Sunday June 29th 2014
 
 


- Patients stories

Donald F. Seemann
    

ICD for Ventricular Fibrillation

    Syndicated Columnist Judy Foreman

    On undergoing Catheter Ablation.

    Former Vice-President Richard Cheney
    

Why former Vice President Richard Cheney has an ICD.

    Author Deborah Daw Heffernan

    Living with an ICD.

    Roger Blanchette

    Sudden Cardiac Death, a survivor's story.

    Lawrence Beckmen
    

After frightening episodes of fainting, Lawrence Beckmen's healthy and happy lifestyle was restored.

    Sebastian Hitzig

    Millions of patients have been helped by pacemakers and ICDs. No story is as remarkable as that of Sebastian Hitzig.

 

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NASPE-Heart Rhythm Society is located at Six Strathmore Road, Natick, MA 01760 Phone: 508-647-0100 Fax: 508-647-0124
Copyright NASPE-Heart Rhythm Society

 

Heart Failure
Risk Factors

There are a number of diseases, medical conditions and other factors that put people at higher-than-average risk for heart failure. Not everyone with these risk factors develops heart failure, but they put extra stress on the heart that may lead to the condition. The odds of developing heart failure are especially high in people who have more than one of these risk factors.


Coronary Artery Disease (CAD)

Like all the organs and tissues of the body, the heart needs oxygen and other nutrients carried by the blood to remain healthy. When the blood vessels become narrow or clogged so that not enough blood reaches the heart, damage is done to the heart muscle which, in turn, may affect its ability to pump blood efficiently. The most common cause of CAD is arteriosclerosis (sometimes called "hardening of the arteries"), a condition in which cholesterol and fatty deposits called "plaque" build up in the arteries. CAD also may be caused by blood clots that lodge in the arteries and interfere with the normal flow of blood.


A substance called arteriosclerotic plaque clogs the blood vessel. color illustration

A substance called arteriosclerotic plaque clogs the blood vessel.

 


Past heart attack (myocardial infarction)

A heart attack occurs when an artery that supplies blood to the heart is blocked so that no oxygen reaches the heart muscle. When this happens, part of the heart "dies" (the area of dead muscle is called an "infarct"). The remaining, healthy tissue must take over the job of pumping blood, an extra burden that may weaken the heart's pumping ability.

 


Heart Rhythm Disorders (arrhythmias)

When the heartbeat is too fast, too slow or irregular (out of rhythm), it may not be able to pump enough blood to meet the needs of the body. In these cases, once the underlying problem is identified and treated, the symptoms of heart failure may go away before significant damage is done to the heart muscle.
ECG, normal rhythm

A normal heart rhythm (left).

The abnormal rhythm (right) is a potential cause of cardiac arrest.
ECG, abnormal rhythm
 

 


Alcohol and Drug Abuse

Excessive use of alcohol, or abuse of drugs such as cocaine and amphetamines place added stress on the heart that can lead to heart failure or other heart diseases. These substances also can damage the cells of the heart. Some environmental toxins and prescription drugs also can contribute to the problem.
 

Abnormal heart valves

The valves that open and close to allow blood to pass between the chambers of the heart may be damaged by disease or infection (endocarditis). Sometimes, heart valve defects are present at birth. Whatever the cause, if the valves don't open or close completely with each heartbeat, the heart muscle has to pump harder to keep the blood moving. If the workload becomes too great, heart failure can develop.
 

 


Heart muscle disease (cardiomyopathy) or inflammation (myocarditis)

Any damage to the heart muscle itself increases the risk of heart failure. Heart muscle disease or infection may be caused by a number of factors, including congenital problems (defects present at birth), drug or alcohol abuse, bacterial or viral infections or other, unknown reasons.
 

Heart defects present at birth (congenital heart disease)

If the heart and its chambers don't form correctly in the developing fetus, the normal parts of the heart must make up for defects by working harder. Over time, the added stress may cause healthy structures to "fail" and lead to HF.
 

 


Diabetes

Diabetes tends to increase the levels of cholesterol and triglycerides -- unhealthy fats that contribute to coronary artery disease. People with diabetes also are more likely to be overweight and have high blood pressure. These factors must be carefully monitored and controlled because they put extra strain on the heart and can lead to heart failure, as well as to other cardiovascular diseases, such as heart attack and stroke.
 

 


High blood pressure (hypertension)

doctor and patient, color photo Uncontrolled high blood pressure doubles a person's risk of developing heart failure. If the pressure created by blood flow through the vessels of the circulatory system is too high, the heart has to pump harder to keep the blood circulating. Over time, the extra burden can thicken the heart muscle and eventually weaken the heart.

 


Sometimes, an otherwise healthy heart may temporarily have trouble keeping up with the body's need for oxygen and other nutrients carried by the blood because of problems unrelated to the cardiovascular system. These problems are less common than other causes for heart failure, but it is important to monitor heart function in people who have:

An abnormally low number of red blood cells (severe anemia)

It is the job of the red cells to carry the oxygen needed to maintain life in all the cells of the body. If there are not enough of these cells, the heart pumps at a faster rate to circulate the smaller number of red cells quickly enough to supply the oxygen the body needs. Over time, the extra burden may lead to heart muscle damage.
 

 

An overactive thyroid gland (hyperthyroidism)

The thyroid gland affects the rate at which the body metabolizes food and other substances. If the thyroid is overactive, the body works at a faster pace, and the heart may be overworked as it adjusts to keep up with the body's increased demand for oxygen and other nutrients. Waste products also build up more quickly in the cells, and must be picked up by the circulating blood and carried to the kidneys, liver and elsewhere to be processed and excreted.
 

Lifestyle Factors that Increase the Risk of HF

Risk factors associated with heart disease in general also may contribute to heart failure, including:

High cholesterol
Cigarette smoking
A family history of HF or other cardiovascular diseases.

 

no smoking, color illustration

TREATMENTS

Heart Failure
Treatment

doctor and patient, color photo Although heart failure (HF) is a serious condition that may get worse over time, in some cases it can be reversed. Underlying problems such as heart valve disease, high blood pressure, abnormal heart rhythms or coronary artery disease may be treated before significant damage is done to the heart.

Even when the heart muscle is impaired, there are now a number of treatments to relieve symptoms and stop or slow down the gradual worsening of heart failure. In some cases, the function of the heart can be improved.

The treatment prescribed for each individual depends on the type, cause, symptoms and severity of heart failure. Usually, more than one therapy is used.



The goals of therapy for heart failure are to:

Relieve symptoms and improve the quality of life.
Slow the progression of disease.
Reduce the need for emergency room visits and hospitalization.
Help people live longer.
 
The treatment options for HF are:
Therapy for underlying diseases and other factors that contribute to heart failure
Lifestyle changes
Medication
Cardiac resynchronization therapy
Surgery

[ ]

 

Therapy for Underlying Diseases

A top priority in the treatment of heart failure is to treat the conditions that contribute to the disorder. For example, surgery or angioplasty may be performed to open clogged blood vessels in patients with coronary artery disease, and medications prescribed to control high blood pressure, diabetes, anemia or thyroid disease.

Heart failure often impairs the electrical system that controls the normal, steady rhythm of the heartbeat. Abnormal electrical signals that arise from damaged heart muscle may cause a heartbeat that is too slow (bradycardia), too fast (tachycardia) or irregular. Arrhythmias are common in heart failure patients.

It is particularly important to treat abnormal heart rhythms (arrhythmias) in patients with heart failure.


The Role of Electrophysiology

Electrophysiologists are cardiologists who have additional education and training in the diagnosis and treatment of abnormal heart rhythms. Close collaboration between these specialists and other doctors who treat patients with heart failure is important. For example, some of the drugs that are used to treat arrhythmias also decrease the heart's pumping ability. This can cause heart failure to become worse and lead to more arrhythmias. The goal of therapy is to treat abnormal heart rhythms and heart failure together.

heart map, computer image

Electrophysiologists create "heart maps" that pinpoint the sites that give rise to abnormal heart rhythms.


Treatments for arrhythmias may include:

ICD, color photo

Implanted devices range in size from that of a half- dollar to the size of a small beeper.

Implanted devices
Catheter ablation
Medications


Remarkable advances in the technology and function of implanted cardiac devices have been achieved over the past 10 years. The devices also have decreased in size. Now, they are being studied in clinical trials as treatment for patients with heart failure who are at risk of developing heart rates that are too rapid or too slow because of progressive muscle damage that can affect the heart's electrical system.

Most of these devices can be implanted with minor surgery that may be done as outpatient procedures, or requires only a day or two in the hospital. Wires (leads) are placed in the right upper and lower chambers of the heart. A small computer, or microprocessor, is implanted under the skin, usually near the collarbone. These remarkable "built-in" computers have enormous potential to increase survival and the quality of life for the patient with heart failure. Heart failure patients may be treated with permanent pacemakers, hemodynamic monitors, implantable defibrillators (ICDs) or resynchronization devices. Often, one or more of these features can be present in a single or 'combined' device.


Pacemakers are used to treat a heartbeat that is too slow. This may be due to heart muscle damage. Sometimes, the drugs prescribed to treat heart failure slow the heart rate. In these cases, a pacemaker may be needed to support the use of medications. Traditionally, pacemakers are attached to one or two thin wires (leads), which are placed in the right upper and lower chambers of the heart. The pacemaker continuously monitors the heart's natural rhythm and stimulates (paces) one or both chambers if the heart rate drops below a certain number of beats per minute. The patient does not feel the electrical signal that is sent from the pacemaker to the heart.

Modified pacemakers also are being used to directly treat heart muscle weakness (see resynchronization therapy) in selected patients. Pacemakers have other features, as well. They can detect arrhythmias before the patient has symptoms, and lead to earlier diagnosis and treatment of heart rhythm disorders.


Implantable Cardioverter Defibrillators (ICDs) are pacemaker-like devices that continuously monitor the heart rhythm, and deliver life-saving shocks if a dangerous heart rhythm is detected. They can significantly improve survival in certain groups of patients with heart failure who are at high risk of ventricular fibrillation (VF). VF is a deadly heart rhythm disorder that is the primary cause of sudden cardiac death (SCD). ICDs also have the ability to act as pacemakers for too-slow heart rates and can be modified to provide resynchronization therapy.

 

ICD, color illustration

An ICD is implanted in the shoulder area to deliver a controlled electric shock if it detects a dangerous heart rhythm.


Heart failure patients who may benefit from ICDs include people who:
  • have survived cardiac arrest
  • have a rapid, recurrent heartbeat called sustained ventricular tachycardia, or VT
  • have a history of heart muscle damage caused by a prior heart attack, and who also have non-sustained VT (a rapid heart beat that stops on its own). An electrophysiology study can determine which heart attack survivors are at risk for cardiac arrest and may need an ICD. In clinical trials, ICDs were of particular benefit for individuals with cardiomyopathy (heart muscle damage) caused by a prior heart attack.
  • Have an ejection fraction of 30 percent or lower. (A clinical trial of heart attack survivors with low ejection fractions found that ICD therapy saved lives compared to medications alone, even in patients with no history of VT. The benefits were so significant, the study recently was stopped early so that all patients could have the option of an ICD).

Heart failure patients face a significant risk of sudden cardiac death over the course of their disease. Other clinical trials are under way to compare ICDs with conventional drug therapy, and ICDs may soon be recommended for even more patients with heart failure.

Catheter ablation (also called radiofrequency ablation, or RFA). In this procedure, one or more flexible, thin tubes (catheters) are introduced into the blood vessels and directed under x-ray guidance to the heart muscle. A burst of radiofrequency energy heats and destroys very small areas of tissue that give rise to abnormal electrical signals.

 

 

Lifestyle Changes

People with heart failure usually can make lifestyle changes to improve their symptoms or control some of the factors that contribute to heart failure. For example, most people with HF will see an improvement in their symptoms if they:

  • get regular exercise, including physical rehabilitation programs for some patients. Exercise must be modified, however, and patients must get plenty of rest when heart failure symptoms are not stable. This avoids putting too much stress on the heart.
  • eat a "heart healthy" diet that avoids sodium (salt), and is low in fat, especially for patients with coronary artery disease.
  • don't smoke and avoid exposure to secondhand smoke.
  • do not drink alcohol, or limit their intake to no more than one drink two or three times a week.
  • lose weight.
  • avoid caffeine or limit its intake.
  • reduce stress.
  • weigh themselves daily. A sudden gain in weight means an increase in the build up of fluids and may be a sign that their condition is becoming worse.
  • keep track of symptoms and report any worrisome changes to their doctor.
  • see their doctor frequently for regular checkups to monitor the progress of their condition.

exercise bike, color photo

fruit

bathroom scale


 

 

Medications

There are a number of medications for heart failure that work in different ways, and most people take more than one drug. Medications may be prescribed to:

expand the blood vessels
reduce the amount of water and sodium (salt) in the body, which reduces the workload on the heart
strengthen the heart muscle's pumping action

Types of medication prescribed for heart failure include: pill bottle, abstract illustration

  • Angiotensin converting enzyme (ACE) inhibitors. These drugs counteract the action of certain hormones that the body forms in response to heart failure and can cause the condition to get worse. ACE inhibitors dilate, or widen, the arteries. This improves the flow of blood so the heart does not have to pump as hard to circulate blood.

  • Beta-Blockers lower blood pressure and decrease the heart rate. This reduces the workload on the heart. They also block the effects of hormones and help slow the progression of HF, and prevent heart rhythm problems.

  • Diuretics (water pills) help the kidneys produce more urine and rid the body of excess fluid.

  • Spironolactone is a type of diuretic that prevents the loss of potassium. When used in patients with advanced heart failure, it can reduce hospitalizations and prolong life.

  • Potassium and magnesium supplements are often prescribed in combination with diuretics to replace the excessive loss of these minerals, which are excreted in the urine.

  • Digoxin makes the heart beat stronger and slower, and regulates the rhythm of its contractions.

  • Anti-arrhythmic drugs treat abnormal heart rhythms.

 


Cardiac resynchronization therapy (CRT)

The U.S. Food and Drug Administration (FDA) recently approved the first of a new type of pacemaker that paces both sides of the heart simultaneously to coordinate their contractions and improve their pumping ability. Heart failure patients who have a delay in the electrical impulses to the lower chambers of the heart, a condition called bundle branch block, are potential candidates for this therapy. According to clinical trial results with selected patients, cardiac resynchronization therapy:

Increased the amount of daily activities patients could perform without experiencing the symptoms of heart failure
Extended the exercise capacity of patients with Heart Failure, as measured by the distance they could walk in 6 minutes
Improved the overall quality of life
Promoted changes in the anatomy of the heart that improved cardiac function
Reduced the number of days patients spent in the hospital, and the total number of hospitalizations

How Does CRT Work?

In the normal heart, the electrical conduction system delivers electrical impulses to the left ventricle in a highly organized pattern of contractions that pump blood out of the ventricle very efficiently. In some patients with systolic heart failure caused by dilated cardiomyopathy (an enlarged heart) this electrical coordination is lost. Uncoordinated heart muscle function leads to inefficient ejection of blood from the ventricles. CRT devices pace both the left and right ventricles simultaneously to resynchronize the muscle contraction and improve the efficiency of the weakened heart.

Clinical trials are under way to determine if resynchronization therapy improves survival in heart failure patients, and whether resynchronization devices work best if they are incorporated into pacemakers or ICDs.

Implantable Hemodynamic Monitors use pacemaker technology in which a pacing-type wire is placed in the lower right chamber (ventricle) of the heart. This wire has a sensor at the tip, which measures blood pressure in the ventricle. It monitors the status of heart failure patients and the effects of drug therapy. It provides information that may make it possible to intervene early to diagnose and treat worsening heart failure, before symptoms develop or hospitalization is needed. The technology may be available in future pacemaker, ICD and resynchronization devices.

 


Surgery

Surgery is used to treat underlying disease that contributes to heart failure in some patients, such as:

surgeon, color photo Coronary artery bypass graft (CABG) surgery or angioplasty to prevent or treat heart failure caused by blocked arteries.
Surgical implantation of an artificial heart valve, or surgical valve repair.
Surgery to treat congenital heart defects.

Surgical treatments for heart failure itself include:

implanted artificial heart, color illustration

Recent advances in technology may make transplantation of artificial hearts an option for more patients in the future.


Heart transplantation. Transplant may be the best option for patients with the most severe types of heart failure. This treatment is available to only a small number of patients, however, because of the shortage of donor hearts.
Left ventricular assist devices (LVAD) may be implanted in the chest to increase the pumping action of the heart. Until recently, LVADs required a large, hospital-based console to which the patient was attached while waiting for a transplant. These devices are now smaller and may enable certain patients to go home with them. The devices may be used as a primary treatment, or as a bridge to heart transplant in adults. Clinical studies show that patients with severe heart failure who receive an LVAD have a lower risk of death than people who are treated with medications alone.
LVAD unit, color ilustration

Miniaturized battery-powered LVAD units now make it possible for many patients to leave the hospital.

Surgery to restore the shape and size of the heart

The electrical signals that cause the heart muscle to contract move in a spiral pattern. The heart and its chambers are shaped somewhat like a football - which can be thrown in a spiral pattern. This is the ideal shape for the heart to receive the signals that cause it to beat. In heart failure, however, the heart often enlarges so that it looks more like a basketball. The shape of the heart no longer "fits" the electrical pattern, which makes it less efficient. A number of promising surgical procedures are being investigated to address this problem by reconstructing parts of the heart to make its shape more normal. These procedures, often called heart reconstruction surgery include:

surgery, color photoValve repair and revascularization. Studies in which damaged heart valves are repaired and/or the blood flow to damaged areas of the heart is restored (revascularization) have shown promise in reducing the size of the heart and improving cardiac function in some patients with heart failure.
Dynamic cardiomyoplasty. In this procedure, one end of a muscle from the patient's back is detached and wrapped around the ventricles of the heart. After a few weeks, the relocated muscles are conditioned with electrical stimulation to behave and "beat" as if they were heart muscles. The procedure may benefit the failing heart by improving its pumping ability, limiting heart enlargement and reducing stress on heart muscle.
The Batista procedure, also called "partial left ventriculectomy," removes a section of the wall of the left ventricle. The edges of the ventricle are repositioned and sewed together, and the mitral valve and valve parts are repaired or replaced. This procedure is no longer performed by most surgeons, however, because its long-term results have been poor.
The Dor procedure, also called "endoventricular circular patch plasty" or EVCPP, is used when an aneurysm forms in the ventricle following a heart attack. In the surgery, a looped stitch is made that shrinks the area of dead and scarred heart tissue where the aneurysm formed. Sometimes, a patch made of Dacron or human tissue is used to cover other areas of defective muscle. The goal of the surgery is to return the ventricle to a more normal size and shape.
The Acorn procedure involves slipping a mesh-like "sock" around the heart and stitching it in place to reduce the size of the heart or prevent it from becoming any larger.

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