Heart Problems
Atrial Fibrillation, AF (short version)
Atrial fibrillation means that the atria are electrically activated irregularly and extremely frequently (more than 300 times per Minute) and thus the ventricles are irregular and often with over 100 beat per minute quite fast. Most patients notice this as a rapid and irregular heartbeat or palpitation, sometimes it only feels like chest discomfort though and can mimic a heart attack.
When having certain risk factors, patients with AF have a higher risk of suffering a stroke and therefore need to take blood thinners of a special type for a lifetime. Whether and how atrial fibrillation is to be eliminated depends on numerous criteria and characteristics. In general, atrial fibrillation can be treated with medication, it can also be eliminated (at least temporarily) with an “electric shock” (cardioversion) or with an ablation in the left atrium in order to have a regular rhythm (Sinus rhythm) for a longer period of time.
Long version
Basically, there are many different cardiac arrhythmias, some of them very harmless, but some much worse than atrial fibrillation.
Atrial fibrillation is not uncommon from a certain age. In the total population, the incidence is about 1%; in older people, however, almost 20%, on average one in five of over 70-year-olds has atrial fibrillation. A quarter of today's 40-year-olds will get atrial fibrillation in the course of their lives.
What is AF? Atrial fibrillation is an irregularity of the heartbeat, whereby the atria (anterior chamber of the heart) are excited very quickly, chaotically and irregularly (about 300-600 excitations per minute), the ventricle is also irregular, but not as fast as the atria, in most cases the pulse is about 100-180/min. In this case, an atrial fibrillation with a rapid response of the ventricles is distinguished, where the pulse is > 100/min but one may also have atrial fibrillation, where the ventricle is irregular but not fast. One can therefore have atrial fibrillation but still a pulse of 60/min. Between the atria and ventricles there is a "regulator" (the so-called atrioventricular node) which, depending on the condition, transmits the atrial excitations to the chamber quickly or slowly . A fast pulse is both more unpleasant and dangerous overall than a slow pulse.
The cause: The very exact formation of atrial fibrillation is not well known. There are risk factors (such as obesity, diabetes, alcohol, smoking, genetics, sleep apnea, hypertension and some other conditions) and it is known that in most cases the triggering of atrial fibrillation occurs via pulmonary veins (those are connected with left atrium).
Why is atrial fibrillation a problem: due to the fact that the atria are excited very quickly and chaotically, they lack sufficient contractive power, the atria only flicker and hardly shorten, whereby the blood is somewhat more static than it is with a slow and regular rhythm of the atrium.There is also a kind of appendix of the atrium, the left atrial appendage (LAA), a small embryonic "sack," where the blood stagnates even more pronounced in atrial fibrillation. As a result, blood clots can form in the LAA, and in an unfavourable case they can travel to the brain (from the LAA they succeed via the atrium into the left ventricle, from there then via aorta into the brain) - the most common cause of the stroke. Strictly speaking, it is the main initial problem of atrial fibrillation. However, this can be prevented with blood thinning. Other problems are the palpitations, which can be felt from very mild to very unpleasant. Moreover, the quick and irregular heartbeat in a continuing basis may damage the heart: the pumping strength can decrease with the time.
In elderly, however, atrial fibrillation - on medication - may be left alone without aggressive treatment in the sense of benefit-risk-assessment.
Protection from stroke: It is known that about 30% of strokes occur due to atrial fibrillation.
However, it is also known that patients with atrial fibrillation have very different risks of developing stroke. In certain risk populations, one in 10 patients suffers a stroke within a year if they have atrial fibrillation and do not take blood thinners. In other populations with fewer risk factors, the risk of stroke may be 2% per year. Based on a large number of studies, these risk factors were sorted and the so-called CHADS-Vasc-score was established. The risk features included therein are chronic heart disease or heart weakness, hypertension, disease of the vessels, stroke, age and sex.
A score of 0 or 1 means low risk of stroke, the risk for major bleeding on blood thinners is about as low as the risk of stroke without blood thinners, so with 0 points blood thinning is not recommended at all, with a single point it is a matter of consideration but not a must. With 2 or more points, blood thinning is recommended. It is clear that with higher age one has more risk factors and therefore higher score and higher risk for stroke. With blood thinner one can reduce the risk. However, since strokes can also have other mechanisms (such as blood pressure, cerebral hemorrhage, atherosclerotic plaques, etc.), patients with atrial fibrillation and blood thinners can still have a stroke, although the risk is of course higher without blood thinners.
Because the human clotting cascade is very complex, not every drug known in the population as a blood thinner helps. The blood thinners that prevent stroke in atrial fibrillation are either the so-called vitamin K antagonists or the New Oral Anticoagulants (NOAKs). Aspirin, on the other hand, would not protect against stroke in atrial fibrillation.
Types of atrial fibrillation:
Atrial fibrillation can be either new ("newly diagnosed atrial fibrillation", which you notice for the first time and which is documented by the doctor), already known atrial fibrillation, which comes and goes by itself (paroxysmal), atrial fibrillation, which exists for a long time and persists and atrial fibrillation, which is there for a very long time and is already accepted (permanent).
When to treat atrial fibrillation: Blood thinning is only a prophylaxis to prevent a stroke. Whether to treat atrial fibrillation or nor (rhythm vs rate control) depends on few factors:
Age: Not a fixed criterion, but aid. For someone who is 90, the management of AF in terms of risk-benefit assessment may be different than for someone who is 50 especially if no or very little symptoms are present.
Impairment: Atrial fibrillation should usually be eliminated if patients have symptoms or if cardiac damage is already present (heart failure).
Symptoms: These can be highly variable: Patients usually complain of palpitations, irregular heartbeat or shortness of breath. However, symptoms can also be very nonspecific, such as fatigue, general weakness, or exertional weakness. Therefore, it can sometimes be challenging to make the causal connection between symptoms and documented AF.
Treatment options: If there is a definite connection between symptoms and AF, we call it symptomatic atrial fibrillation and then, beyond the question of blood thinning, it is recommended to eliminate the atrial fibrillation as well.
Medications: there are medications that slow down the heart beat, but do not break the atrial fibrillation per se (for example, beta-blockers). This is a good way to treat the symptoms, but it cannot ensure a normal, regular rhythm.
There are also drugs that act specifically on the atrium in such way that the atrial fibrillation is not only terminated, but also the normal rhythm can be maintained with it. However, these drugs do not always succeed (in only about 50% of cases) and they sometimes have side effects or contraindications, where they may either be discontinued or not given at all.
Atrial fibrillation can also convert to normal rhythm (sinus rhythm) on its own, spontaneously. This happens frequently in the first 48h after the onset of AF. If this doesn't happen, the medication doesn't achieve it and sinus rhythm needs to be established, then the so-called electrical cardioversion comes into play. It uses an electric shock (100 to 200 joul) to "reboot" the heart. This is done under short anesthesia, otherwise the electric shock can be very painful.
In order to remain free of atrial fibrillation in the long term, it is also possible to undergo an electrophysiological study. In this procedure, the pulmonary veins, which in most cases trigger atrial fibrillation, are ablated at the points where they join the left atrium, so that there is no longer any electrical connection between the atrium and pulmonary veins. In about 70% of cases, persistent relief from atrial fibrillation episodes is achieved. Since there are other mechanisms of atrial fibrillation development besides pulmonary veins, some of which are unknown, ablation cannot reliably free all patients from atrial fibrillation. However, the method of ablation continues to evolve, with new aspects and procedures emerging that improve both the safety and effectiveness of this method.
Whether, when and with which method the patients have to be treated is being decided depending on numerous criteria and remains quite individual.
Blood Pressure (short version):
In Europe, hypertension is diagnosed when the upper value reaches 140mmHg and the lower 90mmHg. Between 130-139Hg (upper, systolic value) or 85-89mmHg (lower, diastolic value) can be called the "gray area". Since it is known that blood pressure can shorten life span, be one of the causes of heart attack and stroke, it is important to detect and treat it in time. The first measures are lifestyle modification and exercise, then numerous medications come into play. A more precise cause of high blood pressure is usually not detectable. There are some factors that can influence blood pressure or promote hypertension, but in most cases no definite cause is found and essential hypertension is assumed.
Long version:
Put simply, it is the pressure of the blood flow on the vessel wall. The higher this is, the greater the likelihood that the vessel wall will be damaged either acutely or chronically. Since our organs are all sheathed with vessels for blood supply, damage to the vessels can thus damage the organs as well. Thus, high blood pressure can also cause a heart attack or coronary artery disease. Kidney weakness can also result from this mechanism. A large proportion of strokes are also caused by high blood pressure.
A distinction is made between the systolic and diastolic values. The norm is known to be 120/80 mmHg, although a value of 110/70 would be even better. The first value is the so-called systolic value, i.e. the pressure that occurs when the heart beats. The second value is the diastolic value, i.e. the pressure that prevails in the vessels during the resting phase, roughly speaking between beats. Often, however, the first value is considered more important, but the second, which represents the "resting phase", is prognostically more important. A high diastolic value shows the chronic course better and is to be regarded as a sign of vascular damage.
When to speak of hypertension is defined somewhat differently in different countries. In Europe, a value of 140/90 is considered the beginning of hypertension - high blood pressure as a disease. In the USA, a systolic value of 130mmHg is considered to be high blood pressure. What is certain, however, is that high blood pressure must be recognized and treated at an early stage, because this is the only way to significantly extend life expectancy.
If the systolic value reaches over 200mmHg, it is called a hypertensive emergency - urgent help must be provided, because the risk of stroke (but also other life-threatening conditions) increases significantly.
Therapy: In the earlier stages of hypertension and when it is not yet pronounced, one starts with lifestyle modification: weight loss, sports, healthy diet, abstinence from nicotine and alcohol. After a few months, the values are monitored. If the values are still not in target range, a drug therapy is started. Currently, it is recommended to start with a combination of two or more blood pressure medications, if possible. There are several options and this is handled differently depending on the situation. Since the complete effect of the medication can take several days to weeks, the success is only monitored in a few weeks, usually with a long-term blood pressure monitoring. After that, the therapy can be adjusted (dose increase or reduction, addition of other medications, etc.). Effective and permanent control of blood pressure is the key to success. There are not that much heart conditions or risk factors that contribute more to increased mortality than untreated or inadequately treated hypertension.
Heart Failure (short version)
Patients who have heart failure usually complain of weakness on exertion, shortness of breath that occurs with little physical exertion, general weakness and, above all, very often swollen legs ("water in the legs)." There are numerous causes of heart failure, diagnosed and treated differently.
The most important examination is echocardiography (heart ultrasound), but also blood tests may be essential. Apart from this, a cardiac catheter examination or therapy with a pacemaker or defibrillator may also be considered.
Long version
A distinction is made between heart failure with reduced cardiac output (the ejection fraction from the heart is reduced) and heart failure despite normal pumping capacity. In addition, heart failure can occur due to various cardiac arrhythmias, as well as after a heart attack or due to heart valve problems.
Depending on the symptoms and the echocardiography, we further decide what the underlying cause may be and which diagnostic method should be used next. For example, if the heart's pumping power is impaired, cardiac catheterization may be an option. If there is a high degree of insufficiency of one of the heart valves, valve repair may be an option. Treatment of certain cardiac arrhythmias may also be the solution.
In most cases, patients come to us for swollen legs or. This occurs because the heart cannot pump out the blood in the quantity and at the speed needed, the blood stagnates in the legs (due to gravity) and the water comes in from the blood vessels into the tissues. This is how so-called edema in the legs develops.
In addition to researching the cause of the heart failure and treating the problem, medications are usually administered at the same time to stimulate the kidneys and lead to more urination. Due to the increased excretion of excess water, the legs get slimmer. The lungs, frequently overloaded with water due to heart failure, can also be relieved with diuretics ("water medication"), which may improve breathing. Sometimes larger "water deposits" develop between the lungs and the pleura, which cannot be completely relieved with medication alone, so that the water may have to be removed from the lungs or from the interstitial space (between the lungs and the pleura) with a needle punction.
Withdrawing the water is only a relief but not a treatment of the cause. As mentioned earlier, the cause can involve very different aspects of the heart's work.
If there is valve leakage or valve stenosis, the heart cannot perform properly. In the case of valve leakage, it can cause blood to stagnate in the lungs because it is constantly flowing back from the left ventricle through the leaky valve into the atrium. If the valve on the aorta is narrowed, the blood cannot be properly pumped out of the heart, eventually the compensatory mechanism of the heart is exhausted and the blood again stagnates in the lungs. If the problem affects the right heart (i.e. the small circuit between the lungs and the heart), leg swelling usually develops first.
There are several methods of treating an insufficient or stenotic valve. The classic option is cardiac surgery, where the heart can be operated directly by intervening on the chest wall. Nowadays, such operations are routine and are performed in very high volume and with very good results in Germany. However, for patients who are at high risk for such surgery, there are so-called minimally invasive methods through a hole in the chest wall as well as catheter-based methods where a new valve is inserted through the inguinal vein or the insufficient valve is "clipped" without surgery as with a stapler. All of these methods have advantages and disadvantages, so decisions are made on an individual basis and in terms of risk-benefit considerations.
Patients who have a circulatory disorder of the heart muscle (narrow coronary arteries or history of heart attack) can also develop heart failure, usually due to muscle weakness caused by impaired oxygen supply. In this case, cardiac catheterization with treatment of the narrowing in the vessel with a stent may be an option.
In some patients, depending on their cardiac output, symptoms and ECG, it is possible to treat the heart failure with a special pacemaker, which allows the heart to pump more synchronously. In addition, if the heart pumping capacity is highly reduced, it is sometimes advisable to install a defibrillator, which can protect patients from sudden cardiac death. However, a defibrillator is only there to "resuscitate" the heart with shock delivery in the event of a malignant arrhythmia, so it is not a treatment for heart failure per se and is only considered in a certain situation.
Apart from the "repairs" to the heart, there are numerous medications that are standardly applied to one type of heart failure or another. In most cases, there are four different medications, some or all of which are started together, depending on the situation, and the dose is increased over time. These medications have been shown in the numerous studies that the patients on them live longer and better with heart failure than those without. It has also been proven that these drugs can improve the heart pumping performance (ejection fraction) in many patients. In this regard, strict and consistent intake as well as dose increase is of tremendous importance. Even if patients need to go from 0 right away to 4-5 medications, consistency of intake should remain the focus.
Occasionally there are patients who do not improve despite all these efforts, devices and medications. Kidney function worsens, shortness of breath does not improve and heart failure, like almost all chronic diseases, progresses. In rare cases, we must then also speak openly about the "end of life" concepts, since heart disease is unfortunately not always treatable or curable. Such patients with "terminal" heart failure also receive appropriate counseling, treatment and support.
Coronary Artery Disease (CAD)/Heart Attack, short version
In short, our heart is a muscle that needs a lot of energy to pump. To do this, the heart - like all other organs - is supplied with blood vessels that transport the necessary material, including oxygen, to the muscle cells. If these vessels are narrowed or completely blocked, a heart attack can occur, and the heart muscle can perish due to the lack of oxygen. Such a narrowing or occlusion of these vessels is called coronary artery disease, CAD.
long version:
The heart has three large vessels that cover it like a wreath (corona in latin). That where the name coronary vessels comes from. There are many reasons why they may get narrowed or clogged, the most common and important risk factors are smoking, high cholesterol, genetic predisposition, disease of the leg vessels, high blood pressure, diabetes. These factors can cause the vascular wall to become diseased and atherosclerotic changes to take place. Eventually, soft or hard plaques develop, a kind of calcification of the vessels, narrowing the lumen. Due to that narrowing not enough blood can reach the peripheral muscles of the heart. This can lead to chest pain - called angina pectoris. Usually, such chest discomfort develops under stress and subsides at rest. Often the discomfort is described as a burning sensation under the breastbone, but sometimes it is also very atypical, like shortness of breath or constriction in the neck. In the worst case, however, there may be a complete blockage of the vessel - an acute myocardial infarction. The symptoms may be similar to those described above, but usually much more pronounced and present even at rest. This lack of oxygen caused by the blockage cannot be compensated by the heart muscle for long time, the muscle cells perish and - in the absence of treatment - this leads to the development of a scar in the heart muscle - this area can no longer contribute to the heart pumping, which can sometimes cause a very dramatic decrease in the pumping function of the heart. This sometimes results in a pronounced breathlessness because the heart can no longer pump out enough blood to the body. In case of acute occlusion of a coronary vessel, the best and practically the only therapy - is reopening the occluded vessel. This takes place in a cardiac catheterization laboratory, where a thin catheter is advanced to the heart via the arm or inguinal arteries and, under X-ray fluoroscopy, the occluded or narrowed vessel is reopened with a wire advanced via the catheter. The site is then reopened with a metal scaffold (stent) so that the vessel resumes the diameter of the healthy portion of the vessel. This procedure may be useful not only in heart attacks, but also in stable patients who often experience such chest pain. Besides cardiac catheterization, medications also play an important role. As a rule, from the moment the diagnosis of coronary artery disease is established, patients are put on several medications, most of them for the rest of their lives. These are medications that thin the blood, medications that lower cholesterol levels, and, if necessary, blood pressure-lowering and pulse-lowering medications. Depending on the concomitant diseases, other medications may also be considered.
Once the disease has been diagnosed and the treatment started, the ball is in the patient's court. You can influence your prognosis, especially with physical activity, healthy diet, cessation of harmful habits (such as smoking), regular medication and regular check-ups you can ensure that your health is maintained for a longer time.
Syncope / Fainting, short version
Unconsciousness or TLOC (Transient loss of consciousness) is called syncope in medical language. This is characterised by a short duration (a few seconds) and complete unconsciousness (missing memory for those few seconds). Patients usually wake up without any symptoms and know quite clear what has happened. Often, the cause is a cardiac arrhythmia, which is then to be found in the course of diagnostic measures.
long version
About half of all people experience an episode of unconsciousness at least once in their lifetime. Sometimes the patients are wetted or have a tongue bite, just like in epilepsy, so often this is the challenge – to distinguish the one from the other.
Often, especially in young people, a syncope can be quite harmless and may often occur situationally (situative syncope). But not infrequently a cardiac diseases may be the cause. The most common cause is a slow pulse or a pause in the heartbeats, which causes a lack of oxygen in the brain and the person falls unconscious.
It is known that in a healthy person the brain can remain active for about 6 seconds without a heartbeat/without oxygen supply. After 6 seconds without blood flow the brain shuts down - unconsciousness or syncope occurs. Since usually the heart then starts beating again, the brain recovers quite quickly and one regains consciousness. However, depending on the duration and type of cardiac arrhythmia, the event can vary greatly. Sometimes the pause is borderline, but still not enough to completely shut down the brain, patients report "black in the face" and "almost been gone", but still stay conscious and remember every second - we then call it presyncope, which usually has the same consequence as syncope - if we find the cause, it should be treated. If the cause is a long pause in heartbeats, then there is often a problem in the conduction system of the heart. These can usually only be treated with the help of a pacemaker, a "pill" against such disturbances of the heart rhythm does not exist at present. The situation is different if there is a clearly definable and correctable cause, such as a disturbance of the blood potassium or an acute heart attack - in this case, it is still possible to postpone the pacemaker therapy and wait a while after the cause has been treated appropriately. Basically, any loss of consciousness can have a life-threatening cause; malignant cardiac arrhythmias can also cause syncope. In young people, the causes are usually relatively harmless, often so-called situational or situative syncope (for example, due to fear, when blood sample is being taken or because of extreme tension), but even at a young age, a cardiac arrhythmia can occur in an otherwise completely healthy person. Although not every loss of consciousness is an emergency that should be clarified or diagnosed in the hospital, every syncope should be thoroughly clarified despite age - whether outpatient or inpatient, whether at family doctor office or by a cardiologist, depends on the clinical picture.
The diagnostic method of subcutaneous (under the skin) insertion of a loop-recorder (sort of a microchip), which records ECG in a constant mode, might also be of importance during the work up of a syncope. Thus, after the next syncope, it is possible to detect on the ECG whether there were rhythm disturbances during syncope. Often, this rhythm recording is used to indicate pacemaker therapy.
Sudden Tachycardias / Arrhythmias, short version
Many patients complain of sudden episodes of palpitations, noticing that the heart beats too fast. The heart beat may appear both regularly and irregularly. This is referred to as cardiac arrhythmia (CA). There are many different CAs, many of which - especially at a young age - are quite harmless. In older patients, atrial fibrillation is by far the most common CA. In young individuals, however, the so-called re-entrant tachycardias - CAs, where the heart suddenly starts beating extremely fast and regularly, but just as suddenly also stops ("on-off phenomenon"), predominate. These CAs in young people are usually harmless but quite uncomfortable. If there is a wish for treatment, EP-Study and ablation is usually the only curative option.
Another type of CA is the so-called extrasystole or premature beats, where the heart gives one or more beats "out of sequence". Many people experience this as "skips," like when the heart takes a short break and then follows up with a powerful beat. These CAs are also common - especially in young people - but mostly harmless. Sometimes treatment with Betablockers may be reasonable.
Long version
Regular cardiac arrhythmias (CA) are quite common, also in young people. In most cases, these are healthy individuals with no heart problems whatsoever and in whom the heart is also classified as healthy and inconspicuous in retrospect. It does not affect the heart muscle per se, but the "electrics" of the heart, i.e. the "conductors" that transmit the electrical signals in the atrium or from the atrium to the ventricle. In this process, certain disturbances can occur even in healthy people, which do not always represent a disease value.
The so-called AV node re-entrant tachycardias are the most common CAs, mainly (but not only) affecting young people. An area between the atrium and ventricle responsible for conduction transmission (AV node), has a special property in that it has two conduction pathways to the ventricle (dual property of the AV node) and thus in certain situations allows the excitation to run both to the ventricle and back to the atrium. This can create a circuit where excitation continues uninterrupted and the ventricle is getting constantly excited. This creates heart rates of up to 200/min. That this can then be unpleasant is understandable. As suddenly as the tachycardia begins, it can also stop quite suddenly, as if the switch were flipped. Curative treatment usually consists of ablating one of these two conduction pathways. The drugs (such as betablockers) may sometimes relieve the tachycardia, but they are usually of little help. Almost 30% of population have such a dual characteristic of AV-node, only not all of them experience tachycardia. As mentioned earlier, this type of CA is usually not life-threatening. Whether to recommend ablation or not depends largely on how heavy the attacks stress the patient und whether everyday life suffers. If the episodes occur a few times a year and disappear after a few minutes, there is usually no need for treatment. Sometimes it is possible to stop the tachycardia with certain actions on your own. For example, the Valsalva maneuver is often recommended, where one should briefly press in the abdomen and let go, like during defecation. Sometimes the so-called carotid pressure massage (massaging on one side of the neck where the carotid artery runs) helps. Sometimes drinking cold water can also terminate the episode. However, if the tachycardia continues for hours, the emergency room should be visited to avoid complications.
An extra "conduction pathway" may also be located elsewhere between the atrium and ventricle, i.e., not in the area of the AV node - these are rather the rare cases where an anatomical feature is present and triggers basically the same CA as described above. This likewise tends to affect younger people, but occurs somewhat less frequently. However, both the symptoms and the course and therapy are similar to AV nodal re-entrant tachycardia.
Sometimes patients report that they frequently experience "skips," that it feels like the heart stops beating briefly and is then followed by a strong beat. This often feels like fluttering in the chest, palpitations for 1-2 seconds, but no longer tachycardia. However, these "lapses" can occur several times in a row and last for several minutes or hours, yet there is no feeling that the heart is racing, but rather like a recurring additional beat with short pauses. So-called extrasystoles or premature beats are often described in this way or in a similar way. They can appear in atrium (premature atrial beat) or in ventricle (premature ventricular beat). This is usually a harmless CA affecting more or less all people. Everyone experiences extra beats from time to time, some very many, some only isolated. Many do not even notice them, but there are patients who notice their extra beats clearly and find them very unpleasant. In most cases, the heart is still healthy, and often no special treatment is required. But depending on the number of premature beats and the discomfort they cause, it may make sense to treat them - either with medication or with the help of ablation. Since this decision depends on many factors and is made on an individual basis, no general recommendation can be made.
There are, in addition, a number of CAs that can arise in both healthy people and people with heart disease and can be more malignant than the CAs described above. Therefore, it is prudent to clarify any type of CAs in a timely and thorough manner. Whether this requires an ECG, a Holter ECG, or even an eventrecorder remains highly individualized and depends on the type and frequency of cardiac arrhythmia.
Valvular Disease, short version
Valvular disease is usually defined as leakage (regurgitation/insufficiency) or narrowing of one or more heart valves. While low-grade valve defects are not uncommon and are often found in healthy people, high-grade stenosis or insufficiency are problematic in most cases and require treatment.
When a heart valve does not close properly, blood partially flows back into the chamber from which it was just pumped out. In the long run, this can lead to heart failure and various complaints - most frequently shortness of breath. If the valves are narrowed (usually due to calcification), the blood cannot be pumped out to the desired extent - in long run it usually leads to similar complaints as with valve insufficiency and require a treatment as well.
long version
Our heart has four valves: the mitral valve, the aortic valve, the tricuspid valve and the pulmonary valve. The last one is rather rarely a problem in adult age. We will address the two most common and relevant problems here:
Mitral valve regurgitation: the mitral valve, located between the left atrium and ventricle, is insufficient and does not close completely, thus allowing blood from the left ventricle to partially return to the atrium during each heart contraction (systole). When there is a high-grade insufficiency over time, quite a lot of blood flows back, and the atrium is chronically overloaded with volume and increases in size. At some point, this leads to exhaustion of the compensatory mechanisms, the blood backs up into the lungs, one gets shortness of breath at the slightest exertion and at some point even at rest. Heart failure develops, the heart pumping power (ejection fraction) may also decrease under certain circumstances and the problem may become irreversible at some point. The sooner such a high-grade leakage of the mitral valve is detected, the sooner a treatment can be started and an improvement can be expected. Now, there are many factors and causes that can lead to valve insufficiency. Therefore, it is important to understand the cause first and foremost.
A number of examinations are performed for this purpose, including transesophageal echocardiography and, if necessary, cardiac catheterization/ coronary angiography. Occasionally, a cardiac MRI may also be considered. Depending on the causes and treatment options, further steps may then follow. Basically, if there is a high-grade insufficiency that causes discomfort or changes in the left ventricle dimensions, it should be treated or eliminated. This can either be done surgically (an open or minimally invasive repair or replacement of the valve) if patients are suitable for surgery. Or a non-surgical repair can be done using a "stapler" while accessing the heart through the inguinal veins. But even for this the patient must be well suited, not every type of valve insufficiency can be treated with this method, even if the patient himself does not want surgery and would only agree to this invasive method. For example, if the valve has too much calcification, then this method is usually unsuitable. Therefore, accurate selection and imaging is crucial for the result.
An equally common problem, especially in older patients, is narrowing (stenosis) of the so-called aortic valve (the valve through which blood is conveyed from the left ventricle to the aorta during pumping. In most cases, this occurs due to calcification, which simply increases with age. There are no medications that can reverse this process. Therefore, if the stenosis develops from moderate to high grade and discomfort is experienced, the valve should either be surgically replaced (open surgery in younger and healthier patients preferable) or minimally invasively, through the groin arteries, with a catheter using the so called TAVI method. In this procedure, a biological valve attached to a nitinol scaffold is placed in the position of the calcified aortic valve via inguinal artery and through the aorta and released, crushing the old valve against the aortic wall.
These two methods can help many patients with mitral valve regurgitation or aortic valve stenosis without major cardiac surgery and may have a positive impact on quality of life as well as longevity. However, it must be taken into account that, on the one hand, not all patients are suitable for these methods and, on the other hand, the result may not always be perfect. In this regard, patients are individually informed and advised.
Cholesterol, short version
There is hardly a topic in medicine that has been as well studied as the relationship between cholesterol and cardiovascular disease. Especially in patients with myocardial infarction or coronary artery disease, it has been clearly demonstrated that the level of cholesterol in the blood is directly associated with mortality. In these patients, it is worthwhile to reduce cholesterol levels to the minimum - with lifestyle, diet, nicotine abstinence, exercise and medication. Important: cholesterol can be elevated even in slim and otherwise healthy people, it is not always the expression of unhealthy diet, it can also be genetically elevated.
long version
Cholesterol is a general expression of fat components found in various forms and variations in our blood. In the general population, we often speak of "good" and "bad" cholesterol. Although this is too simplistically expressed, we would also discuss these two elements here, the so-called HDL (high-density lipoprotein) and the LDL (low-density lipoprotein), which are actually transport proteins, but have become well established as prognostic parameters. HDL is the so-called good cholesterol, the higher the level, the better. This is because HDL helps transport cholesterol to the liver, from where it is then excreted by the body. Therefore, a normal or high HDL is a sign that fat metabolism is working well.
To assess the risk of (further) heart attack, the bad cholesterol, LDL, is often measured. This one transports cholesterol from the liver to the tissues. In the worst case, the cholesterol then accumulates in the vessels and leads to so-called atherosclerosis. In the case of the coronary arteries, over time it can lead to narrowing (coronary artery disease) and even complete occlusion of the vessels, which can manifest with a heart attack.
Especially for people who already have an established coronary artery disease (CAD), it is important to lower LDL levels usually with the rule: the lower the better. Since lifestyle modification, nicotine abstinence, exercise and a healthy diet are often not enough, patients with elevated LDL levels turn directly to drugs. The first substance to be prescribed is always the so-called statins. There are many of these: simvastatin, pravastatin, rosuvastatin, atorvastatin, and so on. They lower the LDL level but also stabilize the plaques already formed in the vessels, thereby reducing the likelihood of an increase in vascular narrowing.
If the target LDL cannot be achieved despite maximum dosages of these substances, additional substances are usually added. There are several escalation levels, up to weekly or monthly injections, if the LDL level remains stubbornly high or if new cardiac events occur and the LDL level needs to be lowered even further. The fact that further lowering brings a reduction in mortality has been proven in several randomized studies and is beyond question. However, sometimes it is very difficult to achieve the target LDL-Level, which is why there are lipidologists (specialists in lipid metabolism) to whom patients can then be referred.
Whether, with what, and when to treat elevated LDL in otherwise healthy people (without heart problems) depends on risk factors and certain scores and can be discussed on an individual basis. First and foremost, the general rule is to lower LDL levels through exercise, nicotine abstinence, and a healthy diet, especially if there is no history of cardiovascular disease.