Cardiology

It is the main manifestation of vascular calcification (arteriosclerosis). Arteriosclerosis in the heart means a heart attack, arteriosclerosis in the head means a stroke and arteriosclerosis in the leg means arterial occlusive disease. There is no such thing as simply “pipe-free”. However, we know very well that we can stop the progression of arteriosclerosis by optimally adjusting the 10 risk factors. Both the well-known “old five” risk factors and the newly recognized “new five-even bigger” risk factors are treated, above all through the “poly-pill” movement. A certified nicotine-free seminar and interactive lectures round off the individual adjustment of the therapy in individual visits.

The disease (anatomy, frequency)

CHD is characterized by constrictions or occlusions of the coronary arteries, which are responsible for blood flow to the heart. This is due to deposits, so-called plaques, which consist of cholesterol, other fats, inflammatory cells and connective tissue. The diameter of a blood vessel slowly but steadily decreases. If the blood flow is severely reduced (ischemia), the heart muscle is no longer supplied with sufficient oxygen and nutrients. At the same time, metabolic waste products accumulate. The causes of the development and progression of CHD are not yet fully understood. It is clear that, in addition to a predisposition to the disease (hereditary component), lifestyle plays an important role: Smoking, lack of exercise and obesity are significant risk factors. An undetected and untreated high cholesterol level, high blood pressure and diabetes also increase the risk of developing CHD.

In Germany, 6 million people suffer from CHD.

Complaints

One of the most important symptoms of CHD is chest tightness (angina pectoris). Initially, symptoms occur under physical stress, later also for no apparent reason. The symptoms can radiate into the neck or jaw area, the back, the shoulder or the abdomen. Shortness of breath and/or shortness of breath can also be signs of CHD. The symptoms often occur during physical exertion, for example when walking fast or climbing stairs, and then disappear again when the exertion is over – this is a stable situation, the so-called stable angina pectoris (= CCS, chronic coronary syndrome)

However, if the symptoms occur at rest (unstable angina pectrois), e.g. at night in bed, this is a warning sign: This form is particularly dangerous as a possible harbinger of a heart attack. If our coronary arteries become completely blocked, the heart muscle can no longer be supplied with sufficient oxygen. In this case, you should call for medical help immediately (call 112).

Diagnostics

If the doctor suspects the presence of CHD, he/she will carry out various tests on you, in particular an electrocardiogram (ECG), blood pressure measurement, blood and metabolic tests or a cardiac ultrasound (ECHO). The most accurate way to detect CHD is with a cardiac catheterization.

Treatment

What can those affected do?

• Daily exercise (e.g. cycling, walking, dancing or swimming) will keep your heart fit, even if you already have CHD.
• In addition to exercise, you should make sure you eat a healthy diet: We recommend lots of fruit and vegetables, but little meat and convenience products. A typical heart-healthy diet is the so-called Mediterranean diet, which is rich in olive oil, nuts, sea fish, fruit and vegetables.
• You should not smoke even in old age – smoking damages your own heart, but also the heart and the health of those around you through passive smoking. Try to stop smoking.
• Avoid drinking alcohol, especially if you are taking medication.
• The medication can only work properly if you take it as prescribed by a doctor.
• If you experience severe heart problems, shortness of breath or unconsciousness, do not hesitate to call for medical help.

Treatment options

Drug therapy is the basis of treatment for all patients with CHD. As a rule, the medication must be taken long-term.

• Anticoagulants prevent blood platelets from sticking to the walls of the coronary arteries. People with CHD are usually given acetylsalicylic acid – known as ASA.
• Statins ensure favorable blood lipid levels. This means that fewer plaques accumulate on the inside of the vessels.

Beta-blockers, ACE inhibitors and other medications can also be used permanently for certain clinical pictures.

For sudden symptoms outside of a heart attack, nitrates such as nitro spray or nitro capsules or ranolazine can help temporarily. If medication does not succeed in controlling the symptoms or if examinations indicate a pronounced CHD with multiple constrictions or occlusions, doctors have two further options for opening (revascularizing) vessels.

You can insert vascular stents using a cardiac catheter. These are small tubes made of wire mesh that are inserted into a container to keep it open.

If several vessels are affected or if the constrictions are unfavorable for a stent, European guidelines advocate bypass surgery. Constrictions are then bridged by additional blood vessels (bypass).

Rehab and AHB (requirements, benefits)

After acute coronary syndrome (ACS): Whether after a cardiac catheterization procedure or aortocoronary bypass surgery with an uncomplicated course, rehabilitation should begin after just a few days, as this significantly reduces mortality and further hospital stays (morbidity).

In the case of chronic coronary syndrome (CCS): cardiac rehabilitation should also be carried out, as this significantly reduces mortality and morbidity. Patients with

• limited prognosis due to inadequately controlled cardiovascular risk factors
• persistent and limiting cardiac symptoms (angina pectoris and/or dyspnea) without the possibility of coronary revascularization (restoration of vascular perfusion)
• concomitant diseases that increase the risk of an unfavorable course of CCS, such as peripheral arterial occlusive disease (paVK), COPD, diabetes mellitus or chronic kidney disease.
• Endangerment or already existing restriction of professional and/or private participation as a result of CCS.

The benefits of AHB / rehab are

According to the guideline*, cardiac rehab has a positive influence on the following points:

• additional lifetime (reduction in mortality) as the scientifically “hardest” endpoint
• non-fatal re-infarctions
• non-fatal strokes
• Repeated hospital admissions/stays
• the individual, health-related quality of life

The risks in the course after acute coronary heart disease (e.g. renewed or persistent myocardial ischemia, stent occlusion or restenosis, myocardial insufficiency and arrhythmias) are known. Cardiac rehabilitation is therefore responsible for the close medical care of patients with timely detection and treatment of such risks. Drug therapy and, in particular, the necessary lifestyle changes with physical training continue to be of central importance in cardiac rehabilitation. In addition to improving the clinical prognosis, these measures also aim to ensure or restore individual quality of life and social integration (participation) in the long term.

*Guideline on cardiac rehabilitation (LL-KardReha, DACH 2020) in German-speaking Europe Germany, Austria, Switzerland

Typical rehabilitation goals

• Assessment of physical resilience (recognizing alarm signals and the limits of the body)
• Increasing the walking distance on a flat surface with/without a rollator
• Improved performance when climbing stairs (number of floors)
• Information on CHD, high blood pressure, dealing with anxiety, learning to deal with your own vulnerability
• Minimization of risk factors (setting cholesterol levels, blood sugar, blood pressure, dysstress, abdominal fat, nicotine, lack of exercise)
• Smoking cessation / “What are the benefits of not smoking?”
• Psycho-mental stabilization, learning relaxation methods
• Improvement of difficulty falling asleep / sleeping through the night
• Improvement of wound healing
• Improvement of the pain situation

Therapy at the GZO

• Diagnostics (specialist visits, resting ECG, echocardiography, wound assessment, blood count, stress ECG, blood count)
• Optimization of pharmacotherapy (drug adjustment of blood coagulation, blood lipid levels, pumping performance, stress reaction of the heart)
• Physical training mainly in the form of aerobic endurance training using the endurance or interval method (ergometer cardiovascular training, terrain training or Nordic walking, group gymnastics and everyday training, medical training therapy)
• Knowledge transfer about the disease Basics for understanding CHD, its development (cardiovascular risk factors, risk behavior and risk diseases), its consequences and treatment options. In addition, training courses on hypertension, arteriosclerosis, disease management, measurement of blood coagulation and lipid metabolism
• Nutritional advice A typical heart-healthy diet is the so-called Mediterranean diet, which is rich in olive oil, nuts, sea fish, fruit and vegetables. Nutritional counseling is available in the form of individual counseling, group counseling and a training kitchen.
• Social care and prescription of medical aids
  Psychological counseling and therapy (learning relaxation methods such as PMR, imagination, Qi Gong; individual and group sessions if required)

What happens at home?

In order to seamlessly maintain what has been achieved in the rehabilitation clinic (phase II rehabilitation), we arrange a heart group (phase III rehabilitation) as an outpatient aftercare program

• Moderate endurance training in the THF range (training heart rate), ideally 5×30 min or 3×50 min supplemented by a cardio group, plus moderate strength training and coordination 2-3 times a week
• Participation in “Disease Management” programs (DMP) for coronary heart disease. These are structured GP treatment programs for chronically ill people. The aim is to coordinate and optimize the treatment and care processes of patients over the entire course of their illness and across the boundaries of the individual service providers (GP, specialist, physiotherapy).

After balloon dilatation/stent implantation

Balloon dilatation/stent implantation is a treatment option for arteriosclerosis.

After heart bypass surgery (link to KHK)

Cardiac bypass surgery is a treatment option for arteriosclerosis.

After heart valve surgery

The most common valve disease is aortic valve stenosis (narrowing), followed by mitral valve insufficiency (leakage). Both valves belong to the left ventricle, which supplies the body’s circulation with oxygen-rich blood. If aortic valve stenosis or mitral valve insufficiency progresses, this can lead to heart failure, as the heart muscle has to do more work than intended. Cardiac arrhythmia can also be the result.

Three methods are available for both flaps:

• Invasive, i.e. through open surgery,
• non-invasive through catheter procedures,
• minimally invasive using endoscopy technology.

The ideal procedure is determined in advance by the heart team, consisting of cardiologists, cardiac surgeons and anesthesiologists, in a “valve conference”.

Thanks to our INCREASE research project (optimized pre-, intra- and post-operative rehabilitative care of valve patients) in cooperation with Augsburg University Hospital, we have maximum expertise for all heart valve diseases.

Aortic valve stenosis is described below as an example.