There are Significant Technical Advances in Heart Surgery

Bird, looking for something? (Dr. Noorali Bharwani)
Bird, looking for something? (Dr. Noorali Bharwani)

I met a gentleman who has had a stroke, suffers from coronary artery disease and has a malfunctioning aortic valve – a valve in the left lower chamber of the heart from where the blood is pumped out to the rest of the body.

I also read in my book (Dr. B’s Eight Steps to Wellness – page 90) that the heart muscle is the hardest-working muscle in the body. It pumps out 60 milliliters of blood at every heartbeat. Every day, the heart pumps out at least 10,000 liters of blood. The heart has the ability to beat over three billion times in a person’s life. Isn’t that something?

The heart is like a grand central station. If the central station breaks down then all the lines come to a stop. We don’t want that. So we need to keep our heart healthy. But if you are unlucky like the gentleman I mentioned earlier, then you have to look for medical and/or surgical help.

Pursuing a healthy life style in terms of regular exercise, healthy eating and no smoking is a good thing. If you inherit bad genes then you have to increase your efforts to prevent the disease. If you need medications then your good doctor will help you with that.

There are surgical options for coronary artery disease. If putting stents in plugged vessels does not help then surgical treatment is required. Coronary artery bypass graft (CABG) surgery has become a routine procedure.

The majority of coronary surgical procedures are performed for multiple vessel disease. Overall, the mortality rate of coronary artery surgery is low, at around two to three per cent, although this benefit is offset by a complication rate of 20 to 30 per cent. It is important to evaluate various physical, psychological and social side effects of CABG as well.

Now the technology has improved to a point where patients with more advanced coronary artery disease and extensive coexisting conditions are taken care of. “Off-pump” procedures, in which the heart does not have to be stopped, were developed in the 1990s. These patients generally have fewer complications, less leg pain, and shorter hospital stays.

Options for treating damaged aortic valve are many. The valve can be repaired or replaced in many ways. In the United States, surgeons perform about 99,000 heart valve operations each year. Valve replacement is most often used to treat aortic valves in the left lower chamber of the heart. Your surgeon may choose a mechanical valve, which is usually made from materials such as plastic, carbon, or metal. Mechanical valves are strong, and they last a long time.

Your surgeon may choose a biological valve, which is made from animal tissue or taken from the human tissue of a donated heart. The procedure may be open-heart surgery or the new technique of minimally invasive valve surgery thorough small openings in the chest wall. In some cases, minimally invasive valve surgery can be done using a robot.

Minimally invasive surgery cannot be done in patients who have severe valve disease, have clogged arteries or are overweight.

Research shows around two per cent of people treated with aortic valve replacement will die in the first 30 days after surgery. However, the risk of death from surgery is far lower than that associated with not treating severe aortic disease.

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Preventing Stroke Important for Independent Lifestyle

Tranquility - One way to relax and meditate. (Dr. Noorali Bharwani)
Tranquility - One way to relax and meditate. (Dr. Noorali Bharwani)

“There are many ways of breaking a heart. Stories were full of hearts broken by love, but what really broke a heart was taking away its dream – whatever that dream might be,” said Pearl S. Buck (1892–1973), a bestselling and Nobel Prize–winning author.

What stroke does to a person is to take away a dream. But where there is a will there is a way. Two basic things required for any kind of success are: patience and perseverance. With appropriate help from family, friends and caregivers much can be achieved, although it may take time.

What is more important is to prevent stroke in the general population and especially people who are at a high risk.

A commentary in the Canadian Medical Association Journal (CMAJ November 19, 2013) titled, “Stroke prevention in older adults with atrial fibrillation,” by Michiel Coppens, MD and colleagues, discuss the use of new oral blood thinners that reduced the risk of bleeding in the brain by 30 to 70 per cent compared with warfarin. The new medications were at least as effective as warfarin in preventing stroke due to reduced blood supply to the brain.

People with atrial fibrillation have irregular heartbeats, which make them prone to forming blood clots. Warfarin is the most commonly used drug (also used as rat poison) as a blood thinner in humans to prevent blood clots. The main drawback is that the patient has to have regular blood tests to make sure the blood is not too thin. It may cause internal or external bleeding.

The new oral blood thinners (dabigatran, rivaroxaban and apixaban) are approved in more than 80 countries for stroke prevention in patients with atrial fibrillation. Patients do not require blood tests to check if the blood is dangerously too thin.

According to the CMAJ article, the key points to remember are that many patients do not receive recommended blood thinner treatment. The new oral blood thinners offer consistent benefits over warfarin in older (age 75 years or older) patients with atrial fibrillation.

The article says the rate of internal brain bleeding, the most feared complication of blood thinners, is related to age and is sharply reduced by the new blood thinners relative to warfarin, making these agents particularly attractive for older patients.

Like any new medication, only time will tell whether the drugs are safe and superior to currently used warfarin or should I say rat poison? Talk to you again soon. Take care and don’t forget to listen to music, dance and laugh.

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Broken-Heart Syndrome is also known as Takotsubo (Stress) Cardiomyopathy

Nurse helping a senior patient. (Wavebreak Media)
Nurse helping a senior patient. (Wavebreak Media)

Takotsubo cardiomyopathy is a transient acute illness typically precipitated by acute emotional stress. It is also known as “stress cardiomyopathy” or “broken-heart syndrome.” In 2011, there was an article on this subject in a medical journal, Circulation, by Dr. Scott W. Sharkey and his colleagues from the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN explaining the signs, symptoms and treatment of this illness.

In Japanese, “tako-tsubo” means “fishing pot for trapping octopus,” and the left ventricle (pumping chamber of the heart) of a patient diagnosed with this condition resembles that shape.

This is a fairly new condition recognized initially in Japan in 1990, with the first report emerging from the United States in 1998. Takotsubo cardiomyopathy starts suddenly, with symptoms of chest pain and, often, shortness of breath. The condition affects women older than 50 years of age (only 10 per cent in men). Most patients go to the emergency department thinking they have a heart attack.

Sharkey gives examples of emotional stressors which include grief (death of a loved one), fear (armed robbery, public speaking), anger (argument with spouse), relationship conflicts (dissolution of marriage), and financial problems (gambling loss, job loss). Physical stressors include acute asthma, surgery, chemotherapy, and stroke.

“Although patients with takotsubo do not have significantly narrowed coronary arteries, in the early hours takotsubo and heart attacks share many similarities in presentation, including chest pain and breathlessness, as well as abnormalities in both the electrocardiogram and blood biochemical tests,” says the article. But coronary angiogram will show normal coronary arteries but unusual shape of the left ventricle that has given takotsubo its unique name.

Once the diagnosis is made (via several invasive investigations) patients are in the intensive care unit for at least 24 hours, during which time vital signs are monitored and blood is tested for troponin (a protein released by injured heart muscle). Medications are used to promote recovery of heart muscle and blood thinners are used to avoid a stroke caused by a blood clot traveling from the heart to the brain.

Major life-threatening complications are infrequent. Low blood pressure (hypotension), fluid buildup in the lungs (congestive heart failure) and a chaotic heart rhythm will require appropriate medications.

“Fortunately, with timely recognition and supportive therapy, takotsubo events are reversible, and recovery is usually rapid and complete. Heart function (contraction) gradually improves over several days and is usually normal by hospital discharge (3–7 days). The term stunned heart muscle is commonly used to indicate that injury in takotsubo, although initially profound, is only temporary. Drugs are discontinued once heart contraction has returned to normal,” says Sharkey.

Why would acute stress cause heart failure? This is an unresolved question. It may have something to do with the autonomic nervous system. It has been suggested that when powerful hormones such as adrenaline are released in excess, the heart muscle can be damaged in patients with takotsubo. Fortunately, the long term prognosis is good. Nearly all patients survive an acute takotsubo episode. In approximately five per cent of patients, a second (or third) stress-induced event may occur. Best thing is to avoid stressful situations. Relax, do deep breathing exercises and keep smiling.

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Low Dose Aspirin Increases the Risk of Upper Gastrointestinal Bleeding

Aspirin bottle. (iStockphoto)
Aspirin bottle. (iStockphoto)

Low-dose acetylsalicylic acid – also known as aspirin – (75 mg⁄day to 325 mg⁄day) is recommended for primary and secondary prevention of cardiovascular events, but has been linked to an increased risk of upper gastrointestinal bleeding (UGIB), according to a study published by Valkhoff and his colleagues (Can J Gastroenterol. 2013 Mar;27(3):159-67).

They analyzed several studies. All studies found low dose aspirin use to be associated with an increased risk of UGIB. The mean number of extra UGIB cases associated with low dose aspirin use was 1.2 per 1000 patients per year. Sounds like a small number when you think of the number of people who take aspirin all over the world. But the authors indicate use of low dose aspirin was associated with a 50 per cent increase in UGIB risk.

What about other anti-inflammatory drugs? Are they safe?

Commonly used traditional anti-inflammatory drugs like ibuprofen are also known as non-steroidal anti-inflammatory drugs (NSAID) are widely used for all kinds of pain. An editorial by Jacob Josh, Professor of Medicine, University of Ottawa, Ottawa, Ont. titled, “Anti-inflammatory drugs: What is safe?” (CMAJ August 29, 2006), says “Sixteen thousand deaths a year in the United States and 1900 a year in Canada were blamed on NSAID-induced gastric perforations, obstructions and bleeds. NSAID use was complicated also by numerous other side effects, including hypertension, heart failure and renal insufficiency.”

The risks are not limited to long-term use. Clinically significant adverse cardiovascular events are noted within the first 30 days of treatment.

Do you always have to take an NSAID if you are in pain and thus increase the risk of complications? Not really. You can try other modalities of pain relief by rest, application of ice and use of acetaminophen. Acetaminophen, up to 4 g/day, is as effective as an orally administered NSAID in about 40 per cent of patients with mild to moderate osteoarthritis.

Then there are occassions when pain cannot be relieved by what we call conservative measures. So we have to weigh our options. First, we should assess patient risk. There is an increased risk of gastric toxicity if:
-the patient is over 65,
-has had previous upper GI bleed,
-there is concurrent therapy with low-dose aspirin, corticosteroids or anticoagulants.

Under these conditions we should try prescribing a coxib (like Celebrex) or traditional NSAID with concurrent cytoprotection (to protect the stomach lining) with misoprostol or a proton pump inhibitor. If the patient has had a recent heart attack or episode of congestive heart failure, then he should not take NSAID or coxib.

Josh says, “In case of uncontrolled hypertension, we should not choose an NSAID or coxib until the blood pressure is well controlled. If the patient has controlled blood pressure that becomes elevated while taking an NSAID or coxib, even by 5 mm Hg systolic, adjust the antihypertensive medications or stop the anti-inflammatory, or both.” Monitor renal function as well.

Josh says there is nothing like a safe NSAID or coxib. In high-risk patients, we should avoid them. Concomitant use of low dose aspirin does not protect you from cardiac side-effects of NSAID or coxib. There is adequate data to suggest aspirin enhances the gastric toxicity of anti-inflammatory drugs as mentioned earlier.

If you are in pain, careful use of painkillers is very important. If you are taking aspirin as a prophylaxis against cardiac problems then weigh your risk factors and your options. If you are taking NSAID for chronic pain then you need to know your risks. Discuss risk vs. benefits of the medications you are taking with your doctor.

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