Heart Failure – a growing concern to the local health sector

May 25, 2014 News

---

…but collaborative efforts can make a difference, says Cardiologist

By Sharmain Grainger

Although there are evident efforts being undertaken to improve the delivery of health care in Guyana, there are yet some disturbing trends that are threatening to diminish the gains made. Among these are the increasing cases of heart failure that have surfaced in recent times.
This phenomenon, is however not unique to Guyana, as according to Resident Cardiologist at the Caribbean Heart Institute (CHI), Dr Mahendra Carpen, “this has been going on for a number of years all over the world.” In fact, heart failure has been listed as a leading cause of death in some sections of the world.

CHI, which represents a public-private partnership, is conveniently housed in the Georgetown Public Hospital Corporation.
According to Dr Carpen, heart failure is an advanced stage of heart disease. At this point, he noted, the heart is so incapacitated that it is unable to function effectively to circulate blood throughout the body.
And there are a number of reasons that can lend to this development. But the number one cause is that of blockages, explained Dr Carpen.  Nevertheless, other factors such as heart attack and high blood pressure among others are of equal concern, he noted.
“Some people have inherited conditions, and some conditions result from environmental factors, whether it may be chemicals or whether it is something that is in the water or something in the air, or some infection…all of these can have a part to play in causing heart failure,” he disclosed.
And according to him, among the patients he sees frequently at CHI are those with advanced heart failure, some of whom were found to have a history of working in interior locations.
Just last week, Dr Carpen saw at least four of these patients, all of whom were below the age of 55.
“Either they are still working there or worked there for a number of years…It is a very troubling trend I have noticed and I am very worried about it,” said Dr Carpen, who disclosed that CHI is in the process of compiling data in order to undertake a scientific analysis.
“This is something we have become very vigilant about at CHI, in fact when I see patients who have this kind of history come to me, one of the first things I would do for them is  an echocardiogram to get an accurate and objective assessment.”
“I don’t know if it’s mining or some kind of infection that is prevalent there…We don’t currently have what is necessary to make a definitive pronouncement on it, but the first step really is the compilation and assessment of data,” disclosed Dr Carpen.

MANIFESTATION
The condition of heart failure can be classified as either Systolic or Diastolic heart failure. The former classification is used when a patient’s heart muscle is unable to pump enough blood around the body, while the latter speaks to when the heart muscle does not relax enough to accommodate the return of blood to the heart.
A common cause for Diastolic heart failure is high blood pressure, a condition Dr Carpen says is rather prevalent here in Guyana.
But according to him, Systolic heart failure is a rather daunting development as it hinders the heart from operating as a pump to circulate blood.
“When that muscle gets weak or thinned out that is when that pump is unable to function to send blood to the brain, the legs, the kidneys and so forth,” Dr Carpen pointed out. And because the blood is not being distributed throughout the body, an obvious outcome is that the blood is instead backed up into the lungs, thereby causing patients to develop symptoms such as shortness of breath.
“Developing shortness of breath can start in a very subtle way…an individual might try to run up the stairs or walk a little further than usual and realise that they can’t do it like they used to and persons may adjust to this limited lifestyle,” Dr Carpen theorised.
The manifestation of this condition, he disclosed, may gradually develop to a point where persons may awaken from their sleep with intense bouts of coughing or they might start panting for breath even when they are lying down. Lying down too may require that they be propped-up with two or more pillows in order to be comfortable, and as the condition progresses it could lead to swollen feet or the neck veins becoming especially conspicuous. “When it gets really bad even the tummy swells up, the liver gets enlarged and swollen, and some persons may also have abdominal pains,” Dr Carpen revealed.
As if the foregoing progression of the condition is not bad enough, the Cardiologist informed that doing simple things like speaking can eventually become a difficult task.
“Persons may find that they cannot speak in full sentences and have to stop in the middle of a sentence to take a breath…and this might just be a normal eight-word sentence,” he noted.

MANAGEMENT
But there are several ways that the condition can be effectively managed, Dr Carpen intimated. Management can only be effective, he said, if patients are properly diagnosed.
“When you examine a patient with a suspected heart condition you essentially look for edema (swelling caused by excess fluid trapped in the body’s tissues), you look for fluids in the lungs that could affect a person’s ability to breathe, fluid in the abdomen, distension of the veins in the neck, which is a direct reflection of the pressures in the heart…All these things you use as your clinical tool before you actually start doing investigations,” said Dr Carpen.
However, an echocardiogram test, which is deemed an ultrasound of the heart, is in fact the way to go to obtain an accurate assessment of the heart, he noted. An echocardiogram, he explained, is a process that can ascertain the function as well as the thinness or thickness of the heart muscle, assess the structure and the valves, and even measure pressure without doing anything invasive.
According to Dr Carpen, “this is an absolutely critical test that we have at our disposal that we can use to diagnose and manage these patients properly…Gone are the days when you only rely on just stories and your own clinical assessment.”
“There are lot more objective measures of managing patients, but first and foremost you must be able to determine how badly this heart muscle is damaged; how badly the function of the heart is compromised, so that you know how to treat and what medications are appropriate,” said Dr Carpen.

TREATMENT
And it is expected that patients with heart failure will be required to use a great deal of medication in order to stabilise their conditions, which of course may be seen as a major drawback.  But according to Dr Carpen, there is no avoiding the fact that patients must adhere to a rigid treatment course.
“When my patients ask me ‘how long I should take medicines for’ I usually tell them for as long as you want to live, because for heart conditions you generally have to live with them and learn how to control them, especially with heart failure,” said Dr Carpen.
He however noted that although a lot of patients regain heart function with the use of medicines, quite a lot do not and therefore have to adjust to taking medicines in order to help improve their quality of life.
And, of course, patients should always try to find out from their doctors not only the name of the medicines prescribed to them, but also their purpose, Dr Carpen asserted.
Among the medicines used to treat heart failure is lasix, commonly referred to as a water pill, which is intended to help control patients’ symptoms, the Cardiologist said.
However, he is convinced that medicines that really help to make a difference, in terms of survival rate, are beta-blockers, a line of drugs including metoprolol, carvedilol and to a lesser extent atenolol. Another class of drugs commonly used are those referred to as the ace-inhibitors or Angiotensin Receptor Blockers (ARBs) such as captopril, ramipril, enalapril and losartan, all of which have been shown to improve patients’ longevity.
According to Dr Carpen, patients may also find themselves on drugs such as isordil and GTN which can help to dilate the blood vessels and reduce the pressure in the lungs.
“When medicines can only get you to a certain point then those patients require something else and that is when treatment for advanced heart failure and advanced heart disease becomes complicated and very expensive and time-consuming,” disclosed Dr Carpen.
In order to prolong life and improve quality of life, advanced heart failure will become absolutely necessary, said Dr Carpen.  This may include cardiac-resynchronisation therapy which essentially works to control the heart muscle, and has proven to help prolong life.

EARLY ATTENTION
But addressing heart failure may be long in coming for some patients, since according to the concerned Cardiologist, societal culture sees some persons suffering from the associated symptoms “trying a number of different things before reaching to a doctor to be assessed.”
This, according to Dr Carpen, is not necessarily the best approach and therefore amplifies the need for more efforts to be directed towards education of the population with a view of even lending to the prevention of the condition.
And such an objective can be realised, he noted, through intensified collaborations that will cater to educating the public of the symptoms of not only heart failure, but other health issues that may not be effectively addressed without the intervention of medical practitioners. “People need to be empowered so that they can become more aware of these conditions, of their own health, so that they can take more control and become more responsible for their own health.”
According to Dr Carpen, heart failure, even with the best medical therapy, has a 20 per cent chance of mortality per year. This therefore translates to one in five patients dying per year of heart failure, hence amplifying the need to work towards prevention or early detection.

Pic name Carpen

Caption:

Pic names heart failure and heart failure1

---

---