carotid endarterectomy is the most common surgical treatment for carotid artery disease. Surgeons make an incision at the location of the blockage in the neck and a tube is inserted above and below the blockage to reroute blood flow. Surgeons can then remove the fatty plaque.
A carotid endarterectomy can also be done by a technique that does not require blood flow to be rerouted. In this procedure, the surgeon stops the blood flow just long enough to peel the blockage away from the artery.
HEART TRANSPLANTATION
The first heart transplants were performed in the late 1960s. With modern anti-rejection medicines it has become an established operation giving hope to a select group of patients who would otherwise die of heart failure.
The need for a heart transplant can be traced to one of many heart problems, each of which causes damage to the heart muscle. The two most common heart problems are idiopathic cardiomyopathy (disease of the heart muscle without a known cause) and coronary artery disease (the buildup of plaque in the arteries of the heart).
As the heart problem gets worse, the heart grows weaker and is less able to pump oxygen-rich blood to the rest of the body. Because the heart must work harder to pump blood through the body, it tries to make up for this extra work
by becoming enlarged (hypertrophied). In time, the heart works so hard to pump blood that it may simply wear out, overcome by disease and unable to meet even the smallest pumping demands. Medicines, mechanical devices to assist the heart, and other therapies can sometimes help and even improve a patient’s condition. But when those treatments fail, transplantation becomes the only option.
Not all patients are suitable for a heart transplant, and there may be a long wait for a donor.
REHABILITATION
Contact the British Heart Foundation, from whom we learn that:
Cardiac rehabilitation programmes aim to restore confidence and benefit both heart patients and their families.
These programmes feature three key areas – exercise, relaxation and information on lifestyle and treatment.
The aim of a cardiac rehabilitation programme is to help you to recover and resume as full a life as quickly as possible after a cardiac event. It also aims to help promote your health and keep you well.
Cardiac rehabilitation can be helpful if you have had a heart attack, a coronary angioplasty, or coronary artery bypass surgery. It can also be helpful if you have other conditions such as angina or heart failure.
Ideally, cardiac rehabilitation should begin when you are admitted to hospital. In many hospitals a member of the cardiac rehabilitation team will see you on the ward to give you information about your condition and about the treatment you have had.
Cardiac rehabilitation continues after you leave hospital. Some rehabilitation teams are able to telephone or visit you and can support you in the first few weeks at home.
Cardiac rehabilitation programmes and services vary widely throughout the country. You can find details of the programmes that are available in the UK through the British Heart Foundation. You will need to be referred by your GP or cardiologist.
