Heart Disease UK

From Richard N. Fogoros, M.D.,

Treating dilated cardiomyopathy and heart failure
The first rule of treating cardiomyopathy and heart disease is to aggressively seek out and treat any reversible underlying cause. Treatment for coronary artery disease or valvular disease needs to be optimized. Thyroid disease, anemia, or nutritional deficiencies need to be reversed. Abnormal tachycardias need to be aggressively controlled.
While attempting to identify and stabilize the underlying cause, treatment should be instituted to minimize the symptoms of heart failure and to optimize the efficiency of the failing heart. The mainstay of treatment has been and remains medication, but transplant surgery has saved thousands of lives, and new medical devices are being developed to treat cardiomyopathy and heart disease.

Drugs
Digitalis. Digitalis agents improve the force of heart muscle contraction by increasing the amount of calcium inside cardiac cells.
If digoxin helps this condition, its effect seems to be marginal. Also, a recent study suggests that digoxin might actually be detrimental in women who have heart failure.
Diuretics. Diuretics, or “water pills,” increase the elimination of sodium through the kidneys. Eliminating sodium reduces the fluid retention that occurs in heart failure, helps rid the lungs of the excess fluids that cause shortness of breath, and helps reduce leg swelling. Most patients who have experienced an episode of heart failure are placed on daily therapy with diuretics.
ACE inhibitors. ACE inhibitors act to dilate blood vessels in the body. This is extremely important, because in heart failure the body responds by constricting blood vessels, and the constriction of blood vessels greatly increases the work of the heart. ACE inhibitors have proven to be the most effective in improving both the symptoms and the outcome of patients with heart failure. Virtually every patient with heart failure should be on an ACE inhibitor.

Antiarrhythmic therapy.
Unfortunately, patients with moderate to severe dilated cardiomyopathy have a significantly increased risk of sudden death from ventricular arrhythmias. Also unfortunately, antiarrhythmic drugs have never been shown to reduce that risk. The implantable defibrillator has been shown to significantly reduce mortality in certain subsets of patients with cardiomyopathy, particularly in those with prior heart attacks. A trial has shown that patients with prior heart attacks whose ejection fractions are less than 30% have a significantly improved survival when they receive implantable defibrillators.

Cardiac resynchronization therapy (CRT).
CRT is a new form of treatment for some patients with dilated cardiomyopathy. CRT is a form of cardiac pacing that stimulates both ventricles (right and left) simultaneously. The purpose of CRT is to coordinate the contraction of the ventricles, which improves the efficiency of the heart, and increases the amount of blood pumped with each heart beat. Any patient with dilated cardiomyopathy and a complete or partial bundle branch block should be considered for CRT.

From Richard N. Fogoros, M.D.,

Getting what you need from your doctor
Anyone diagnosed with heart disease should expect the following:
1)Insist on a thorough search for a definitive underlying cause. Especially important is to rule out undiagnosed coronary artery disease and valvular heart disease.
But you need to make sure that your doctor aggressively focuses on looking for all reversible causes of cardiomyopathy, before further heart damage is done.
2)Insist on being placed on ACE inhibitors and beta blockers. These two drug therapies for cardiomyopathy are relatively recent, and in the case of beta blockers are counterintuitive and against what many doctors have been taught for years. But these therapies are now well-documented not only to improve symptoms, but also to reduce mortality with dilated cardiomyopathy.
3)Insist on being carefully instructed on how to monitor yourself to reduce the frequency of the periodic exacerbations of heart failure seen with dilated cardiomyopathy. It is now felt that by looking for telltale changes in vital signs and weight, the exacerbations of heart disease that lead to periodic hospitalization can often be “headed off” by timely medication adjustments.
4)Insist that your doctor specifically address the issue of life-threatening arrhythmias. While usage of the implantable defibrillator is limited by the FDA, appropriate indications for using this life-saving device in patients with cardiac problem are changing frequently. Since a large proportion of deaths in patients with dilated cardiomyopathy are sudden and due to arrhythmias, this is an important issue that needs to be periodically revisited.
5)Ask your doctor if you are a candidate for CRT. This new therapy is possibly the most important recent advance in treating cardiac failure, and many doctors are still completely unaware of it.

From Richard N. Fogoros, M.D.,
A useful treatment for angina your cardiologist doesn't want to hear about.
Recent data documenting the effectiveness of Enhanced External Counterpulsation (EECP) for the treatment of angina has failed to bring this apparently effective procedure into the mainstream of cardiology practice. In this article, DrRich discusses what EECP is, how it works, and why cardiologists are avoiding this safe, noninvasive treatment like the plague.

What is EECP?
EECP is a mechanical procedure in which long inflatable cuffs are wrapped around both of the patient’s legs. While the patient lies on a bed, the leg cuffs are inflated and deflated with each heartbeat. This is accomplished by means of a computer, which triggers off the patient’s ECG so that the cuffs deflate just as each heartbeat begins, and inflate just as each heartbeat ends. When the cuffs inflate they do so in a sequential fashion, so that the blood in the legs is “milked” upwards, toward the heart.
EECP has two potentially beneficial actions on the heart. First, the milking action of the leg cuffs increases the blood flow to the coronary arteries. Second, by its deflating action just as the heart begins to beat, EECP creates something like a sudden vacuum in the arteries, which reduces the work of the heart muscle in pumping blood into the arteries. Both of these actions have long been known to reduce cardiac ischemia (the lack of oxygen to the heart muscle) in patients with coronary artery disease. Indeed, an invasive procedure that does the same thing, intra-aortic counterpulsation (IACP, in which a balloon-tipped catheter is positioned in the aorta, which then inflates and deflates in time with the heartbeat), has been in widespread use in intensive care units for decades, and its effectiveness in stabilizing extremely unstable patients is well known.
While a primitive form of external counterpulsation has also been around for a long time, it has not been very effective until recently. Thanks to new computer technology that allows the perfect timing of the inflation and deflation of the cuffs, and produces the milking action, modern EECP has been greatly enhanced.
EECP is administered as a series of outpatient treatments. Patients receive 5 one-hour sessions per week, for 7 weeks (for a total of 35 sessions). The 35 one-hour sessions are aimed at provoking long lasting beneficial changes in the circulatory system.

How effective is it?
EECP now appears to be quite effective in treating chronic stable angina. A randomized trial with EECP, showed that EECP significantly improved both the symptoms of angina (a subjective measurement) and exercise tolerance (a more objective measurement) in patients with coronary artery disease. EECP also significantly improved “quality of life” measures, as compared to placebo therapy.
More recent data show that this improvement in symptoms following a course of EECP seems to persist for up to five years.
Furthermore, there is also preliminary data suggesting that EECP may be useful for treating unstable angina, as adjunctive therapy after revascularization (i.e., with angioplasty, stent, and/or bypass surgery), and even as first-line (instead of last resort) therapy for more routine forms of angina.
Finally, clinical trials have suggested that EECP may be useful in improving symptoms in patients with heart failure.

From Richard N. Fogoros, M.D.
How EECP works, and who it may help
Who is likely to benefit from EECP?
Based on what is already known, EECP should be considered in anybody who still has angina despite maximal medical therapy and prior revascularization. No cardiologist could argue logically against this. And, frankly, if a patient insisted on trying EECP prior to agreeing to purely elective revascularization for chronic stable angina, the cardiologist might not like it, but would be hard pressed to give anything beyond a purely emotional reason as to why this should not be tried.

Why does EECP work?
The mechanism for the sustained benefits seen with EECP still amount to speculation. Everyone can agree that there are good reasons for EECP (just as for IACP) to benefit the heart while the therapy is actually taking place. But as to why the benefit of EECP persists even after the therapy is finished, no one can say for sure.
There are preliminary data suggesting that EECP can help induce the formation of collateral vessels in the coronary artery tree, by stimulating the release of nitric oxide and other growth factors in within the coronary arteries.
There is also evidence that EECP may act as a form of “passive” exercise, leading to the same sorts of persistent beneficial changes in the autonomic nervous system that are seen with real exercise.

Can EECP be harmful?
EECP can be somewhat uncomfortable, but is not painful. In fact, it is apparently very well tolerated by the large majority of patients.
But not everyone can have it. People probably should not have EECP if they have certain types of valvular heart disease (especially aortic insufficiency), or if they have had a recent cardiac catheterization, an irregular heart rhythm, severe hypertension, significant blockages in the leg arteries, or a history of deep venous thrombosis (blood clots in the legs). For anyone else, however, the procedure appears to be quite safe.

From Richard N. Fogoros, M.D.
Why cardiologists don't like it - and what you should do about it
Despite its increasingly apparent potential usefulness, EECP is hardly taking the cardiology world by storm. In fact, it seems that for most cardiologists EECP is not even on the list of potential treatments for coronary artery disease. Why is that?
There are several possible reasons. Let us dispense with the most obvious first, namely, that EECP doesn’t pay well. A series of 35 treatments costs $5000 to $6000 dollars. That’s not chicken feed, but keep in mind that we’re talking about 35 hours of therapy over 7 weeks, which involves not only the doctor’s time but also the time of office staff, nursing personnel, etc., etc. Still not a terrible return, but when you consider that a cardiologist can often bill that much by spending a morning in the lab.
Then there’s the fact that EECP remains somewhat intellectually unsatisfying. To your average cardiologist, there’s no reason at all that anyone should have thought it would work in the first place – that temporarily providing counterpulsation would have lasting effects. And the fact that it apparently does work is merely blind luck, and leaves investigators scrambling ridiculously to explain why it does. This is a less than satisfying way to advance science.
In addition, to most cardiologists, EECP is logistically difficult. To accommodate patients for EECP, they would not only have to purchase expensive equipment, but also would have to radically change the organization of their offices, their office staff, and their space.
Finally, and most importantly, EECP has nothing in common with what cardiologists do. Cardiologists study and treat the heart, for goodness sake. They stress it, image it, measure it, pace it, shock it, stent it, ablate it, revascularize it, and bathe it in drugs. What they do takes years of specialized training and expertise, millions of dollars of high-tech equipment, and tremendous manual dexterity, and it brings them significant prestige, even within the medical community.
This is the real reason the average cardiologist is completely ignoring EECP, as if it doesn’t even exist. They simply can’t believe anyone really expects them to do this.
In any case, you may need to raise your cardiologist’s consciousness. If you have coronary artery disease that has proved difficult to treat, then you need to bring EECP up yourself.
Once enough patients show themselves to be aware of this new therapy and to be expecting it, suddenly EECP will no longer be beneath cardiologists, and they’ll eagerly find a way to incorporate it into their practices.

How can you receive EECP?
If you are a candidate for EECP and wish to pursue it, start with your doctor. If your doctor discourages you from pursuing EECP, make sure he/she gives you a good reason for discouraging it. Good reasons would include: you don’t have the sort of coronary artery disease or angina that would benefit from EECP; your coronary artery disease is of the type that requires revascularization; or you have one of the contraindications for having EECP.