- The Washington Times - Monday, June 3, 2002

For more than 70 years, heart disease has been this nation's leading killer, claiming hundreds of thousands of lives annually.
No one is predicting this death toll which has exceeded 700,000 per year since 1965 will drop sharply anytime soon.
"We're doing everything we can. But it's going to linger," said Dr. Robert Bonow, president-elect of the American Heart Association. "The figures are plateauing. We'd like to see them decline dramatically."
Overall deaths from cardiac disease are dropping only slightly, at about 2 percent a year, while cancer mortality the nation's second-leading cause of death has been falling 6 percent a year, according to federal statistics.
"The population is aging, so as we get better at treating heart attacks and have survival at younger ages, a large number of Americans are living with damaged hearts that incrementally" lose effectiveness as the person gets up in years, he said in an interview.
Dr. Bonow sees a "dividend of saving people" in their 50s and 60s from death by myocardial infarction and other cardiovascular disorders. He said a large and growing population of patients in their 70s and older have symptoms such as shortness of breath, fatigue, cough, confusion and swollen ankles and feet, which they may or may not recognize are effects of an ailing heart.
Heart failure in the elderly more often is triggered or worsened by related medical problems than it is in younger patients.
"The incidence of heart failure is increasing," as "the longevity of heart attack patients is increasing," said Dr. Steven Kaufman, a cardiologist at the Washington Hospital Center.
Dr. Jay Cohn, a professor of medicine at the University of Minnesota Medical School and founder of the Heart Failure Society, agreed. "We've reduced mortality from heart attacks from 20 percent to 5 or 6 percent. But heart damage is progressive. Over a course of years, the heart damage [suffered by a heart-attack survivor] may progress to heart failure," he said in a telephone interview.
Dr. Cohn said heart failure is the "only cardiac disease that's growing." With "people getting older, we anticipate heart failure will grow rapidly," he said.

'Smoking is devastating'
The disorder is not necessarily as ominous as its name suggests. Heart failure does not mean a patient's heart stops pumping as it does in cardiac arrest. Instead, it means the heart is not pumping all the blood it should, so it is not working effectively.
This relatively new category of much older heart patients whose hearts are unable to pump enough blood to meet physical needs is one of a handful of reasons for the small 2 percent annual declines.
Other factors besides cardiac failure that doctors see as contributing to a continued plateauing of deaths from heart disease include the rise in obesity, the public's resistance to exercise, and a refusal by many teen-agers and young adults to heed anti-smoking messages.
"Smoking is devastating," Dr. Kaufman said.
Cardiac failure is the factor that has received the least public attention. President Bush declared February "Heart Failure Month." But most Americans are not acquainted with the disorder and doctors aren't always good about diagnosing it.

Hard to detect
Virgie Harris-Bovelle, a District-based psychotherapist, says that was her situation four years ago, when she experienced pain in her chest and her left shoulder and had to cut out most exercise because she found it exhausting.
Ms. Harris-Bovelle, who declined to reveal her age, said she had a heart attack in 1983. She says she was successfully treated with medication and a balloon angioplasty about six months after the heart attack.
"I did quite well" until those new symptoms developed in 1998, she said in an interview.
Ms. Harris-Bovelle said her regular cardiologist kept insisting nothing was wrong with her, even though her pain grew worse. She suffered dizzy spells and had a persistent cough. "One night I woke up in terrible pain and went to a hospital emergency room. The hospital admitted me, but my doctor wound up discharging me," she said.
Ms. Harris-Bovelle said she continued to feel "terrible" and visited her primary care physician, who said he thought she had pleurisy.
"I collapsed on the escalator right after leaving his office and returned to the hospital. This time my daughter called a new doctor," she said.
This physician and his professional colleagues diagnosed the patient as having congestive heart failure and arrhythmia and implanted a defibrillator in her chest. A defibrillator sends an electrical charge to the chest wall that converts an abnormal heart rhythm to a normal one and restores normal circulation.
Ms. Harris-Bovelle says that, at least on one occasion, the defibrillator "fired" and "saved my life."
Asked about her health today, she says: "I work every day. I do volunteer work for the American Heart Association. I have a very active life.
"It was quite an ordeal," Ms. Harris-Bovelle said. "But I have an excellent team of doctors now." She also said she has "learned to listen" to what her body tells her, rather than relying solely on a doctor's judgment.

Afflicting nearly 5 million
Nevertheless, the medications Ms. Harris-Bovelle needs to keep her healthy are a financial burden because she has no prescription drug coverage. "They cost $25,000 a year," she said.
According to the 1999 Harvard Medical School Family Health Guide, congestive heart failure (CHF) is one of the major causes of illness and disability in the United States and is the leading cause of hospitalization in people older than 65.
CHF afflicts nearly 5 million Americans, and the numbers are rising, especially among the elderly. Although heart attacks are decreasing, deaths from heart failure are increasing.
Between 1979 and 1998, the number of deaths from heart failure more than doubled: from 25,074 to 50,228, according to the National Center for Health Statistics. Of those, deaths from CHF climbed from fewer than 20,000 to nearly 47,000.
CHF can be caused by damage from heart attacks; prolonged high blood pressure; atherosclerosis, or a narrowing of blood vessels from high-fat, high-cholesterol diets; a primary disease of the heart muscle (cardiomyopathy); a disease of the heart valves, which control blood flow; or a congenital heart defect.
In CHF, the left ventricle of the heart and sometimes, the right ventricle begins failing as a pump. The left ventricle is responsible for pumping oxygen-rich blood to all parts of the body, except the lungs. The right ventricle's job is to pump blood low in oxygen into the lungs to make it oxygen-rich.
When the heart cannot pump enough blood, the body retains salt and water, and blood volume increases. The result is a backup of blood into the lungs and other tissues.
Early symptoms of CHF include difficulty in breathing especially when lying down and easy fatigue. The shortness of breath occurs when the blood backs up into the lungs. When blood backs up in veins, fluid starts to leak out of veins, causing swelling. Older people with CHF often display acute confusion.

Living with CHF
As Ms. Harris-Bovelle's case indicates, CHF is not an automatic death sentence. Treatments have improved significantly over the last decade. A patient's prognosis depends on the severity of the underlying medical condition and how fast he or she gets treated.
Robert F. Smith, 74, of Los Angeles has been living with CHF for seven years. As he has found out, it can develop in people with no previous history of heart disease. "I never had a heart attack, but seven years ago, I started getting shortness of breath," Mr. Smith, an ex-smoker, said in a telephone interview.
He takes a variety of prescription drugs to treat his heart disease, emphysema and high blood pressure, which was diagnosed more recently. "And I'm on oxygen therapy 24 hours a day," he said.
As Mr. Smith found out through back-to-back hospitalizations in January and February that CHF can make a patient more vulnerable to serious infections.
As for his current state of health, Mr. Smith said, "I feel pretty good. But physical exercise is exhausting. I know my doctor would love to see me run around the block, but that's not going to happen." However, Mr. Smith is able to drive and lives independently.
Heart specialists also continue to be worried about other risk factors for deaths by heart disease. Obesity and smoking each cause hundreds of thousands of deaths in the United States annually, and many of the victims die of heart disease.
According to published reports, the number of American men weighing more than 300 pounds has climbed by 50 percent since 1998: to one in 80 men. The number of women weighing more than 300 pounds has risen 67 percent in the past four years: to one in 200.
Dr. Bonow calls the increase in obesity alarming, since obesity is a risk factor for diabetes, which is a major risk factor for heart disease. Diabetics are four to five times more likely to suffer heart disease than non-diabetics.

Importance of exercise
Research published earlier this year found that poor physical fitness is a better predictor of death than other well-established risk factors, such as smoking, high blood pressure, heart disease, diabetes or high cholesterol.
Nearly a third of the approximately 6,000 older men in this study, conducted by doctors in the Veterans Affairs Palo Alto Health Care System in California, had suffered heart attacks. The study found that the least-fit patients gained the most in terms of improved survival because of regular exercise.
But the researchers acknowledge that getting Americans to exercise is a hard sell. They say 40 percent of the population does not exercise.
For years, U.S. surgeon generals have called smoking the "most preventable" cause of death in this country. The good news is that just 23 percent of the U.S. population now smokes down from 47 percent in the 1960s. The bad news is that a third of high-school seniors do so, according to a national report released in April.
Dr. Bonow said older Americans seem to be getting the message about the dangers of smoking, but teen-agers and young adults are not. New research from the University of Massachusetts found that adolescents can become addicted to smoking in just a few weeks.
The American Heart Association believes these are all areas that need to be addressed through stepped-up research and prevention efforts. The AHA is seeking $2.3 billion in federal funding for heart research and $316 million for stroke research in fiscal 2003. Those amounts would be up from $1.9 billion and $262 million in the current fiscal year.
Also, the AHA wants an additional $240 million for federal prevention programs in the next fiscal year that starts Oct. 1.
Dr. Bonow says federal money for heart and stroke research has been "inadequate" and "below what is needed to counter the burden these diseases impose on the nation."
While nearly 900,000 Americans died from heart disease or stroke in 2000, according to the National Center for Health Statistics, Dr. Bonow noted that "nearly 62 million Americans about one person in five are living with the often debilitating consequences of these diseases."
Dr. Stephen Epstein, executive director of the Cardiovascular Research Institute at Washington Hospital Center, has been involved in some of the most promising heart disease research in recent years. He has pioneered the concept that infection or inflammation is a factor in some heart disease. He has also used gene therapy to grow new blood vessels for pigs and mice whose severely narrowed vessels put them at risk for heart attacks.
"We've experienced a wonder of therapeutic advances in the last few decades, and I think the major breakthroughs in therapy have been made," he said.
The list of "major breakthroughs" in procedures, devices and medications include pacemakers, open-heart surgery, balloon angioplasty, heart transplants, artificial hearts and drugs that can interrupt heart attacks or strokes.
"Now there will be a lot of hard work to develop innovative approaches to bring down mortality [rates]," said Dr. Epstein.
When pressed, he says those "innovative approaches" also could be major breakthroughs and that gene therapy could be available in the next five years to grow new blood vessels in humans whose narrow, constricted veins and arteries put them at increased risk for cardiovascular disease.
It's a strategy that would eliminate the need for balloon angioplasty, which often has to be repeated, Dr. Epstein said.
Within the decade, he said, stem-cell therapy will be available "to grow new heart muscle" in those "who have had heart attacks, whose hearts have filled with scar tissue."
Such approaches, said Dr. Epstein, "would absolutely decrease mortality" from heart disease.

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