From the December 1, 2003 U.S. News & World Report by Katherine Hobson

Hearts that struggle to pump are a huge and growing problem

Listening to Sheldon Artz''s cardiac history is enough to give anyone heart palpitations. In 1991, he felt twinges during a tennis match, ignored them, played a tiebreaker, showered, and then decided to call 911. Artz, now 62, should know better--he''s a doctor. Despite the delay, he survived that heart attack and a second one, and then had a triple bypass. The Cleveland-based physician thought he was on the mend. But a few years later he started to experience shortness of breath, muscle weakness, and fatigue. Artz knew what was happening: His heart, injured by the attacks, was having trouble pumping blood throughout his body. Artz had systolic heart failure, the most common form of the disease, and there was no cure.

But there were ways to slow the decay. Artz turned first to a series of drugs that temporarily improved blood-pumping ability and later to a then experimental pacemaker. "They really buy time," he says.

Artz''s timing was fortunate. Just about five years before he felt his heart failing, doctors had little to offer people like him but a few palliative drugs to relieve discomfort during an inexorable decline. "I felt rather helpless," says Randall Starling, one of Artz''s doctors and the head of heart failure and cardiac transplant medicine at the Cleveland Clinic.

That has changed, and just in time. Heart failure is a huge and growing problem, since the population it most often afflicts--patients over 65--is also huge and growing. The condition accounts for more hospitalizations among this age group than any other disease. The increase also comes, ironically, from the success doctors have had in treating other cardiac diseases. "People used to die from their heart attacks, and most of them don''t die anymore," says Joseph Rogers, a cardiologist at Barnes-Jewish Hospital in St. Louis. "What people are left with is damaged heart muscle."

Doctors now know that the body produces a host of hormones to compensate for that muscle''s reduced pumping capacity by speeding it up and raising blood pressure. But over time, that can actually hurt more than it helps. "The body''s own mechanisms to heal the heart are carried too far," says Frank Smart, medical director of heart failure and transplantation at the Texas Heart Institute in Houston.

The drugs now being prescribed keep those hormones from reaching their targets and so stave off their damaging effects. The first line of defense: a class of drugs called ACE inhibitors, which lower levels of a hormone that causes high blood pressure. In studies, heart patients who took ACE inhibitors alone had a 25 percent lower risk of dying than those who didn''t. Drugs called beta blockers, which prevent adrenaline from accelerating the heart rate, can be even more helpful. A 2001 study found that adding a beta blocker to ACE inhibitors and other drugs resulted in 35 percent fewer deaths than in the group not receiving the drug. "It has revolutionized things in the treatment of heart failure," says Starling.

Potent cocktails. The pills can pile up. Patients may take drugs to clear the excess water from the body that accumulates because of the heart''s inefficient pumping. Add aspirin to prevent clots, digoxin to strengthen the heartbeat, and maybe a statin to reduce cholesterol, and some patients are taking 10 different medications. But the cocktail often works. "The drugs can slow the progression of the disease, prolong survival, and reverse the damage to the heart," says Smart. Some of these drugs are also used in patients with less common and less fatal diastolic heart failure--when the heart can still pump well but doesn''t relax enough to completely fill with blood, leaving the overall pumping volume still reduced.

But medications are not a permanent solution for everyone. That''s where some of the newer devices come in--either as temporary help while hoping for a heart transplant or as a longer-term solution. Because saggy, baggy heart muscle doesn''t beat smoothly, in 2001 the Food and Drug Administration approved a biventricular pacemaker that places an additional electronic regulator on a wall of the left ventricle to stimulate a more efficient heartbeat. "We''ve now inactivated a significant number of patients from the heart transplant list because they''ve done so well," says Gilbert Mudge, director of cardiac transplants at Brigham and Women''s Hospital in Boston. Implanted defibrillators may also be used for patients who have heart failure after a heart attack.

More recently, left ventricle assist devices (LVADs)--small, surgically implanted pumps that take over for part of the heart--have become an option. They''re approved for patients awaiting transplant. Last year, the FDA approved one, made by Thoratec, a medical device company based in Pleasanton, Calif., as a longer-term solution for seriously ill people who aren''t eligible for a transplant. James Dorsey of Westboro, Mass., got one at the end of this past summer. "It''s done wonders for me," he says. "I''m back walking a mile a day."

The LVADs aren''t perfect. Patients must tote around battery packs—Dorsey uses a fisherman''s vest--and some complain about noise and discomfort. The consequences of malfunction are also significant. "When your car won''t start, you have a bad day, but when your LVAD doesn''t start, you have a really bad day," Smart says. Still, there''s reason to hope. Because technology is improving and doctors are learning how to avoid complications like infection, Mudge predicts that in five years there will be five to 10 times as many LVAD implants each year as heart transplants--or more than 20,000 a year.

A heart transplant is still often the only solution for end-stage heart failure. They''re extremely rare--just about 2,200 are done annually--and are getting more so as demand increases while the supply doesn''t.

The inadequacy of the transplant solution has made heart failure treatment a hotbed of research. More drugs may be on the horizon. Researchers now suspect that in addition to the hormones blocked by existing drugs, chemicals released during the body''s healing process--inflammation--hurt heart muscle. Vasogen, a Canadian drug company, is now enrolling patients in a large trial to see if its anti-inflammation drug, Celacade, reduces death and hospitalization among heart failure patients.

On the device front, the Cleveland Clinic''s Starling is studying whether a fabric sheath placed around the heart will prevent it from getting too big and allow better pumping, similar to the way a weightlifter''s belt restricts and reinforces stomach muscles. Researchers are also eyeing stem cells, those rare and seemingly magical cells that can mature into any type of organ. At the recent American Heart Association meeting, German researchers said heart attack survivors whose bone marrow stem cells were introduced into the heart appeared to have grown new heart tissue, and saw improvement.

It will likely be years before there is widespread use of stem cells. Artz, using current treatments, ran out of time and heart muscle in 2002. He had to turn to a donor heart, but it didn''t start beating when placed in his chest. Again, Artz got lucky and quickly got a second transplant. Though he ran into a string of complications, things are looking up. He''s taking tennis lessons and looking forward to a ski trip in January. Doctors, for their part, are looking forward to a day when patients don''t need to depend on luck but on heart failure treatments that will be permanent solutions.

An estimated 4.8 million Americans have heart failure, and 71 percent of them are age 60 and older.