How Doc­tors Are Mend­ing Bro­ken Hearts

Rapid and more ef­fec­tive treat­ments are curb­ing Europe’s No. 1 killer.

Reader's Digest International - - Contents - BY SUSANNAH HICKLING

ROD GAM­BLE’S FATHER DIED OF A HEART AT­TACK at 59, and there were signs that Rod too might not live to see old age when he de­vel­oped life-threat­en­ing car­diac rhythm prob­lems in his early six­ties. But thanks to ever-im­prov­ing heart treat­ments, the re­tired par­cel dis­tri­bu­tion com­pany man­ager from Scun­thorpe in the United King­dom is still fit and ac­tive at 72.

Af­ter the self-de­clared “sports fa­natic” col­lapsed twice while play­ing golf in 2008, doc­tors di­ag­nosed an ab­nor­mally slow heart­beat. They fit­ted him with a pace­maker that de­liv­ered elec­tri­cal im­pulses to stim­u­late his heart to beat at a nor­mal speed. Rod came to be to­tally re­liant on the de­vice, which sat just un­der the skin be­neath his left col­lar­bone with a wire lead­ing through a blood ves­sel to the heart.

But the pace­maker was not with­out its prob­lems. It had to be re­placed af­ter six weeks when the pac­ing wire moved, and then Rod de­vel­oped an in­fec­tion af­ter the bat­tery—worn out from be­ing used at 100 per cent ca­pac­ity to keep him alive—had to be re­placed in Septem­ber 2014.

“Early one Sun­day morn­ing I got up to go to the bath­room,” he re­mem­bers. “I felt some­thing run­ning down my chest.” To his hor­ror he saw that the in­fec­tion had split the pace­maker scar wide open, the wire was hang­ing out and pus was ooz­ing out of an inch­wide wound.

The in­fec­tion meant that a sim­ple re­place­ment was out of the ques­tion but in June 2015 a new kind of pace­maker came to his res­cue. The Mi­cra

Tran­scatheter Pac­ing Sys­tem was the world’s small­est, a tenth of the size of a stan­dard de­vice, but, even bet­ter, it would be im­planted into the heart it­self, mak­ing it wire­less and in­vis­i­ble. “When I saw it, I couldn’t be­lieve it,” he says. “It was like a bul­let with tiny hooks!”

Two years later, he plays golf most days, goes to the gym and is very thank­ful for med­i­cal ad­vances. “All I want is to live as long as pos­si­ble,” he says. “I’m thor­oughly en­joy­ing life.”

HEART DIS­EASE is the num­ber one killer in Europe. Ac­cord­ing to the most re­cent sta­tis­tics from the Euro­pean Heart Net­work, more than 85 mil­lion peo­ple were liv­ing with car­dio­vas­cu­lar dis­ease (CVD) in Europe in 2015 and it ac­counts for 45 per cent of all deaths in Europe.

But the trend is down­ward. Car­dio­vas­cu­lar dis­ease is no longer the main cause of mor­tal­ity in Bel­gium, Den­mark, France, Italy, Lux­em­bourg, the Nether­lands, Por­tu­gal, Slove­nia, Spain and the United King­dom. In fact, an­nual deaths from car­dio­vas­cu­lar dis­ease in Europe are down from 4.3 mil­lion in 2008 to 3.9 mil­lion to­day.

Pro­fes­sor Mike Knap­ton, as­so­ciate med­i­cal di­rec­tor at the Bri­tish Heart Foun­da­tion, cites a num­ber of rea­sons for this. “Lev­els of smok­ing have been re­duced,” he says, “there have been some im­prove­ments in diet and phys­i­cal ac­tiv­ity, and high blood pres­sure and choles­terol are bet­ter man­aged.” More peo­ple also have rapid ac­cess to treat­ments at spe­cial­ist car­diac cen­ters.

Im­por­tantly, those treat­ments are more ef­fec­tive. Only 50 years ago, bed rest and mor­phine were the stan­dard ther­a­pies for a heart at­tack—when blood flow to the heart is in­ter­rupted by a block­age, usu­ally caused by a build-up of fatty ma­te­rial in the artery, caus­ing dam­age to the heart mus­cle. Sur­vival rates were low.

But now, as Pro­fes­sor Knap­ton ex­plains, “Re­cent ad­vances in the treat­ment and man­age­ment of CVD to re­duce mor­tal­ity or im­prove qual­ity of life have re­sulted in a use­ful range of in­ter­ven­tions avail­able to pro­fes­sions and pa­tients.”

So what do to­day’s doc­tors have in their tool­box to mend bro­ken hearts?

DRUGS

Aside from drugs pre­scribed to cut the risk of heart at­tacks and stroke, such as statins for high choles­terol and anti-hy­per­ten­sive med­i­ca­tion for high blood pres­sure, a wide range of drug ther­a­pies are avail­able to treat car­dio­vas­cu­lar prob­lems when they oc­cur. These in­clude throm­bol­y­sis for a heart at­tack (or a my­ocar­dial in­farc­tion, to give it its med­i­cal name). This in­volves in­ject­ing clot-bust­ing medicine into an artery to dis­solve a blood clot and re­store the blood sup­ply to the heart.

Mean­while, a new treat­ment for heart fail­ure—when the pump­ing ac­tion of the heart is in­ad­e­quate—has been touted as a won­der drug. Ev­ery day 10,000 Euro­peans are di­ag­nosed with heart fail­ure and 15 mil­lion are thought to be liv­ing with the con­di­tion. There is a high risk of death within five years. How­ever, in tri­als En­tresto (sacu­bi­tril val­sar­tan) was shown to re­duce car­dio­vas­cu­lar death by 20 per cent com­pared to the stan­dard treat­ment, hos­pi­tal­iza­tion for heart fail­ure by 21 per cent, and death from any cause by 16 per cent.

“We have been able to show a rapid im­prove­ment in a few weeks in the con­di­tion of the pa­tients treated,” con­firms Dr. François Pi­card, a heart spe­cial­ist from Bordeaux Hospi­tal, France.

ANGIOPLASTY AND STENTING

To re-open an acutely blocked artery that has caused a heart at­tack, you may re­ceive clot-bust­ing drugs or un­dergo an angioplasty, or both. Angioplasty in­volves trac­ing a catheter up an artery in a leg or arm to open up con­stricted coro­nary ar­ter­ies un­der lo­cal anes­thetic and then in­flat­ing a tiny bal­loon to push back the block­age against the artery wall. In ad­di­tion to its use in treat­ing acute heart at­tacks, angioplasty is also used to re­lieve sta­ble angina symp­toms—chest pain

brought on by ac­tiv­ity or stress—that are caused by the nar­row­ing of coro­nary ar­ter­ies.

Ger­many has the high­est rate of angioplasty pro­ce­dures in the OECD. “It’s very clear from stud­ies of more than 20 years ago that in pa­tients with acute my­ocar­dial in­farc­tion you re­duce mor­tal­ity, im­prove sur­vival and also pre­vent heart fail­ure by this rapid re­open­ing of the artery with a catheter,” says Pro­fes­sor Jo­hann Bauersachs, di­rec­tor of the Depart­ment of Car­di­ol­ogy and An­gi­ol­ogy at Han­nover Med­i­cal School. Speedy in­ter­ven­tion pre­vents dam­age. With­out angioplasty, on the other hand, at least 20 to 30 per cent of peo­ple suf­fer­ing a ma­jor heart at­tack would die, he says. “It is a very clear life-sav­ing ther­apy.”

Some­times one or more stents—a small stain­less steel mesh tube—are in­serted to keep the blood ves­sel open. These have im­proved markedly. The bare-metal stents of the 1990s led to re-nar­row­ing of the artery in 30 per cent of cases. “Since 2005 we have had sev­eral gen­er­a­tions of drug-elut­ing [drug-coated or med­i­cated] stents that se­crete a spe­cial sub­stance that pre­vents re-oc­clu­sion,” says Bauersachs. These have brought the rate of re-steno­sis down to 5 to 10 per cent. “The prob­lem of coro­nary artery dis­ease is mostly solved with these re­ally very safe and ef­fec­tive drug-elut­ing stents.”

Petr Re­housek, an or­tho­pe­dic sur­geon from Cˇeské Bude˘jovice, Czech Repub­lic, is a liv­ing tes­ta­ment to the ef­fec­tive­ness of angioplasty and stenting. In 1996 at age 51, he had pain in his chest while cut­ting the grass and was di­ag­nosed with a heart at­tack. Af­ter be­ing given throm­bolytic drugs, Petr was air­lifted 150 kilo­me­ters to a hospi­tal in Prague for an angioplasty. Dur­ing the pro­ce­dure doc­tors placed two stents in one artery. Since then he has had a fur­ther four an­gio­plas­ties and five stents to treat nar­row­ing in other ar­ter­ies.

He finds the pro­ce­dure it­self un­com­fort­able. “When they put the catheter in, they block the artery for a short time and you have pain and feel pres­sure in your chest,” he says. But it has made a last­ing difference to his qual­ity of life. “I can take part in sports in the same way as be­fore and in the same way as peo­ple who haven’t had angioplasty,” says. He still works as a doc­tor, cy­cles to work and last win­ter was win­ning ski races in his age group.

PACEMAKERS

These life-sav­ing elec­tri­cal de­vices have been used to treat heart rhythm

ANGIOPLASTY TO RE­OPEN AN ARTERY IS A “VERY CLEAR LIFESAVING THER­APY,” SAYS PRO­FES­SOR JO­HANN BAUERSACHS.

prob­lems since the 1960s. Stan­dard pacemakers only treat a slow heart rate, while im­plantable car­dioverter de­fib­ril­la­tors (ICD) can also de­liver an elec­tric shock to re­store a nor­mal heart rhythm for peo­ple with a lifethreat­en­ing heart rhythm dis­tur­bance, such as a very rapid heart rate.

Smaller than a match­box, the de­vice is im­planted un­der the skin on the chest un­der lo­cal anes­thetic and the wires guided to the heart via a vein. How­ever, the new, smaller wire­less pacemakers, such as the Mi­cra, are in­tro­duced through a catheter via a vein in the leg and threaded up to the heart. “Aside from the slight pain from punc­tur­ing the vein and in­ser­tion of the de­liv­ery sys­tem, there is no pain or dis­com­fort,” says Dr. Jens Brock Jo­hansen of the car­di­ol­ogy depart­ment at Odense Univer­sity Hospi­tal, Den­mark.

VALVE RE­PLACE­MENT

Rob Hack­will, 58, was born with a nar­row aorta, the body’s main artery. When he was 13, doc­tors said there was noth­ing fur­ther they could do to fix his heart. “It worked very hard to push blood through a hole that was too small,” ex­plains Rob. “My heart was al­ways rac­ing.” He grew into a pale, thin adult. In 2001 he was told that his heart was dan­ger­ously en­larged and he was in im­mi­nent dan­ger of a heart at­tack.

But the Lyon, France-based jour­nal­ist was re­lieved to find that car­diac medicine had moved on in leaps and bounds since his child­hood. Within weeks, he had open-heart surgery to im­plant a new heart valve made of plas­tic, which, with the help of blood­thin­ning drugs, should last him the rest of his life. “I had color in my cheeks for the first time,” says Rob. He now leads a nor­mal life and ear­lier this year be­came a father for the fourth time.

“The symp­toms for some­one who is dis­tressed and dis­abled by a dam­aged aor­tic valve will con­sid­er­ably im­prove with aor­tic valve re­place­ment,” says Pro­fes­sor Knap­ton of the Bri­tish Heart

Foun­da­tion. These days it can be un­der­taken with much less in­va­sive op­er­a­tions, avoid­ing open heart surgery.

In tran­scatheter aor­tic valve im­plan­ta­tion (TAVI), a valve is usu­ally in­serted un­der lo­cal anes­thetic through a catheter in an artery from the groin or via an in­ci­sion in the chest wall. It is es­pe­cially suited to el­derly or very sick pa­tients who are too frail for more in­va­sive surgery. As with an angioplasty, a bal­loon is in­flated in the heart and a new valve is then po­si­tioned. Valves are of­ten made of animal tis­sue and don’t re­quire anti-co­ag­u­lant drugs, but they don’t last as long as Rob Hack­will’s com­pos­ite valve.

In Ger­many TAVI is more com­mon than open-heart surgery. It is of­ten used to treat aor­tic steno­sis—nar­row­ing of the aor­tic valve—which af­fects one in ten peo­ple over the age of 80. “It is so easy to per­form now and so safe,” says Han­nover car­di­ol­o­gist Jo­hann Bauersachs, whose old­est TAVI pa­tient was 97. “With TAVI, a pa­tient is able to get out of bed the next day and they stay in hospi­tal five to seven days.” This com­pares to weeks of hos­pi­tal­iza­tion and re­ha­bil­i­ta­tion af­ter open-heart surgery.

CATHETER ABLATION

Catheter ablation is used to treat heart rhythm dis­tur­bances (ar­rhyth­mia) us­ing fine wires threaded into the heart through blood ves­sels to burn or freeze small ar­eas and cre­ate a scar that blocks ab­nor­mal elec­tri­cal sig­nals. It is used on peo­ple with atrial fib­ril­la­tion (AF)—a heart rhythm dis­or­der that can cause stroke or coro­nary heart

dis­ease—whose heart rhythm re­mains ab­nor­mal in spite of drug treat­ment. There will be an es­ti­mated 14 to 17 mil­lion pa­tients with AF in the Euro­pean Union by 2030, with 120,000 to 215,000 new cases di­ag­nosed each year. They of­ten suf­fer de­bil­i­tat­ing pal­pi­ta­tions, short­ness of breath, tired­ness, weak­ness and de­pres­sion. But over half of peo­ple who have catheter ablation have no fur­ther symp­toms.

ELEC­TRIC CARDIOVERSION

For Am­s­ter­dam res­i­dent Pa­tri­cia Vlas­man, how­ever, ablation was not able to bring per­ma­nent re­lief for her atrial fib­ril­la­tion, caused by a se­ri­ous con­gen­i­tal heart prob­lem. The 46-yearold, who was born with hy­per­trophic car­diomy­opa­thy—in which the my­ocardium, the mus­cu­lar wall of the heart, thick­ens and stiff­ens—has also had “all the med­i­ca­tions pos­si­ble” and a pace­maker. Pa­tri­cia, au­thor of Open­hearted—My Life with Car­diomy­opa­thy and Heart Fail­ure, finds that only elec­tri­cal cardioversion helps re­store nor­mal heart rhythm.

Un­der short-act­ing gen­eral anes­thetic or se­da­tion, med­i­cal staff give elec­tric shocks us­ing elec­trodes at­tached to large sticky pads placed on the chest and con­nected to a de­fib­ril­la­tor ma­chine. “Af­ter cardioversion my chest be­comes calm again and that is such a re­lief,” says the Dutch mother of one who suf­fers nau­sea, dizzi­ness, breath­less­ness and a rapidly beat­ing heart when she has ar­rhyth­mia. “Just to breathe again, full to your belly, in­hal­ing the air, that is awe­some.”

How­ever, the treat­ment is only a short-term so­lu­tion for Pa­tri­cia. She has had 103 car­diover­sions and doc­tors have now put her on the wait­ing list for a heart trans­plant. Around 2,000 Euro­peans re­ceive a new heart ev­ery year and half will live for ten years or more, with some pa­tients liv­ing more than 25 years af­ter the trans­plant.

Vlas­man knows she owes much to new drugs and tech­niques, and the skill of doc­tors. “I’m lucky that I’ve been able to live longer and see my son grow­ing up,” she says. “I re­al­ize this ev­ery day and it makes me grate­ful.”

Nine years ago, Rod Gam­ble was di­ag­nosed with dan­ger­ous car­diac prob­lems.

Pa­tri­cian Vlas­man, 46,

is await­ing a new heart.

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