By Di Websdale-Morrissey
Those with strong steady hearts often take them for granted. But those with less reliable organs can now take heart.
In our early life, we mostly speak of our hearts in the context of love. We give our hearts to our lovers, we whisper heart-felt words of love; feel heartbreak at love's loss. For millennia, poets have spun delicate linguistic castles from the very fibres of heart muscle.
Even we of the third millennium, who know the heart's anatomy and physiology intimately, still use heart-as-soul metaphors.
In our youth, this heart, the organ of our soul, is the heart that occupies our foreground.
In later life, its physiological functions intrude. Although heart disease can, and does affect the young, it is more usual to encounter it in our middle years and beyond. By then our parents might be taking heart medication and our doctors will begin to speak unsettlingly of high cholesterol or blood pressure readings. Heart-as-organ suddenly takes centre stage.
The heart is basically a pump — an elegant, complex, four-chambered blood pump. The chambers on the right side receive oxygen-depleted blood from the body, then send it to the lungs for re-oxygenation. The chambers on the left receive the re-oxygenated blood and dispatch it on its endless cycle around the body. The average adult heart does this 60 to 80 times a minute, thus creating the wave of blood that we call our pulse.
This organ is a valiant worker. Those of us whose hearts are strong and steady take them for granted. Those for whom the daily routine of pills to regulate beats, thin blood, reduce fluid and those for whom the slightest exertion means breathlessness and pain, know their pump as both slave and master.
Myocardial Infarction (heart attack), Cardiomyopathy, Heart Block, Heart Failure. All can mean little at the moment of diagnosis. Martin sat in a cardiologist's office recently listening to the doctor's clear and patient summary of the 80-year-old's serious heart condition. It was hard. The words describing heart disease drop like boulders into one's life, the positive words of encouragement, the suggested treatments, can be lost in the mental scramble for denial. "All I could think of was, why?" says Martin. "I had low cholesterol and low blood pressure. How could this happen?" Later, the questions arrive with a vengeance. Exercise? Diet? Sex? Only an individual's doctor can give the definitive answers to these questions.
Most risk factors for heart disease — family history, smoking, high cholesterol, high blood pressure — are well documented and more recently, prolonged depression and social isolation have been added to the mix, but sometimes the reasons are elusive, and we are left to simply deal with the reality.
Yet medicine can now offer them a great deal. Diagnostic tools identify the site and nature of problems with stunning accuracy, while medication can ameliorate cause and reduce symptoms. Surgical interventions, once the stuff of science fiction, are now routine, and refinements in all forms of heart management mean a greatly enhanced quality of life.
All of the above means little at the moment of diagnosis:
What can go wrong?
Heart problems can be divided into four basic groups:
- The pump's fabric — the heart muscle — can become thin and weak, or thicken. Both mean inefficient pumping.
- The valves inside the heart that prevent backflow can narrow, or leak.
- The coronary arteries that feed the heart itself can become blocked or narrowed by atheroma, sometimes called plaque (deposits of fat, cholesterol and cells).
- The electrical prompting system can short-circuit.
Cardiologists might order several tests to determine diagnosis and treatment. Some are relatively simple. Blood tests reveal much including evidence of any very recent heart attack. Electrocardiograms (ECGs) graph your heart's electrical activity.
They involve attaching leads to your chest, are painless and take only a few minutes.
Next might be a stress test at a hospital where you will be asked to perform a simple sustained exercise such as walking on a treadmill. The doctor watches for the changes in your ECG that might indicate cardiac stress.
Magnetic Resonance Imaging (MRI) and Computed Axial Tomography (CAT) detect any abnormalities by displaying your heart's function and topography.
More invasive diagnostic techniques include angiograms and transoesophageal echocardiograms (TOEs). Both are done in a hospital setting, usually as an out or day patient, and require some sedation. During an angiogram, the cardiologist makes a small incision in the groin and introduces a fine catheter with a micro-camera attachment. The doctor threads this through to the heart to view the condition of coronary arteries.
During a TOE, the patient swallows a fine tube with a micro-camera that allows views from behind the heart. It is used to assess valve performance and detect clot formation.
Cardiologists have powerful arsenals of drugs at their disposal and they usually use a combination of these for optimal benefit. Patients might find the strict medication routine challenging, especially as they struggle to come to terms with their new medication-dependent lifestyle, yet each drug plays a vital role in the complex treatment designed to lighten the burden on an ailing heart.
Cardiac drugs may be called by various names but they fall into several categories:
Beta Blockers block the effects of adrenaline, which can damage heart tissue and blood vessels over sustained periods.
Diuretics rid the body of excess fluid and salt, thereby reducing blood pressure on the vessel walls.
Calcium Antagonists act to expand the arteries, thus reducing blood pressure.
ACE-Inhibitors block the action of a certain enzyme, thereby allowing blood vessels to relax. They also help to reduce salt and water.
Alpha Blockers lower blood pressure by working on the nerve receptors.
Nitrates relax the muscles in the artery walls allowing for easier circulation. Most often used to treat angina, they are taken orally as tablets or sprays, or given over sustained periods via a transdermal patch.
The nature of the problem will guide the choice of surgical corrective procedure.
A simple blockage might respond to angioplasty. Performed during an angiogram (see above), angioplasty is aimed at opening narrowed blood vessels. The procedure sees a tiny balloon fed through the catheter and inflated at a point where the blood vessel is dangerously narrowed. Once the problem is corrected, the balloon is deflated and removed. If the vessel wall is weak, the cardiologist might thread a tiny hollow cylinder called a stent through the catheter and position it as a permanent wall reinforcement. Either way, uninterrupted blood flow is the desired outcome.
Larger or more complicated blockages of the coronary arteries might require coronary artery bypass graft (CABG) in which blocked vessels are removed and replaced by healthy veins from elsewhere in the body, often the calf. This major surgery involves cutting the sternum (breastbone), temporarily stopping the heart and circulating blood through a bypass machine.
An abnormally rapid heartbeat might need cardiac ablation. Done during an angiogram under heavy sedation, and probably in day surgery, an electric shock is given directly into the heart muscle.
Let me introduce you to your heart: Make a fist with your dominant hand. Your fist is approximately the size of your heart.
Place your fist in the centre of your chest, two finger-widths above the lowest point of your breastbone. Now rotate the fist
slightly so that the surface formed by the thumb is pointing towards your right shoulder and the lower, narrower surface is resting just to the left of the midline. Below your hand, almost matching it in size and position, beats your heart.
When beats are too slow a pacemaker might be needed. This is small computerised box that sits under the skin of the chest and adjusts a heart's rhythm back to a normal range. It is attached to wires fed directly into the left ventricle, the chamber whose contractions expel the refreshed blood from the heart. Pacemaker insertion is performed under local anaesthesia, and sometimes requires an overnight stay.
Inefficient heart valves might need a valve replacement. As with CABGs (see above) the sternum is cut and the heart stopped.
A mechanical valve may replace the faulty valve or one derived from natural tissue (human, pig or cow). A hospital stay of several days might be expected.
When a heart is failing beyond hope of reversal, a transplant might be the answer.
Some hearts are no longer viable pumps and their owners are barely able to perform the simplest tasks. Transplant waiting lists are long, but for those lucky enough to receive one, the new pump, supported by anti-rejection drugs mean a life beyond pain and disease.
"Such modern advances in treatment are offering great benefits to people with heart disease," says Dr Andrew Boyden, Heart Foundation Manager of Medical Affairs. "Furthermore, it is important to recognise that there are many ways a person with a history of heart disease can further improve their health and quality of life by attending to their lifestyle." The Heart Foundation recommends the following: being smoke-free, enjoying healthy eating, being physically active and maintaining a healthy weight.
Those faced with such diagnoses are fortunate enough to live in an era when medicine offers so much. For those of us with hearts still strong, the message must be —care for these precious pumps — maintenance is better than repair.
The heart is both pump and icon, sustaining our lives and providing us with emotional identity. Yet when the moment comes for mine to stop I hope that it is lifted from its cradle in my chest by the gloved hand of a transplant surgeon and stitched into a life beyond mine. Now that notion is truly heart warming.