CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
2/1/2001

Your Heart Medicines and What They Do For You

The heart is a muscle. It is a bag made out of muscle. The bag squeezes shut to pump out the blood about 60 to 80 times a minute when a person is at rest. Each heartbeat pumps about one-quarter of a glass of blood. When a person cranks up and works harder, the heart may run at 150 times per minute or 2-1/2 times a second. It is quite a consideration to think about trying to fill the heart up and empty it 2-1/2 times a second with one-quarter of a glass of blood each time.  The most common things that go wrong with the heart fall into three types. First and by far the commonest disease in our society is blocks that happen in the arteries that supply the heart muscle itself. When these arteries get blocked off from too much cholesterol and other problems, not enough blood goes to the heart to let it do its work, and this is the cause of what is called the heart attack. We have a number of medications that reverse the blocking of the arteries to prevent heart attacks.

The second type of problem that hearts develop has to do with weakening of the heart muscle. This can come from a variety of different diseases or can occur because the heart muscle does not get enough blood to let it do its work. Sometimes, the artery problem mentioned above and the weakening of the heart muscle are related problems.

The third type of problem that hearts get into is difficulty with the rhythm of the heartbeat. Hearts are supposed to beat on a regular basis with a certain period in which the heart fills followed by the squeezing shut of the heart so that it empties. When this rhythm becomes irregular or too fast or too slow, then the amount of blood that the heart pumps is decreased and the person feels terrible. They often will break out in a sweat, feel faint, become nauseated and/or pass out. Probably the most common cause of a person passing out over the age of 50 is a problem with the rhythm of the heart.

Beginning with the heart medicines that treat heart artery problems (coronary artery disease) it is estimated that 95% of heart attacks that occur in the United States are related to high blood pressure, cigarette smoking, diabetes mellitus and high blood cholesterol. (Stopping smoking cigarettes does not require medication although there are medications that help a person stop a cigarette habit. Stopping smoking would decrease the national heart attack rate by one­third.) High blood pressure can be effectively treated with a number of different medications. Somehow, taking the pressure that the heart has to pump against down to the normal range protects the arteries and prevents those arteries from getting clogs in them. There are 10 different classes of blood pressure medications, and they are best used with small doses of several different classes rather than a large dose of one class. There are several medications that help lower blood cholesterol. Anyone who has tried to lower their cholesterol through diet and exercise have most generally been terribly disappointed because it is a lot of willpower and a lot of work with darn little return in lowering cholesterol. Unfortunately, high blood cholesterol is primarily a genetic problem and medications will generally be required to get the blood cholesterol down in a safe range. In the past 10 years, the "statin" family of medications has been shown not only to lower the blood cholesterol but also to decrease the heart attack rate very substantially in the people who use these medications. Various other cholesterol-lowering medications are available and they also have demonstrated effect in lowering the heart attack rate. Unfortunately, they must be used continuously in order to be effective. Simply taking them for several weeks to get the cholesterol down and then stopping the medication is no use.   The cholesterol goes right back up and the problem is recurrent.

The last group of medications used to treat coronary artery disease are the diabetic medications. Surprisingly, insulin has no major benefit in preventing heart attacks although it does keep blood sugars lower. There are now several medications on the market that do effectively treat diabetes and lower the heart attack rate in people with diabetes.

The second broad group of medications used to treat heart problems address the question of helping the heart become more efficient in pumping blood. In the past, the Great American Way (as always) was to try to make the heart stronger so that it would beat better for a longer period of time. Thus, the strategy was to provide medications to create a stronger heart. This strategy has been tested now for 40 years and just does not work. Any medications that made the heart stronger resulted in a greater strain on the heart, it wore out quicker and the mortality rate in people with that therapeutic strategy was higher than in the patients that were not treated at all. Then some bright individual came along and said, "If flogging a failing heart does not help, let's see if we can give a heart less work to do so it will last longer."  This strategy works. Three classes of medications called beta-blockers, angiotensin receptor blockers (ARB's), and ACE inhibitors all have demonstrated life saving effects and improvement in the quality of life for people who have heart failure. These medications unfortunately take months to have a significant effect but by six months after the medication has been started, there is a clear and definite difference in the functional state and the mortality in people who use these drugs as opposed to people who do not.

The last family of medications for hearts is directed to control the rhythm of the heart. One can think of the heart as having a clock that tells the heart when to beat. When the clock shorts out or runs too fast or runs too slow, there are medications that can be used to correct the problem. This group of medications is very complex. As an example of the type of problem we encounter, we just had a lady come into the hospital because she would awaken in the middle of the night in a drenching sweat, short of breath, with chest pain and her heart beating 160 times a minute. The heartbeat was very irregular. Because the heartbeat was so fast, the heart did not have time to fill up with blood. Thus, each heartbeat only put out a small amount of blood. She was given medications to slow the heart rate and make it more regular. Unfortunately, as sometimes happens, this resulted in the heartbeat going too slow. When her heartbeat got below 40 beats a minute, it just did not go fast enough to keep her body going so she needed a pacemaker which was placed at St. Mary's Hospital in Pierre. Now the medicine that was given to her to keep her heart from going too fast could be safely given without the danger of her heart going too slow and she has returned home to a normal life.

The healthcare providers at your local clinic are well versed in the above information. They can help adjust medications and initiate appropriate interventions when necessary. Consultations with a cardiologist are obtained frequently to "get their blessing" on the treatments that are being provided or to adjust the treatment appropriately.

Heart disease is the leading cause of death in the United States. It is responsible for the death of one in every four people. The health care providers at your local clinic take this problem very seriously and urge you to do the same. I have had many patients tell me that there are things that are worse than dying; taking care of your heart can prevent some of these. Most specifically, sitting in a chair, short of breath and so weak that you cannot do anything, lacks significant recreational value. Please take your heart problems seriously.