The heart fails slowly

19. December 2014

Head of the Cardiac Failure (CF) Centre of the East-Tallinn Central Hospital and cardiologist Tiina Uuetoa admits that people tend to underestimate cardiac failure and don’t realise that it should be taken very seriously, as it’s comparable to cancer in terms of severity.

The outlook of a patient with cardiac failure is poor – half of them only live for four years after being diagnosed.Forty percent of patients hospitalised with cardiac failure die or need repeated hospitalisation over a year.

Dr Uuetoa says that CF usually takes a long time to develop.It comes slowly, but it comes to stay.

CF is a chronic disease with exacerbations.The patient’s outlook deteriorates every time the chronic disease exacerbates.It results in frequent hospitalisation, shorter life and poor quality of life.

Dr Uuetoa adds that hospitalisation is the most expensive part of CF treatment.The cardiologist points out that whilst the US have left a big part of the outpatient treatment of CF patients on their own shoulders, the more emphatic Estonia has headed in the other direction and found the wealth to afford the establishment of an outpatient network for monitoring people suffering from chronic diseases, including patients with CF.

Two centres in Estonia

There are two cardiac failure centres in Estonia.Both of them are situated in Tallinn and the first of them, which was established six years ago, is in the central hospital.No separate centre has been established in Tartu yet.

Patients with cardiac failure reach the CF centre by different channels.In Estonia, family doctors refer patients to the centre, the hospitals keeps its own patients there for monitoring and sometimes patients arrive in other ways.“Large centres manage around a thousand patients every year,” says Uuetoa.

“Nurses play an important role in the outpatient treatment of CF, as they are the ones who monitor the patients.In many countries, nurses also have the right to write prescriptions, which is an optimal way of using resources.Every patient doesn’t necessarily have to see a doctor,” she adds.The nurse arranges for the patient to be referred to a specialist if necessary.

Uuetoa admits that there are also people suffering from cardiac failure who don’t really need to be in a cardiac failure centre and can easily be monitored by family doctors instead.“The general practice in the world is that patients with severe cardiac failure are the ones kept in the cardiac failure centres for monitoring,” continues Uuetoa.“This is done until the patient only needs to make an appointment with a nurse once a month for a health check and is then sent home to continue with treatment.”If any signs for concern appear, the patient’s options are extraordinary hospitalisation, or an appointment with a specialist will be sent up for them within 48 hours.

It’s important to carry on living well

There are two directions for the treatment of patients with cardiac failure:one is the quality of life and the other is the outlook.“The modern therapy that we offer is closely related to outlook and in social terms, outlook often carries the information about how long the patient will live and how long they will be able to work,” says Uuetoa.Quality of life, however, is very important for the person themselves.“Sometimes we say that for some patients, the quality of life is the first treatment goal and the outlook is only in second place,” continues the cardiologist.For example, an 85-year-old patient for whom it’s important to remain social and cope by themselves, be free of pain and not gasping for air – their expectations of life are rather small and simple.They would like to live some more and want the time they have left to be as good as possible.Uuetoa says that conversations with patients and their relatives about treatment options are often very difficult and serious.The wish to have a life that’s worth living is usually top of the list for people.“Not one of the patients has put down their foot and said they’ll be around for another 50 years.Instead, they tend to set themselves simple goals like their children finishing school or getting married – they want to see these things,” she adds.

Uuetoa admits that at the present, many things in Estonian medicine tend to be done by way of emergency care.“This, however, is the least smart and most expensive way of doing things,” she says.

Speaking about the compliance of patients, the cardiologist says that she’s saddened by how patients tend to underestimate the importance of medication, and some of them never start taking their pills properly.“Regular treatment is the first thing needed to keep the disease under control,” emphasises the doctor.

Many new technical options

Speaking of treatment options, Uuetoa says that many changes have occurred in modern medicine in recent years and many of the tools used to treat patients are increasingly more technical.For example, resynchronisation therapy is often used to treat patients with cardiac failure in addition to the classical combination of pills and intravenous treatment -In addition to the East-Tallinn Central Hospital, resynchronising pacemakers are also implanted at the regional hospital and the Tartu University Hospital.The purpose of these pacemakers is to achieve synchronised operation of the heart.“Just the fact that the left and right ventricle of the heart are made to work synchronously improves the patient’s outlook considerably” adds the cardiologist.

Heart transplants, or more specifically the existence of the necessary capacity in Estonia, is a more painful topic.Tiia Uuetoa finds that the best thing for Estonia when planning heart transplants should be cooperation with the other Baltic States or Helsinki, which is in fact the direction that the regional hospital has chosen for itself.

She also points out the quickly developing options of stem cell therapy.“Maybe planting stem cells in the heart will help us replace the so-called drowsy parts of the heart that don’t work with working tissue and the patient won’t even need a heart transplant.”However, this is all in the future.

The treatment of CF has become more complex over time, continues Uuetoa, and classic medication has become side-lined.For example, the classic CF drug digoxin is now used to support other treatment and is no longer the drug of first choice.

Find the cause

Uuetoa emphasises that cardiac failure is always a complication and never the primary diagnosis.“When someone is suffering from cardiac failure, the first thing I would say to family doctors is, ‘find what caused it’,” says the cardiologist.

Hypertension and diabetes are a very large group of CF causes.Another group of causes are myocardial infarction and cardiomyopathies, the causes of which are not known, and arrhythmia.“These patients may live with cardiac failure for years and when they suddenly develop acute arrhythmia, they become decompensated and end up in the care of doctors,” she says.

Lack of money is once again a problem for family doctors in Estonia.The cardiologist says that very sensitive markers detected in blood are used to diagnose CF in the world, which work by the yes/no principle, i.e. if the level has increased considerably, the patient has cardiac failure, and if there is no increase, the patient doesn’t have the condition.The same marker would point the family doctor in the right direction before a consultation with a cardiologist, ultrasound and other tests – it shows whether the patient has CF or whether they are suffering from other health problems.


Source:Health News