ARTICLE XV - Beta Blockers – An Answer to All Problems!

The drug that is closest to the heart of cardiologists and most widely prescribed for a variety of indications. Literally responsible for saving millions of lives every year and making people survive through the painful angina and even drag them out of the hopelessness of myocardial infarction. The drug that is used most extensively for high blood pressure and which has given a new lease of life to patients with cardiac failure. The drug that is being used for anxiety and migraine in millions of patients in the general practice – this drug is called BETA BLOCKER.

Let’s explore the role of this group in many cardiac problems starting from high blood pressure to heart failure and heart attack.

HYPERTENSION AND BETA BLOCKERS:
Beta-blockers makes the heart beat more slowly and less strongly. They work by blocking the action of nerves supplying the heart that release a chemical called Noradrenalin. This helps to control the rhythm and force of heart muscle movement. It also effects and tones down the central sympathetic activity. Beta blockers have been in the forefront of antihypertensive arsenal for the last two decades. They have been shown to be highly effective in reducing systolic and diastolic blood pressure specially in persons with high sympathetic drive or who are tense. They are effective in reducing total death rate, strokes and kidney failure in patients with high blood pressure. Beta blockers can effectively reduce the thickness of muscle of heart due to high blood pressure. Beta blockers are well tolerated by a majority of patients and have been found to very safe in all age groups and both genders. They have a special role to play in patients with compelling indications like angina, heart attack, and heart failure. This is the only group of drugs to show reduction in heart attacks in white, non smoker males.

Being highly effective drugs with extremely safe profile, the group has earned a special place, for itself in the drugs used for hypertension. These are the most commonly used and often the drug of first choice for this indication.

ANGINA AND BETA BLOCKERS
The commonest presentation of Coronary artery disease – when a person develops blockages in the blood supply of heart, is angina. Physical or mental stress leads to increasing heart rate and blood pressure, which leads to chest pain called angina. Beta-blocker slow the heart rate and reduce the heart’s workload. When the heart does not have to work as hard, it requires less oxygen. This in turn can help relieve or prevent chest pain (angina). To treat and prevent these pains, beta blockers have proved to be very effective. Beta-blockers are often used with the medications to treat angina. Beta blockers are the drugs of first choice in most patients presenting with angina. There is ample data to support its role in angina where it decreases the frequency of angina episodes and increase effort tolerance/ exercise capacity. The severity of anginal attacks decreases markedly with Beta blockers.

Role of beta blockers in Heart attack:
Heart attack is a common presentation of coronary heart disease. Here the blood supply to a part of heart blocks completely causing death of that portion of heart. There are two ways to approach a patient with myocardial infarction. The first one is opening the blockages in arteries to re-initiate blood going to the heart, the other one is decreasing the demand of blood supply to muscles of heart and this is what this magical drug does. Beta blockers have been shown to reduce the size of myocardial infarct – dead portion of heart in animal and human models. Beta blockers reduce lipolysis, that is the break down of fats. Beta-blockers given within hours of the start of a heart attack reduce both the risk of death and recurrent heart attack. They have well established anti-ischemic, anti-arrhythmic and anti-hypertensive effects. Large trials have shown impressive reduction of morbidity and mortality with oral and intravenous beta blockers. Evidence strongly suggests that most people should take beta-blockers for at least 6 months and may be two years after a heart attack, and probably longer to get the most benefit. It applied to both genders regardless of age. It is a must for all those who suffer from hypertension. The intake is oral and should be taken continually for about two years. Almost all drugs show similar effects, although water soluble beta blockers have a clear advantage over others. But for people who have asthma and hypotension, this drug is not recommended, however controlled diabetes is not a contraindication to beta blockers as the benefits outweigh the hazards.

Role of Beta-Blockers in Heart Failure
Heart failure is a significant public health problem effecting 15 million people world wide. There has been an increasing incidence of heart failure in contrast to the decreasing incidence of heart diseases. The associated hazards as found in Framingham study, mortality rate 17% in one year, 30% in two years and 50% in five years.

For the past 40 years medical students have been taught to avoid Beta Blockers in heart failure. Beta Blockers work by blocking adrenaline which increases force of contraction of heart muscle and improve its performance. Beta blockers are like double edged sword. Due to their negative effects on heart rate and contractility, they can worsen the heart failure but, used properly and judiciously they ameliorate the patients status and have salutary effects on the clinical status, exercise capacity and reduce death rate. This has been one of the most wonderful ‘rediscovery’ of the effects of beta blockers. This is also an example of how clinical experience and experimentation can alter the course of action and carve new place.

Many large trials have been conducted to evaluate the efficacy of beta blockers in large populations with mild, moderate and severe heart failure and patients with left ventricular dysfunction after a heart attack. There was a definite and marked reduction in mortality. All cause mortality and hospitalization was reduced significantly. Hospitalization due to any cause was reduced markedly.

Who are the patients that will benefit from beta blockers therapy? All patients with mild, moderate or severe but compensated heart failure on standard treatment of ACE Inhibitors and diuretics are candidates for beta blockers. There are important points to be kept in mind as only stable patients should start beta blockers. Preferably, doses should not be changed of ACE Inhibitors for one month and diuretics for 2 weeks. Ideally patients should not have required intravenous supporting drugs in the last one month.

This is an exercise that requires persistence and patience! One has to start with a very small does and then the dose has to be increased very slowly over weeks while monitoring heart failure status, blood pressure and heart rate. Some patients may deteriorate initially, that is why persistence is very important and patients have to be encouraged to adhere to the therapy. Many patients may not see any change in their clinical status initially that is why patience is required and patients have to be motivated to hold on to the treatment.

Various trials have now documented that Beta Blockers used carefully reduce heart failure symptoms and improve the quality of life. Beta blockers have been shown to reduce the risk of all cause mortality, such as sudden death and death from progression of heart failure. Beta blockers have been effective in reducing hospitalization. Compelling evidence now exists to support the safety and efficiency of Beta Blocker therapy in heart failure.

What are the specific side effects? Patients may complains of fatigue, slow heart rate and low blood pressure. Speciation caution has to be exercised in patients with reactive airway disease and decompensated stated.

Tachycardias:
Many patients with structurally normal heart have the propensity to develop very fast beating of heart – tachycardia, presenting as palpitations, fluttering or loss of consciousness in severe cases. Because of their effects on sinus node and AV node – two important pulse generators, this fast beating can be effectively controlled. The drug may be used intravenously for immediate effects and it is effective in most cases. It is used in oral preparation for the prevention of further attacks.

Other cardiac problems:
Beta blockers have found an application in many other fields.

· It is used to relieve the obstruction in patients presenting with severe outflow obstruction like right pumping chamber outflow obstruction.
· It is effective in reducing heart rate where patient has very fast heart rate specially accompanied by obstruction like narrowing of the valve – door between left storing and pumping chambers.
· It is used effectively in reducing rapid and powerful contraction in patients with markedly thickened interventricular septum called hypertrophic obstructive cardiomyopathy HOCM.

Miscellaneous:
There was a time when newer indications were found for the usage of beta blockers every week. The drug was tried and many times quite successfully in many scenarios outside the world of cardiology.

· The drug alleviates anxiety and are used by many for allaying anxiety in stressful situations like presentations, examinations and speeches. They do not impair intellectual powers but reduce the ‘fast beating’ of heart and the unwanted ‘tremors’ and ‘cold sweat’. These drugs are used extensively by psychiatrists, all over the world, for reducing anxiety and counter the tachycardic effects of some drugs.
· They are used for tremors – mainly senile tremors.
· Many people with migraine (headaches) have been able to reduce the severity and frequency of episodes.
· Beta blockers are used in patients with liver disease like Cirrhosis for reduction of pressure in liver.
· They are used in patients with thyroid gland hyperactivity called thyrotoxicosis for controlling their symptoms.

Side Effects
Like all potent drugs beta blockers have side effects and pros and cons have to be weighed for all clinical conditions and patients. Side effects of beta-blockers may include lack of energy or drive, fatigue, vivid dreams and erection problems (impotence). It can decrease blood flow to fee and hands, causing them to feel cold and increase leg pain brought on by exertion (intermittent claudication). May cause dizziness and lightheadedness, more likely to occur when started or when the dose is increased. In people with diabetes, beta-blockers can insignificantly increase blood sugar levels. More importantly beta blockers may mask warning signs of low blood sugar, such as increase in pulse rate and sweating. Beta-blockers may worsen medical conditions such as asthma, heart failure, and certain heart arrhythmias. Beta-blockers should not be stopped without first discussing with the doctor. The risk of heart attack may be increased when beta-blockers are stopped suddenly.

Beta blockers are drugs with multiple actions and have been used in many cardiac diseases like high blood pressure, angina, heart attack and heart failure. They have wide-spread applications in non cardiology world. By and large they are well tolerated and have certain side effects which have to be watched.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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ARTICLE XIV - Evidence Based Medicine – What is it?

“Where is the wisdom we have lost in knowledge and the knowledge we lost in information?” Richard Smith.

There are new trends being followed in medicine, and new winds are blowing in this rather progressive field! The focus of this new ‘trend’ is, ‘what is the evidence?” You cannot get away by saying anything which cannot be supported by ‘evidence’. We need evidence to make a diagnosis and we need evidence to request investigations as to what are the chances of clinching the diagnosis by employing a certain investigation. To use a certain group of drugs we need evidence of its benefit and safety record. There are some very interesting stories about drugs. Many drugs which were though to be good for one indication turned out to be a remedy for another ailment. A drug called Captopril in the beginning was suppose to cause leakage of proteins from kidneys and we used to give albustix to our patients to check this. Now, it is being used for the treatment of the same leakage of proteins. A drug was introduced to treat high blood pressure but it was found that it had more effect on growth of hairs and now it is being used for baldness in the form of creams. Aspirin till very recently was used only as a pain killer, now it is being used for a host of new indications which were never through of before. It is become a ‘darling’ drug of doctors specially cardiologists, neurologists and all interested in blood vessels.

Where do we get this evidence from? We conduct trials, which means we give the drug to half of the defined population and the other half gets tablets similar in shape but without any active material. Or similarly we apply a certain diagnostic test to half of randomly selected and the other half serves as ‘control’ population. Statistical tests are applied to find out any ‘objective significance’. Trials are being conducted everywhere and the purpose is to answer a question. Most of these trials are placebo controlled and double blind which means to study the effect of drugs and compare with placebo and both patients and doctors do not know about the placebo, so that we can study the real effect of the drug per-se. Many trials are sometimes put together to answer a specific question and this is called meta analysis.
The reason ‘trials’ were invented land are being practiced so fervently, is that in the world of medicine two plus two is not always equal to four. Some drugs which appear very good in laboratory and animal experiments, produce disastrous results when tried in a large number of human beings. In the current scenario, whenever a new medicine or a new diagnostic technique is introduced, it is evaluated objectively and evidence is collected before it can be marketed and accepted for human use. A new drug has to be tested in head to head comparison with established therapy to prove its efficacy and establish its safety.

Evidence based medicine has been defined as, ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” But perhaps it can be more accurately defined as, “the enhancement of clinician’s traditional skills in diagnosis, prevention and related areas through the systemic framing of the relevant and answerable questions and the use of mathematical estimates of probability and risk.”

Most doctors have so far been making decisions on what we learnt from text books, on the basis of anecdotes – personal or those experienced by colleagues and seniors, press cuttings, expert opinions (known as eminence based medicine) and guided by cost minimization. But the correct way is to formulate ‘an answerable question’ from the available information. This may be about symptoms diagnosis correlation, diagnostic signs, diagnosis per-se, prognosis of illness, cost effectiveness of a procedure or treatment and other issues. Having formed a question best evidence is sought from clinical examination, laboratory workup and current literature consisting of published trials and meta analysis. The data is critically evaluated for its validity and usefulness in terms of clinical applicability. Then an opinion is formed in the light of this evidence. Next two steps are perhaps more important and essential. This evidence has to be incorporated in the clinical practice and then the performance has to be evaluated at regular intervals.
The critics among doctors who believe in traditional medicine are against it on the following grounds: “Evidence based medicine seems to replace original findings with subjectively selected, arbitrarily summarized, laundered and biased conclusions of indeterminate validity or completeness. It has been carried out by people of unknown ability, experience, and skills using methods whose opacity prevents assessment of the original data.”
Medical practitioners belonging to any walk of health science realize that many a times we have faltered on assuming things on their face value. Two plus two is not always four in the world of medicine, it can swing in any direction by any multiple. Estimates from early eighties suggested that only around 10-20% of medical interventions including drug therapies, surgical operations and X-rays and blood tests were based on sound scientific evidence.
Howe can doctors incorporate evidence based medicine in our clinics and hospitals so that our patients can benefit from it? There is no doubt that we should be all practicing evidence based medicine in our personal capacity and as health managers at the level of a unit, hospital or provincial level. How do we enforce evidence based medicine in our clinical practice? First of all identify and prioritize clinical, psychological and social problems. Perform a complete and competent clinical examination to establish a diagnosis. Consider additional problems and risk factors needing attention. Where ever necessary seek evidence from systematic reviews, guidelines, clinical trials, and other sources. Assess the evidence on account of completeness, quality and strength. More importantly ask yourself if valid and relevant evidence is being applied and is it both scientifically justified and intuitively sensible? Present the pros and cons of different options to the patient in easy to understand fashion and help to formulate a final recommendation. Most importantly arrange for review, recall, referral and further case wherever required.


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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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ARTICLE XIII - Heart Diseases in Eve – What’s new?

“Women are immune to heart problems,” is a wrongly held belief. The biggest killer of women is neither breast cancer nor uterine problems. Most women lose their lives to heart problems and strokes. Though, they may be less common in women before menopause but afterwards the disease is not only more common in females, it is more aggressive and flows a more serious course. Most women, even in the West, are not aware of the gravity of situation. This requires urgent attention and a well coordinated prevention plan.

A landmark meeting of specialists was held in Canada called the ‘First International Conference on Women, Heart Disease and Stroke’, on May 10, 2000. This took account of the situation and made elaborate recommendations. Some of the recommendations made there were to involve women in the development, implementation and evaluation of programs and services. To remove barriers to women’s participation in leadership positions in all sectors. Most importantly, to tailor programs and services to women’s needs including primary prevention, screening, diagnosis and treatment, prevention of recurrence, rehabilitation and support programs and services

What are the major factors?
Important factors have been identified which play a substantial role in the causation of heart diseases and strokes in both men and women.

a. Poverty:
It is the biggest curse around the World. The picture becomes more obvious when one realizes that more than 1000 million people live in absolute poverty, approximately 900 million are illiterate, about 2000 million people are deprived of potable water and approximately 800 million people go hungry every day. Though it may seem incredible but the truth is that there are 150 million undernourished children under 5 years of age and 14 million children less than 5 years old die every year. Women are the worst sufferers of this appalling poverty.

b. Response to stress:
Individuals cope in a variety of ways to external stress. Health effects of stress are shaped by social and cultural factors. Western assumption is that host response mechanisms operate only at the level of individual. The cross-cultural research suggests that many other factors have important roles to play and determine the response to stress. The response to stress of women in developing countries may be different and more severe.

c. Roles of Women
The women of today and yesterday has been “E”-woman which means EVERYTHING TO EVERYONE AT EVERY TIME. Women have various roles which vary by culture and country. Women tend to have primary responsibility for maintaining a home and caring for family members – young and old. This creates double workload, looking after family and in many cases earning money. As compared to men more efforts have to be put in by women in looking after family and fulfilling all family members’ need.

d. Inequalities of society:
Though health services are inadequate for the general population but of what is available women face great inequalities due to unequal access to and use of basic resources. Major reason for that is unequal access to primary care across all strata. Health policies and programs do not address this problem objectively and positively and this leads to persistence of inadequate and inappropriate health services for women.

How to promote women’s heart health?
Considering the risk factors for heart problem and stroke, a policy was decided upon to work on some guiding principles. For the promotion of women’s heart health and prevention and management of heart diseases and stroke following goals may be considered and worked at:

· Heart healthy habits:
Women have same risk factors as men. Conglomeration of risk factors has to be appreciated. Recognition of risk factors and control of risk factors is the foremost principle. Modifiable risk factors are high blood pressure, high cholesterol, smoking, lack of exercise and obesity. Health promoting dietary habits and regular physical activity have to be promoted. Health promoting dietary habits should be conducive in reducing weight by reducing caloric intake and regular exercise. Diet has to be modulated to keep cholesterol in lower limits. Regular physical activity for all ages and both sexes should be ingrained in our priorities and emphasis should be placed on it from young age. Women in developing countries are not encouraged to exercise and participate in sports. These civil barriers have to be broken and females have to be encouraged to remain active and take regular exercise.

· Research:
There is a need to address the issues of heart disease and stroke among women, including cardiovascular health and disease among women and the impact of preventive and therapeutic intervention on women. This should include gender sensitive research, education, training and supportive environments for women researchers. There is dire need, especially in Pakistan for involvement of women directly in the identification of women’s research issues, methods, analyses and interpretation of results.

· Dissemination of information:
There is urgent need to develop an “info-structure” to effectively disseminate the latest research pertinent to women. Recommendations on latest guidelines issued by various bodies have to be made public. Burning issues in women’s health need media attention and any conclusion drawn need to reach the end users. Ongoing programs need surveillance and monitoring of their findings and to be made available to general public on print and electronic media.
In conclusion, we have to recognize that heart diseases and stroke are the leading causes of death among women in the developed world and are fast approaching the same status in the developing world. Gender inequity, poverty, illiteracy, unemployment, and lack of access to health services influence women’s health, and we have to take appropriate actions to address these and other underlying determinants of health, and promote a healthy lifestyle that would help prevent heart diseases and stroke in women.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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ARTICLE - XII - How to treat heart failure? (Part-II)

Treatment depends on the cause of heart failure, the type and severity of symptoms and how well the body is able to compensate. Early testing is important because early treatment can sometimes prevent heart failure from worsening or even reverse its progress. Lifestyle changes and medication can improve the quality and length of life.

Life style modifications:

Regardless of cause of failure and severity of symptoms, there are certain rules to follow for every one. Diet and lifestyle modifications are important in managing the symptoms.

Limit Fluid intake. Excessive fluid puts extra load on heart and can make it harder for the already weakened heart to pump. Monitoring fluid intake can reduce complications and hospitalization. All foods that melt such as ice cream, gelatin, or frozen ice treats and foods that contain a lot of liquid such as soup are considered liquids. To relieve thirst without taking extra water, chewing gum or rinsing mouth with water and spitting it out can be tried.

Limit sodium intake: When a patient has heart failure, one need to eat less sodium, a component of salt, Excessive sodium leads to retention of water that makes it harder for the weakened heart to pump and leads to worsening of heart failure. Fluid may build up in the lungs – making it harder to breath. It may accumulate in feet, ankles, legs, and abdomen. Sodium intake should be limited to less than 2 g (2000 mg) per day and keeping track of sodium intake is the surest way of evaluating diet. Processed and restaurant food are high in sodium. Remember, food can be tasty and still be low in sodium.

Exercise: Exercise is very important for people with heart failure. If the patient is not already active, he should be encouraged to start an exercise program. Prescribed exercise is often part of a cardiac rehabilitation program.

Weight: Heart is entrusted with the responsibility of supplying nutrition in the form of blood to all parts of body. Losing weight can favourable lessen the load on heart. Over weight patients should be very strongly urged to lose weight.

Smoking: Smoking increases the risk of heart disease and makes it more difficult to exercise.

High blood pressure: Exercising, limiting salt intake, and controlling stress can help keep blood pressure in a healthy range.

2. Drugs: We are lucky that we have a host of drugs available, to not only control the complaints associated with heart failure but also favourably effect the eventual outcome. Added medications may be used depending on how well the patient tolerates the prescribed medications:

· Diuretics: Water tablets form the corner stone of heart failure treatment. The body is over loaded with extra fluid and the only way to get ride of this is through increased urine output. The drug has to be used very carefully because excessive use can lead to loss of salts and water leading to dehydration. Supplements of potassium are required on a regular basis to compensate for the loss. Some diuretics have special Potassium retaining effect and the combination of a loop diuretic and potassium sparing diuretic makes a logical choice. Renal function may dictate the type of diuretic to be used.
· ACE inhibitors: ACE inhibitors have been a wonderful addition in the armamentarium of anti-failure drugs. They have been proven to reduce death rate and improve symptoms in patients with mild, moderate or severe heart failure. Their efficacy has been established in patients with poor heart function but no obvious evidence of heart failure. This medication reduces the heart’s workload, lowers blood pressure, and optimizes heart function. Every patient with heart failure should benefit from ACE inhibitors. Some patients develop intractable cough with ACE inhibitors, they can benefit from the new class of drugs called Angiotensin receptor inhibitors.
· Beta Blockers: Beta blockers have revolutionized the management of heart failure patients. The research one the use of Beta blockers in heart failure, has shown that Beta blockers prevent worsening heart failure and in some cases improve heart function. However, some patients are not able to take them because of their side effects.
· Additional medications for coronary artery disease (CAD), high blood pressure, diabetes, infection or inflammation of the heart muscle (such as myocarditis), thyroid problems, heart valve problems, and abnormal heart rhythms (arrhythmias) may be required.

3. Definitive treatment:
In some cases, heart failure can be reversed when the underlying problem can be corrected, such as heart valve replacement surgery and treatment for hyperthyroidism. Sometimes heart failure develops shortly after a heart attack; heart failure can sometimes be reversed in these cases when treatments such as coronary artery bypass surgery or angioplasty, medication, and cardiac rehabilitation improve blood flow.

4. New treatment options:
Recent research has focused on developing devices that can help cardiac failure.

· Cardiac resynchronization therapy: Biventricular pacemakers can synchronize the rhythm of the heart’s chambers (cardiac resynchronization). Cardiac resynchronization is typically used for people with heart failure who also have certain problems with their heart’s electrical system. A recent study suggests that cardiac resynchronization may offer improvements in heart function, exercise capacity, and quality of life beyond that seen with medications alone in these people.
· In some cases when standard medical treatment does not help worsening symptoms of heart failure, other measures are considered. These include heart transplant, artificial hearts, and left ventricular assist devices (LVADs) – mechanical pumping devices that are implanted into the chest. However, these options are only for a very small number of people.

Heart failure is a life long malady and it demands understanding and commitment by the patient. Patient’s attitude and level of participation in the treatment can strongly effect the treatment outcome. Making the required changes in life style and complying with dietary restrictions can have a positive impact on the eventual prognosis. Taking the medications as directed, controlling the diet, and getting regular exercise are key lifestyle changes to control heart failure symptoms and preventing worsening of heart failure.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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ARTICLE XII - How to pass the ‘Failed Heart’ (Part-I)

“No, this is not possible, I cannot have heart failure,” said Abdul Qayyum, 50 years old bureaucrat with clenched fists and raised eyebrows. His argument were, “I can walk around and attend my office, so I cannot be too unwell!”It took him some time to accept the diagnosis. His next question was, “Is it the end of story? Shall I ask for retirement and confine my activities?” He was very happy to learn that firstly, heart failure was not synonymous with cardiac arrest/death and secondly, near to normal life was possible with new medical treatment. Some new drugs have effects on improving the outlook of disease and new technology is evolving to mitigate the suffering of patients with heart failure.

Heart failure is the end result of many diseases that effect the heart. Some diseases effect muscles of heart either through infections or deprivation of blood supply – coronary artery disease. Certain diseases effect the doors of heart called valves, either by restricting their motion or rendering them incompetent and leaky. High blood pressure puts extra load on heart and heart muscle has to generate higher pressure to pump blood. This extra effort taxes heart and eventually leads to heart failure. Heart tries to compensate by either beating fast or increasing in size, but eventually gives in. This stage is called heart failure as heart cannot meet the demands of body.

For the management of heart failure, prompt and accurate diagnosis of the disease causing heart failure is of paramount importance. There are several causes of heart failure. Several different tests are required to determine the exact cause of heart failure. In some cases the cause of heart failure can be reversible (such as a heart valve defect) or treatable (such as a thyroid problem) but in a majority of cases drug treatment is used to reduce the symptoms and improve the outlook.

How to work up heart failure? In patients with symptoms suggestive of heart failure, many tests may be required. Recently there has been a lot of research on a special blood test called brain natriuretic peptide (BNP), which can be used to diagnose heart failure and correlates well with severity of failure. The level rises when heart failure worsens. Electrocardiography (ECG) and Chest X-ray are the bare minimum cardiac tests. Echocardiography (echo) is the best and simplest way to determine heart function and whether it is systolic or diastolic heart failure. Echocardiography can also help to determine the cause of heart failure and help guide treatment decisions.

Nuclear scanning – a non invasive nuclear test is done to identify areas of the heart that are not receiving adequate blood flow (ischemic areas) and assess the left ventricle’s ability to function. Cardiac blood pool scan (radionuclide ventriculography) is often used when echocardiography results are less likely to be accurate due to a person’s weight or breast size of the presence of severe lung disease. Radionuclide ventriculography provides an accurate method for assessing the pumping ability of the left ventricle. However, it is less useful for evaluating the presence of heart valve disease and thickening of the heart muscle. ThalliumRadionuclide ventriculography provides an accurate method for assessing the pumping ability of the left ventricle. However, it is less useful for evaluating the presence of heart valve disease and thickening of the heart muscle. ThalliumRadionuclide ventriculography provides an accurate method for assessing the pumping ability of the left ventricle. However, it is less useful for evaluating the presence of heart valve disease and thickening of the heart muscle. Thallium/MIBI scan can detect reduced blood flow to heart. Cardiac catheterization and angiography can be used to identify blocked or narrowed coronary arteries and to measure pressures inside heart. Test results can help diagnose conditions that might cause or worsen heart failure symptoms.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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ARTICLE XI - So you had a Heart Attack – What next!

Khalid seemed visibly upset and was trying to hold back his tears. He was in his early forties and had just entered his pratical life. He had two small kids and a very lucrative job. He had many dreams and many unfulfilled plans. He was perfectly healthy so far and it had not occurred to him in his wildest dreams that he will end up in CCU one day. But as luck would have it, he suffered a heart attack one morning, and here he was in CCU on the second day of his admission.

I could see a hot of questions written all over his face. Is it the end of his career and will he lead a nearly crippled life? Does it imply that he will be confined to his house for the rest of his life? Does it mean that he necessarily has to go for a bypass operation< Will he not be able to enjoy golf again? Does he have to remain content with a boiled diet without any meat? Should he pursue his MBA degree? Should he still consider an addition in his family?

Heart attack can mean different things to different people. For most patients it is an important event but it passes off like another event and the person can go back to normal life. There is a definite mortality attached to it. Half of the persons who die of heart attack die within first hour and that too because of irregular beating of heart. In a few cases, it is not even recognized as a heart attack. Later, once patient is stable in CCU and has received definitive treatment then the death rate does down. Ninety percent of patients will leave CCU and hospital alive on their feet.

There was a time when patients were kept in the hospital for weeks and they were not allowed to lave the bed for a month. Things have changed for the better! Patients who are otherwise stable are mobilized after forty eight hours. They are discharged if they are otherwise stable on third or fourth day. If they have any problems – mechanical or electrical, they are kept under observation for as long as necessary. Patients who undergo angioplasty after heart attack may be discharged the next day and allowed to return to work much earlier. Patients are advised rest and leave from work for four weeks. Gradual mobilization is recommended after discharge. Starting from ten minutes on an empty stomach at a leisurely pace morning and evening and then building it up slowly to thirty minutes twice a day. Most patients can expect to go to work after four weeks.

When and what tests does one require after a heart attack? The basic philosophy is firstly to document the extent of damage in terms of function of left ventricle – main pump. Secondly, determine the extent of blockages in vessels supplying heart – coronary arteries, and thirdly look for all risk factors and try to improve them. Most patients will be required to undertake tests like effort tolerance test and echocardiography. This is to identify patients who will be requiring further tests like coronary angiography and hence requiring interventions like angioplasty and bypass operation. Not every patient who suffers from heart attack needs angiography or bypass surgery. Patients on very demanding and physically tough jobs or those who are young are advised coronary angiography irrespective of the result of effort tolerance test.

Big question for the family is what to allow the patient to eat? Many patients on their first visit after heart attack bring their youngest child who demands a list of forbidden food. This young lad turns out to be mama’s detective on a special duty. Depending on other risk factors like diabetes, high blood pressure and high cholesterol, there is not a lot that a patient should be denied. Preferably, food should be low in cholesterol within no ghee, butter, fat, egg, and internal organs. Small quantity of chicken and meat are allowed and fish is encouraged. No bar on bread or rice unless the patient is fat and calories have to be watched. Soups are allowed but should not replace normal food. Some roughage in the form of salad and fresh or boiled vegetables should be encouraged as it prevents constipation. Half cream or skimmed milk may be consumed. Juices especially fresh may be encouraged if the patient is not diabetic. Fresh fruits are always welcome.

Most patients are able to retain their job and follow their pursuits unless it is very risky and demanding. A few months down the lane most people will have forgotten about the event and gone back to their old life styles. Competitive sports and jobs in armed forces may be difficult to retain. Most intellectuals and bureaucrats have had a heart attack by the fifth decade but they continue to follow their jobs and hobbies.

Can one have another heart attack after the first one? Why not! So one has to put in efforts to correct one’s risk profile. For those who are diabetic, blood sugar level has to be meticulously controlled by keeping a very vigilant watch on diet and taking prescribed medicines regularly. Patients with high blood pressure have to bring their blood pressure to normal range or lower than that. Salt has to be restricted and treatment plan adhered to. Cholesterol has to be brought down regardless of the baseline levels. Strict control on diet is required and nowadays we are very liberal in prescribing cholesterol lowering drugs like statins. They have been shown very convincingly to reduce deaths and requirement of angiography and interventions like bypass and angioplasty in treated patients with salutary effects on lipid profile.

With modern treatment, like clot dissolving drugs and angioplasty – opening of vessels with balloons and stents, the outlook has improved remarkably. Most patients can go back to their original job and life style in four weeks. Regular exercise, discretion in diet and adherence to treatment are the golden rules to follow. For the majority of patients who sustain a heart attack, it is not the end of the world!

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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Article X - Management of Heart Attack – the Recent Advances!

The immediate management of heart attack called acute myocardial infarction, entails accurate and prompt diagnosis of heart attack based on history, ECG and blood test for release of cardiac enzymes. For monitoring and definitive treatment, quick assessment and early referral to a coronary care unit (CCU) is required. Management includes general measure and drugs – pharmacotherapy. Effort has been made to describe various strategies and drugs under the headings of rationale and evidence, indications, protocol and dosage and precaution.

MOBILITY:

Patient is confined to bed for the first 24 hours being monitored in CCU. Patients with persistent chest pain, irregular beating of heart called arrhythmias or heart failure are immobilized for longer duration. In uncomplicated heart attack gradual mobilization according to a set protocol should be followed.

OXYGEN:
Rationale and Evidence
Increased oxygen concentration is helpful at the time of heart attack to protect jeopardized heart muscle. It is helpful in reducing ventilation and perfusion mismatch. Administration of 100% oxygen has been shown to reduce ECG changes and have some effect on reduction of heart attack severity and size in animal and human models.

Who should get it?
Supplemental oxygen to all patients with overt breathlessness and those who have low oxygen saturation. Routinely it may be administered to all the patients with uncomplicated heart attack during the first 2-3 hours. There is no convincing evidence of any significant benefit in uncomplicated heart attack beyond 3 hours. Oxygen may be administered by nasal prongs or mask. The rate may be adjusted in arterial desaturation guided by repeat estimation. Nasal prongs may cause nasal irritation and mask may cause claustrophobia.

PAIN KILLERS
Rationale and Evidence:
Heart attack pain is very severe and capricious accompanied with impending feeling of death. Pain increased sympathetic activity hence increasing oxygen metabolic demand. This has to be relieved in shortest possible time with effective analgesics in appropriate dosage through proper route and repeated at proper intervals.

Who should get it?
Every patient with severe chest pain with ECG evidence should receive adequate analgesics. Those patients presenting after pain resolution may not be candidates for analgesics.

Precaution:
Morphine and analogues may depress breathing and extra caution must be exercised in old patients and those with chronic chest problems. Morphine and analogues cause vomiting, so anti-emetics should be given prophylactically.

CLOT DISSOLVING TREATMENT (Thrombolytic therapy):
Rationale and Evidence:
Last decade has been the decade of clot dissolving drugs called Thrombolytics. Convincing evidence from many large trials involving large patient population has secured a steady place for Thrombolytic therapy in the management of heart attack. This has revolutionized the management of acute heart attack. There has to be a solid reason for withholding Thrombolytic therapy. Dewood studies showed that a clot is involved in hart attack in more than 85% of cases.

This aim is early, complete and sustained blood flow to heart muscle. Cloth dissolving strategy involving intracoronary and intravenous administration of various agents has eventually reached a state of consensus. Clot dissolving therapy to reperfuse reduces death rate by 21% in patients with heart attack that means saving 21 lives per 1000 patients. The effects are time dependent as evidence suggests maximal benefit within two hours, optimal within six hours though definite benefit lasts till 12 hours. An estimated 35 lives per 1000 are saved when initiated within one hour as against 16 lives per 1000 when given 7 – 12 hours after the onset of symptoms.

Who should get it?
Clot dissolving drugs benefit all patients irrespective of age, gender, and presences of other conditions like diabetes mellitus. All patient presenting with heart attack within six hours of onset of symptoms must be administered clot dissolving Thrombolytics. Patients presenting within 6-12 hours should be considered for Thrombolytics. Patients presenting with symptoms suggestive of heart attack with left bundle branch block an ECG finding, should be candidates for Thrombolysis. Patients presenting after 12 hours with persisting pain and ECG changes should be considered for reperfusion theraphy after weighing pros and cons. More aggressive approach is desirable in younger patients and those with large heart attacks. It is, however, the elderly who get more benefit from Thrombolytic therapy.
Concerted efforts should be made that maximum number of patients benefit from this therapy. Initial evaluation in casualty department and CCU should be prompt and should not take more than twenty minutes in total. Consolidated data shows that 1.6 lives can be saved per hour per 1000 patients. Time is muscle, and every effort should be made to administer Thrombolytics as soon as possible.

Precautions:
Patients with contraindications to clot dissolving thrombolytics, like active internal bleeding, history of stroke, brain tumour, suspected aortic dissection, prolonged resuscitation, proliferative retinopathy, acute pancreatitis, fixed accelerated high blood pressure and bleeding disorders should not be given Thrombolytics. Streptokinase should not be used after 7 days and before 6 months of first administration due to the presence of antibodies.

ANGIOPLASTY:
Rationale and Evidence:
Coronary angioplasty provides the distinct advantage of not only opening the occluded artery by taking care of the superimposed clot but also dilating the primary lesion. The success rate of opening the infarct related artery is 95%. With the employment of stents the results are getting better. Infarct related artery has to be opened quickly, with lower rates of acute and subacute occlusion and restenosis. A pioneer study showed higher patency rates of coronary artery with reduced morbidity and mortality rates. It can be employed as the first and only procedure called primary angioplasty. In case of failure of clot dissolving treatment it is used as a rescue procedure called rescue angioplasty. Primary angioplasty should be performed by skilled operators backed by experienced personnel.

Who should get it:
The evidence from different trials support better outcome in terms of morbidity and mortality with anagioplasty as compared to thrombolytics. This mode of reperfusion is preferable wherever the facilities and expertise are available. It is the treatment of choice for patients presenting with low blood pressure called cardiogenic shock associated with large infarcts. It is of great importance for patients who cannot receive clot dissolving thrombolytic therapy. Patients who have received thrombolytic therapy in the last six months or who are allergic to it can derive benefit from angioplasty. Patients who fail to respond to thrombolytic therapy should be subjected to angioplasty.

The time taken from reporting to hospital to inflation of balloon in patients undergoing angioplasty should be comparable to the time taken in patients receiving clot dissolving drugs. This requires prompt assessment and management in the casualty department and CCU. Quick and in time referral to the Catheterization laboratory is mandatory. Round the clock availability of skilled operators and experienced staff and a well stocked Catheterization laboratory are very essential for the success of any programme. Cardiac surgical team should be available in case of emergency.

Precautions:
This mode of reperfusion involves high cost due to high cost of catheterization laboratory and hardware involved. It is subject to the availability of highly skilled and experienced operator and staff round the clock. Very few hospitals have such facilities so this can be offered to a very small segment of society.

ASPIRIN:
Rationale and Evidence:
Very few treatment modalities have been so well and widely received and practiced as aspirin in heart attack. Aspirin in does of 40 mg can reduce the aggregation property of platelets. In a summary of 33 trials, heart attack in patients on Aspirin was reduced from 25% to 11%. Many trials have shown remarkable beneficial effect.

Who should get it?
Every patient with no contra-indication to aspirin should be given aspirin as soon as possible. Administration of beta blocker, ACE inhibitors, reperfusion with thrombolytic therapy or primary PTCA, presence of hypotension, hypertension, bundle branch block, complete heart block, diabetes pose no contraindication to aspirin.

Every patient with suspicion of heart attack should be given aspirin 300 mg to chew as soon as possible and continued indefinitely in dosage of 75 mg per day. Various enteric coded brands are available in the market to reduce hyperacidity.

Precautions:
Patients with proven ulcer on endoscopy or barium meal, history of gastic bleeding or those receiving antiulcer treatment should not be given aspirin. Patients with known allergy should not be given aspirin. Other platelet inhibitors may be considered in patients who have allergy or who cannot tolerate aspirin.
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VESSEL DILATOR – NITRATE:
Rationale and Evidence:

Nitrates have muscle relaxation effect hence causing dilation of all vessels. This causes reduction in load on heart hence reducing oxygen demand. Intravenous therapy has been shown in animal and human models to reduce infarct size.

Who should get it?
Patients presenting, with heart attack in the first 24-48 hours, specially in large anterior heart attack, persistent chest pain and high blood pressure. It may be continued beyond 48 hours in patients with persistent chest pain or recurrent angina and breathlessness. Routine use after 24-48 hours is not recommended.

Nitroglycerine or Nitrate infusion is started and titrated while monitoring heart rate and blood pressure. Blood pressure reduction by 10% or heart rate increase by 10% should warrant reduction in dosage and closer monitoring. Long term oral therapy has not been found to have any significant effect on morbidity and mortality.

Precautions:
Patients presenting with blood pressure less than 90 mmHg, or slow heart rate should not be given Nitrate infusion. Lowering of blood pressure and increase in heart rate should be closely monitored.

BETA BLOCKERS:
Rationale and Evidence:
Beta blockers reduce heart rate and contractility hence decreasing oxygen demand. This has been shown to reduce heart attack size in animal and human models. Beta blockers decrease fatty acids. They have a well established role in ischaemia – reduce blood supply, arrhythmia – irregular heart beating and high blood pressure. Large trial and meta analysis have shown impressive reduction of morbidity and mortality with oral and intravenous beta blockers.

Who should get it?
Every patient regardless of age, gender, reperfusion strategy and therapy, time period, type of heart attack, associated comorbid condition should get it. It is of particular importance in patients with recurring chest pains, fast heart rate and high blood pressure.
Evolving heart attack should be given intravenous beta blocker watching blood pressure and heart rate closely. Oral therapy in appropriate dosage should be instituted at the earliest and continued preferably for two years. Perhaps all beta blockers in proper dosage confer similar effects. Beta blockers with longer half life have the advantage of convenience of dosage and lesser side effects.

Precautions:
Patients with asthma, chronic chest problems, low blood pressure – hypotension, overt heart failure, slow heart rate, uncontrolled or brittle diabetes should not be given beta blockers. Mild heart failure may be challenged with beta blockers under close supervision. Controlled diabetes is not a contraindication to beta blockers as the benefits outweigh the hazards.

ACE INHIBITORS:
Rationale and Evidence:
Dead – infracted segments stop contracting following a heart attack, other segments become hyperactive to maintain heart function. Heart undergoes remodeling in which it enlarges in size with increased wall tension on non infracted segments. Studies have shown that higher volumes are associated with higher chances of heart failure and increased morbidity and mortality. ACE inhibitors (ACEI) have been shown to reduce load on heart hence reducing wall tension and help is not increasing heart volumes. Use of ACE inhibitors in patients with symptoms of heart failure or evidence of reduced function derive maximal benefit with significant reduction of mortality and morbidity as shown in many large well conducted trials.

Who should get it?
All patients without contra indications to ACE inhibitors should be considered for it. It is particularly helpful in patients with symptoms and signs suggestive of heart failure or who have evidence of heart dysfunction – large dimensions and poor contraction even in absence of symptoms.

ACE inhibitors should be started with small dosage to obviate any low blood pressure episodes. The dose has to be built up gradually if patient can tolerate it. Systolic blood pressure should be mentioned closely. Optimal effects can only be expected at appropriate dosage Determined efforts should be made to optimize the dosage during hospitalization.

Precautions:
Patients with systolic blood pressure less than 90 mmHg should not be given ACEI. Those showing marked decrease in blood pressure, ACEI should be withheld and restarted at small dosage after some time. Those having persistent cough or intolerance to ACEI may be considered for Angiotensin receptor blockers like Losartan, Valsartan, Candesartan etc.

ANTI COAGUTANT – HEPARIN:
Rationale and Evidence:
Clot dissolving Drugs can open up the infarct related artery but for sustained patency Heparin had been advocated for a long time. Recent evidence from a large trial analysis does not support the regular use of Heparin following Streptokinase unless patient is at high risk for clot formation and dislodgement. Those patients who do not receive Thrombolytics may derive some benefit from Heparin. In the setting of unstable angina, intravenous Heparin has been shown to reduce morbidity and mortalilty.

Who should get it?
Patients presenting with unstable angina should get Heparin. Patients presenting late for thrombolytics should be considered for Heparin. In patients at high risk for clot formation and dislodgement like large or anterior infarction, irregular heart beat, or left ventricular clot, intravenous Heparin is preferred. Intravenous (IV) Heparin in patients receiving selective thrombolytics like tpa or alteplase is recommended.

Precaution:
Strick regimen should be followed as under dosage leads to treatment failure and overdosage causes bleeding complications.

FURTHER MANAGEMENT
This depends on the further course of disease. Uncomplicated heart attack patients are mobilized and discharged on 4th to 7th days of admission. An exit exercise tolerance test is favoured by some groups to identify patients at high risk requiring early angiography and intervention. Any mechanical, electrical or ischaemic complication is dealt with according to its merit.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah

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