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FirstHealth of the Carolinas
Heart 101

Maybe it’s because all the other organs— vital and otherwise—depend on the heart to circulate life-sustaining blood.

Or maybe it’s because, unlike most other organs, the heart can be felt and sometimes heard beating in the chest.

Or because poets and philosophers through the ages have used the heart as a symbol for the soul, portraying it as the place where goodness, love and courage reside.

Whatever the reason, the heart holds a special place in our, well, in our hearts. We know that as long as it keeps working, we are alive, and that when it stops …

This year, and every year, more Americans will die from heart disease than from any other cause. It is the biggest killer of both men and women.

When something goes wrong
Romantic depictions notwithstanding, the heart is actually a large, tough muscle with tubes and chambers through which blood flows. Crisscrossing that muscle are circuits for the electrical impulses that keep the heart beating.

A number of things can go wrong with various parts of the heart, causing it to function inefficiently and, eventually, to stop working altogether.

The most common heart problem, by far, is blocked coronary arteries. A high level of cholesterol in the blood can cause plaque deposits to build up on the inside of the arteries that lead to the heart, restricting the amount of blood that can get through. If the blockage is severe enough, the section of the heart that is fed by that artery can begin to die from lack of oxygen.

That is a heart attack.
Coronary artery disease is often detected after patients start feeling pain or pressure in their chest. Their primary care physician typically refers them to a cardiologist for evaluation, which usually includes an electrocardiogram (EKG) and a treadmill stress test. Depending on the test results and the severity of symptoms, the patient may need a cardiac catheterization procedure to find out how many arteries are blocked and to determine the exact location and extent of the blockage.

Cardiac catheterization involves passing a plastic tube called a catheter through a blood vessel to the heart, where a dye is injected directly into the coronary arteries. By following the progress of the dye on a monitor, the cardiologist can see where blood is flowing freely and where it is encountering obstacles.

Allen Strunk, D.O.

Two new technologies—magnetic resonance (MR) angiography and computed tomography (CT) angiography—now give cardiologists non-invasive alternatives to cardiac catheterization for some patients, according to Allen Strunk, D.O., an invasive cardiologist with Pinehurst Cardiology Consultants.

“If you have patients who appear to be at relatively low risk of having significant coronary artery plaque, but their stress test suggests that there is blockage, we might do an MR angiogram to see if they have signs of plaque,” Dr. Strunk says. “If they do, then they clearly need a cardiac catheterization. But if our clinical suspicion is correct and the MR angiogram is perfectly normal, then we have pretty strong evidence that the stress test result was a false positive and the patient probably doesn’t need a catheterization.”

However, many insurance companies do not yet cover MR or CT angiograms.

How to treat heart disease
If a cardiac catheterization shows that a patient has a severe blockage in one or more coronary arteries, the patient may have either an angioplasty procedure to open the artery or bypass surgery to route blood around the blockage.

Angioplasty involves inserting a balloon into the artery and inflating it to press the plaque against the artery wall. Then a metal scaffold called a stent is inserted to hold the artery open once the balloon is removed. Some stents are now coated with drugs to prevent the formation of scar tissue, which can restrict blood flow.

As angioplasty technology has improved, the percentage of people having coronary artery bypass surgery has decreased. But it remains the best option for some patients.

John Streitman, M.D.

John Streitman, M.D., a cardiac surgeon with Pinehurst Surgical, says the biggest change in bypass surgery over the past 10 or 15 years has been a much more aggressive approach to post-operative care.

“We used to be more cautious,” he says. “We were slower getting patients off the ventilator, getting them up and walking and getting them home. Now we try to have our patients off the ventilator the same day as surgery, and they usually go home in four or five days. We have found that patients not only tolerate earlier mobilization, but they might even benefit from it.”

Just as improvements in angioplasty have reduced the number of coronary bypass procedures, improvements in medications have helped slow the growth of angioplasty procedures nationwide, according to David Cowherd, M.D., an interventional cardiologist with Pinehurst Medical Clinic.

“The primary components of today’s better medical therapy are the cholesterol-lowering statin drugs such as Zocor, Lipitor and Crestor,” Dr. Cowherd says. “Statin therapy can easily cut one’s cholesterol in half.”

Less cholesterol in the blood means less plaque build-up in the arteries.

Heart “electricians”
While some cardiologists deal primarily with problems involving the heart’s plumbing—its tubes, chambers and valves, others focus on the heart’s electrical system. Electrical impulses triggered by signals from the brain continuously circulate through the heart to keep it beating in rhythm.

David Cowherd, M.D.

Mark Landers, M.D.

Ker Boyce, M.D.

When something goes wrong with the electrical circuitry, the heart can beat too fast, too slowly or in an erratic fashion.

“Some abnormal heart rhythms are relatively harmless, and we can treat those with medications,” says Mark Landers, M.D., of Pinehurst Cardiology Consultants, who specializes in cardiac electrophysiology. “Other heart rhythms are basically harmless, but they may be very frightening or cause some symptoms that are not harmless, such as passing out.

Such rhythm problems are often treated with stronger medications. In some cases, the cardiologist may use a catheter to cauterize the spot where the problem is originating.

Some heart rhythm disturbances can be deadly.

“The most dangerous rhythms come from the ventricles, the lower chambers of the heart,” says Ker Boyce, M.D., a cardiologist with Pinehurst Medical Clinic who specializes in electrophysiology.

These abnormal ventricular rhythms can have a number of causes including prior heart attacks, blocked arteries, viral infections or the toxic effects of cancer chemotherapy drugs.

“We use defibrillators, which we implant beneath the skin of the chest, to control abnormally fast heartbeats from the bottom chambers,” Dr. Boyce says.

For abnormally slow heartbeats, there are pacemakers.

The most common rhythm disturbance is called atrial fibrillation. Instead of beating regularly, the heart quivers or beats chaotically. It is rarely fatal and sometimes doesn’t cause any symptoms. But in severe cases, it can be debilitating and is a leading cause of stroke (see story on page 28).

Depending on the precise nature of the problem, treatment options may include medication, cauterization of the trouble spot with a catheter, or surgery.

Other common heart problems include valves that don’t open or close properly and congestive heart failure (see story.)



July 27, 1987:
A red-letter day
in heart care

The emergence of FirstHealth Moore Regional Hospital as a major heart care center began just over 20 years ago, on July 27, 1987, when David Cowherd, M.D., of Pinehurst Medical Clinic performed the hospital’s first cardiac catheterization procedure.

“I can remember patients being very apprehensive about being in a new program with a young doctor,” Dr. Cowherd says.

But some patients did put their trust in that young doctor. And as he showed that he could keep patients safe and provide expert diagnosis of coronary artery disease, more and more patients began to come to him.

Dr. Cowherd has now performed more than 10,000 cardiac catheterizations, and the number of invasive cardiologists— those who perform diagnostic catheterizations—at Moore Regional has grown from one to 15.

The cardiac catheterization program became so successful so quickly that in 1990 Moore Regional began offering both bypass surgery (John Krahnert, M.D., performed the first bypass operation) and balloon angioplasty for the treatment of blocked coronary arteries.

Acute Myocardial Infarction: Heart attack.

Angina (angina pectoris): The chest discomfort that occurs when the blood oxygen supply to an area of the heart muscle does not meet the demand. In most cases, the lack of blood supply is due to a narrowing of the coronary arteries as a result of arteriosclerosis.

Angiography: A procedure performed to view blood vessels after they are injected with a dye that outlines them on X-ray.

Angioplasty: A procedure with a balloon-tipped catheter to enlarge a narrowing in a coronary artery; also called percutaneous transluminal coronary angioplasty (PTCA).

Atrial fibrillation: Abnormal heart rhythm where the upper chambers of the heart (the atria) quiver instead of beating normally, creating an irregular pulse.

Arteriosclerosis: Hardening and thickening of the walls of the arteries; also called “hardening of the arteries.” Arteriosclerosis can occur because of fatty deposits on the inner lining of arteries (atherosclerosis), calcification of the wall of the arteries, or thickening of the muscular wall of the arteries from chronically high blood pressure.

Atherosclerosis: A process in which deposits of yellowish plaques containing cholesterol, lipid material and lipophages are formed within large and medium-sized arteries. The plaque can increase in size and harden over time reducing blood flow. It can result in a bleeding into and then the clotting off of an artery, resulting in a heart attack.

Arrhythmia: An abnormal heart rhythm. The heartbeats may be too slow, too rapid, too irregular or too early.

Blood pressure: The pressure of the blood within the arteries, produced primarily by the contraction the heart muscle. Measurement is recorded by two numbers. The first (systolic pressure) is measured after the heart contracts and is highest. The second (diastolic pressure) is measured before the heart contracts and is lowest. Generally lower than 120/80.

Bypass: An operation in which a surgeon creates a new tubular pathway for the movement of fluids and/or other substances in the body. Also coronary artery bypass graft (CABG).

Cardiac catheterization: A procedure that identifies possible problems with the heart or its arteries. During a cardiac catheterization, a thin plastic tube, or catheter, is inserted into a blood vessel in the groin or arm and then guided up toward the heart. A special dye is injected into the catheter so X-rays can show if the patient has any artery blockage or other heart problems.

Cardiac rehabilitation: A program for people with heart disease that is designed to reduce future heart risks.

Cardiologist: A doctor who specializes in treating heart disorders.

Cardiovascular disease: All diseases of the circulatory system including acute heart attack, ischemic heart disease, valvular heart disease, peripheral vascular disease, arrhythmias, high blood pressure and stroke.

Congenital heart disease: A malformation of the heart or the large blood vessels near the heart. The term “congenital” means born with or present at birth.

Coronary angiography: The most accurate method for evaluating and defining coronary artery disease (CAD). Coronary angiography is used to identify the exact location and severity of CAD.

Coronary artery disease: A major cause of illness and death, coronary artery disease (CAD) begins when hard cholesterol substances (plaques) are deposited inside a coronary artery.

Coronary arteries: The vessels that supply the heart muscle with blood that is rich in oxygen. They are called the coronary arteries, because they encircle the heart in the manner of a crown.

Coronary artery bypass graft (CABG). A form of bypass surgery that can create new routes around narrowed and blocked coronary arteries, permitting increased blood flow to deliver oxygen and nutrients to the heart muscle.

Electrocardiogram (EKG): A recording of the electrical activity of the heart.

Electrophysiology: The study of electrical activity in the heart.

Heart attack: Also known as a myocardial infarction; the death of heart muscle from the sudden blockage of a coronary artery by a blood clot.

Heart failure: The inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency.

Hypertension: High blood pressure; defined as a repeatedly elevated blood pressure exceeding 140 over 90.

Invasive cardiology: A special branch of cardiology that uses invasive procedures to treat heart disease. These procedures generally require insertion of instruments through the skin and into the body to treat a problem, thus the term “invasive.”

Percutaneous transluminal coronary angioplasty (PTCA): The use of a balloon-tipped catheter to enlarge a narrowed artery.

Statins: A class of drugs that lower cholesterol.

Stent: A tube designed to be inserted into a vessel or passageway to keep it open.

Stenosis: Narrowing or constricting of a duct, canal or blood vessel.