Heart Of The Matter: Treating The Disease Instead Of The Person

by LEANA WEN

June 25, 201411:05 AM ET

Maria Fabrizio for NPR

A 56-year-old man is having lunch with his wife at a seafood restaurant just outside Boston when he develops crushing chest pain. He refuses an ambulance, so the man’s wife drives him to the ER.

What happens next says a lot about the difference that being a doctor or a patient can make in how one feels about the health care system.

First, how did the patient and his wife see the trip to the hospital?

When the man arrives in the ER, he is told to take off his shirt. He lies in the hallway, in pain, naked from the waist up. Strangers surround him. They don’t introduce themselves, and they talk over him, at each other.

Pagers ring and there’s a lot of beeping. Someone else must be really sick, he thinks; that must be why no one is paying attention.

After a few minutes, he signs some forms and finds himself being wheeled into an elevator. Masked figures enter. He feels a cool liquid flowing into his veins. The lights go out.

He wakes up hooked up to machines, uncertain what has happened. It takes several hours for the staff to find his wife, who is still waiting in the ER lobby and has no idea why her husband is in intensive care.

They are both surprised when they find out, two days later, that he’s had a heart attack. As soon as they get home, they file a complaint with the hospital about their terrible experience.

Now, how did the staff at the hospital see it?

A triage nurse greets the patient immediately upon his arrival and finds out that he has chest pain. Within three minutes, he gets an electrocardiogram that shows he is having a heart attack. The ER doctor activates the special heart attack pager, which immediately summons the emergency cardiology team.

The doctors and nurses arrive and bring the patient up to the catheterization suite. There, the attending cardiologist threads a catheter through an artery in his groin and pushes it all the way to his heart, where the doctor sees on an X-ray machine that a vessel is blocked. She inflates a small balloon in the catheter, opening the artery and restoring the flow of blood to the man’s heart.

All told, it took only 22 minutes from the time the man entered the hospital for the cardiology team to clear the blockage. The cardiology team is proud that they beat the national averagefor what they call door-to-balloon time by 42 minutes. The faster a blockage can be cleared, the better the odds are for a full recovery.

The patient gets well without complications. Two weeks later, he’s back at work and exercising again. The ER and cardiology teams consider the man’s case a resounding success.

Why then are there such different views of the same ER visit? Who’s right? The doctors who believe they delivered exemplary care, or the patient and his wife who feel he was treated badly?

As an emergency physician and advocate for my patients, I frequently hear clashing stories like these. When I review the cases, I find that the doctors and nurses are often surprised by the patient’s complaint because they did everything by the book and made no medical mistakes.

Indeed, in this case, every measure of sound medical care was met: prompt diagnosis, speedy and effective treatment and an uneventful, full recovery.

The objective measures that health care workers focus on are necessary, but they’re not enough by themselves. Every provider in this man’s case had good intentions and was working hard to respond to the medical emergency. But in their rush to open the blocked heart artery, they treated him as a disease to be cured, not a person to be cared for.

Would it have alleviated the patient’s anxiety for the doctors and nurses to introduce themselves, and to ask if he wanted his wife by his side? Would it have helped to assure him that all the activity was happening around him because everyone was trying to take care of him?

I think those simple courtesies would have made a difference.

These instructions aren’t on typical checklists for treatment of heart attack, yet they are part of caring for people as human beings. In modern medicine, we are fortunate to have incredible high-tech options available, but we must not forget the low-tech approaches that can improve communication and quality of care.

Patients and family members can also speak up when they are confused and scared. It’s possible that doctors explained what was happening, but not clearly enough.

What if the patient said he didn’t understand what was going on? What problems could have been avoided if the patient and his wife didn’t wait until after he was discharged to raise their concerns?

The two viewpoints of this ER visit end with one thing in common. Just as the providers were surprised by the patient’s complaint, the patient and his wife were taken aback when the team that I was part of presented them with their doctors’ point of view.

“We had no idea they were trying so hard,” the man said. “It’s too bad we didn’t know that at the time.”

Wen is an attending physician and director of patient-centered care research in the Department of Emergency Medicine at George Washington University. She is the author of“When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Care,” and founder of Who’s My Doctor, a project to encourage transparency in medicine.

Source:  http://www.npr.org/blogs/health/2014/06/25/324005981/heart-of-the-matter-treating-the-disease-instead-of-the-person?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20140625

Congestive Heart Failure and Cardiac Rehabilitation

Cardiac Rehab programs now open to heart failure patients

 

Many who could benefit from attending cardiac rehabilitation didn’t have a coverable diagnosis. Yes they had significant heart disease with congestive heart failure, but were not covered to attend rehabilitation. For many years I assisted in fighting to get this coverage. It is wonderful to see it finally here. This opens access to many patients who would benefit from exercise, lifestyle intervention, education, prevention and managing of their chronic heart disease.

Congestive Heart Failure Patients finally Get Cardiac Rehabilitation

Congestive Heart Failure Patients finally Get Cardiac Rehabilitation

This is great news. I worked for many years petitioning our Congress and Senate to urge CMS to cover Cardiac Rehabilitation services for Congestive Heart Failure patients. There is a large subset of patients who can be much better served and monitored through cardiac rehabilitation to prevent readmissions. Congratulations to the AACVPR for helping attain this coverage from CMS, that is a very big deal.

 

 

 

WASHINGTON — Medicare has proposed covering cardiac rehabilitation services for patients with chronic heart failure 4 years after saying there was little evidence to support doing so.

The proposed coverage decision would expand access to rehab for a wider range of heart patients. Medicare currently covers rehab only for patients who have had an acute MI in the preceding year, coronary artery bypass surgery, heart or heart-lung transplant, or other major events.

The Centers for Medicare and Medicaid Services (CMS) came to the determination after reviewing literature on the rehab service from 2006 to August 2013. It announced the decision online late last week.

“Since chronic heart failure often results from coronary artery disease and hypertension, evidence on behavioral interventions in the treatment of these conditions provide additional supportive evidence,” the agency wrote. “With the accumulated evidence that supports the benefits of the individual components of cardiac rehabilitation programs, the evidence is sufficient to determine that participation in these multi-component programs improves health outcomes for Medicare beneficiaries with chronic heart failure.”

The agency is seeking public comments on the proposed decision and will post a final determination later.

Under the proposal, the agency would pay for rehab services — exercise, behavioral risk factor reduction, health education, and personal counseling — for patients with left ventricular ejection fraction of 35% or less and New York Heart Association class II to IV symptoms with at least 6 weeks of heart failure therapy.

The American Heart Association praised the CMS announcement.

“We are gratified that the agency recognized the evidence that pointed to the need for this expansion, and look forward to the day when this coverage will enable millions of heart failure patients to reap the benefits of cardiac rehabilitation,” AHA President Mariell Jessup, MD, said in a statement.

The AHA, along with the American College of Cardiology, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the Heart Failure Society of America had asked CMS to consider adding CHF for coverage of cardiac rehab.

The CMS decision follows a study of nearly 2,300 patients that showed that aerobic exercise is safe for heart failure patients and effectively improves clinical outcomes. The patient population CMS is including is effectively the same as that in the trial, Ileana Pina, MD, professor at Albert Einstein College of Medicine in the Bronx, N.Y., told MedPage Today in a phone interview.

“Even though we knew all the good things exercise can do, a lot of physicians were not recommending it because the patients would have to pay out of pocket to go to a cardiac rehab program,” Pina, vice chair of the clinical cardiology council at the AHA, said.

She said many patients without this rehab option end up going to skilled nursing facilities because of their condition.

Roughly 17% of those age 65 and older have heart failure, according to CMS.

Resource for Heart Failure

http://www.heartfailurematters.org/EN/Warning-signs/Warning-signs

 

Below is some of the content from the above listed web site. It is a great resource for helping heart patients to understand the warning signs of heart failure and the actions to take. If you are a heart patient, or the significant other/caregiver take the time to review this site. It is important sometimes the symptoms sneak up on you.

 

 

Heart failure can be managed well with the right treatment and lifestyle adjustments, as recommended by your doctor or nurse. However, it is important to monitor all your symptoms on a regular basis as heart failure can progress slowly.

 

You can use the list on the left or any of the links below to learn more about the symptoms you should be monitoring and what to do if they get worse.

 

You should call for help immediately if you experience:

 

Persistent Chest pain that is not relieved by glyceryl trinitrate (GTN / nitroglycerin)

Severe and persistent shortness of breath

Fainting

 

You should inform your doctor as soon as possible if you experience:

 

Increasing shortness of breath

 

Frequent awakenings due to shortness of breath

 

Needing more pillows to sleep comfortably

 

Rapid heart rate or worsening palpitations

 

And you should discuss any of the symptoms below with your doctor or nurse.

 

Rapid weight gain

 

Progressive swelling or pain in the abdomen

 

Increased swelling of the legs or ankles

 

Loss of appetite/nausea

 

Increasing fatigue

 

Worsening cough

 

To help you monitor your symptoms, please click on the links below to find useful resources that you can download, print and fill in. You can then take these with you when you see your doctor or nurse and discuss your symptoms.

 

Symptom and event diary

 

Monitoring your heart failure chart

 

Warning signs leaflet

 

 

 

Exercising with heart disease

Start slow and add a little more over time. Make it feel  as if when finished feel like you could have done more easily. Begin exercising at this intensity for several sessions before making large increases in your intensity or effort required to be physically active. . Remember the whole goal is to adapt, and by doing so the body is changing how it responds. In the early recovery stage  the exercise prescription is very light. Do you know What exercise prescription is best for you?

Since exercise should be part of your everyday routine in order to make it a lifelong habit  injury avoidance is important to be aware of overuse signs and symptoms, to rest those muscles when needed.  Occasionally cardiovascular disease patients develop Peripheral Artery Disease and symptoms can present similarly to overuse. Pain should signal the body to be aware that something is going on.  Take some time to evaluate that pain, what happens with it, does it always come on at a certain time or point of the exercise or activity? How long does it take to go away? Can it be avoided while being active by another means for instance switching from walking to biking?  Make sure you communicate these findings with your healthcare practitioner as they could be signals of other health conditions related to heart disease and it’s recovery.

Some exercise and activity is better than none, so start slowly. Even a warmup is better than no exercise session here is why  warming up before strenuous activity helps your heart.

Don’t expect results overnight, but do take small steps each day. Move that blood around, push it through the muscles. Make the muscles use the oxygen in the blood  more efficiently. Exercise helps the the heart recover and stay strong.

You might not notice any big changes—especially in your weight—for a few weeks or even months. It is still good for your heart health! It is not all about weight loss. Forget the scale for a while. In fact many who initially start to exercise following hospitalization are  Sedentary at the start and will gain a couple of pounds. It is their muscles getting pumped up, holding and utilizing more blood flow. Generally the focus on how you feel.

 When not to exercise is if you are presenting with Signs and symptoms of heart problems. Exercise should be avoided if  if you are presenting with congestive heart failure, or are presently sick. When returning to exercise following illness 

Symptoms to be alert for include these.

Do You Know Your Heart’s Ejection Fraction?

Today I ran into a young woman I assisted in Cardiac Rehabilitation after she had a heart incident. One of the first things she said to me with a smile on her face was that her ejection fraction had increased from 15% to 55%. This means her heart essentially is functioning within normal limits of 50%-70%  in it’s pumping ability. She went on to tell me she was off to go snowshoeing in the woods. I was so proud, as working with patients over time you learn and share a lot about your lives, and for her this was huge!

Ejection fraction is a measurement of the percentage of blood leaving your heart each time it contracts.

When the heart beats, it contracts or squeezes and then relaxes. During heart contraction, it pushes the blood within the pumping chamber  out. When your heart relaxes, the chambers or ventricles refill with blood. No matter how forceful the contraction, it doesn’t empty all of the blood out of a ventricle. The term “ejection fraction” refers to the percentage of blood that’s pumped out of a filled ventricle with each heartbeat.

A normal LV ejection fraction is 55 to 70 percent. The ejection fraction may decrease if:

• A heart attack has damaged the heart muscle such that it cannot forcefully contract
• The valves of the heart are not working properly
• Blood pressure has been uncontrolled  for a long period of time
•  Weakness of the heart muscle, such as dilated cardiomyopathy

I get great gratification in this patient announcing this for another reason. I have a history of arguing with cardiologist about teaching patients their heart’s condition by reading their medical reports with them. As part of the intake to cardiac rehabilitation the charts are reviewed so both the patients and the clinicians have a solid understanding of their heart condition and the plan to manage the heart condition. Many patients enter rehabilitation with their last echo cardiogram or other studies showing the patient has a severely reduced ejection fraction. Some people will always have a reduced ejection fraction and others will recover depending on the severity of condition. A late presenting large heart attack may have permanently reduced pumping ability of the heart, where as a stent placed early in a heart attack may improve within a very short time. Other conditions slowly change over time, getting better or worse these include hearts that have cardiomyopathy, or pacemakers.

I believe heart patient’s understanding of their ejection fraction an important part of managing their health. The cardiologist was worried I would scare his patients.  The cardiologist  felt people would psychologically not improve if they knew their ejection fraction was low.  Many people with a reduced ejection fraction will not have any significant functional limitations or symptoms. I have worked with people with ejection fractions in the 8-10% who can function pretty normal including performing weight or resistance training exercises. On the other hand some folks with an ejection fraction of 30-40% can feel symptoms of fatigue or shortness of breath with mild exertion.

For many through building structured exercise they can improve the muscular strength of their body thus reducing the effort the heart has to work to meet the demands for oxygenated blood. Exercise does improve the ejection fraction in many studies, but if it doesn’t it still  improves the functional ability and quality of life of most individuals. Cardiac Rehabilitation programs often will note  an improvement in patients  ejection fraction. It is typical to undergo echo cardiogram studies approximately three month post intervention or event. I believe it is more of an insurance reimbursement issue which makes  most scheduling occur at 3 months post, but also gives the heart time to recover and medical management to be fully effective, and this is typically how long a cardiac rehabilitation program lasts.

When the overeager patient comes in and wants to give themselves a workout equivalent to a stress test on their first few sessions  of cardiac rehabilitation to prove to themselves they are ok,  we will  use information such as their ejection fraction to determine  and educate how much effort they should safely perform.  Then there is the  scared patient who has been living with a reduced ejection fraction and had short of breath and  gets a bi-ventricular pacemaker  the cardiac rehabilitation staff encourages them to increase their workloads as their ejection fraction is likely much improved and now can feel safe pushing the intensity. Reviewing this information with you healthcare provider can help you to understand your heart and any limitations it may have.

Read more about ejection fraction here