Take Heart

Nathaniel Ellison had always been a vigorous man, accustomed to swimming, snorkeling, golfing and tossing his grandchildren high into the air. But congestive heart failure brought on by a series of heart attacks stole those pleasures.

“I couldn’t walk down to the corner. I couldn’t breathe,” the retired McDonald’s restaurant owner recalls of those rock-bottom days about two years ago when his heart worked at a third of its capacity and he sank into depression.

Even his doctor had given up.

At one point, his breathing became so labored that he made a trip to the emergency room at USC, where cardiologist Uri Elkayam started the Pasadena man on an intensive regimen of medications to get his heart pumping more efficiently and eliminate fluid in his lungs.

“When he saw me the next week, I was a new person,” Ellison, 65, recalled recently after a brisk nine holes of golf.

“It seems like I have been given my life back again. I can do all the things I want to do and thought I would never be able to do again. I only have Dr. Elkayam and God to thank.”

Ellison’s case illustrates how aggressive management with a handful of powerful medications can stabilize patients with advanced heart failure and reduce their return visits to the hospital. According to a UCLA study, such treatment can get nearly a third of those waiting for new hearts off transplant lists.

Health plans are paying attention.

They’re seeing that spending money upfront for intensive treatment of very sick cardiac patients can pay dividends down the road: shorter hospital stays and fewer patients who require heart transplants, which cost anywhere from $100,000 to $1 million.

“Almost every university or large medical center and also now health care organizations . . . have found out that organized heart failure programs can improve the health of patients . . . and at the same time, although it seems paradoxical, reduce the cost of treatment,” said Elkayam, director of the cardiac-failure program at USC.

A Combination of Four Drugs Being Encouraged

A group of cardiologists calling itself the Advisory Council to Improve Outcomes Nationwide in Heart Failure is encouraging more doctors to use four types of drugs together that have posted successes: digitalis to stimulate the heart; diuretics to remove excess fluid; ACE inhibitors, now the cornerstone of cardiac failure treatment, to relax blood vessels; and beta-blockers to block the stress hormone adrenaline and reduce the workload on the heart.

In the Jan. 21 issue of the American Journal of Cardiology, the group reported that three years of studies have shown that using these medications together could cut deaths by 100,000 and result in 1 million fewer hospital admissions nationwide.

Congestive heart failure--the inability of the heart to pump blood efficiently and deliver nourishing oxygen to the body--can stem from a variety of illnesses, including blocked coronary arteries, damaged valves and chronic high blood pressure.

It creates shortness of breath, leg swelling and severe fatigue. The top diagnosis among hospitalized Americans over 65, it’s responsible for an estimated $11 billion in annual spending. Doctors estimate that about 5 million Americans have congestive heart failure, and that number is expected to swell as the population ages.

“It’s a paradox of how well we treat heart patients. Ten to 20 years ago, people died. Now we’re so much better at treating heart attacks and [at] surgery, people live long enough to develop heart failure,” said Dr. Americo Simonini, director of the Cedars-Sinai cardiac failure program.

Several medical centers in Southern California have heart failure programs, while HMOs and doctors groups here and nationwide have launched pilot programs. And the federal Health Care Financing Administration in Washington, which administers Medicare, is reviewing applications for heart failure management studies.

UCLA, which does the most heart transplants in the country, has the longest-running heart failure program, established 14 years ago and targeted to transplant candidates. A 1987 study by UCLA researchers published in the Journal of the American College of Cardiology found an 85% reduction in hospital readmissions and estimated savings of $9,800 per patient when patients received diuretics and ACE inhibitors and intensive education about managing their illness.

Building on growing evidence that such approaches work, USC added a program and Cedars-Sinai Medical Center recruited Simonini from the University of Michigan last year to head its program.

Medications, Surgery and Other Options

“In the past, we were limited in what we could do for these patients. What we have learned is that there is a hell of a lot more we can do with an organized approach to the diagnosis and management of heart failure,” said Dr. P.K. Shah, cardiology chairman at Cedars-Sinai. In addition to medications, cardiac failure programs also rely on surgery, like bypasses, valve repair and valve replacement, as well as pacemakers and defibrillators to correct abnormal heart rhythms.

Heart failure patients often resign themselves to a poor quality of life and a spot on the transplant list, where they may die waiting for a donor organ. But in the care of knowledgeable cardiologists and cardiac nurses, some are being pulled back from the brink. Or, at the very least, their conditions are stabilized long enough to wait for a new heart.

Patients “come to me with this hopelessness. I say, ‘It’s OK. You can read “War and Peace” someday, if you want to,’ ” Simonini said.

UCLA’s program, which treats 300 to 400 patients a year, provides two to three days of intensive intravenous medication and monitoring in the hospital, as well as education about diet, medicines, exercise and monitoring daily weight for salt and fluid buildup. The goal is to help patients live more healthfully and independently.

The impressive medical outcomes and potential for significant cost savings have prompted some health insurers--which not long ago refused to contract with UCLA’s cardiac failure programs--to shift their attitudes, according to Eric N. Marton, executive director of UCLA’s private cardiovascular practices.

“You’re talking hundreds of thousands of dollars in savings that leads to much, much better quality of life,” Marton said.

Dr. Warren Strauss, a regional medical director in Southern California for Woodland Hills-based Health Net, applauds the cardiac care center approach for the sickest patients.

“They have really rescued a large number of patients who were thought to be end-stage due to mismanagement in the community,” said Strauss, a cardiologist.

ACE Inhibitors and Beta-Blockers Work

Conventional cardiac failure treatment has relied on diuretics and digitalis. The addition of ACE inhibitors and beta-blockers, which require more intensive monitoring, have been responsible for the dramatic improvements in cardiac patients’ quality of life.

Even though the drugs have posted marked successes for several years now, cardiac failure patients remain under-treated. Some primary care doctors--and even cardiologists--don’t know about the best way to manage heart failure. In some cases, fear of side effects or drug interactions makes doctors wary of pushing medication doses to levels that are truly effective.

In addition, many cardiologists are less likely to commit to the painstaking task and time needed to adjust medications. Elkayam says that when sick cardiac patients don’t respond to the first line of medication prescribed by their primary care doctors or cardiologists, these doctors often refer them prematurely for transplants.

As a result, fewer than half of cardiac failure patients receive prescriptions for ACE inhibitors, which block angiotensin, a heart-stressing hormone.

The hormone “is one of the worst enemies” because it constricts the arteries, makes it harder for the heart to pump blood, enlarges the heart and stimulates another hormone that causes retention of salt and water and shortness of breath, Elkayam said.

Cardiac failure also responds to beta-blockers--used for decades to lower blood pressure--to block adrenaline and reduce the workload on the hearts of cardiac failure patients. Yet, most doctors learned back in medical school that beta-blockers are bad for heart failure because they slow an already weakened heart.

“It wasn’t until recently that we were brave enough to do large trials of low-dose beta-blockers to show that beta-blockers, in fact, not only improve survival, but improve the function of the heart,” Simonini said.

Finding the Proper Dose Takes a Lot of Effort

Getting the dosage right can be time-consuming. For example, the beta-blocker carvedilol must be started at very small doses and then increased under close supervision over weeks.

“Not everybody has the time to do that, and the insurance companies don’t really cover that in every patient,” Elkayam said.

The multi-pronged approaches have posted successes--some dramatic, others modest.

Eatau Beer, a 56-year-old sales clerk from Garden Grove, went from healthy to suddenly sick with cardiac failure after a silent heart attack.

“I couldn’t get up and go to the bathroom,” she said. She told her family doctor she was “too damned young . . . and too ornery to die.”

The doctor referred her to Simonini, who recommended double bypass surgery and medication. Today, Beer feels “95% better.”

At 78, Irving Berlin, who had a heart attack and underwent quadruple bypass surgery years ago, may not be doing as well as Beer. But until he got drug treatment last summer for cardiac failure, he was “next to the graveyard.”

Health plans recognize that in addition to the sickest patients, “there are large numbers of patients in heart failure who aren’t that severely ill but are disabled, who run the risk of sudden death because of mismanagement,” Strauss said. To that end, Health Net, which serves 2.4 million patients statewide, is working to devise programs that rely on more economical care, like having nurses or health aides visit cardiac failure patients at home to monitor their conditions and their compliance with medication.

Programs like UCLA’s are “not butter that can be spread over the whole bread of Southern California,” Strauss said.