BHIA Heart Health Articles

Cardiac Arrest: Treat Heart Failure Fully and Avoid Cardiac Arrest

By Roman Pachulski, MD

There is little more dramatic in its presentation than a patient with cardiac arrest.

Regardless of what field of medicine doctors may practice now, all surely have vivid memories of running to a “code blue” during medical training. As anyone in emergency, cardiac or critical care medicine can attest, the algorithms for treating this catastrophic complication have changed tremendously over the past 25 years. But more fundamentally, we have been striving to preemptively treat high-risk subgroups with the added benefit of symptomatic improvement in heart failure.

It turns out that the road to effective arrhythmia therapy that underlies most cardiac arrests crosses the path of effective heart failure therapy. Although seemingly intuitive now, we followed a bumpy road from frankly counterproductive approaches to effective therapy, and finally preventive interventions.

Eighty eight percent of sudden death is due to cardiac arrhythmia, and of that, 85 percent is due to ventricular tachycardia. It has long been known that survival diminishes about 10 percent per minute after onset of circulatory arrest.

From a public health standpoint, preventive strategies should impact the largest possible number of patients. Unfortunately, as the prevalence of cardiac arrest rises in increasingly high-risk populations from those with prior infarction, to those with heart failure or to those with documented prior ventricular tachycardia, the absolute numbers of patients actually diminishes, robbing the value of prophylactic intervention.

Patients with prior heart attacks have six times the risk of cardiac arrest as the general population, and heart failure patients have nine times the risk.

Early therapeutic attempts were empiric pharmacologic approaches with procainamide, quinidine and fleacainide that under rigorous scrutiny were found to increase mortality. The dated controversy over drug efficacy assessment through invasive electrophysiology study or repeat Holter recordings was thereby rendered moot by the inefficacy of drug therapy.

More recently, in the COMPANION trial even amiodarone had no mortality benefit in the chronic treatment of ventricular tachycardia over optimal pharmacologic heart failure therapy.

A multiplicity of trials including AVID, MADIT 1 and 2, and MUSTT documented the benefit, not only of defibrillation, but prophylactic implantation of a defibrillator in heart failure patients. These large, well-structured trials repeatedly show relative mortality reductions of 20 to 31 percent. Similarly, field trials have documented dramatic survival improvement with early defibrillation using automatic external defibrillators that first responders can operate.

For those office-based primary care practitioners, including many obstetricians who feel they never see cardiac arrest patients, it is worth reviewing that 59 to 64 percent of mildly to moderately symptomatic heart failure patients otherwise well and stable die from cardiac arrest. These constitute the bulk of the office going heart failure patients.

The latest trials, SCD-HEFT and COMPANION investigated the symptomatic benefit of biventricular pacing in heart failure patients with bundle branch block.

Biventricular pacing activates both the right and left ventricle directly rather than activating only the right ventricle and allowing passive activation of the hemodynamically more important left ventricle. Electronic activation of the left ventricle is achieved by cannulating the coronary sinus from the right atrium and placing the lead in a branch vein. Heart failure patients with biventricular pacing live better, and those with defibrillators live longer.

In an analogous fashion, the evolution of heart failure therapy has taken perhaps a counterintuitive turn from digoxin and diuretic to a strong emphasis on afterload reduction, potassium sparing agents and beta blockade.

The only procedural therapy found to improve both the quality and quantity of life in heart failure patients, short of transplant, is biventricular defibrillator implantation.

The gaping maw between heart failure drug therapy and cardiac transplantation with its chronic donor organ paucity and narrow applicability has been bridged by biventricular defibrillator implantation with its diminutive surgical risk in trained hands.

Device implantation results in symptomatic improvement in 80 percent of appropriately selected individuals and can be further improved through the use of advanced echocardiographic techniques including color tissue Doppler mapping to optimize atrioventricular and even interventricular activation times (figures 1 and 2).

The best treatment for cardiac arrest therefore involves the confluence of optimal heart failure pharmacotherapy with beta blockade and biventricular defibrillator implantation when appropriate.

Dr. Roman Pachulski completed his medical training at the University of Ottawa in 1983 and postgraduate training in cardiac electrophysiology at the University of Pennsylvania in 1990. He is board certified and current in Internal Medicine, Cardiology and Cardiac Electrophysio-logy. He currently practices on Stone Oak Parkway in San Antonio, having moved from New York where he was Chief of Cardiology at Bassett Heart Institute, a Columbia University affiliated teaching hospital.

Increasing Your Heart Health

One of the most detrimental things to the overall heart health of a human being is the intake of cholesterol and fatty foods. One of the best ways to increase your heart health is to lower your intake of fatty foods and cholesterol.

If you are interested in increasing your heart health there are many ways you can reduce the intake of fatty foods and cholesterol in your diet. For starters you should consider dropping any fast food and junk food that may be a part of the regular food intake out of your diet. This means that you will need to drop the French fries and greasy hamburgers out of your diet to improve overall heart health. When you are at the grocery store you should try to avoid stocking up on junk food items like potato chips and other greasy fat filled items that can be hazardous to your heart health. Try to replace these fatty foods with fresh fruits and vegetables that are certainly much better for your heart health than greasy cheesy curls and other unhealthy fare. Making sure you receive your recommended daily allowance of all the essential vitamins and minerals can be a tremendous boost to your heart health as well, so be sure to make sure you take a daily multi vitamin.

Fatty foods, particularly those high in saturated fat and cholesterol, can be hazardous to your heart health due to the fact that they have the potential to clog the arteries around your heart (and indeed many of the blood vessels in your body) with dangerous, blood stopping plaque. This plaque can build up around your artery walls and cause all sorts of problems with your heart health, up to and including a life threatening situation like a heart attack or stroke.

A combination of things such as a healthier diet and exercise can improve your heart health and if you believe that your heart health may be in question you should consult your doctor immediately.

Heart Disease and Women’s Health: What You Need to Know

Significant progress is being made in raising awareness of a primary threat to women’s health: heart disease, which has traditionally been viewed as an issue mainly concerning men. Thanks in part to awareness campaigns launched by the current First Lady, Laura Bush, and the designation of the month of February as a national awareness month for women and heart disease, women are increasingly realizing that heart health matters for them, not just for their husbands, brothers, and fathers.

Upon hearing the phrase “women’s health,” most people promptly think of reproductive health (e.g., breast self-exams, regular gynecologist appointments, prevention of ovarian cancer) and health issues that commonly manifest after menopause, such as osteoporosis. However, recent statistics show that heart disease is the number-one killer of U.S. women, killing more each year than all cancers combined.

Historically Viewed as a Man’s Problem

Past studies indicate that women presenting to hospital emergency departments with signs of impending heart attack (e.g., nausea, sweating, dizziness) were much more likely than men to be sent home without a proper diagnosis. Research also shows that primary physicians are less like to prescribe preventive treatment to their female patients, such as cholesterol-lowering drugs, blood-pressure reducing drugs, and cardiac rehabilitation, further exposing women to the risk of heart disease.

It is important for women to take charge of their cardiac health. Some risk factors are uncontrollable, such as getting older, your family’s health history, and race (heart disease is more common among African-American women, for example). But preventive efforts within a woman’s control include cutting down on or (preferably) quitting smoking, eating a healthy diet that includes avoiding foods that are high in saturated fat, getting regular exercise for 30 minutes at least 5 days a week, and maintaining a healthy body weight. If you aren’t sure what weight range is considered healthy for your size, check with your physician.

Also, you do have a measure of control, to some extent, when it comes to your family’s health history. Empower yourself by learning if members of your family have had high cholesterol, high blood pressure, or have experienced heart attacks. This knowledge can help you work with your healthcare provider so that he or she can prescribe preventive treatments such as those mentioned above.

Educate Yourself on Heart Disease

Another way to protect yourself from life-threatening or permanently disabling effects of heart disease is to be aware of signs and symptoms. Although heart disease is commonly referred to as the “silent” killer because of seemingly absent symptoms, warning symptoms often do occur but are mistakenly attributed to other causes. For example, arm or chest pain, especially during stressful times or periods of intense activity, can signal poor heart health and a risk for heart attack. So can frequent fatigue (tiredness) for no apparent reason; heart palpitations, or abnormal beats; and shortness of breath.

The most common sign of an impending heart attack for women is, as in men, chest pain or a feeling of discomfort. This “discomfort” can manifest as tightness, a squeezing sensation, or a feeling of pressure. Cold sweats are another common sign for both genders, as is pain in the left arm. But women may be slightly more likely than men to experience a variety of other symptoms, including nausea, vomiting, shortness of breath, and pain in the jaw or back just before a heart attack.

Other issues of concern regarding women and heart health include the use of birth control pills and hormone therapy. Premenopausal women using birth control pills generally are at little increased risk for experiencing heart disease caused by birth control use. However, women who smoke or who have high blood pressure should consult with their healthcare provider before going on birth control pills, as studies have shown the pill can increase the risk of heart disease for smokers or women with high blood pressure. Hormone therapy was traditionally viewed as actually helping to prevent heart disease, but recent studies show it actually carries more risks than benefits in this area.