Caring Hearts 50th Edition

Know your resting
pulse rate. Also know
a safe exercising
pulse rate. Try taking
your pulse during
exercise. This way,
you can see if your
heart is beating at a
safe exercise rate. If it
is too high, slow
down

How much exercise for in those sports. The reduced risk for day. Share this with your provider. If
cardiac patients cardiovascular death was 36 percent these symptoms are very bad or do not
for aerobics, 41 percent for go away when you stop the activity,
Aerobic physical activity in patients swimming and 56 percent for racket let your provider know right away.
with known CVD is usually sports. Your provider can give you advice
considered as part of the cardiac about exercise at your regular medical
rehabilitation program. Studies Pace Yourself and Know Your appointments.
showed around 30% reduction in Limits
total cardiac events with aerobic Know your resting pulse rate. Also
exercise training programs in patients If exercise puts too much strain on know a safe exercising pulse rate. Try
with heart disease.Low-risk patients your heart, you may have pain and taking your pulse during exercise.
with a previous heart attack, bypass other symptoms, such as: This way, you can see if your heart is
surgery or angioplasty should be beating at a safe exercise rate. If it is
advised to undergo an aerobic · Dizziness or light too high, slow down. Then, take it
exercise training program of headedness again after exercise to see if it comes
moderate to vigorous intensity of 3–5 back to normal within about 10
sessions/week, 30 min/session. · Chest pain minutes.

Medically supervised programs for · Irregular heartbeat or pulse You can take your pulse in the wrist
high risk patients with treating area below the base of your thumb.
doctors advice · Shortness of breath Use your index and third fingers of the
opposite hand to locate your pulse and
Sports and heart · Nausea count the number of beats per minute.

People who regularly swam, played It is important that you pay attention Drink plenty of water. Take frequent
racket sports (tennis, squash or to these warning signs. Stop what you breaks during exercise or other
badminton) or did aerobics are doing. Rest. strenuous activities.
(including dancing) were less likely
to die for any reason, but especially Some useful tips
from cardiovascular disease, than
were people who did not participate Always carry some nitroglycerin pills
with you.

If you have symptoms, write down
what you were doing and the time of

50TH EDITION|CARING HEARTS|51



Dr. Jacob Abraham ♥ Be the difference for someone you love

MD, PDCC If you are called on to give CPR in an emergency, you will most
HOD, Cardiac Anaesthesia, likely be trying to save the life of someone you love: a child, a
Lisie Hospital spouse, a parent or a friend who is in cardiac arrest.

♥ What is CARDIAC ARREST?

A sudden unexpected condition where heart stops beating.

It hence stops pumping blood to brain, lungs and other vital organs
of body.

♥ How do I know if it is cardiac arrest?

The person is UNCONCIOUS and not responding to you.

Not breathing or breathing weirdly.

There is no pulse – but you don’t always need to make sure of this

IF THE ABOVE HAPPENS OUT OF A HOSPITAL
9 OUT OF 10 TIMES THE PERSON WILL DIE!!
A PROMPT CPR CAN TRIPLE THEIR SURVIVAL CHANCE!

50TH EDITION|CARING HEARTS|53



♥ How does CPR help? a breath‘ into a person whom we may not
know and is worried we are not doing it right.
You do the job of the heart – manually attempt
to squeeze the heart and pump blood and Hands only CPR avoids these as it is extremely
whatever oxygen is left in the body to rest of simple to do and only uses our hands and is
the organs. just as effective for first few minutes!

♥ Why hands only? Nobody is going to blame you for attempting
this life saving procedure.
Studies show most of the time we don’t
attempt CPR is because we don’t want to ‘kiss

STEP 1

First call for help or ask someone
to call an ambulance.

STEP2

♥ Lay then flat on back on firm surface
♥ Kneel by their side
♥ Lock fingers of both hands one over the other and

place it in the centre of their chest

♥ Without bending your elbows push down hard and

fast on their chest.

♥ How hard – chest should go down 5-6 cms – enough

to squeeze the heart remember.

♥ How fast – As fast as you can about 120 times/min

How long – Until you are exhausted or patient regains
consciousness or help arrives.

50TH EDITION|CARING HEARTS|55



Dr. Joby K Thomas As we all know heart attack is a Who all can develop heart attack?
big killer continues to be so
MD, DM, despite advances in the treatment Potentially anyone!
Consultant Cardiologist options and technology becoming more
Carithas Hospital, accessible and affordable. Public But more commonly men than women,
Thellakom, Kottyam awareness about lifestyle modifications especially after 45 years.
and seeking treatment on time can help
Prompt recognition reduce the mortality and morbidity Smokers ,sedentary people with less
of symptoms, and associated with heart attacks. And this exercise , diabetic patients, people with
timely management mortality and morbidity of heart attacks high BP or cholesterol (despite all the
using the optimal mainly affects young earning population social media controversy regarding
technology can help and affects young families and society and cholesterol , it’s still a major risk factor),or
us reduce the nation as such. So it is important that we with family history of heart attacks are
burden of this new cardiologists try to educate public more more prone to develop heart attacks .
age scourge which regarding heart attacks , its prevention and
is taking a big toll disease as such so that public can seek Is heart attack different from “blocks’?
on humanity medical help timely and avert a potential
catastrophe. That is the background of this Heart attacks develop in patients with
article. Preventive measures had been blocks in coronary arteries ( blood vessels
discussed in this forum before and hence I supplying heart muscles ). But very rarely
am not going to elaborate on that here, heart attacks can develop even without
instead I shall try to detail about the blocks , but that is very rare and we need
disease symptoms and available treatment not discuss that in detail as it’s very
options . uncommon . And all blocks need not
develop into heart attacks .

How does a block present ?

As we have seen all blocks may not cause
heart attacks. A lot of them could be
asymptomatic as they may be too small to
produce a reduction in blood flow and
hence symptoms . Sometimes patients may
get used to a block developing over years
and may be asymptomatic for long time till
heart is significantly compromised.

Symptomatic blocks may present like
Effort related angina
Unstable angina ( minor heart attacks )
NSTEMI ( intermediate heart attacks )
STEMI ( major heart attacks)

50TH EDITION|CARING HEARTS|57



Heart failure Anybody with symptoms occurring at excellent long term patency , but still
Sudden cardiac death rest (heart attack) should seek there can be around 2% stent
medical help urgently , and if failures. And patients with stents
What are the symptoms of blocks ? available should go to hospital in an need to be on medications for life
Effort related angina mostly presents ambulance . term to keep it open.
like central chest pain or heaviness
occurring after a brisk walk or heavy Who all need angioplasty or surgery ? Do patients need medicines after
exertion. Sometime it could be like a angioplasty or surgery ?
squeezing like sensation or burning in Patients with exertional
chest. Same symptoms may radiate to symptoms, (angina or shortness of Anybody developing a block has an
jaws , throat upper back or arms or breath due to heart failure ) or inherent tendency , genetic and
sometimes appear alone in above asymptomatic patients with positive acquired, to develop blocks and they
mentioned areas.There could be TMT can undergo an elective run a lifetime risk of developing
another group , totally asymptomatic , coronary angiogram. If blocks are in blocks in same or other blood
or having shortness of breath on the proximal part of major blood vessels and hence they will need
exertion which is taken as ‘normal’ vessels ( towards the origin of blood lifetime medications to prevent
for age. They can be diagnosed with a vessels) they will have to undergo further blocks and to maintain
stress test . TMT is the commonly angioplasty or bypass surgery patency of stents and grafts .
used stress test in our part of the depending on the type and number of
world. But TMT can miss 25% of blocks. If blocks are in small What is new ?
such blocks and report as negative branches or distal part ( towards the
(normal) despite blocks . Angiogram end) of a major blood vessel, blocks can FFR- It is test to assess the
is the test to diagnose such blocks , be treated medically in such patients. functional significance of a block. A
but we don’t do it on asymptomatic positive FFR means a block is
patients , that is the reason to Patients with major heart attack needs significant and needs angioplasty or
emphasize on the importance of to undergo angiography and a bypass grafting. It is commonly
preventive lifestyle modifications . subsequent angioplasty on an used in effort angina patients and
emergency basis , ideally within 90 asymptomatic patients with positive
Same symptoms occurring at rest is minutes of reaching hospital. Major stress test .Heart attack patients
termed a heart attack. A discomfort heart attack happens when a vessel is don’t usually need this test.
lasting less than 30 minutes is defined 100% blocked and every minute
as a minor or intermediate heart attack delay is killing heart muscle supplied IVUS/OCT – they are like a camera
( depending on changes in ECG or by that blood vessel and causing looking inside the blood vessels and
blood tests ). A major heart attack will permanent irreversible damage. A help us study the nature and
have symptoms lasting more than 30 delay can cause heart pumping failure significance of a block and to know
minutes. Occasionally patients may and can cause heart failure later on . how well is stent ‘put’ inside a
feel only extreme fatigue, profound blocked vessel. It is important
unexplained sweating or shortness of Patients with minor or intermediate because a ‘well put’ stent has a
breath alone without pain. All these heart attacks can wait for 24 to 48 better long term patency .
symptoms warrant an emergency hours before undergoing an
medical help. angiogram and need subsequent Concluding a concerted preventive
angioplasty or bypass surgery lifestyle modification, prompt
When should one seek medical help ? depending on the nature , type and recognition of symptoms, and timely
Patients with effort related symptoms number of blocks. management using the optimal
can electively take an appointment technology can help us reduce the
and consult his doctor . Are the stents for life ? burden of this new age scourge
which is taking a big toll on
New generation stents are have humanity

50TH EDITION|CARING HEARTS|59



Heart Attack or Myocardial infarction,
the scientific synonym of the common
man’s lay term of attack or block is
nothing but the formation of blood
clot within the arteries (coronary) that
supply the muscle of the heart.The
heart is a muscular pump that pumps
almost 5 litres a minute without a halt
24 hours a day and even more as one
exercises. But when a person develops
a block (plaque) inside the coronary
arteries and due to associated lifestyle
diseases like hypertension, diabetes,
sedentary habits, addictions like
smoking, a person builds up a
cholesterol laden block within the
arteries. The demand of blood supply
through the narrowed arteries cannot
be met for the oxygenation of heart
muscles. This demand and supply
mismatch produces a cardiac
ischaemic pain and if stressed further
can produce a rupture of the plaque

Dr Girish PV It is a common thing in practice to (block) inside the coronary artery to
MD DM AFESC FSCAI see patients, relatives and even produce a clot within and acutely
very educated people making an obstructing the system. Result is total
Director Heart Failure Clinic and Transplant error in distinguishing between Heart cut off of blood supply to that portion
attack and Cardiac arrest and use of the heart muscle supplied by the
Consultant Interventional Cardiologist, these words interchangeably. Though artery- a HEART ATTACK.. With
one is related to the other as cause of severe pain in chest, arm, jaw, neck
Metromed International Cardiac Centre. the other essentially these are two and even abdomen along with
different clinical syndromes. sweating, sometimes just a burning

50TH EDITION|CARING HEARTS|61



Many cases of chronic heart Our Heartfelt Thanks
failure with previous heart attacks
have a high chance of cardiac Mr. C Gopalakrihshnan the former P R O of the
arrest and sudden cardiac death
when stressed due to rhythm Foundation joined us in November 2006 and
disorders developing all of a was involved in all the projects of the Foundation
sudden causing heart to vibrate until he formally left the Foundation in 2018
and stop abruptly electrical silence after 12 long years of sincere and diligent service
Cardiac arrest to the Foundation. We in the Foundation fondly
remember his dedication and commitment in all
sensation patient feels fatigued and can even die suddenly. projects he handled. We wish him a happy and
When Death happens due to a heart attack only we call it a healthy retired life.
CARDIAC ARREST otherwise, heart attack is a condition
which gives you time to get an ecg and other assessments Sidestep salt
to diagnose, start medicines and allows doctors to decide
the reopening strategy ( revascularization) of the blocked If the entire U.S. population reduced its average
vessel usually with an emergency Angioplasty (primary)
or surgery as decided by the results of investigation like salt intake to just half a teaspoon a day, it would
echo and angiogram. significantly cut the number of people who
develop coronary heart disease every year,
In contradiction, CARDIAC ARREST is a sudden abrupt report researchers in the New England Journal
failure of the heart function, it stops beating and in turn of Medicine. The authors suggest that salt is
leads to cessation of breathing and results in loss of one of the leading drivers of rising healthcare
consciousness unless attended urgently with resuscitation costs in the United States. Processed and
measures CPR massage of chest wall with compressions restaurant-prepared foods tend to be especially
and assisting breath with a bag and mask or a defibrillator high in salt. So think twice before filling up on
paddle often seen in public spaces like malls and your favorite fast-food fix. Consider using a salt
stationsthe person does not revive. Heart attack is only one substitute, such as Mr. Dash, if you have high
major cause of cardiac arrest .It may be due to other blood pressure or heart failure.
conditions like electrolyte disturbance rhythm disturbance
of the heart slow or very fast needing an electric shock to 50TH EDITION|CARING HEARTS|63
revive in most cases. Common situation precipitating
cardiac arrest are electrocutionblunt injury to chest high
grade fever with heart involvement especially viral
fever,drowning chronic kidney disease, fluid or blood
around the heart .Intense exercise can cause cardiac arrest
in hypertrophic thick hearts Cardiomyopathy cases.Many
cases of chronic heart failure with previous heart attacks
have a high chance of cardiac arrest and sudden cardiac
death when stressed due to rhythm disorders developing
all of a sudden causing heart to vibrate and stop abruptly
electrical silence Cardiac arrest.

Dr. Jay B Pattom have 2 heart attacks in the past 3 initially validated by various
years with triple vessel disease. On population studies conducted in
MD-Medicine (PGI-Chd) further enquiry it was evident that he western populations. However various
DM-Cardiology (PGI-Chd) had “a strong family history of multiethnic and Asian population
Consultant Interventional Cardiologist premature Coronary artery disease” studies have more or less validated
RenaiMedicity, Kochi similar findings in our populations as
The concept of “Family history of well. So the six pertinent questions
As a 35 yr old man with an premature Coronary artery disease” that need to be addressed are as
acute inferior wall was first added as a conventional risk follows…
myocardial infarction was factor for developing Cardiovascular
being shifted out of the cardiac disease along with risk factors like Q1.what does one mean by “family
catheterization lab after an age,smoking,diabetes, history of premature Coronary
emergency primary angioplasty and Dyslipidemia,low HDL in the ATP artery disease”?
three stents to alleviate three critical set of guidelines, which was Q 2.How does one evaluate or
blocks in two of his coronary arteries, basically a tool to guide control of ascertain this risk?
one was left pondering about what deranged cholesterol and LDL levels Q 3. What is the additional risk
could possibly be the reasons for with diet,lifestyle changes, statins incurred by having this?
such critical triple vessel disease in a and other drugs -thereby reducing the Q 4.Does this have a prognostic
very young person. His family was 10 year risk of developing effect?
equally concerned about how a young Cardiovascular disease. These were Q 5.What are the reasons for it?
man with no previous traditional risk
factors like Diabetes, Hypertension,
Dyslipidemia, smoking, obesity could

64|CARING HEARTS|50TH EDITION

Q 6.And finally what can be done to reduce ones risk? “You can’t change your
To address the first query as to what exactly entails a genes,but you can change your
lifestyle and in turn reduce
family history of premature CAD- Many times patients your risk factors. Family history
quote instances of CAD in cousins, uncles, aunts doesn’t have to be your
(second/third degree relatives) as evidence of strong destiny”
family history. But what is clinically validated by large
population cohort studies isCAD in First degree relatives premature CAD and found prevalence as high as 30% for
(Father,mother,brother,or sister) only. And by premature western populations and 15% for Asians. Coronary artery
meaning in a male less than 55 years and female less than calcium scoring using CT Coronary angiogram has been
65 years of age. On the contrary many are unaware of used by few studies to show increased CAC(Coronary
what constitutes CAD. So the question that one needs artery calcium) scores in asymptomatic individuals or
to ask is “if any first degree relative,male under the advanced coronary atherosclerosisfor one’s age and
age of 55 years or female under age of 65 years has gender. The effect of a reported family history
history of angina, heart attack, angioplasty or ofpremature CHD was similar across all ethnic groups.
Coronary artery byepass surgery.” If yes then there’s Therelationship existed with both a sibling history and a
a definite risk. parentalhistory of premature CHD.

So how and why does a family history of premature The only heartening thing is that the long term
CAD portend a risk? Our body is made up millions of prognosis and outcomes seem better for such people who
cells, withabout 25,000 different genes.Genes determine develop a coronary event as they are younger ,have less
how we look and how our bodies work, and we inherit of left main disease or triple vessel disease, are more
them from our parents. Genes can pass on high risk likely to be compliant to medical therapy ,adopt healthy
conditions such as high blood pressure and high lifestyles more diligently, and hence have better long term
cholesterol levels to name a few. These conditions can survival as compared to patients with traditional risk
also increase your risk of developing heart diseases. factors.
There’s no single gene that increases your risk - it’s
likely that several genes play a part. So finally what’s the solution asone really can’t change
Are inherited conditions same as family history? ones family history can they? Take care to determine and
Inherited conditions are caused by a fault (or mutation) in control the modifiable risk factors which additionally
one or more of your genes. The most common inherited increase your risk of developing cardiovascular
conditions are cardiomyopathies (heart muscle diseases), diseases.These includenot smoking or quitting, being
channelopathies(inherited life threatening arrhythmias), physically active, eating a healthy balanced diet,keeping
and familial hypercholesterolemia ( high cholesterol to a healthy weight and body shape. Consult a doctor to
levels).Family history is more complex as it can be the check your blood sugars, lipid profile, and Blood
combination of shared genes and shared pressures regularly and control with adequate lifestyle
environments passed down from one generation to the changes and medications as prescribed.
next, that increase the risk of developing a disease
rather than a single faulty gene. A noninvasive test like a Treadmill test (TMT) or CT
Coronary angiogram may be required for early disease
The relative risk for CAD in first-degree relativesof detection.
affected persons ranges from 2 to 12 times that of
thegeneral population. Risk increases with the number of To conclude “You can’t change your genes,but you
primaryrelatives affected and at younger ages of onset. can change your lifestyle and in turn reduce your risk
Various population based studies have looked at factors. Family history doesn’t have to be your
angiographic Coronary artery disease patients and then destiny”
retrospectively enquired about family history of

50TH EDITION|CARING HEARTS|65

Dr. Iwin Varghese 1. Weight fat or muscle, and it doesn’t tell you where
the fat is. For body fat, you need to use
MRCGP, GP other body composition methods such as
Principal (Family Physician) skinfolds or smart scales.
Ashford Medical Partnership
Ashford, Kent. 2. Body Mass Index (BMI)

Being overweight or This is a measure of your overall body
obese increases your risk mass – including bones, blood, organs
of many health problems. and fat. For it to be accurate, you need
But it’s not just the reliable scales.
amount of fat: where it is
matters too. If you’re tracking your weight over time, BMI is used to work out if you are a
weigh yourself at the same time of day, healthy weight. It is calculated by taking a
Fat around the abdomen under the same conditions and on the person’s weight in kg and dividing it by
(belly) is linked to even same of scales. In the morning, after their height squared. The higher the
higher risks of diabetes, emptying your bladder, is a good time. figure, the more overweight you are and
heart and circulatory the greater your health risks.
disease and cancer. The plus side:
Quick and easy with minimal cost. The plus side:
So, how exactly do you
measure body fat? There The down side: Quick and easy and with minimal cost.
are numerous methods, It only measures total body weight – it And it matters: for most adults, there is a
some better than others. doesn’t take into account changes in body

66|CARING HEARTS|50TH EDITION

clear correlation between higher 4. Waist: hip ratio are at increased risk of type 2
BMI and negative health diabetes and heart and circulatory
consequences. As with any weight disease.
measure, you need reliable
scales, plus you’ll need a tape The plus side:
measure for height. You only need a piece of string (a
tape measure will also work). It
The down side: works for any race, age or gender.

It can’t differentiate between fat and This is the ratio of waist 6. Bio impedance –
lean muscle weight. It isn’t very circumference to the hip “smart scales”
accurate for people who are elderly, circumference. The higher the ratio,
pregnant, or very muscular. the more fat is stored around the waist Smart scales don’t just give your
or abdomen – in other words, an “apple weight, but also a host of body
3. Waist circumference shape”. This shape poses a greater health composition stats including your
risk than fat stored elsewhere in the body fat percentage. They can look
This is a measurement of your waist body (a “pear shape”). like normal scales with foot plates,
to check if you are carrying too much or have additional hand plates.
fat around your abdomen (belly). The plus side:
You can have a healthy BMI and still All you need is a tape measure and a They work by sending tiny electrical
have excess abdominal fat, meaning simple calculation: waist measurement impulses through the body and
you are still at risk of heart disease, divided by hip measurement. You can measuring how quickly they return.
type 2 diabetes and stroke. use any units as it is only the ratio that This works because the current flows
is important. High risk is defined as a more easily through the parts of the
The plus side: waist-hip ratio above 0.90 for males body that are mostly made up of
All you need is a tape measure. It’s a and above 0.85 for females. water, such as muscle and blood,
good way to measure fat round your than through fat or bone.
abdomen. The down side:
You need to know where to place the The plus side:
When measured properly, its measuring tape – measure the Simple and quick. The measurement
accuracy is typically within 5 per circumference of your hips at the can be taken as easily as standing on
cent of the body fat value measured widest point of your buttocks. For scales. The percentage of body fat is
using underwater weighing, which is your waist circumference you need to given instantly. Some will also
one of the most accurate ways of measure around the waist, midway connect to a fitness app so you can
measuring body composition. between the bottom of your ribs and track your progress.
top of your hips.
The down side: The down side:
5. Weight to height ratio - The reliability of the results can vary
These are measurements of excess the “string challenge” – if you’re dehydrated then the
body fat, not a precise measurement amount of body fat will be
of body composition. For an accurate This is another way of looking at overestimated. You also need to take
reading you need to know where to how much abdominal (belly) fat you the measurements in similar
place the measuring tape. have. Measure your height with a conditions to get reliable and
piece of string, then fold the length accurate results. They are not
Wrap a tape measure around the of string that matches your height in suitable for people with pacemakers.
waist midpoint between the bottom half and check to see if it fits around Some are relatively inexpensive but
of your ribs and top of your hips. For your waist. If it doesn’t, it means you some models can be pricey.
most people this is just above the
belly button.

50TH EDITION|CARING HEARTS|67

Dr Jaideep C Menon Background: Heart failure presenting with preserved ejection
(HF) has been singled out as fraction for which there is no specific
Consultant Cardiologist an epidemic and is a treatment. Despite progress in
Amrita Institute of Medical staggering clinical and public health reducing HF-related mortality,
Sciences, Kochi problem, associated with significant hospitalizations for HF remain
mortality, morbidity, and healthcare frequent and rates of readmissions
expenditures, particularly among continue to rise. To prevent
those aged e”65 years. The case mix hospitalizations, a comprehensive
of HF is changing over time with a characterization of predictors of
growing proportion of cases readmission in patients with HF is
imperative and must integrate the
impact of multi-morbidity related to
coexisting conditions. New models of
patient-centred care that draw on
community-based resources to support
HF patients with complex coexisting
conditions are needed to decrease
hospitalizations.

Heart failure (HF) is a major
public health problem, with a
prevalence of more than 5.8 million in
the United States and more than 23
million worldwide. In 1997, HF was
singled out as an emerging epidemic.
An epidemic can reflect increased
incidence, increased survival leading

68|CARING HEARTS|50TH EDITION

About 30% of
Intensive care facility

admissions in any
cardiac care hospital
would be related to

treatment of heart
failure. Conservative

estimates put
the prevalence of

heart failure

to increased prevalence, or both To assess the burden of HF in is thought to be unknown, some of

factors combined. Delineating the populations and study its these cases may have a genetic

respective responsibility of each of epidemiology, standardized criteria basis).

these factors is essential to understand that can be used on a large scale for About 30% of Intensive care

the determinants of the HF epidemic. ascertainment from medical records facility admissions in any cardiac

Progress in the primary prevention of are needed. care hospital would be related to

HF would lead to decreasing Approximately 1–2% of the adult treatment of heart failure.

incidence of the disease while population in developed countries has Conservative estimates put the

improvement in medical care would HF, with the prevalence rising to prevalence of heart failure as

result in improved survival, in turn e”10% among persons 70 years of between 1.3 to 4.6 million, with an

increasing the prevalence of HF. Both age or older. There are many causes annual incidence of 491,600-1.8

incidence and survival in turn play a of HF, and these vary in different million. Extrapolating from western

major role in the genesis of the burden parts of the world. At least half of data there would be about 28lakh of

of hospitalization among patients patients with HF have a low EF (i.e. heart failure patients with an

living with HF. HF-REF). HF-REF is the best estimated 280,000 admissions with

Definition-In the American understood type of HF in terms of heart failure in a year in India.

Heart Association (AHA)/American pathophysiology and treatment, and Before 1990, the modern era of

College of Cardiology guidelines, HF is the focus of these guidelines. treatment, 60–70% of patients died

is defined as “a complex clinical Coronary artery disease (CAD) is the within 5 years of diagnosis, and

syndrome that can result from any cause of approximately two-thirds of admission to hospital with worsening

structural or functional cardiac cases of systolic HF, although symptoms was frequent and

disorder that impairs the ability of the hypertension and diabetes are recurrent, leading to an epidemic of

ventricle to fill or eject blood.” The probable contributing factors in many hospitalization for HF in many

guidelines underscore that “it is cases. There are many other causes of countries. Effective treatment has

largely a clinical diagnosis that is systolic HF, which include previous improved both of these outcomes,

based on a careful history and viral infection (recognized or with a relative reduction in

physical examination.” As HF is a unrecognized), alcohol abuse, hospitalization in recent years of 30–

syndrome and not a disease, its chemotherapy (e.g. doxorubicin or 50% and smaller but significant

diagnosis relies on a clinical trastuzumab), and ‘idiopathic’ dilated decreases in mortality.

examination and can be challenging. cardiomyopathy (although the cause

50TH EDITION|CARING HEARTS|69

EPIDEMIOLOGY incidence of HF for patients with pressure (SBP) of 144–154 mmHg is
Transitions
CHD ranges from 0.4% to 2.3% per 0.1% to 0.6%, as demonstrated in the
India’s economic development,
industrialization and urbanization year, suggesting that 120 000–690 Hypertension Optimal Treatment
have been accompanied by
transitions that contribute to the 000 Indians could develop (HOT) and United Kingdom
increase in the overall risk of HF.
First, the population of India is symptomatic HF due to CHD every Prospective Diabetes Study (UKPDS)
ageing due to recent successes
against communicable diseases such year, assuming none has HF at trials, respectively, then the number of
that the number of people >60 years
old will increase from 62 million in baseline and the at-risk population new HF cases due to hypertension may
1996 to 113 million in 2016.8 HF is
predominantly a disease of the does not diminish. After 5 years, the increase from 118 000–708 000 per
elderly, as the lifetime risk for HF
increases with age, so the burden of total number of HF patients accrued year in 2000 to 214 000–1.3 million
HF is likely to increase with the
ageing population. could range from 600 000 to 3.5 per year in 2025, conservatively
Burden of CVD and risk factors
million; with an estimated 50% assuming that the bulk of patients with
CVD is currently the leading
cause of death in India and its mortality at 5 years, the prevalence of hypertension in India have a SBP in
prevalence is projected to rise. In
2000, there were an estimated 30 HF due to CHD alone could be the 144–154 mmHg range. After 5
million people with coronary heart
disease (CHD) alone in India, or a estimated to range from 300 000 to years of HF incidence based upon year
nearly 3% prevalence. The annual
1.75 million. Nevertheless, as the 2000 estimates for hypertension, the

prevalence of patients with CHD total number of HF patients accrued

rises, so too will the prevalence of could range from 590 000 to 3.5

patients with HF. The prevalence of million; with an estimated 50%

other risk factors of HF is also rising mortality at 5 years, the prevalence of

in India. In addition to the ageing HF due to hypertension alone could be

population described above, the estimated to range from 295 000 to 1.8

prevalence of hypertension is million. However, this possibly

projected to increase from 118 represents an underestimate, due to

million (2000) to 214 million (2025). conservative estimates of the

If the annual incidence of HF in prevalence of hypertension, as well as

patients with a systolic blood the linear relationship between risk of

Let the music move you

Whether you prefer a rumba beat or two-step tune,

dancing makes for a great heart-healthy workout. Like
other forms of aerobic exercise, it raises your heart rate
and gets your lungs pumping. It also burns up to 200
calories or more per hour, reports the Mayo Clinic.

Focus on the middle Stretch it out

That is, focus on your middle. Research in the Journal Yoga can help you improve your balance, flexibility,

of the American College of Cardiologyhas linked excess and strength. It can help you relax and relieve stress. As
belly fat to higher blood pressure and unhealthy blood if that’s not enough, yoga also has potential to improve
lipid levels. If you’re carrying extra fat around your heart health. According to research published in
middle, it’s time to slim down. Eating fewer calories the Journal of Evidence-Based Complementary &
and exercising more can make a big difference. Alternative MedicineTrusted Source, yoga
demonstrates potential to reduce your risk of
cardiovascular disease.

70|CARING HEARTS|50TH EDITION

HF and blood pressure that occurs for a 5% prevalence of obesity (BMI years for a HbA1c <6% to 11.9 per
values even <140 mmHg. The annual >30 kg/m2) in India would lead to an 1000 person years for a HbA1c
incidence of HF due to obesity (body estimated 180 000–300 000 cases of >11.9%. Taking the estimate of HF
mass index [BMI] >30 kg/m2) has HF annually. After 5 years of the incidence based upon optimal
been estimated to increase by 0.3% in incidence of HF based upon 5% glucose control, the annual incidence
women and 0.5% in men, in the obesity prevalence estimates, the of HF due to diabetes may increase
Framingham Heart Study, after total number of HF patients accrued from 73 600 (2000) to 161 000
adjustment for age, hypertension, left could range from 900 000–1.5 (2025). After 5 years of HF
ventricular hypertrophy, myocardial million; with an estimated 50% incidence based upon the diabetes
infarction, valve disease, diabetes and mortality at 5 years, the prevalence estimates for the year 2000, the total
cholesterol. Few studies in India have of HF due to obesity alone could be number of HF patients accrued could
used a BMI threshold of 30 kg/m2, estimated to range from 450 000 to be 368 000; with an estimated 50%
which makes it difficult to accurately 750 000. mortality at5 years, the prevalence of
estimate the prevalence of obesity. HF due to diabetes alone could be
Reddy et al. estimated the prevalence Similarly, the prevalence of estimated at 184 000. However, this
of obesity (BMI >30 kg/m2) in 10 diabetes in India is projected to is likely to be an underestimate, due
970 participants from urban Delhi and increase from 32 million (2000) to to conservative estimates of HbA1c.
rural Haryana in 2002 to be 6.8%. 70 million (2025). The incidence of
Using these estimates as a benchmark, HF has been demonstrated to
increase from 2.3 per 1000 person-

50TH EDITION|CARING HEARTS|71

Dr. Salman Salahuddin,

MD, DM, MRCP(UK),
Cardiologist at Malabar Institute
of Medical Science, Calicut,

30 year old Smita decides that initiated on appropriate treatment, and better diagnosis, treatment and
it’s time to get fit and get into
shape, and she decides to has been doing well thereafter. prevention of heart disease. The future
resume her morning jogging routine
after a long time. She takes her This is not science fiction and is in of cardiovascular care will be
smartwatch and proceeds for her fact the most basic application of transformed by advances in artificial
morning jog around the park. Ten digital healthcare delivery which is intelligence, digital health technology
minutes into her jog, an abnormal possible today. More than ever, and mobile devices as a means to
heartbeat is detected by her people today are connected by mobile prevent and treat heart disease.
smartwatch which is transmitted to technologies. Nearly 80% of the Artificial intelligence has clear
her physician instantaneously. Her population in India own a mobile potential to enhance every stage of
digital assistant in her smartphone phone, and nearly half of them have patient care — from research and
subsequently books an appointment smartphones. The ever-increasing discovery, to diagnosis, to selection of
for her with her physician, who then computing power and ability of therapy.
suggests an echocardiogram and a
wearable cardiac monitoring device smartphone technologies, wearable Let’s have a look at a few methods in
to monitor her cardiac rhythm.
Subsequent evaluation revealed that sensors and point-of-care diagnostic which modern day technology can
she had valvular heart disease
affecting the mitral valve with an devices could transform cardiology transform health care services in our
intermittent rhythm disorder called
atrial fibrillation. She is then and health care, potentially leading to country.

72|CARING HEARTS|50TH EDITION

mHEALTH and openness to further adopt Service) professionals can
Mobile health, or mHealth, is the telehealth and unlock its benefits. incorporate mobile technology to
input data that is sent straight to the
subset of digital health that focuses on Apart from the Fitbits of today, receiving hospital before the
the use of mobile and wearable there are several pocket devices patient’s arrival so that patients are
devices and software applications. (Skeeper, MOCA heart device) and attended immediately, minimizing
The growing recognition that “health” even patches (Vital Connect’s Patch) the traditional paperwork tasks.
takes place outside of the hospital and which can monitor more than the
clinic, plus recent advances in mobile usual pulse rate- these are capable of Imagine this scenario - a 55 year old
and wearable devices, have propelled measuring complex variables like fisherman, staying 50 kms from the
the field of mHealth. Cardiovascular heart rate variability , respiratory main city, gets a sudden chest pain
disease and prevention are major rate, blood pressure, stroke volume, while having dinner. He alerts the
opportunities for mHealth, as mobile etc. emergency medical services of a
devices can monitor key physiological nearby hospital- a mobile ICU
signals (e.g., physical activity, heart ENHANCED HEALTHCARE reaches his home in 5 to 10 minutes.
rate and rhythm) for promoting DELIVERY His general condition is assessed in
healthy behaviors, detecting disease, the mobile ambulance- his vital
and aid in ongoing care. An important way how technology statistics, oxygen saturation and
revolutionizes healthcare industry is ECG are obtained and these are
There is a plethora of mobile by improving healthcare delivery for
healthcare apps and platforms which patients. The majority of India’s
help the public monitor their day to
day health needs, and also to connect Kardiamobile by AliveCor offering personal ECG monitoring
with their healthcare professional.
Apps like PatientConnect and population resides in the rural sector. transmitted immediately to the
HeartFailureStorylines have been Distances to regional healthcare cardiologist in the hospital in the
shown to reduce readmissions among centers can cause a significant main city, who diagnoses a major
heart failure patients. Dhadkan is an problem to this set of population. heart attack. The doctor advises to
Indian app developed by IIT Roorkee Here, EMS (Emergency Medical start lifesaving medications and
in collaboration with AIIMS, New
Delhi, that collects data on blood
pressure, heart rate and weight and
transmits it to a designated caregiver.
Personal wearable technology like the
Kardiamobile by AliveCor, and the
Apple Watch instantly captures one’s
ECG onto his/her mobile which can
be transmitted or saved for personal
use. A recent research commissioned
by Philips in 15 countries, in which
India was included, found that about
two-thirds (67%) of Indians feel
comfortable or neutral about seeking
medical advice from their doctor
through a health application on their
phone, suggesting a high willingness

50TH EDITION|CARING HEARTS|73



administer an injection called help triage patients needy for higher Technology is all set
thrombolytic which can potentially care. A recent research estimates that to have an
save his life before he reaches the the implementation of telemedicine unprecedented
main hospital. The injection is technology could save India $4 impact on healthcare
given- there is good relief of pain - billion to $5 billion every year and in terms of building
the patient reaches the main hospital replace half of in-person outpatient the foundation
in an hour in a stable condition. He consultations in the country. blocks towards a
subsequently undergoes an connected home and
angioplasty for a residual block and 3D PRINTING healthcare
is back home after a few days in 3D (three-dimensional) printing is a ecosystem
good shape. Timely delivery of compelling new technology that has
healthcare especially in heart the potential to revolutionize cardiac models may be used for planning
attacks and strokes, makes a huge interventions. In the field of structural surgery also show in deciding the
difference in saving lives. heart disease, this rapidly evolving correct size of device for or structural
TELEMEDICINE technology can make a powerful heart interventions like TAVI
Digital communication between impact. In patients with complex (Transcatheter Aortic Valve
patients and physicians or clinical congenital heart disease (CHD), this Intervention). Utilization of this
staff can revolutionize healthcare allows precise understanding of the technology is growing, and, with time,
delivery in rural areas. Patients patient’s anatomy and the resultant the potential benefits of 3D printing
visiting a telemedicine clinic are physiology, enabling more informed will evolve drastically.
brought face-to-face with medical decisions and precise pre-surgical
experts across India through video planning. Apart from this, 3D printing also has
linking that allows patients and 3-D printed anatomical models its utility in making prosthetic
doctors to see one another.. Using created from a patient’s computed implants. Researchers in Chennai have
telemedicine, the finest doctors in tomography (CT), magnetic even made an artificial 3D
India can effectively offer their resonance imaging (MRI) or 3-D implantable ear which has the ability
services to patients living even ultrasound imaging datasets can be to grow normally in rabbits.
thousands of kilometres away. used for procedural planning and Orthopedic titanium 3D printed
hands-on clinical education. These implants have been revolutionized
A patient from a rural health center options for restoring mobility to those
consulting a specialist in the city in need, providing accurate
customized sizing.
Simple transmission of clinical data
like ECGs from a rural centre to a Technology is all set to have an
cardiologist in a tertiary centre can unprecedented impact on healthcare in
terms of building the foundation
blocks towards a connected home and
healthcare ecosystem. Going back to
Smita- she has decided to buy an
Apple watch for her 70 year old father
too, to keep an eye on him and his
heart- reinforcing her faith in
technology.

50TH EDITION|CARING HEARTS|75

Dr. Shaji Palangadan

Consultant – Cardio Thoracic &
Vascular Surgery
Kerala Institute of Medical Science,
(KIMS), Trivandrum

The dynamic speciality of
Cardiac surgery is
relatively new in the field
of Medicine. The first
open heart surgery was
done just 65 years back
after the invention of
heart lung machine in
1953 by Dr John Gibbon.
Rapid advancement in
the field is happening
with gain in knowledge,
introduction of
technology and
procurement of skills.
Dramatic advances is
expected in the near
future which will make
the cardiologist and
cardiac surgeon work as
a team developing patient
friendly, less risky and
less morbid procedures
focusing on early
recovery with good
cosmetic appeal.

76|CARING HEARTS|50TH EDITION

Ischemic Heart Disease obligate lifelong blood thinners (anticoagulants) which
Primary culprit vessel angioplasty is the treatment for need constant monitoring and carries risk of bleeding.

acute heart attack. Only very rarely is cardiac surgery Cardiac Transplantation and
indicated in the acute scenario, for example, when Mechanical Circulatory Support
complications of heart attack occur like sudden severe
valve leak or severe muscle damage causing holes With advances in organ preservation, transport, better
between the chambers of the heart or when the heart immunosuppression, reduction of infections and
muscle ruptures externally into the pericardial cavity. In monitoring for rejection without biopsy from heart, the
the future, effective use of devices may help to tackle results of heart transplant are getting better day by day.
these complications without resorting to cardiac surgery. Currently the upper limit of storage time of heart (time
elapsed when heart is arrested in donor till it starts getting
In nonacute cases, there are circumstances where the supply from the recipient –‘ cold storage time’ is around 5
interventional cardiologist and cardiac surgeon have hrs. Techniques and technologies to harvest the heart and
difference of opinion regarding best line of management. then cannulate and make it beat again by a sterile device
Evolution of more scientific evidence will help to focus will allow transport to distant places. The organ is then
on best practices, reducing practice variation and rearrested again in the recipient hospital and transplanted
unnecessary or harmful procedures.
Patients with advanced heart failure who are
Heart teams have evolved which will work in unison functionally limited with symptoms at rest or minimal
to combine interventional and less invasive surgeries and exertion, who require medications as continuous infusion
these hybrid procedures can be increasingly applied for to maintain blood pressure and patients awaiting heart
coronary revascularisation, with minimally invasive or transplant are candidates for Mechanical Circulatory
robotic surgery for left sided vessels and angioplasty for Support (MCS). The current mechanical circulatory
right sided blocks. A “hybrid room” where the support device systems are more efficient, less bulky and
catheterisation lab and operating room is combined, more advanced with low complications. These devices
helps to perform both procedures in one sitting.. can be used as bridge to transplant till suitable donor
hearts are available or even as destination therapy. Short
Valvular Heart Disease term and Long term devices are available. Temporary
Nonsurgical valve replacement procedures via catheters support is used to support patients through a high risk
in cathlab are on the rise. The candidates for such procedure till recovery or to provide time to assess
procedures initially werethe frail and elderly patients prognosis and guide definitive treatment. Long term
with multiple comorbidities. The future will see more of support devices support either one ventricle (Left
these devices being used in lower risk and younger Ventricular Assist Device – LVAD) or both ventricles
patients. The transcatheter valve replacement procedure (Biventricular Assist Devices – Bi VAD).The future focus
which was started for aortic valveis now being expanded of MCS will be to reduce infection, decrease clotting and
to cater to other valves also. Once a transcatheter valve bleeding complications, reduce the size of the devices
fails that problem also can be tackled without surgery by and early implantation before the onset of organ failure.
introducing another valve inside the first valve,called a
“valve-in-valve” procedure. Regenerative medicine in cardiovascular surgery holds
great promise. The goal is to regenerate the myocardium
Tissue valve usage will be on the rise making mechanical with stem cells which can change the current reliance on
valves obsolete. Tissue valve durability is being cardiac transplantation and MCS devices.
improved with better tissue preparation and preservation
techniques.The future may bring the ‘ideal’ custom made Minimal Access Surgery
bioengineered valves from patients own stem cells which Minimally Invasive Cardiac Surgery (MICS) or Keyhole
will reduce the need for mechanical valves that require

50TH EDITION|CARING HEARTS|77



Cardiac surgery is performed through a small incision, operating table, changing surgical instruments attached to
often using specialised surgical instruments. The surgery robotic arms. MICS holds great promise and in future
is performed between the ribs without need to cut the about 80% of cardiac surgeries will be done via MICS
breast bone (sternum). The potential benefits include less
blood loss, lower infection rates, reduced pain and Conclusion
trauma, faster recovery, shorter hospital time and quicker The newer developments in cardiac surgery points to
return to normal activities with smaller less noticeable bright future. The heart team has been a patient-focused
scars. In robot-assisted heart surgery, the surgeon works advance that allows the expertise of all the relevant
from a remote console with magnified high definition 3 D cardiovascular specialists to consult and recommend the
view on a video monitor and the surgeon’s movements best evidence-based treatment plan for each patient. These
are translated precisely to the robotic arms at the newer strategies, albeit a bit more expensive provide
operating table which moves similar to human wrist. A value, extend life and relieve human suffering.
second surgeon and the surgical team assist at the

Laugh out loud

Don’t just LOL in emails or Facebook posts. Laugh out

loud in your daily life. Whether you like watching funny
movies or cracking jokes with your friends, laughter may
be good for your heart. According to the AHA, research
suggests laughing can lower stress hormones, decrease
inflammation in your arteries, and raise your levels of
high-density lipoprotein (HLD), also known as "good
cholesterol."

Go fish Move it, move it, move it

Eating a diet rich in omega-3 fatty acids can also No matter how much you weigh, sitting for long periods

help ward off heart disease. Many fish, such as of time could shorten your lifespan, warn researchers in
salmon, tuna, sardines, and herring, are rich the Archives of Internal Medicine and the American
sources of omega-3 fatty acids. Try to eat fish at Heart AssociationTrusted Source. Couch potato and desk
least twice a week, suggests the AHA. If you’re jockey lifestyles seem to have an unhealthy effect on
concerned about mercury or other contaminants blood fats and blood sugar. If you work at a desk,
in fish, you may be happy to learn that its heart- remember to take regular breaks to move around. Go for
healthy benefits tend to outweigh the risks for a stroll on your lunch break, and enjoy regular exercise in
most people. your leisure time.

Be a kid Take the scenic route home

Fitness doesn’t have to be boring. Let your inner Put down your cell phone, forget about the driver who

child take the lead by enjoying an evening of cut you off, and enjoy your ride. Eliminating stress while
roller skating, bowling, or laser tag. You can have driving can help lower your blood pressure and stress
fun while burning calories and giving your heart levels. That’s something your cardiovascular system will
a workout. appreciate.

50TH EDITION|CARING HEARTS|79

Dr. Anish P G The rising prevalence of treatment of symptomatic ischemic
symptomatic ischemic heart heart disease include medical therapy
MD (General Medicine), DM (Cardiology) disease poses several and revascularization. There are
Assistant Professor in Cardiology challenges in the management of the nonpharmacological treatment
MOSC Medical College Hospital, varying spectrum of patients. The approaches like EECP, spinal cord
Kolencherry, Ernakulam, Kerala spectrum of symptomatic patients stimulation, myocardial laser
varies from those who are treatment- revascularization, gene therapy etc.
naïve to those who remain These approaches are generally
symptomatic after optimal considered for patients who have
revascularization to those who refuse refractory ischemic symptoms after
to undergo revascularization. Now a failed medical therapy and
days, patient preference plays a key revascularization.
part in deciding the optimum mode
of treatment in any clinical scenario. What is EECP therapy?
The standard of care for the
External counter pulsation therapy was

80|CARING HEARTS|50TH EDITION

developed on the hemodynamic resulting in a diastolic augmentation Repeat therapy may be needed in
principle of diastolic augmentation of of blood flow and also an increase in some patients.
blood pressure in a manner similar to venous return. These hemodynamic
intra-aortic balloon counter pulsation changes lead to an improved Which group of patients benefit
and has evolved in to an alternative coronary perfusion pressure during from EECP therapy?
non-invasive tool for the management diastole. The cuffs are deflated just
of patents with refractory angina. before the onset of systole resulting Patients with debilitating angina and
in reduction in systolic vascular chronic heart failure who are poor
EECP therapy consists of three sets of resistance and decreased cardiac candidates for revascularization
pneumatic cuffs attached to each of afterload. procedures and have suboptimal
the patient’s legs at the calf and lower results from other therapies. The
and upper thigh. The patient’s cardiac EECP therapy involves 35 one-hour United States Food and Drug
rhythm is monitored and the sessions, 5 days a week over 7 Administration (FDA) has approved
sequential inflation and deflation of weeks. Two sessions can be done in EECP (Class IIb) for the
the cuffs are electronically triggered a day if the patient desires so and is management of refractory angina and
using a computer in relation to able to tolerate. The course is heart failure. It has also been tried in
specific time points in cardiac cycle. extended if the patient do not start to patients with hypertension and acute
The adjustments on the timing of develop improvement in the coronary syndrome.
inflation and deflation provides symptom status until late in the usual
optimal blood movement on a finger treatment course. Extension of The noncardiac conditions where it
plethysmogram waveform. The duration of therapy is determined in has been tried are restless leg
inflation is timed with the R wave on a case by case basis by the individual syndrome, retinal artery occlusion,
the electrocardiogram. It produces a treatment goals such as reduction in erectile dysfunction, hepatorenal
retrograde flow of blood in the aorta, symptom frequency or intensity. syndrome and syndrome X, even
though the use of it in these
conditions is not approved.

Figure 1. The timing of inflation and deflation of cuffs in EECP

50TH EDITION|CARING HEARTS|81

Table 1. Contraindications for EECP vasodilatation and improved coronary
Contraindications for EECP blood flow. Oxidative stress plays a
key role in the pathogenesis of
Any surgical intervention within 6 Deep vein thrombophlebitis vascular atherosclerosis. EECP is
weeks believed to reduce the degree of
oxidative stress by the reduction in the
Cardiac catheterization within 1–2 Severe hypertension (>180/ 110 mm circulating levels of proinflammatory
cytokines like TNF alpha, monocyte
weeks of Hg) chemoattractant protein – 1 and hs-
CRP.
Uncontrolled arrhythmia or The presence of abdominal aortic
controlled arrhythmias that could aneurysm, local infection, vasculitis Shear stress is a known stimulus for
interfere with equipment triggering of the extremities, a burn, open coronary collateral development and re-
wound, or bone fracture on any limb cruitment also. Upregulation of vascu-
subjected to ECP treatment lar endothelial growth factors (VEGFs)
and platelet derived growth factors by
Dual chamber pacemakers with Patients undergoing major shear stress aids in angiogenesis. A 6-
atrial pacing may interfere with anticoagulation therapy with week course of EECP has been demon-
inflation timing sequence prothrombin time >1.5 strated to increase the density of mi-
crovasculature per square mm in the in-
Aortic insufficiency Heart rates <35 or >125 beats/min farcted regions in animal models. EECP
may promote improvement in exercise
Severe pulmonary disease Bleeding disorders duration with no change in peak double
product by reduction in peripheral vas-
Limiting peripheral vascular disease Pregnant women and women of cular resistance.
involving the iliofemoral arteries childbearing age who do not have a
Are there any scientific clinical
negative pregnancy test evidences supporting the beneficial
effects of EECP?
What are the beneficial effects of proposed to explain the therapeutic
this procedure? effects of EECP. They are 1) Evidence on the performance of EECP
improvement in endothelial function, comes from non-randomized studies
The observed beneficial effects 2) promotion of angiogenesis and and international registries involving
include reduced frequency of angina new collaterals, 3) reduction in approximately 15 000 patients and
and use of nitroglycerin, improved atherosclerotic burden, 4) several small randomized, controlled
exercise tolerance and quality of life, improvement in ventricular function, trials. The Multicenter Study of
decreased myocardial oxygen and 5) peripheral training effects Enhanced External Counterpulsation
demand, increased venous return and analogous to that of exercise. (MUST-EECP) randomized trial (n
cardiac output, improved endothelial =139 patients) demonstrated a 15%
function, prolonged time to exercise- Endothelium plays an integral part in rise in the time to the onset of 1 mm
induced ST depression on 12-lead the vascular homoeostasis. ST-depression and 25% fewer angina
electrocardiogram and improvement Endothelial dysfunction leads to episodes per week. In the prospective
or resolution of myocardial perfusion imbalance in the vasodilator and evaluation of EECP in heart failure
defects. Side effects are equipment- vasoconstrictor stimuli on the (PEECH) trial, 187 patients with
related, mostly leg and back pain, vasculature with strong adverse chronic heart failure (70% with
skin abrasion, bruising, blistering, consequences in the coronary blood ischaemic background) were
edema, and paresthesias. flow. EECP increases the shear stress
on the vessel wall which leads to
Mechanisms of benefit increase in the release of endothelial
nitric oxide resulting in
Several mechanisms have been

82|CARING HEARTS|50TH EDITION

EECP therapy involves 35 one-hour sessions, 5 days a week over 7
weeks. Two sessions can be done in a day if the patient desires so
and is able to tolerate. The course is extended if the patient do
not start to develop improvement in the symptom status until
late in the usual treatment course

randomized to conventional treatment group compared to placebo. recommendation that EECP therapy
should be considered for
or EECP therapy, which was shown to Buschmann et al demonstrated that symptomatic treatment in patients
with refractory angina (Class IIa,
improved exercise tolerance, quality collateral flow index and FFR L.O.E- B). ACC AHA 2014 Focused
Update of the Guideline for the
of life, and New York Heart increased significantly in the EECP Diagnosis and Management of
Patients With Stable Ischemic Heart
Association (NYHA) functional group compared to the control group. Disease provides a class IIb
recommendation for EECP: EECP
classification. In a meta-analysis of 949 patients, may be considered for relief of
refractory angina in patients with SIHD.
There are two randomized trials on the anginal class was improved by one (L.O.E-B).
efficacy of EECP on the development CCS Class in 86% of patients.

of coronary collaterals. . Gloekler et al These results prove the concept and

studied the effect on invasively clinical effects of EECP treatment

measured collateral development, and prompted 2013 ESC guidelines

showed significant improvement in the on the management of stable

invasive collateral flow index in EECP coronary artery disease to the

Know your numbers

Keeping your blood pressure, blood sugar, cholesterol, and

triglycerides in check is important for good heart health. Learn the
optimal levels for your sex and age group. Take steps to reach and
maintain those levels. And remember to schedule regular check-ups
with your doctor. If you want to make your doctor happy, keep good
records of your vitals or lab numbers, and bring them to your
appointments.

50TH EDITION|CARING HEARTS|83

Dr Mathews Paul MD, DM, FIC Coronary heart disease is a exercise training) are among the
leading cause of death mainstays of conventional treatment.
Consultant Interventional Cardiologist among both men and women Some heart patients also turn
Moulanahospital,Perinthalmanna, in the modern world. to chelation therapy using disodium
Malappuram,Kerala EDTA (ethylene diamine tetra-acetic
Majority of the people have been acid), a controversial complementary
routinely following health approach.
conventional,scientifically proven
treatment modalities. Chelation therapy has long been used
as a treatment for mercury and lead
Lifestyle changes (such as quitting poisoning, but it isn’t a proven
smoking), medicines, interventional treatment for heart disease. It can
and surgical procedures, and cardiac potentially cause serious side effects
rehabilitation (a program consisting when used as a heart disease
of education, counseling, and treatment. Even so, some doctors and
complementary health practitioners
have used chelation therapy to treat
heart disease and stroke.

In chelation therapy, you are given
disodium ethylenediaminetetraacetic
acid (EDTA) through a series of
weekly intravenous (IV) treatments,
each lasting about 30 minutes.

In general, the medication seeks out
and sticks to metals and minerals in
your bloodstream, creating a
compound that your body removes
when you urinate. Chelation therapy
is promoted as a treatment for heart
disease because it’s thought that the
medicine sticks to calcium found in
fatty deposits (plaques) in the
arteries.

However, chelation therapy for heart
disease remains controversial. Here’s
what we know so far:

• The Trial to Assess Chelation
Therapy (TACT) didn’t provide
enough evidence to support
routine use for heart disease. But
it did find that chelation therapy
offered moderate protection
against future cardiovascular

84|CARING HEARTS|50TH EDITION

events, such as strokes and heart Find your happy place
attacks, in those with diabetes. TACT2
is a new study whichwill focus A sunny outlook may be good for your heart, as well as
specifically on people with diabetes.
your mood. According to the Harvard T. H. Chan School
• The American Heart Association and of Public Health, chronic stress, anxiety, and anger can
the American College of Cardiology raise your risk of heart disease and stroke. Maintaining
say it’s uncertain whether chelation a positive outlook on life may help you stay healthier
therapy is helpful as a treatment for for longer.
heart disease.
Pump some iron
• The Food and Drug Administration
hasn’t approved chelation therapy for Aerobic fitness is key to keeping your heart healthy, but
use as a heart disease treatment.
it’s not the only type of exercise you should do. It’s also
• However, the researchers also important to include regular strength training sessions
concluded that there is not enough in your schedule. The more muscle mass you build, the
evidence to support the routine use of more calories you burn. That can help you maintain a
chelation therapy for this population. heart-healthy weight and fitness level.

• Chelation therapy for heart disease has Walk it off
known risks and side effects. The most
common is burning at the IV site. Other The next time you feel overwhelmed, exasperated, or
side effects include fever, headache,
nausea or vomiting,Abnormally low angry, take a stroll. Even a five-minute walk can help
blood-calcium levels clear your head and lower your stress levels, which is
(hypocalcemia,sudden drop in blood good for your health. Taking a half-hour walk every day
pressure,drop in bone marrow counts is even better for your physical and mental health.
(bone marrow suppression),heart
failure,kidneydamage,etc Brush your teeth regularly

Before trying chelation therapy as a heart Good oral hygiene does more than keep your teeth
disease treatment, discuss with your doctor
about the benefits and risks. white and glistening. According to theCleveland Clinic,
some research suggests that the bacteria that cause
The Cardiology organizations do not gum disease can also raise your risk of heart disease.
recommend Chelation therapy as a useful While the research findings have been mixed, there’s no
treatment option for coronary artery downside to taking good care of your teeth and gums.
disease.However studies are going on to
prove their benefits in diabetic patients who 50TH EDITION|CARING HEARTS|85
already had heart attack.

It has never been proved that chelation
therapy dissolved any cholesterol plaques in
the blocked arteries.It is never an alternative
to the scientifically proven treatment
modalities like angioplasty or bypass
surgery.

Avoiding essential medicines, food
and water during ramadan rarely met
with unforeseen consequences
especially in those persons having
cardiac , diabetic and neurologic
diseases.

The diabetic patients are worse
affected in the form of hypoglycemic
spells , uncontrolled diabetes with all
its accompanying complications like
diabetic keto acidosis, acute coronary
syndrome and cerebrovascular
accidents .

Fasting has been practiced from the very Some staunch believers because of
origin of human race. It has been strongly their very strong faith in religion over
recommended by all religions and included in do taking less amount of food and
all religious scriptures. The duration and the water at night than required and they
methods of fasting are different in different are the one who may land up in more
religions. troubles.

This article has been written with the
twin idea of addressing this very
important issue and to give tips to
avoid such eventualities

The muslim community has one month long fasting Taking enough water before

during the month of ramadan apart from short term breakfast, each major meals and also

Dr Abdul Khader fasting during hajj and muharam before sleep at night has been

MD, DM In ramdan fasting one has to abstain from solid and recommended as a health tip by all
Cardiologist, Amala type of medical practitioners
Institute of Medical liquid food from early morning to sunset which
Sciences, Thrissur. includes essential medicines taken during day time . including naturopathic healers .

No other religion to my knowledge has such strict Water taken in adequate quantity ,6 to

recommendation while they go through fasting. In 8 glass per day , is essential for proper

40 days or 8 days fasting bychristian community or urination and to excreat the toxic

during various occasions of fasting by hindus there metabolic products generated by the

are no restriction for taking food ,water or medicines organ systems in the human body.

86|CARING HEARTS|50TH EDITION

During fasting when less amount of over to the evening time after 4.Those addicted to smoking seen
water is consumed the water and breaking the fast when the patients using cigarettes or beedies
electrolyte metabolism can be take more food. immediately after breaking the fast .
deranged with accompanying This is to be avoided as the sudden
malfunction of the body due to If by chance the amount of food increase in the blood level of
accumulation of toxic metabolites and consumed is less in quantity it is nicotine or carbon monoxide from
hemoconcentration. better to reduce the amount of oral smoking can induce spasm of the
hypoglycemic drugs taken on that heart blood vessels ( coronary artery
This can lead to the production particular day . The same is spasm)
various types of urinary stones applicable to the dose of insulin
causing diseases of kidney, ureter and injected . Tailor the dose depending 5. Take all medicines after food
urinary bladder on the requirements. It is better to with plenty of water to avoid gastric
consult your doctor before ramdan / irritation and stomach bleeding .
Elderly patients with heart disease fasting and get correct advise
and especially adult with heart regarding medication and timing of 6 Anti hypertensive requirements
disease and blueish discoloration of intake of various drugs . also
mucous membranes have a tendency
to cause stroke and pulmonary Gastero intestinal complications like may change with fasting, hence
infarction during fasting gastritis, acidity , bleeding from frequent BP examination in sitting
stomach , bleeding from rectum and standing position is essential
So inorder to escape from these forms ,constipation , nausea ,vomiting during the time of fasting to adjust
of eventualities ensure good in take of ,cramps and colics are very common the dose . How ever never skip any
water after breaking the fast to during fasting . medicines with out proper reason
compensate for the less intake during during fasting
the time of fasting in day time Some of the tips regarding food and
especially when the ramadan month medicine intake found useful during 7 There is no need to change the
comes in summer season. fasting is discussed below statin dose or time of intake during
fasting .
Other problems are related to the 1. Take enough water .Adequate
drugs taken and the timing of the water intake likely to prevent colics Fasting has been found to improve
drug. due to stone formation and avoid the well being and over all heath of
constipation. all persons
Majority of the doctors ask their
patients with heart disease to take 2. Take enough vegetables , wet and irrespective of the religion,
antiplatelet agents like aspirin( dry fruits and nuts . Diabetic patients provided you are little bit careful in
Ecosprin) and clopidogrel ( clopilet , can take orange ,apple , watermelon, your food and drug intake .
clopitab, plagerin ) during noon time pear, ground nut , cashew nuts , less
after food . This can be changed and it ripe fruits . Vegetable and fruits For muslims fasting is one among
is better that it is taken after breaking increase the bulk and the five important rituals to be
the fast . obeyed during their life so what ever
fiber consumed and is good for may be the reason as far as possible
Similar is the case with antidiabetic preventing constipation they have to obey and adhere to it .
drugs also . Only very sick patients are exempted
3. Avoid taking food containg too from fasting . If there is a likely
Diabetic patients better take less much chille, oil and gravy as the first chance of causing death by fasting
number of oral hypoglycemic drugs at food during the time breaking the then also it is exempted .
the beginning of fasting in the fast . Avoid samusa puffs , lemon
morning. More strong medicines and juice ( contains citric acid ) , strong
Insulin ingections can be switched coffe or tea and also smoking

50TH EDITION|CARING HEARTS|87

Dr. Bino Benjamin High blood pressure is sometimes known as “the silent killer”. This is
because it increases the risk of heart disease and stroke, but often goes
MBBS, MD, DM, unnoticed due the lack of obvious symptoms.
Cardiologist
Jubilee Mission Hospital, Are you a hypertensive taking multiple drugs to bring it down? Is your BP still
Thrissur. remaining high and uncontrolled? You are probably having resistant
hypertension

Although most of the times hypertension is treated successfully with
medications and lifestyle changes, resistant hypertension is not so easy to treat.

What is resistant hypertension?

If you’re taking proper dose of atleast three blood pressure medications, and one
of those is a diuretic (water pill), and still your BP is not under control, you are
having resistant hypertension.

How to confirm this diagnosis?

Make sure you’re getting accurate blood pressure readings. There are several
reasons why you might get an inaccurate reading.

• The blood pressure cuff is too small - this usually happens whe your body

weight is high

• You haven’t taken proper rest before checking blood pressure.

88|CARING HEARTS|50TH EDITION

• You experience “white coat hypertension,” or elevated Managing hypertension is not
always easy. By making these
BP due to anxiety in the doctor’s office. small changes in lifestyle, you
can get a good control of your
• You smoke or have caffeine right before having your blood pressure most of the time

blood pressure taken • Take a low-sodium diet (less than 2.3 grams per day)
• Reduce the amount of processed foods you eat —
Even after ruling out all of these above factors, and your
BP is still elevated, you have resistant hypertension. they’re usually high in sodium.

What’s reason for resistant hypertension? • Follow healthy diet which includes lots of fruits,

1. Your wrong lifestyle is the commonest reason for this vegetables, whole grains and lean protein.
problem. If you’re sedentary, smoking, eating a high
sodium diet, consuming a lot of alcohol and overweight, • Limit your alcohol intake.
your medications may not work optimally. • Make sure you’re taking your BP medications correctly

2. Medications you take for other ailments can worsen and at the scheduled time.
the problem. Pain killers such as ibuprofen, steroids,
oral contraceptives and nasal decongestants, all can • If your medication is causing unpleasant side effects,
boost your blood pressure. Show all of your pills,
including over-the-counter medications and herbal or inform your doctor and get alternative medicines - don’t
food supplements to your doctor just stop taking it.

3. Obstructive sleep apnoea can contribute to resistant • Learn to check your BP at home. Log the results and
hypertension. If you snore loudly or have excessive day
time sleepiness inform this to your doctor. show them to your doctor

4. After ruling out all the above possibilities, your Managing hypertension is not always easy. By making
doctor may look for other causes related to hormones or these small changes in lifestyle, you can get a good
vascular problems. control of your blood pressure most of the time. These
will help you in the long run, reducing your risk of heart
Steps you can take to overcome resistant disease and stroke.
hypertension

• Exercise regularly

Kick your housework up a notch

Vacuuming or mopping the floors may not be as invigorating as a Body

Slam or Zumba class. But these activities and other household chores do
get you moving. They can give your heart a little workout, while burning
calories too. Put your favorite music on and add some pep to your step
while you complete your weekly chores.

Go nuts

Almonds, walnuts, pecans, and other tree nuts deliver a powerful punch

of heart-healthy fats, protein, and fiber. Including them in your diet can
help lower your risk of cardiovascular disease. Remember to keep the
serving size small, suggests the AHA. While nuts are full of healthy stuff,
they’re also high in calories.

50TH EDITION|CARING HEARTS|89

Butter is high in
saturated fat, so
restrict yourself to
small amounts and
use alternatives for
everyday eating

waistline is the same. The big
difference is their effect on
your cholesterol levels, so it’s
important to consider the type as well
as the amount of fat you are eating.

Industrially produced trans fats ( in
India most hotel and fast food are
cooked in hydrogenated vegetable oil
which is high in transfat) and too
much of this worst form of fat can
increase the risk of coronary heart
disease by raising the level of
harmful LDL cholesterol, which can
contribute to blood vessel blockage.

Even home cooked food can be high
in saturated fats. These include
butter, lard and ghee, plus coconut
and palm oil (often found in
confectionery and biscuits).
Saturated fats are also in whole milk,
cream, cheese, cakes and chocolate.

Dr. Iwin Varghese Myth: All fats in food are the same Swapping saturated fats in your diet
for unsaturated fats
MRCGP, GP Reality (monounsaturated and
Principal (Family Physician) All fats are high in energy and have polyunsaturated) can help lower
Ashford Medical Partnership an identical calorie value (9kcal per cholesterol levels. Find unsaturated
Ashford, Kent. gram), so their effect on your fats in avocados, olive, rapeseed and
sunflower oils, oily fish, seeds and
90|CARING HEARTS|50TH EDITION nuts.

Myth: I need to eat a low-fat diet Myth: Butter is better Make time for
to look after my heart breakfast
Reality
Reality The first meal of the day is an
Butter is high in saturated fat, so
As our understanding develops, it’s restrict yourself to small amounts important one. Eating a
clear we need to consider the overall and use alternatives for everyday nutritious breakfast every day
balance of our diets. eating. can help you maintain a
A Mediterranean-style diet is healthy diet and weight. To
famously associated with lower rates Try mono or polyunsaturated spreads, build a heart-healthy meal,
of cardiovascular disease, attributed such as olive oil or sunflower spreads reach for:
to the inclusion of olive oil, grains, (a new manufacturing process solved
beans, lentils, fruit, vegetables, oily past concerns about their trans fat · whole grains, such as
fish and nuts. content). Liquid oils can also be used oatmeal, whole-grain
for cooking and baking instead of cereals, or whole-
This is not a low-fat diet, but the fats butter. wheat toast
are mostly unsaturated. It seems to be
the overall combination that makes it Myth: Any kind of meat is · lean protein sources,
so successful. bad for my heart such as turkey bacon
or a small serving of
Myth: Cutting out all fat is good Reality nuts or peanut butter
for my heart
Lean meats such as chicken , without · low-fat dairy products,
Reality the skin, are healthier options, as they such as low-fat milk,
are lower in saturated fat. Red and yogurt, or cheese
Such a drastic approach isn’t processed meats can be high in
necessary, and excluding fat can saturated fats and may also have · fruits and vegetables
mean missing out on nutrients and added salt.
fatty acids that our bodies need, such 50TH EDITION|CARING HEARTS|91
as omega-3 and omega-6 fats. Watch out for the white bits of fat in
Beef, Pork and Mutton and trim them
These polyunsaturated fats are found off where possible.
in oily fish, nuts, seeds and the oils
made from them.

Dr.Rachel Daniel Two important parts of recovery and continuing health after any heart
surgery are a good diet and a regular exercise routine.
MD (General Medicine),
DNB (General Medicine), If your doctor has recommended a particular diet, it’s important that you
DNB (Cardiology) follow it. If a special diet has not been recommended, balanced, heart-healthy
Chief Interventional cardiologist nutrition can speed healing and lessen fatigue. Weight control is also
N.S Hospital important for your heart health; excess weight increases the work of the heart
Kollam, Kerala and slows recovery.

After your heart surgery you may find that you do not feel hungry. Certain
foods maynot taste the same. This may be because of the surgery itself or the
pills that you aretaking. You need to be sure to eat foods that will supply your
body with enough caloriesand protein to allow your body to heal and recover.

What steps should I take to eat a heart- healthy diet?

• Ideal portion breakdown: Eat small amounts of food throughout the

day. The ideal daily diet should include 4 servings of whole grains, 5

92|CARING HEARTS|50TH EDITION

servings of vegetables, and 2 servings of fruits. After heart valve surgery, during
However, this may vary depending on the actual recovery and beyond, make sure
energy requirements of the patient. to eat a variety of fruits,
vegetables, whole grains,
• Good protein foods are (1) fish - different variety of breads, lean meats including
fish and low-fat dairy products
fish such as salmon, sardines, and mackerel are a rich
source of omega-3 fats. Omega 3 fats help protect the • Dairy: Switch to low-fat dairy such as skim
heart and will allow your body heal faster than
usual.(.2)Other good protein sources are skinless milk, yogurt, cheese and include it in your
poultry,egg white, yogurt, legumes and nuts. everyday diet

• Salty foods: Limit your intake of salty foods. Try • Sugary foods: Try to avoid sugary foods

to keep salt intake to less than 3g per day unless completely. These may make you gain weight.
your doctor has given you a different amount.
Prepare meals with minimal salt as it will help • Water consumption: Take adequate fluids
prevent water retention and keep blood pressure
normal. daily to maintain proper fluid balance in the
body.
• Vegetables and fruits:incorporate high fibre foods
• Alcohol intake may interfere with the effect of
like fruits & vegetables to maximize fiber intake.
some medications or increase your blood
• Green leafy vegetables:A person after heart valve pressure.

surgery will be prescribed blood thinning drugs, • After a valve replacement, do not use
i.e Oral anticoagulants which are Vitamin K
antagonists. It is mandatory to keep the level of supplemental calcium without approval from
these drugs in a particular level in blood by your healthcare provider.
regular monitoring . So patients on oral
anticoagulants have to restrict the intake of To summarise, after heart valve surgery, during
Vitamin K rich foods like green leafy vegetables. recovery and beyond, make sure to eat a variety of
fruits, vegetables, whole grains, breads, lean meats
• Whole grain benefits: Whole grain food items such including fish and low-fat dairy products. Foods that
are high in saturated fats, sugar, salt, and sodium
as whole grain bread, brown rice, oats, barley, and should be limited. Processed meats should be avoided.
rice help improve your energy levels and are considered In general, a low-fat, low-cholesterol, high-fiber diet
good for your heart. Make sure to include a couple of is best.
servings of whole grain in your daily diet.
50TH EDITION|CARING HEARTS|93
• Eggs: Eat up to 2 egg yolks per week. Use
egg substitute or egg whites when you are
cooking or baking.

• Controlled fat consumption:

1.Limit your consumption of fats like processed fats,
red meats, organ meats.

2. Switch to healthy fats derived from nuts, avocados,
seeds, fish ,fat trimmed meat, skin removed chicken.

3. Limit the usage of oil while cooking. Use unsaturated
oils, like olive oil , sun flower oil, rice bran oil. Most
important is to limit the amount of oil for cooking per day.

Interview with Q . Could you briefly describe about
your family and education?
Dr Jayan Parameshwar
I was born in Bombay (now Mumbai)
Consultant Cardiologist where my father spent a lot of his
Royal Papworth hospital, Cambridge working life. I did my MBBS in
JIPMER, Pondicherry which I think
Dr Parameshwar did his undergraduate medical training in Pondicherry, gave me an excellent foundation for
India followed by residency in Internal Medicine in New Delhi. His the rest of my medical career. I was
cardiology training was in Hillingdon Hospital and at the National Heart fortunate to get a place for MD
and Brompton Hospitals. He was actively involved in research into (Medicine) at AIIMS, New Delhi. Six
predicting prognosis in heart failure and exercise testing in heart failure. months after my MD I left for the UK.
I spend a few years doing general
He joined the transplant programme at Royal Papworth hospital in medicine and then cardiology
1991 and became a consultant in 1996. He is recognised nationally and (research and clinical). In 1991, I
internationally for his work in heart transplantation. He has published joined the Transplant Unit at
over 100 papers in the field of heart transplantation and has a national Papworth hospital; I intended to stay a
and international profile in the field. He was involved in setting up the year or so but never left!
advanced heart failure and mechanical circulatory support programme
with surgical colleagues. He is the Chairman of the Cardiothoracic Q. As a cardiologist who is treating
Advisory Group at NHS Blood and Transplant.

94|CARING HEARTS|50TH EDITION

patients who are undergoing or underwent heart have survivedmore than 20 year survivors. These patients

transplants, What are the indications for heart translate? are not just alive; they enjoy a good quality of life.

Heart Transplantation is the best treatment for selected Q. What is your longest survivor?
patients with advanced heart failure. The most common
diagnosis in our patient group is Dilated Cardiomyopathy Our longest survivor has crossed the 35 year mark in
(unlike thirty years ago when Coronary Artery disease April this year.
was more common). Most patients are under 65 years of
age. The donor heart allocation algorithm has changed Q. In Kerala, we initially thought that donation may not
several times over the last twenty years, at present about be an issue, but getting recipients may be the issue, as
80% of patients in the UK are in-patients requiring patients and physicians are not aware about the therapy.
intravenous medication. A significant proportion of But now it is the other way round. Recipients are there,
patients are waiting on mechanical circulatory support. but there is practically no donations. What is the
situation in UK?
Q. How many transplants done under your care?
In the UK, the number of potential recipients greatly
Papworth hospital has carried out 1540 heart transplants exceeds the number of donors. There are about 275-300
(starting in 1979); since I joined the programme we have patients on the waiting list in the UK at any given time.
done just under 1100. As heart transplantation has been part of the NHS for
nearly 40 years, referral pathways are reasonably well
Q. Do you think that the indications in India are the same established though there are still likely to be patients who
as in UK? are not referred appropriately. The advent of long-term
LVADs also increases the number of patients waiting for
I think the indications are likely to be the same though a transplant. In my first year in the field, the UK did 310
the proportion of the different diagnoses may differ heart transplants, last year it was down to about 180.
(perhaps more CAD in the Indian cohort). The number of deaths from road traffic accidents has
fallen markedly over the last 30 years due to seat belt
Q. Having taken part in more than >1000 transplants, do laws and better care of patients with head trauma. Donor
you really think that this therapy really works? age (which is an important factor in heart transplant
outcome) has been increasing in most European
Yes! Taking care of these patients for the last 28 years countries which isalso a problem. This is in contrast to
has shown me how worthwhile it is. Of course, not all the US where donor age has actually decreased slightly
patients do well but at Papworth we now have 1 year and median donor age is now almost 20 years below that
survival of 90%, 5 year survival of 80% and 10 year in Europe.
survival of nearly 70%. There is a significant cohort who

50TH EDITION|CARING HEARTS|95

Q. In Kerala,the main concern is the Q. Are you involved in the transplant
certification of brain death. Do you programs in India and Kerala ?What
think that the process of brain death is your experience? Do you think
certification is different in both that the transplant program inn
these places or they follow the same Kerala is at par with those in other
principe? countries in terms of long term
success?
In the UK brain stem death testing is
done by two independent doctors I have been fortunate enough to be in
who are not part of the transplant contact with heart transplant
team. As far as I know the same programs in Kerala, Chennai and
principles are followed in India but I am not familiar with Bengaluru. All I can do at present is
protocols. There were some concerns in the early 1980s provide advice by email on patient selection and on
(in the UK) but these have been largely allayed over the dealing with problems in immunosuppression etc. Some
years. Indian cardiologists have spent time at Papworth gaining
experience in advanced heart failure medicine including
Q. Here video recording of the process of brain death the care of transplant recipients.
verification is mandatory. Do you have such mandatory
non medical protocols there? Unfortunately I have not seen any data on long-term
outcome from any centre in India. I think it is time a
Video recording is not carried out in the UK. Register is set up with mandatory reporting of results.
This is one way to monitor results and drive up standards.
Q. How people voluntarily come for organ donation in In the UK, we are compelled to submit data to our
UK? Is there any public campaigns, incentives for the national registry and outcomes are continuously
family ? monitored. If a centre shows poor early outcome, an
external review is carried out.
Public campaigns are constant, when people for a driving
license or join university they are automatically asked if Q. What will be the approximate cost of a usual
they want to join he Organ Donor Register. NHS Blood transplant procedure in UK?As you are aware programs
and Transplant has a section devoted to educating the in Kerala are one of the cheapest in the country. What is
public and running campaigns. They employ Specialist your comments regarding this?
Nurses in Organ Donation (SNOD) who are called for
every potential donor and speak to the families of these It is very difficult to answer this question as patients are
potential donors. They also support the families during not charged. The true cost is covered by different
the process and afterwards. Good news stories are departments (surgery, intensive care, pathology). An
constantly on the TV, there is an annual British, European organisation called NHS England commissions heart
and World Transplant Games for recipients which is also transplantation and pay a certain fixed cost to each unit
good publicity. There is no financial or other incentive plus a marginal cost for each procedure.
for donor families.
It is good Kerala has been able to provide the service at a
Q. How often you visit your home place? relatively low cost; this will enable more people to benefit
from the procedure. In the West, heart transplantation is
For the last 9-10 years I have been visiting Kerala almost never paid for by individuals; it is covered by
virtually every year though I am only there for about two medical insurance or the State.
weeks. It is difficult for me to take more time off work,
when I stop working perhaps I will be able to spend more Q. I think that you may be aware about the near total
time in India! shut down of the program in Kerala because of some
false allegations and as a result patients have to be

96|CARING HEARTS|50TH EDITION

In the West, heart transplantation is
almost never paid for by individuals;
it is covered by medical insurance or the State

shifted to other places and some are dying while waiting time during which there is potential damage to the organ.

in the wait list. As a person who have got a fair idea With multi-organ donation, transporting the donor was

about the situation in Kerala, do you think that these not feasible either. Brain-stem death laws were passed in

allegations are blown out of proportion? most of Europe and the US in the 1970s and DCD

While I have not participated personally in organ transplants were no longer carried out.
donation procedures in Kerala, the people I have dealt
with (in the transplant world) have been principled, and DCD kidney transplantation re-started about 15 years ago
interested in providing a service rather than personal and liver and lung about 10 years ago. With the paucity of
gain. Of course all allegations need to be investigated donor hearts and the fall in the number of suitable DBD
but allegations with no data should not be published. donors, the need for expanding the donor pool was great.
Regaining the trust of the population is not easy and will One of my surgical colleagues at Papworth hospital
unfortunately take time. (Stephen Large) started lab research in this field about ten
years ago and it is his work that led to the success of the
Q. Could you suggest some public awareness campaigns clinical program. One of the key developments that
like in UK which can be implemented here to increase allowed DCD hearts to be used was the introduction of
the donations? platforms for machine perfusion of the donor heart during
transport. This removed the "cold ischaemic time"

The campaigns in the UK are run by organisations that element; current data (we have done 70 DCD transplants

are funded by the NHS. A lot of money is spent on this at Papworth) indicates that outcomes at one year are

aspect of transplantation. Perhaps India should look to similar to DBD transplantation. We are more

countries in Asia that have been successful in conservative with donor acceptance criteria in the case of

implementing transplant programmes, I believe Thailand DCD organs while we learn more about long-term

is one. Of course, different cultures pose different outcome.

problems. In the UK, donation figures are lower in Afro- Q. Do you think that DCD as a possible option in Kerala

Caribbean and Asian groups (this poses particular to increase the potential donor pool?

problems in renal transplantation where HLA matching is Introducing DCD transplantation will require changes in
carried out). My answer to Question 10 also covers
the legal framework and in regulation. It is not easy to
some of the answers to this question.
implement. At present DCD transplantation is also much

Q. Sir, I know that there is an option of donating organs more expensive because of the need for perfusion

after death in UK. Could you briefly describe about this technology rather than cold storage of the donor organ

concept? What was the need for such a concept? during transport. (It doubles the marginal cost of a

When heart transplantation first started (in the 1960s), transplant in our setting). In the future the cost of these
hearts were explanted from donors after circulatory death technologies may fall as they are more widely used. At
(cessation of heart beat). Donors and recipients were co- present cost may be prohibitive, the NHS is still
struggling with finding a way to fund this procedure and
located (both in the same hospital), so there was no
transport time. During the process of circulatory death we have been dependent on charitable money.

there is potential ischaemic damage to the heart as blood As an aside, the DCD concept has not been accepted in

pressure falls. As time went on, distant procurement all countries. Germany, for instance does not allow

became more common adding an element of transport donation after circulatory death.

50TH EDITION|CARING HEARTS|97

Mr. Felvin Mathew Cardiac Rehabilitation is the process by which patients with cardiac
disease, in partnership with a multi-disciplinary team of health
Physical Therapist professionals are encouraged to support and achieve and maintain
Lisie Hospital. optional physical and psychological health. The involvement of family members,
take carers are all important for this.

Cardiac Rehab or CR isfor management of people with cardiac disease. Initially,
this rehab was offered mainly to people recovering from a Myocardial Infraction
(MI) but now it is for a wide range of cardiac problems.

Indication for Cardiac Rehabilitation:

Cardiac Rehabilitation should be offered to all cardiac patients who would
benefit. CR is mainly prescribed to patients with
Ischaemic heart diseases, with Myocardial
Infarction, aftercoronary angioplasty, after CABG
surgery and to patients with chronic heart
failure.CR begins as soon as possible in Intensive
Care Units (ICU) only if the patient is in stable
medical condition. Intensity of rehabilitation
depends on patient’s condition and
complicationsof disease.

Goals of Cardiac Rehabilitation: Main goal of CR
is to promote secondary prevention and to enhance
quality of life and to bring back the patient to same
normal life as soon as possible.

a) Medical goal
b) Social or psychological goal
c) Health service goal

98|CARING HEARTS|50TH EDITION

• Improve the cardiac function Phase 11: Post discharge pre exercise period

• Return to work of appropriate or previous level of Phase 111: Exercise and education program

functional capacity Phase 1V: Maintenance

• Restore self confidence Every cardiac rehab must consist of a warm up
• Reduce the risk of sudden death and re- infarction. phase, exercise phase and cool down phase.

• To promote independence of ADL’S for those a) Warm up phase: purpose is to prepare the

compromised. body for exercise by raising the pulse rate in

• Relieve anxiety and depression in patients in their a increased and safe way. It redistributes
blood to active tissues. It prepares the
careers. mind,prepare muscles for the movements
involved in the conditioning period
• To make heart healthy dietary decision.
• To promote early mobilization and discharge from b) Exercise Phase: is set according to the status
and functional capacity of the patient.
hospital Gradually we can increase the intensity for
the phase according to the tolerance level of
• Reduce symptom such as breathlessness and thepatient.

angina. c) Cool down Phase: goal is to bring the body
back to itsresting state. It should incorporate
• Reduce cardiac related hospital admission movementsof diminishing intensity.This
• Restore good sexual health
• Prevent progression of underlying atherosclerotic

process. phase is significant because raised

Phases of Cardiac Rehabilitation: Comprises of sympathetic activity during exercise increase
four phases.The secondary prevention component the risk of arrhythmias immediately post
of CR requires delivery of exercise training, exercise. Older hearts take longer to return
education and counseling risk factor intervention to resting levels.

and follow up. Conclusion: Cardiac rehabilitation is an inexpensive

Phases of Cardiac Rehabilitation: treatment that saves lives. It helps heart patients get back
Phase 1: In hospital patient period on their feet,physically and emotionally, through exercise,
education and support.

Eat chocolate

Dark chocolate not only tastes delicious, it also contains heart-

healthy flavonoids. These compounds help reduce inflammation and
lower your risk of heart disease, suggest scientists in the
journal Nutrients. Eaten in moderation, dark chocolate — not
oversweetened milk chocolate — can actually be good for you. The
next time you want to indulge your sweet tooth, sink it into a square
or two of dark chocolate. No guilt required.

50TH EDITION|CARING HEARTS|99

Mr. Robin Tomy experience.Still healthcare industry care management, accelerate drug
continues to be largely unpredictable. discovery and match clinical trials
Head - Incubation, Even when the "how" of regulation of with patients. It is likely that AI will
Tata Consultancy Services, health care industry in future is a become even more advanced to carry
Thiruvananthapuram subject of ongoing debate, scientists out tasks even without human
come up with new medicines, monitoring in the near future. For
Remember the days when you treatments and technological example AI tools can help reduce
had to wait for hours to get implementations supporting human errors in diagnosis and
an appointment and consult a healthcare industry on a daily basis. treatment and give more time for the
doctor or if you had done any tests, In addition the industry is moving at doctors to work with patients. Deep
you had to go back to the hospital to a fast pace from products or special learning can help in processing huge
collect the result? Thankfully, you equipment to solutions like medical data sets thereby reducing the time
may call it a past era (or at least it's platforms based on big data and taken to identify the drug candidates
getting there). The healthcare health care analytics. The focus is in drug discovery with higher
industry like any other industry is shifting to preventive care and how probability of success. AI can also
also experiencing a huge shift driven the latest technology can be reduce staff overload by automating
by the need for a better customer efficiently used for the same. Let’s monotonous tasks such as accounting,
look at few of the technology trends scheduling, managing electronic
in healthcare industry below. health records, and paperwork. Even
AI is used today in drawing
Artificial Intelligence: The modern conclusion on the Clinical Study
healthcare industry has already Reports. AI is also extensively used in
introduced AI based technologies analyzing images (XRays, MRI, etc)
which helps in various scenarios like

100|CARING HEARTS|50TH EDITION