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CARDIAC RISK

 

Heart Failure Treatment

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What is heart failure?

Heart failure occurs when the heart loses its ability to pump enough blood through the body. Usually, the loss in pumping action is a symptom of an underlying heart problem, such as coronary artery disease.

The term heart failure suggests a sudden and complete stop of heart activity. But, actually, the heart does not suddenly stop. Rather, heart failure usually develops slowly, often over years, as the heart gradually loses its pumping ability and works less efficiently. Some people may not become aware of their condition until symptoms appear years after their heart began its decline.

How serious the condition is depends on how much pumping capacity the heart has lost. Nearly everyone loses some pumping capacity as they age. But the loss is significantly more in heart failure and often results from a heart attack or other disease that damages the heart.

The severity of the condition determines the impact it has on a person's life. At one end of the spectrum, the mild form of heart failure may have little effect on a person's life; at the other end, severe heart failure can interfere with even simple activities and prove fatal. Between those extremes, treatment often helps people lead full lives.

But all forms of heart failure, even the mildest, are a serious health problem, which must be treated. To improve their chance of living longer, patients must take care of themselves, see their physician regularly, and closely follow treatments.

Heart Failure: Questions & Answers


Cardiomyopathy

Cardiomyopathy is the condition in which the muscle of the heart is abnormal. The term is most commonly used in reference to an abnormally large, baggy heart ("dilated") with reduced ability to contract.

Causes of cardiomyopathy
Coronary artery disease: The commonest cause of cardiomyopathy is "heart attack" (also caused coronary or myocardial infarction). A heart attack occurs when one of the three major arteries of the heart block off and blood is unable to reach the muscle of the ventricle, the muscle subsequently dies, forming a scar. This cannot contract in the same way that healthy muscle can.

Viral infections: A virus can attack the heart muscle and lead to cardiomyopathy. Often the heart problem does not become obvious until some time after the viral infection itself (months or years).

Alcohol excess: This is a common cause in Australia. In general, 4 drinks or more per day of beer, wine or spirits on a regular basis, is thought to be enough to damage the heart - sometimes irreversibly. One does not have to be an alcoholic to develop a cardiomyopathy due to alcohol. Fortunately, if alcohol is stopped entirely, there is a 50% chance that the heart will recover, often back to normal.

No known cause ("idiopathic"): In a number of cases, even after extensive testing, no likely cause for cardiomyopathy will be found. This is called "idiopathic"" cardiomyopathy. Perhaps a virus affected the heart some time before, but has now gone, leaving no trace apart from the weakened heart muscle. Nevertheless, even though the cause is not known, medications are still extremely effective in treating the condition.

What is hypertrophic cardiomyopathy?

In this condition, the muscle mass of the left ventricle is larger than normal. In one form of the disease, the wall between the two ventricles (septum) becomes enlarged and obstructs the blood flow from the left ventricle. The syndrome is known as hypertrophic obstructive cardiomyopathy (H.O.C.M.) or asymmetric septal hypertrophy - (A.S.H.). It is also termed idiopathic hypertrophic subaortic stenosis - I.H.S.S.


There are hundreds of other uncommon causes not listed here. For example, cardiomyopathy may occur in the last few weeks of pregnancy or in the first few weeks after delivery.


HEART FAILURE RESEARCH

Care of heart failure patients at St Vincent's Hospital is recognised to be of the highest international standard. It offers diagnosis of and prognostication in heart failure, hemodynamic appraisal, and use of maximum oxygen utilisation and functional parameters to assess progress. There is an active research program into novel therapies.
Standard treatments for heart failure include inotropic therapy, inpatient and outpatient ambulatory inotrope infusions and intraaortic balloon pumping. The Heart Mate left ventricular assist device is available for indefinite long-term support. The heart and lung transplant unit is one of the largest in the world.

In 1999, trials of new therapies in heart failure include:
(1) open label carvedilol - the largest single-centre experience inthe world
(2) MOXCON - randomised trial of rnoxonidine vs. placebo in ACEI treated patients
(3) CHARM - 3 different randomised trials of candesartan cilexetil in patients who are:
i) ACEI intolerant
ii) on ACEI with depressed LV function
iii) in heart failure but with preserved LV function
(4) Tumor necrosis factor receptor antagonist - an exciting new concept of modulating the immune system to control heart failure
(5) INSYNC - a trial of synchronous ventricular pacing

Other therapies which continue to be offered include:
(6) Structured exercise program taught and administered by heart failure physiotherapists
(7) CPAP or biPAP for sleep apnea related to heart failure
(8) aggressive anti-atrial fibrillation therapy and maintenance of sinus rhythm


PULMONARY HYPERTENSION

St Vincent's Hospital is one of the leading centres for the management of pulmonary hypertension in the Southern Hemisphere. Comprehensive diagnostic vasodilator challenges are performed routinely.

Specific treatments offered include:
(1) Prostacycline continuous infusion for patients actively listed for heart-lung or lung transplantation
(2) Inhalational lloprost (subject to funding capacity)
(3) Randomised trial of I5UT (long-acting prostacycline analogue) from January 1999 - subcutaneous infusion, 3 month trial followed by ongoing open-label access
(4) Heart-lung or double-lung transplantation

Contacts:
A/Prof Anne Keogh
Ph: 9361 2641
Fax: 9361 7084
email: akeogh@stvincents.com.au

A/Prof Peter Macdonald
Ph: 9361 2641
Fax 9361 7084
email: pmacdonald@stvincents.com.au



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