Senior Consultant Cardiologist
Sir Ganga Ram Hospital, New Delhi
</b> Ladies and gentleman, we have very important personality all the way from Delhi, Professor S. C. Manchanda, who needs no introduction to the audience. He is a speaker par excellence, a philosopher par excellence and author par excellence. The subject of our discussion and introduction with Professor S. C. Manchanda is on heart failure. Dr. Manchanda had been HOD of All India Institute of Medical Sciences. He is a teacher of teachers. So let us see what he has to give a message on the heart failure.Dr. Manchanda we see a lot of heart failure these days because of rising problems of obesity, metabolic syndrome, people are living longer, having hypertension, diabetes mellitus and there are doing a lot of interventions especially coronary interventions or a pacemakers. So we see diastolic heart failure as well as systolic heart failure. These patients have to be very meticulously managed both by nonpharmacological methods and pharmacological methods and of course some patient may need a surgical or mechanical intervention also. My main question to you is what are the nonpharmacological methods by which we can help these patients so that they do not go into a recurrent or a repeated heart failure? Diastolic more these days as compared to systolic.
</b> Dr. Chopra, you are very right. The incidence of heart failure is not coming down. This is one disease which is increasing in spite of all the preventive and therapeutic measures and this is because we are doing lot of interventions, but the end-stage of most of them is heart failure and heart failure is a very bad prognosis. It can be managed both without drugs and with drugs. Without drugs are very important, nonpharmacological methods. The first thing is you have to decrease the salt intake of these patients, because salt causes more retention of fluid. I also advise all these patients that they should take their weight every day because they have to pass lot of urine, etc. and the weight record tells us how much diuresis they are doing. So the diet is very important, low-salt diet and if they are having disease like coronary artery you have take the other precautions also. The second thing you have to do is exercise. It may look paradoxical, but it has been clearly shown that gradually increasing exercise reduces the incidences of heart failure. If they are having other risk factors like if they are smoking, if they are over weight, they should stop smoking. They should cause the reduction. There are some studies on yoga meditation also which has been shown that meditation can improve the ejection fraction and reduce the incidence of heart failure and also. These are the non pharmacological methods which can be extremely useful. I would suggest that the weight record every day is a very important parameter which tells them whether they are improving or not. If the weight increases, this means fluid is retaining more.
</b> About the drug treatment, what are your words?
</b> Well, there are as you said two types of heart failure, one is systolic heart failure and for that the treatment is quite advanced and they have been several advances. For diastolic heart failure, still we do not have enough drugs. For systolic heart failure, there are three drugs which have been shown to decrease the mortality and these three drugs are ACE inhibitors or ARBs, the second are the beta blockers and the third are some diuretics of aldosterone antagonist. They all have been shown to decrease the mortality. All these patients must also give diuretics because they retain lot of fluids, etc. So these are the drug treatments for these patients and this has saved large number of lives if the drugs are used probably.
</b> Do the statins really help in diastolic heart failure. There is a lot of words people talk of beta blocks and statins in the diastolic heart failure, does it really help?
</b> Well, the management of heart failure is still far from satisfactory. Beta blockers have been tried, but outcome studies have not shown, calcium channel blocker have been in some cases it do. There was a study with spironolactone also which shows, but I think the treatment of diastolic heart failure still has to be evolved. So many things are being said, but we do not know much about diastolic heart failure treatment.
</b> New drugs which are used these days are neprilysin or amrinone in these patients and there is a lot of data coming up with favorable response on neprilysin. Just last month, we had a conference in Indore on heart failure. People talk of these new drug. It is too early I know, we do not have much data, but some initiation or a beginning data or pilot data is already available. What are your views on it?
</b> I think this is a drug which has been found to be extremely useful reducing mortality in addition to the three drugs that I have already mentioned. This drug has not come in India as yet, but I think these several trials I have shown that this could also decrease mortality. So I think this drug could be added to the existing armamentarium and this could reduce the heart failure mortality further.
</b> We would like to have some words from you with lot of people using these days especially in the end-stage heart failure or in what we call as acute decompensated heart failure ADHF various modalities like even they use ECMO or they use some kind of diuresis in these patients and they also use some kind of devices in these patients when that also failed the subjects on the patient with a heart transplant. What are your views on this?
</b> Yes, I think if the heart failure is not controlled or is resistant then there are various techniques done. Sometimes we call in our country we call these patients weekly for a dobutamine infusion they improved slightly, but then they are improved with large number of devices which are available,which are not really very-very cheap in our country and they are usually use as bridge to transplants. As you said, surgery is also very important. Certain patients of mitral stenosis are very well narrowed they will be completely cured by that. The other devices which are used are the cardiac transplant is the final, but before that one can use some left or right hear assist devices, which are costly and cannot be used for a long time, but heart transplant is the final treatment for irreversible heart failure. This is being done in India. Now many centers are doing it with a reasonable result, but there is a big waiting list all over the world and all. So far, one has not been able to make artificial heart, but the progression is on. Electrophysiological studies also sometimes can help. For example CRT, there is a pacemaker which can also help resistant cases of heart failure, but that can be done in certain cases. Sometimes ICD is also used with this CRTD it is called, because most of the patients die of sudden cardiac death. So ICD is also recommended especially if they have a myocardial infarction after 40 days. If ejection fraction is low or if they are again ectopics then they should have an ICD to prevent sudden death and they should have CRT to improve the function.
</b> I see the message is very clearly by Dr. Manchanda. He said that most of the patient of heart failure whether systolic or diastolic heart failure also have some kind of dyssynchrony, may be interventricular dyssynchrony or intraventricular dyssynchrony or atrioventricular dyssynchrony or even a global dyssynchrony by 3D echo and these are the patients who need CRT. It can be CRTD or CRT based on the variables what we get and they are to be very meticulously followed and the data is more favorable. Dr. Manchanda also said that we have got an assist device, LV assist device or many assist devices are there by which we can rarely improve the morbidity and mortality in these patients and heart transplant. The first transplant was done in Delhi, All India Institute of Medical Sciences and subsequently it is in Chennai. Many heart transplants are done now more than 500. If you see in Chennai or Hyderabad or many other places people are doing it now and in the years to come I think this modality also need to be more explored so that our patients are benefited especially who are young in 20s or 30s, we are losing them. The only problem is a donor. You want to give any comment on the donation of the heart. Is it easy, practical, legally, ethically, morally?
</b> The definition of death was by the parliament when I was in All India Institute about 15 years back. So it is very easy and I think the message would be spread that a dying person can give life to seven people. You see for example, heart can be transferred, both the lungs can be transferred, of course the eyes, the both the kidneys and the liver. So I think this message should go and more and more people are accepting it now. We have a very good arrangement in our country now that if there is a donor available there are very faster either aeroplanes or the ambulances which take them free of traffic and daily police and several other police; in Chennai, they could transfer the heart within half-an-hour from several miles and also. I think the progress is very good in our country for cardiac transplant.
</b> So to conclude ladies and gentleman, the message is very clear. Heart failure menace is rising in our country. The time to act is now and to create an impact globally if you want to act meticulously locally. I think Dr. Manchanda has given a very right method. The nonpharmacological method has to be adopted throughout in the form of a salt restriction, in the form of nonsmoking, in the form of weight reduction and of course he mentioned the role of yoga and psychological or behavioral or relaxation techniques which cannot be surpassed. They are very-very important and beside that there are some drugs like ACE inhibitors, beta blockers, even the ARBs people are using these days and diuretics are the real hallmark of the treatment and he also mentioned about the role of mechanical device and surgical device used for systolic and diastolic heart failure and his message was very clear that the diastolic heart failure is becoming more than systolic heart failure because of more obesity. We are very grateful to you sir for giving a message and I am sure with this message, new ideas will emerge, new therapies will emerge and we will be able to have a community meticulously.
</b> Best strategy will be prevention. We should try to prevent the diseases which cause coronary artery disease, valvular diseases and finally detect them at early stage and treat them early. Prevention is the best strategy.
</b> So early diagnosis, early treatment is the answer and the strategy which should be adopted as expressed by Professor S.C. Manchanda. Thank you very much sir.