The Heart: An Incredible Electric Machine

A quick primer on the electrical system of the heart followed by two major breakthroughs in pacemaker technology this year.

What makes the heart beat? Learn about the conduction system, an incredible machine.

A leadless, subcutaneous defibrillator makes the list of 5 biggest medical breakthroughs of the year.

Boston Scientific has begun marketing a FIRST-OF-ITS-KIND DEFIBRILLATOR after receiving FDA approval in September. The implantable device, which protects against sudden cardiac arrest, was developed by a California firm purchased by Boston Scientific and is expected to be a financial win for the Natick-based company. Unlike others on the market, the S-ICD does not touch the heart, instead sending electrical pulses to correct abnormal rhythms through wires implanted just beneath the skin.

http://bostonglobe.com/magazine/2012/10/27/biggest-medical-breakthroughs-year/pLJDenlFAN3XFwwsxfU7CI/story.html

No More Batteries: Piezoelectric Pacemaker Powered By The Heart

An experimental device converts kinetic energy from beating hearts into electricitythan can power a pacemaker, meaning the chance for no more batteries in the future, according to a talk at the American Heart Association’s Scientific Sessions 2012.

The study is preliminary but a piezoelectric approach is promising for pacemakers because they require only small amounts of power to operate. Batteries must be replaced every five to seven years, which is costly and inconvenient.  Piezoelectricity might also power other implantable cardiac devices like defibrillators, which also have minimal energy needs.

“Many of the patients are children who live with pacemakers for many years,” said M. Amin Karami, Ph.D., lead author of the study and research fellow in the Department of Aerospace Engineering at the University of Michigan in Ann Arbor. “You can imagine how many operations they are spared if this new technology is implemented.”

Researchers measured heartbeat-induced vibrations in the chest. Then, they used a “shaker” to reproduce the vibrations in the laboratory and connected it to a prototype cardiac energy harvester they developed. Measurements of the prototype’s performance, based on sets of 100 simulated heartbeats at various heart rates, showed the energy harvester performed as the scientists had predicted — generating more than 10 times the power than modern pacemakers require. The next step will be implanting the energy harvester, which is about half the size of batteries now used in pacemakers, Karami said. Researchers hope to integrate their technology into commercial pacemakers.

Two types of energy harvesters can power a typical pacemaker: linear and nonlinear. Linear harvesters work well only at a specific heart rate, so heart rate changes prevent them from harvesting enough power.

In contrast, a nonlinear harvester, the type used in the study, uses magnets to enhance power production and make the harvester less sensitive to heart rate changes. The nonlinear harvester generated enough power from heartbeats ranging from 20 to 600 beats per minute to continuously power a pacemaker. Devices such as cell phones or microwave ovens would not affect the nonlinear device, Karami said.

http://www.science20.com/news_articles/no_more_batteries_piezoelectric_pacemaker_powered_heart-96003

 

End of Life Choices

For many with heart disease it is a battle to remain living, yet know you are dying from a diseased heart. Many don’t discuss with their healthcare practitioners the choices and decisions they have when it comes to fighting to stay alive or choosing to let go. Over my career I have watched many patients suffer trying numerous medical interventions and medications only to have a horrible quality of life. In the medical community we see patients literally beg their doctors to let them pass, and yet the physician urges them to fight on with the newest surgery or medication. These are issues that heart patients should be able to discuss with their families and health care providers early on, so everyone has a clear picture of your wishes.

When it comes to end of life you have choices

Your choices

  • Stop treatment that prolongs your life. Instead, receive only treatment that focuses on your comfort and quality of life.
  • Don’t stop treatment that prolongs your life.

Key points in making your decision

  • If there is a good chance that your illness can be cured or managed, your doctor may advise you to first try available treatments. If these don’t work, then you might think about stopping treatment.
  • If you stop treatment, you may still receive care that focuses on pain relief, comfort, and the quality of your life. This is called palliative care  or hospice care.
  • A decision to stop treatment that keeps you alive doesn’t have to be permanent. You can always change your mind if your health starts to improve.
  • Even though treatment focuses on helping you live longer, it may cause side effects that can greatly affect your quality of life and your ability to spend time with your family and friends.
  • If you still have personal goals that you want to pursue, you may want treatment that keeps you alive long enough to achieve them.

Reasons to have life support:

  •  You need life support because of an emergency that is not related to your illness.
  •  Life support may help you return to your  normal activities.
  •  Your quality of life is good and you have a sudden event that requires life support..
  •  You could recover well from the event.

Reasons  not to have life support

  • You have other long-term health problems that make it less likely that you will benefit from life support.
  • The risks of life support outweigh the benefits.
  • Life support will not help you return to your normal activities or to a level of activity you would like to have.
  • You want a calm, peaceful death, and you do not want to spend the rest of your life on a ventilator

Physician Orders for Life Sustaining Treatment

I had a patient who wanted to die in cardiac rehabilitation. He expressed this wish often. He was adamant he did not want any life-sustaining treatment, however in rehab we were bound to comply with our standard of care which meant life-sustaining treatment, CPR and defibrillation until the patient was received in the hospital emergency room where his advanced directive were on file. This is the case in most hospital or outpatient settings, even EMS has an obligation to respond unless one has a POLST form visible in their house or on their person.   The only legal way for me to respect his wishes was for him to have a POLST form filled out and on file in the rehab department, and as a card he carried and a form posted in his home. What is POLST. It is an agreement made between  you and your physician about what life-sustaining treatment you with to have. To read more about this visit the link: http://www.ohsu.edu/polst/

Do you have an ICD?

Heart patients who have an ICD need to consider and  discuss the difficult issue of ICD deactivation as  clinical status worsens and death is near. Unfortunately, “clinicians and patients rarely engage in discussions about deactivating ICDs, and most devices remain active until death” and “most patients are not even aware that deactivation of the shocking function is an option.

Palliative care relieves the symptoms of  disease, such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite and difficulty sleeping. It helps you gain the strength to carry on with daily life. It improves your ability to tolerate medical treatments. And it helps you have more control over your care by better understanding your choices for treatment options. Including decision-making and coordinating of issues such as ICD deactivation.

The point of palliative care is to relieve suffering and provide the best possible quality of life for both you and your family.

Palliative and hospice care is often left for the very end of life. By initiating palliative care earlier it reduces emergency department visits and improve symptoms, which increases time at home and quality of life.

Palliative Care
Palliative care teams are made up of doctors, nurses, and other professional medical caregivers, often at the facility where a patient will first receive treatment. These individuals will administer or oversee most of the ongoing comfort-care patients receive. While palliative care can be administered in the home, it is most common to receive palliative care in an institution such as a hospital, extended care facility, or nursing home that is associated with a palliative care team. There are no time restrictions. Palliative care can be received by patients at any time, at any stage of illness whether it be terminal or not.

Hospice

Hospice programs far outnumber palliative care programs. Generally, once enrolled through a referral from the primary care physician, a patient’s hospice care program, which is overseen by a team of hospice professionals, is administered in the home. Hospice often relies upon the family caregiver, as well as a visiting hospice nurse. While hospice can provide round-the-clock care in a nursing home, a specially equipped hospice facility, or, on occasion, in a hospital, this is not the norm. You must generally be considered to be terminal or within six months of death to be eligible for most hospice programs or to receive hospice benefits from your insurance.

Our health care system faces the challenge of allocating limiting resources to an aging population. The focus is on solutions that improve patient quality of life while minimizing unnecessary expenses.  Integrating palliative care into the health care system at an earlier time helps quality of life and reduced cost associated with the disease process.

http://www.getpalliativecare.org/whatis/faq

http://www.caregiverslibrary.org/caregivers-resources/grp-end-of-life-issues/hsgrp-hospice/hospice-vs-palliative-care-article.aspx

Surviving Sudden Cardiac Arrest

Did you survive Cardiac Arrest?

With advanced technology and medicine more people are surviving episodes of cardiac arrest.  Each month, 10,000 people, including children, have a defibrillator implanted to restore normal heart rhythm and prevent sudden cardiac death. For many survivors and their families, leaving the hospital after experiencing a sudden cardiac arrest can be an unsettling experience.  Patient experiences with surviving cardiac arrest  can be quite different. There are some factors that should be addressed.

One is the chest wall soreness. If you had CPR performed on you it is a brutal assault to the chest wall. Between each layer of ribs is a layer called costal cartilage. This cartilage has a very poor blood supply and when the cartilage is inflamed or injured – such as during CPR it can take a long time to heal. Many patients are concerned as it can be hard to distinguish between heart pain and chest wall pain. A few ways of determining is chest wall pain has a very specific location, often you can point to the location where it hurts. This pain doesn’t travel. It can be brought on by specific movements, a stretch or a compression, where heart pains are more likely to come on with a physical or emotional stress, such as brisk exercise, and lessen when the activity is stopped. It is always recommended you discuss any concerns about chest discomfort with your healthcare practitioner.

Memory: 

Survivors also commonly deal with memory loss or delayed recall. Forgetfulness and/or a reduced ability to comprehend or problem-solve can lead to increased stress, anxiety, anger anddepression.

Medical Care :

  • external defibrillator – a vest worn for approximately 3 months which can deliver shocks when appropriate
  •  internal defibrillator these have their issues including inappropriate shocks, or not shocking when should due to lead issues. They also require batteries to be changed approximately every 5 years.
  •  AED   Some choose to simply have an AED around them at all times, of course you need to have people trained to use it, unless you are James Bond
  •  Ablation The irritable nerves are burned out of the heart, this sometimes requires a permanent pacemaker placed
  •  medications to lessen the chances or arrhythmia

Emotional:

Responses, coping, support, are each critical. Every persons responds differently. Some are extremely grateful and feel like each day is a bonus. Others live in a state of Post traumatic stress and are waiting and fearful for the next arrest to occur. Because depression, anxiety and post-traumatic stress disorder are common among people with implanted cardioverter defibrillators, healthcare providers should provide gender- and age-specific information on the potential psychological impact. Unfortunately these are areas that are rarely addressed or well comprehended by patients, who are in a state of emotional shock already from their recent health event and need time to process it all.

I recommend joining a support group or talking with a therapist to help cope with this. Below is a link to the Sudden Cardiac Arrest Association  and Sudden Cardiac Arrest Foundation which I think are some of the best support groups out there.  These include discussion forums, reflections, survivor stories. I have worked with many patients who have survived sudden cardiac arrest. Each has a unique story to tell, some are good and some are horrifying. A listening ear is one thing, but to get support from others who are living it is probably the best support one can get.

http://www.inspire.com/groups/sudden-cardiac-arrest-association/

http://www.sca-aware.org/about-the-sudden-cardiac-arrest-foundation

Support the Sudden Cardiac Arrest causes

https://www.facebook.com/thehbproject

   

ICD’s: Resources, Decision Making, and What to Know

An ICD is an implantable cardiac defibrillator. They are used for people who are high risk sudden cardiac death due to heart arrhythmias  of  ventricular tachycardia or ventricular fibrillation. They are often implanted as a preventative measure when the heart has a poor pumping ability as this makes one prone to arrhythmias. If the ejection fraction (pumping ability) is 30% or less and doesn’t show signs of improving your healthcare provider may consider implanting one.

Special care should be placed not to put excessive strain on the shoulder, arm and torso area where the ICD is implanted. Doing so may damage the ICD or the leads going from the unit to the patient’s heart. For this reason strength training with heavy repetitive weights is often discouraged. The exercises which would potentially damage the leads involves exercises with the arms overhead, such as a Military or shoulder press, seated fly’s,overhead triceps press. By heavy weights we are talking about weights upwards of 100 lbs or more with repeated repetitions and multiple sets. The wiring goes under the first rib, repeated bending and stress to the wires in this area can damage the leads. If your work involves this type of activity be sure to discuss this first with your cardiologist.

Exercise Advice:

  • Exercise with a friend or family member who is familiar with your condition and knows what to do in the event of an emergency.
  • If you exercise at high intensities, you should make sure you have a specific guideline from your cardiologist about your heart rate range. If the heart rate is too high the ICD may sense it as Ventricular Tachycardia. Wearing a heart rate monitor can help you to watch your heart rate range and avoid exercises that spike the heart rate up into the threshold in which the defibrillator is programmed to respond. Your Cardiologist can adjust your ICD settings to recognize the difference between a normal increase in heart rate from exercise and that associated with an abnormal heart rate or rhythm. You should include a low-level 5 to 10 minute warm-up and cool-down phase for aerobic exercise (i.e., walking, cycling) to allow for a slow and steady increase in heart rate.
  • The ICD can be affected by magnetic or electrical fields. You should avoid this and opt for something simpler such as the sum of skinfolds. Heart rate monitors are unlikely to cause any problems in the gym setting. Avoid Bio electric Impedance devices which are used to measure body fat.
Decision Making:
I came across a New York Times article “A Heart Quandry”  recently with the following information. It is something to consider for anyone with an ICD.         http://newoldage.blogs.nytimes.com/2012/06/07/a-heart-quandary/

Going against strong headwinds in his own community of heart specialists, Dr. Kramer emphasizes three important issues that come about when older patients with ICDs face battery depletion.

First, he asks heart doctors to re-evaluate whether the patient still benefits from the ICD. Perhaps, the original heart problem has improved?

Second, he points out that a patient’s experience living with the device may have changed their mind about keeping it active. Perhaps, a patient with inappropriate shocks no longer wants the device?

Third, since the original implant, a patient may have changed their goals of care. Many patients no longer desire life-sustaining shocks—for whatever reason. It’s their choice; but they aren’t often asked.

You may wonder why such obviousness isn’t the norm?

It’s because our healthcare system imparts significant barriers. Dr. Kramer nicely explains two important hurdles. One is that healthcare in the US is fragmented, especially for the infirmed and elderly. Patients may have many doctors, and care is often not well-coordinated. This means, an installer, a proceduralist like me, is left discussing end-of-life care with patients immediately before ICD surgery. That’s not good. I am married to a hospice doctor, so I sort of know how to manage these conversations. This is not the norm for procedure-oriented heart doctors. The other barrier to getting the elderly the best care is our system’s misguided incentives. In our current fee-for-service system, I am rewarded for doing, not discussing not doing. In fact, not doing stuff is very risky—both legally and professionally (ie. loss of referrals.)

Finally, Dr. Kramer and his colleagues call for heart doctors to take the lead in starting “the conversation” with ICD patients. He wants us to share the decision of using invasive, potentially dangerous or ineffective care with the patient. He also asks the scientific community to study the outcomes of patients who undergo elective ICD generator changes. These should not be controversial recommendations.

It’s a huge mistake to equate this kind of smart thinking to rationing. Aligning evidence-based care, especially potentially burdensome surgery in elderly patients, with the goals of the patient is not rationing.  It’s moral, ethical and obvious.

Resources:

There are issues with ICD that patients struggle with. These include the comfort of the ICD, the cosmetic appearance,the stress of having it fire, frequency of battery replacement, leads wearing out, and it working appropriately. I have included a few great resources to help you in living with an ICD.

Sudden Cardiac Arrest Association                     http://www.suddencardiacarrest.org/aws/SCAA/pt/sp/home_page

Powered by Inspire      https://www.inspire.com/groups/sudden-cardiac-arrest-association/topics/living-with-an-icd/

Boston Scientific       http://www.bostonscientific.com/lifebeat-online/live/icd-patients.html

Stress – Tools to help you Cope

When you get overwhelmed by the stresses that life throws at you how do you cope? Many people find they just don’t have good coping skills. They tend to obsess on the problem,  let it effect their mood and interactions for the entire day, or turn to alcohol or tobacco as a coping mechanism.

Stress is normal we will all encounter major stress. What I teach is to plan for how you are going to respond.  Will you let this stress effect your health? Will you allow it the ability to raise your blood pressure, to give you waves of anxiety? Will you breathe short and shallow?   Will your heart race?  Will you carry emotional burden all day?

Stress management is something many don’t give enough time or thought to. I like to look at it as a tool box full of different tools. If you never have used the tools in this box the chances are you won’t know how to use them when you really need them. For that reason stress management is something that is practiced. Kind of like child birth and Lamaze in order for that to work you need to practice.

Some of the initial tools to learn include:

Being in the present - if you are reflecting on past events – take a time out and be in the present. What around you is positive, is it the sunshine, the breeze, family, friends, a flower, a pet, a companion, a song…take the time to be in the present. Sure the past comes back, but if it is too much to bear and you can tell it is effecting your health be in the present.

Breathe - sounds like a cliche right? Well it isn’t. When we experience a major stress we often breath short and shallow only filling the top most portion of our lungs. Take a few deep cleansing breathes. Make your belly extend out when you breath in.  This is a great one to practice and use when you experience a health stress. If you are lying in the ER freaking out about what is happening and feeling powerless, use the breath. Focus on nothing more than taking a breathe in through your nose, feel the air as it travels down into your chest. Try and make it feel like you are bringing the breathe right down to your pelvis.Then slowly exhale out through your mouth. Listen to the sound, feel the cool air go in, and the warm air come out                                                                                    

Imaging  - This one is my favorite for when those stressors haunt me at night and I can’t sleep. Where are you peaceful? For me it’s at the beach. What do you see? What do you feel – warm, cold, a breeze, the warm sand, the cool sand below? What do you smell? What do you hear – the waves lapping the shore, the birds, children laughing.  Sure at first you hear the clock ticking and the voices in your head pulling you away from your peaceful place, but the more you practice this the better you are at tuning them out. Initially just stop and acknowledge the things breaking you away, but then go back to your peaceful spot. This is a great one to practice during medical procedures, it helps to keep your heart rate, blood pressure and respiration rate lower, and gives you a sense of control.  

Exercise -  This is a great form of stress management if you go about it right. Some people feel the need to work out like a mad man. This isn’t so good. When you do this the exercise creates a physical stress response, chances are your body already is responding physically to the other stress. Examples are your blood pressure tends to run higher, your heart rate and respirations are higher. Then you are going to exercise and drive these up even further.  This means you could be burning the candle at both ends. It is far better to take it a little easier than you would for a normal workout, maybe go a little longer, but keep the intensity backed down just slightly. Hit the weights afterwards, try some yoga stretches after – the yoga breath would be quite helpful as well. And while you exercise don’t focus on the stress or finding a solution. Be in the present, focus on the positives.

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Healing the Broken Heart

Healing the broken heart was shared with me by a patient I have known and worked with for years. She is a Women Heart advocate and an inspiring voice to heart disease.
What have you done for your heart today? Have you exercised? Did you eat oatmeal instead of pop tarts for breakfast? Did you take your beta blockers, ace inhibitors, diuretics, supplements or any of the host of pills they give us after our hearts to pot? Maybe you took your blood pressure and (God forbid) weighed yourself. Most of us have been around the block several times at our age. We know what we are supposed to be doing to keep our hearts healthy and functioning.
Well, let me tell you what I did for my heart today. I kissed my husband. I scratched the cat’s tummy till she purred. I smiled at an old man in the grocery store till he winked back. I went to my Tai Chi class, not for exercise, but for the pure joy of movement and good conversation. I came here to talk to you. These are all things I do for my heart.
I had my first heart attack at 45, second at 48, my third was at 51 and then my heart began to fail. The first two attacks were fairly mild and since no obvious reason could be found for them, I simply went on with my life as usual. Each time they offered cardiac rehabilitation, but I felt I didn’t have time for it. I was active, why go to a gym?
Then at 51, I didn’t recover as quickly. My heart never settled back into a normal rhythm and was weak. Within a few days I was passing out in the grocery store. Once, while running the vacuum, My heart went into a rhythm that could no longer sustain life and I went out. I don’t remember falling, but I did. I woke up on the floor, lying across the Hoover with a lump on my head and a bruise, already starting to purple across my chest. I am probably the only woman you will meet who was saved by a vacuum cleaner.
I was so lucky. The doctor believed that when I fell, my chest hitting the vacuum jarred my heart back to beating. The problem was, I didn’t feel very lucky. Within days, I was in the hospital again having a pace maker-defibrillator installed, my ejection fraction, even with the assist of the device was down around 20 percent . I thought life was over and was heartbroken.
This time I was not given a choice about cardiac rehab. I was going on my own or my family would drag me down there. My first day was humiliating. I was the youngest person in the room who did not work there and one of only two women. Ten minutes on the treadmill exhausted me, but I went back two days later. And two days after that and two days after that. That was five years ago next week. I’m still going.
The ICD, the handful of daily meds the structured exercise all started to work. My body was coming back. Even though I was told repeatedly that the exercise was good and would help my heart, I should not expect it to improve my ejection fraction. My heart remained broken. Every time I thought of my family going on without me, my heart ached. When I thought of the grandchildren I might never see, my heart was emptied of all joy. That year, when I put away the Christmas decorations (which by the way, neither of the men in the house had thought to do when I had the attack), I labeled each box carefully so that the next wife would know where they were supposed to be put up.
This is when I realized that there are two sides to every heart. The physical heart and the heart spirit. The Tao Te Ching and Zen practices teach that there are three distinct parts to every human being. The intellectual mind, the body and the spirit. For a person to be fully functional and live a happy life all three of these areas must be cared for and cultivated. The Judeo-Christians have a similar belief, only they refer to the spirit portion as the soul. Other cultures refer to this as the heart. We have all heard people say, “listen to your heart, loving with all your heart and of course, my heart is broken.”
The doctors, the medications, even cardiac rehab all work to take care of the physical heart. It heals, it becomes stronger and many of us live better than we did before our heart events. But the spirit heart is seldom addressed. It is perfectly normal to experience depression after a heart attack or surgery. In fact it is part of the stages of recovery. Your mind, body and soul have been through a great shock. You know your life will be different; you may even be a little embarrassed by the fact that your heart “failed you”.
Stop.
Stop and take a look at that inner heart. The spirit heart, the heart of your soul. What makes it sing? What lifts it up and makes it soar. Find that which fills your heart with joy and lights up the darkest night. It may be as complicated as going back to school to learn something you always wanted to. It may be relearning to ice skate after 23 years. It may be as simple as kissing your husband of flirting with an old man at the grocery store.
A woman’s heart is a tender thing. She is the heart of her household and she carries the hearts of all her family in hers. If her heart is healthy, she does not suffer alone. Take time to heal this inner heart and make it strong and shinning again.
Now, back to my story. Within two years of my rebirthday (that’s the day they implanted the ICD and I began to live again) my ejection fraction was nearly normal and I had lost 70 pounds. No one can tell me why my heart improved so much. There is no scientific explanation. My doctor shrugs his shoulders and says I should be very grateful. It was a fluke. It’s not a fluke, it’s a combination of hard work, medication and bionics, the support of my family and friends and a heart no longer broken.
Five years later, here I am. I wore out the first pacemaker and am my second. I come to cardiac rehab, teach an aerobic class, ice skate, study Tai Chi, and belly dance. Recently, I have taken my soul on a journey into Eastern religion and philosophy. Life is good. It is filled with activity and joy. I plan on using both sides of my heart as long as I can.
Now, what are YOU going to do for your heart today?