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Days Away from a Massive Heart Attack
"I would be walking in the street and have to stop at every corner to get my breath back. It was impossible to walk up stairs -
and simple things like combing my hair and brushing my teeth took a tremendous effort.
"For a long time I thought I had the flu, but it wouldn't go away. When I went to my own doctor he told me
I had congestive heart failure, but he felt that a diet was the solution. So I was eating rice and beans
for weeks. But soon it became clear that I wasn't getting any better. I told him he had to get me to a
cardiologist. In 1994, he referred me to NYU Medical Center."
Quick Action
"What are my alternatives?" van Akelijen asked his NYU cardiologist,
Dr. Frank O'Brien. "You have none," said O'Brien. "A surgeon is on his way right now." The following morning,
cardiac surgeon
Dr. Eugene Grossi performed quadruple coronary bypass surgery and
put van Akelijen on the road to recovery.
Follow-Up for Life
When van Akelijen was diagnosed with heart failure in 1994, he was not alone - some 400,000 new cases are
diagnosed annually. Heart failure kills 38,000 people every year and is a contributing factor in the deaths of
225,000 others. But van Akelijen was fortunate; his heart problems were treatable.
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Life-Saving Diagnostics
"It's so important to make the right diagnosis. It's in the hands of the individual doctor who knows his or her
patient and has all the necessary support." This includes echocardiography, nuclear cardiography, stress tests
(both exercise and pharmacologic), angiography, and studies of electrophysiology.
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Echocardiography's Role in CHF
Seeing is Believing
Zooming In
3-D Image
This procedure, performed by interventional cardiologists, "is an incredible option for patients who might
not survive surgery," says Dr. Itzhak Kronzon, a specialist
in cardiac diagnostics. In the treatment of faulty heart valves,
Dr. Fred Feit, Director of NYU's Cardiac Cathetherization Lab, points out that "highly specialized
surgical techniques can repair valves that otherwise would have to be replaced."
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Elements of Excellence in Managing Heart Failure
Toward a Better Life: Treatment that Works
ACE Inhibitors
Although large-scale studies have demonstrated that ACE inhibitors decrease symptoms and prolong
the lives of heart failure patients, they remain underused. A recent Harvard study found that 69
percent of patients with heart failure were not prescribed ACE inhibitors. And a University of
California study found that 43 percent of the sampled practitioners prescribed inadequate doses. Some
patients have contraindications - low blood pressure and renal failure are the two principal
ones - but many patients would benefit if ACE inhibitors would be more widely prescribed.
Dangerous Heart Rhythms
Rehabilitation: To Strengthen Muscle, Build Confidence
"I didn't know it at the time, but I was days away from a massive heart attack," said 58-year-old Wim van Akelijen.
Almost immediately, van Akelijen underwent a battery of tests. An echocardiogram revealed that his heart
had an ejection fraction of only 20 percent and an angiogram revealed that he had severe coronary artery
disease - the leading cause of congestive heart failure - which can cause myocardial infarction.
The steps that followed in the subsequent 2-1/2 years - extensive drug therapy, closely monitored physical rehabilitation,
continual watchfulness by Dr. O'Brien and his colleagues, and, recently, the timely installation of a pacemaker -
describe a standard of care that eludes many patients seeking relief from the devastating consequences of a failing heart.
At the center of successful treatment is a committed relationship between doctor and patient. "Dr. O'Brien and I are
on a first-name basis because he's going to be my partner for the rest of my life," said van Akelijen.
"The key to treating heart failure," says
Dr. Arthur C. Fox,
Chief of NYU's Division of Cardiology, "is to look for reversible causes - the underlying problems in the heart
that can actually be fixed."
An echocardiographic evaluation identifies defective heart valves, assesses the severity of heart valve disease,
pinpoints areas of heart muscle damage, maps abnormal blood flow patterns, and estimates the strength of the heart's
contractility. High-quality echocardiography provides the cardiologist with a unique opportunity to determine the
etiology of the patient's heart failure. Knowing the precise cause of heart failure allows the physician to make
crucial decisions regarding the most effective treatment. For example, echocardiographic images of the ventricle
can indicate if heart wall motion is compromised, and further pharmacologic or nuclear testing can determine whether
this area is infarcted or merely ischemic; if ischemic, revascularization has a high probability of allowing
the heart to recover.
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Many different types of echocardiography are available. Two dimensional echocardiography provides a good picture
of the overall functioning of the heart and its various parts. The Doppler ultrasound echocardiogram and the color
Doppler are images of heart motion and structures, combined with real-time color images of blood motion,
which are useful for detecting abnormal blood flow and defective heart valves.
The transesophageal echocardiogram (TEE) was pioneered at NYU. With this procedure, an ultrasound device is
attached to a tube that is inserted in the esophagus. Because the echoing device is much closer to the heart,
the procedure produces an image that is 100 times clearer than those of other types of echocardiography. A
full-time echocardiologist evaluates heart function before, during, and after operations. TEE is especially
useful with patients undergoing surgery for faulty heart valves, because it shows the results of heart valve
replacement or repair before a patient's chest is closed.
One of the most innovative tools is 3-dimensional (3-D) TEE. It is often used during valvuloplasty, a procedure
performed in the Cardiac Catheterization Lab
to widen heart valves that have become clogged or narrowed. In valvuloplasty, a balloon-tipped catheter is inserted into the
femoral artery and moved through the blood vessels into the heart, where the balloon is properly positioned
and then inflated, forcing the valve to open wider, and improving the flow of blood.
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Clinical symptoms often seen with all types of heart failure include shortness of breath,
fatigue, swelling of the legs, and persistent cough. A variety of drugs may be used to help
relieve these symptoms, especially diuretics. "But the most fundamental approach to treating congestive
heart failure," says Dr. Feit, "is an angiotensin-converting enzyme (ACE) inhibitor."
ACE inhibitors widen the blood vessels, thus reducing the load on the weakened heart and
allowing it to pump more easily. The importance of this cannot be overestimated, for the
heart - unlike other muscles - cannot rest; it must continue to work even when it is injured.
The relief provided by ACE inhibitors is extraordinarily helpful in treating heart failure
patients.
Life threatening abnormalities in heart rhythm often develop in a sub-group of heart failure patients.
Electro-physiological studies conducted in the catheterization lab may identify patients most at risk
for these arrhythmias. Once identified, these patients are treated with antiarrhythmic drugs or the
implantation of a pacemaker or cardiac defibrillator.
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"Physical rehabilitation is a critical and ongoing part of a patient's recovery process," says
Dr. Mariano Rey, who runs
NYU's Cardiac Prevention and Rehabilitation Center.
"Patients with heart failure do better when they are seen at the hospital bedside by a physical
therapist, who gets them started right away on ambulation and exercise. If appropriate,
they can then be transferred to a dedicated inpatient cardiac rehab program that provides education
about medications and assessment of changes needed in diet and activity to keep their hearts
healthier. Once patients are discharged, they can join an outpatient program. NYU offers 36
exercise sessions and 12 lectures over three months. Help from nurses, cardiologists, psychologists,
and exercise physiologists is always available."
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He first came to NYU in 1981 - as a patient of cardiologist Dr. Martin Kahn - shortly after he suffered a mild heart attack and was treated at another medical facility. His cardiologist at that facility, Rabb said, was "very good - but he wouldn't talk to the patient; he only talked to God. Dr. Kahn, on the other hand, is easy to talk to. He's always there when I need him. I don't do anything without talking to him."
No wonder Rabb feels that way. After Rabb experienced severe heart failure symptoms, Kahn placed him on ACE inhibitors, which brought great relief. His heart problem was properly diagnosed and successfully treated by a triple coronary bypass operation, performed by Dr. Stephen Colvin.
Years later, when a serious heart rhythm irregularity was detected, an internal cardiac defibrillator, which can restore normal rhythm in life-threatening circumstances, was implanted by Dr. Eugene Grossi.
Today, despite some physical limitations, Rabb travels extensively and enjoys a good quality of life. Dr. Kahn calls him a "remarkable man." But Rabb says, "He thinks I'm remarkable because I'm still alive. But I'm alive because of him - he's kept me alive! And it's not just him - it's everyone involved with my care."
"It's Your Heart"
At 6 feet 3 inches and 255 pounds, 61-year-old James Wenz is an active outdoorsman who loves nothing better
than to golf, play ball, hunt, and fish. Even when he developed diabetes, hypertension, and kidney problems in
his fifties, he continued an active life.
But in late 1992, Jim Wenz's energy seemed to desert him. "I'd feel tired," he said, "like I didn't get any sleep. When I climbed subway steps, I'd be huffing and puffing. And on weekends, instead of getting out there and being active, I would sit there like a couch potato and watch TV.
"When my wife noticed that my ankles were swollen, I blamed my blood pressure medication. But when I went to see Dr. Terry Seltzer, my diabetologist, he said, 'It's not the medication that's causing the swelling and fatigue, it's your heart.'"
Soon, Wenz, now in the hands of cardiologist Dr. William Cole, was in the exercise stress lab having a thallium stress test, which he "failed miserably." An angiogram showed the complete blockage of two arteries and partial blockage of one. After Dr. Aubrey Galloway performed a triple coronary artery bypass the next day, Wenz's improvement was remarkable.
He went home a week after the operation and felt like his old self. He gardened and did work around the house. And he began to hunt and fish again in the wilds of Alaska and Montana. "I had ants in my pants," Wenz said, "I couldn't stay still."
Sometime later, Wenz came down with pneumonia so severe that he required intensive care. A team of specialists was assembled. "I had a doctor for every part of my body," Wenz said. "And Dr. Cole - he's one of the nicest gentlemen you would want to meet. The nurses were great, too. I owe my life to NYU - twice." back to top
Medical Research and Quality Care Improve CHF Outcomes
From the experiences of Wim van Akelijen, James Wenz, and Stephen Rabb - the three patients whose stories
are told in this issue of Health Care Solutions - it is clear that a diagnosis of heart failure no
longer has to mean a sentence of hopeless disability leading to early death.
As a result of substantial progress in research on heart failure, there is now enormous opportunity for extending and improving patients' lives. Significant contributions to this research were made by NYU physician scientists, who pioneered the use of cardiac catheterization to determine the basic causes of heart failure.
Taking advantage of this progress required identifying treatable types of heart failure using the best available diagnostic techniques and following up with optimal therapy. The complexity of heart failure and the differences among individual patients necessitate a variety of treatment options, from precise calibration of medication to minimally invasive surgery for valve repair and replacement. Critical to ensuring that all the necessary elements fall into place are strong doctor-patient relationships, and dedicated nursing care.
With effective coordination of all these components of quality care, heart failure patients can live longer and enjoy a better quality of life than would have been possible only a decade ago.
Great Coordination: Nurse Case-Managers
Clinical Pathways
Every patient admitted with a diagnosis of heart failure is screened by a nurse case-manager
specializing in cardiology, to determine the complexity of the case and to assist the attending
physician in coordinating hospital services. Uncomplicated cases are managed with the guidance
of a carefully constructed plan, or clinical pathway, which ensures that diagnostic tests and treatments
begin promptly upon admission and proceed optimally.
Complex Cases
For heart-failure patients who also have illnesses like diabetes or pneumonia, a somewhat longer
pathway timetable is applied. Patients requiring especially complex care are continuously followed
by the cardiology nurse case-manager, who (working with the social work department and community
agencies) also assesses and coordinates post-hospital services needed after discharge. After the
patient is discharged from the hospital, the cardiology nurse case-manager follows up by telephone
to make sure the patient is receiving all necessary services.
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Concerns About Fen-Phen
High quality echocardiography can detect developing heart valve problems or reassure patients
who took diet drugs
The worldwide recall prompted by the U.S. Food and Drug Administration (FDA) of two popular diet drugs - fenfluramine and dexfenfluramine (often paired with phentermine in the well known "fen-phen" combination) - has aroused deep public concern because of the drugs' suspected association with heart valve abnormalities and potentially serious elevations in pressure in the pulmonary arteries.
While many who have taken fen-phen may be alarmed, only a small percentage of this population is likely to be affected seriously.
For those who are concerned about possible side effects, echocardiography offers a non-invasive, painless technique that can definitively diagnose or rule out heart valve abnormalities or elevations of pulmonary pressure, conditions frequently not detected on physical exam, chest X-ray, or electrocardiogram.
Echocardiography can detect even a small amount of valve leakage, which may be the first sign of diet-drug- induced valve damage and can be used to measure the blood pressure in the pulmonary arteries.
NYU's echocardiography lab can be reached at 212-263-5664. The full range of NYU's cardiology services can be accessed by e-mailing Eileen Russo, RN, at the Physician Referral Service: 212-263-5000. back to top
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