17. A footnote on patients on blood thinning medications

I had failed to touch upon the important issue of pregnancy in patients who are on blood thinning medications. Hence this footnote...

Patients who are on blood thinning agents should plan pregnancy.  They should consult their doctor before they get pregnant so that their treatment can be altered to ensure that there is least risk to themselves and the baby. The anti-coagulation should not be completely stopped but the dose may be altered or the drug changed to a safer alternative.Warfarin (oral agent) at higher doses can cause malformations/deformities in the unborn baby and should be stopped and changed over to an alternative blood thinning agent (injectable) before the patient gets pregnant.

Patients who are on warfarin are troubled by the need for regular monitoring of INR and dose alterations. This situation however is likely to change in the future as newer agents are already in clinical use in the west that can be taken orally and do not need blood tests or dose alterations. These drugs however are currently beyond the reach of the average patient in India and much of the developing world.

16. Patients on blood thinning medications

A number of children and adults require medications that thin the blood. These medications are called anti coagulants and the main drug that is prescribed for this purpose is called warfarin.

When does a patient have to take anticoagulants?

Blood thinners are required in a variety of situations for example patients with metal valves in the heart, some patients in whom artificial materials are used during cardiac surgery, patients with some heart rhythm problems, patients who have had strokes due to clots in the brain etc.

These medications should ALWAYS be prescribed by a qualified practitioner

Do these medications need to be taken everyday? How long do they need to be continued?

Anticoagulants like warfarin are usually prescribed as long term therapy which need to be taken on a daily basis. The dosage of the drug needs to be adjusted based on a blood test called the INR (International Normalized Ratio). This test tells us how thin the blood is. The optimal level of INR varies depending on why the drug has been prescribed; for example patients with metal valves may need to have a higher INR value than patients with a heart rhythm problem. This ideal level needs to be individualized for each patient.

Why should the INR be maintained at a particular level?

The INR tells us how thin the blood is. If the INR is too low then the blood has not been thinned enough and there is a risk of clot formation in the bloodstream. If the INR is too high then the blood is too thin and there is a risk of bleeding. This is why INR needs to be maintained at an optimal level.


Are there any specific dietary precautions when taking blood thinners?

Blood thinning medications interact with certain foodstuffs and medications. This can lead to sudden changes in the INR. Patients who are on warfarin should avoid consuming large quantities of green leafy vegetables like spinach, broccoli etc. Excessive alcohol consumption should also be avoided. Certain juices like cranberry and grapefruit also create disturbances in the INR.

Certain medications like antibiotics can result in interactions with warfarin and a high INR. It is important that the patient should consult his or her doctor before starting any new medication along with warfarin.

What about activities?

Patients on warfarin can carry out normal activities but they should avoid contact sports like rugby, kabadi etc. This is because they are at increased risk of bleeding on impact. Children on warfarin can participate in physical non competitive sport but they will not be able to become professional sportsmen/women.

15. Quality of life of patients with birth defects of the heart

     As a doctor looking after patients and families with birth defects of the heart I often get asked ' Will my child have a normal life after the heart defect is treated?' In years gone by when cardiac surgery and key hole therapies were in their early stages of development the results were less than satisfactory and there was a significant risk of death or brain damage attached to treating heart defects. Now with advances in medical technology, increased skill and innovation this risk for most surgeries and key hole treatments is less than 5%. Of course, this risk will vary depending on the how complex the defect is. Overall however it has been reduced significantly over the years.
    
This improvement can be attributed to several factors

1. Advances in cardiopulmonary bypass - during the majority of complex heart surgery the heart needs to be stopped temporarily and during this time the blood is pumped around the body using a machine called the heart lung machine, this technique is called cardio pulmonary bypass
2. Improved post operative care - this has probably been the single most important reason for improved outcomes. Although the surgeon or cardiologist may be the visible face of a successful unit it is the intensive care specialists that really make a difference to the outcome of patients
3. Development of less invasive techniques for treating heart defects - for example many simple and moderately complex defects of the heart can now be treated using key hole techniques avoiding the need for surgery. Also surgical techniques have now been refined where surgeons are able to carry out many operations without stopping the heart

As a result of these advances the majority of patients with heart defects survive even complex operations. Following treatment these children will need regular follow up with the paediatric cardiologist as they grow into adult life. Simple lesions like holes in the heart have an excellent long term outcome and these children grow to be normal adults and can expect a normal life expectancy with a normal quality of life. If they have a good result they can even participate in competitive level sport. With more complex heart defects long term survival remains good with the majority living into their 30s and 40s. As cardiac surgery for complex birth defects has evolved only over the last 30-40 years we do not know what will happen to these patients when they are say in their 50s or 60s. Overall these children have a relatively normal life, going to school, participating in play activities, pursuing careers etc. The majority of women who have had a good result with treatment tolerate pregnancy well although they need closer monitoring and care during pregnancy than the normal population.

In summary the majority of children who are born with heart defects can have a normal life and a fairly good life expectancy. They do need timely treatment and ongoing care to give them the best chance of survival and help them achieve their potential.

14. Caring for patients with heart defects and pulmonary hypertension

     As a consequence of delayed detection of birth defects of the heart patients can develop permanent damage and high pressure in the lungs (pulmonary hypertension). This can lead to them becoming unsuitable for surgery. This is one of the main reasons for emphasizing the importance of early detection and treatment of birth defects of the heart (preferably during pregnancy or soon after birth).
     In this post I will aim to outline the treatment options available to treat patients with pulmonary hypertension who are often not suitable for surgery or keyhole treatment.The reason I want to particularly highlight this group of patients is that their care is often found wanting and in some parts of the world they are simply sent away saying 'Nothing can be done'. Although a complete cure may not be possible for these patients they do require regular follow up, medication and lifestyle advice on issues like pregnancy, contraception, exercise etc.
    Until recently good medical therapy for this group of patients was not available and they were condemned to a life of gradual deterioration and early demise. Now, there are a wide range of medications that are available that can improve the quality of life of these patients and prolong their survival. The medications do come at a cost (between 750 and 5000 INR per month depending on the medication that is used) but they have been shown to improve the exercise capacity and quality of life of these patients and are indirectly believed to improve their long term survival as well. Prior to starting medical therapy patients may require a cardiac catheter test to establish clearly that there is no scope for curative treatment.
     Apart from medications these patients need counselling regarding various issues in life. Pregnancy in women with severe pulmonary hypertension should be strongly discouraged as it can lead to the death. This should be clearly explained to the patient and their family. Good advice regarding safe and reliable contraception should be given. Mild exercise like walking and swimming can be carried out but patients should be advised not to push themselves or participate in a competitive fashion. Activities like weight lifting should not be allowed.
    Above all this, patients with pulmonary hypertension are often adolescents and young adults who suddenly find themselves different from their friends and peers. They have to deal with the emotional trauma of living with a condition that does not have a definite cure. The doctor's consultation should allow them to express their doubts and apprehensions and help them face life with positivity and courage.

13. Teaching videos for professionals

Hemodynamic assessment: Qp/Qs and PVRi

Pregnancy in patients with congenital heart disease

Echo assessment of Double outlet Right Ventricle

Exercise and congenital heart disease

12. Happy to be treating the women of tomorrow

11. Obesity and physical activity in children

     Recent studies of children in the US have shown that at least 30% are either overweight or obese. Although in India we have long faced the problem of under nutrition among our children; increasing affluence, sedentary lifestyle and lack of exercise have now made obesity a growing problem in our country.

What are the adverse effects of obesity and why has it suddenly become a problem in our society?
     
     Obesity is linked with hypertension (high BP), high cholesterol, higher risk of heart attacks and diabetes. So, it is clearly not a benign problem.  Obesity however seems to be taken very lightly in our society. Traditionally the home-cooked Indian food that our grandparents used to eat provided a balanced diet with starch (rice or roti), protein (dal, lentils and occasionally meat) and a small amount of fat (cooking oil/ghee) along with a variety of fruits and vegetables catering to all our nutritional needs. 
     Now, this simple diet has been largely replaced by processed snack foods with high salt content (potato chips, namkeen etc), restaurant food which is often high in both salt and oil content (required to preserve food for longer) and western style fast foods. Also, we all have much more sedentary lifestyles than our forefathers; taking the car to the corner shop rather than walking or cycling and for many of us a major part of the day is spent sitting at a table in a cramped office environment with no access to fresh air or light. Only few young people are motivated to exercise preferring instead to spend time in front of computers and play stations.      

Is childhood obesity really important? Do children not grow out of it?

     Studies have shown that childhood obesity is closely linked to adult obesity. Children who are obese are more likely to grow into adults who are obese. They also have evidence of thickening of their blood vessels even during childhood which is a predictor of future heart attacks and strokes. 
     Also, children with parents who are themselves overweight or obese are more likely to be overweight. So it is important for us to set an example and stay fit.

What can be done to prevent or control childhood obesity?

     A healthy lifestyle should be encouraged from a young age. Adopting healthy cooking practices at home e.g. steaming or grilling vegetable and meat rather than frying is beneficial to all. Daily exercise for 30-60 minutes should be part of a child's routine. Encourage participation in team and individual sport. This will improve not only the child's fitness but also his social skills and make him a better team player/leader. Snacking between meals should be avoided and healthy snacks encouraged e.g. carrot sticks, fruit slices etc.  

Does weight loss in an obese child improve his or her future risk of heart attacks and stroke?

     Studies have shown that intervention in the form of diet control and exercise in obese and overweight children has improved their cholesterol profile and blood pressure. This in turn reduces the risk of future heart attacks and strokes. I cannot over emphasize the importance of healthy living especially during childhood as these lifestyle habits will last lifelong.

10. The joy of being a children's heart doctor

 I am often asked how I cope with seeing small babies and children having serious illnesses and having to undergo major procedures. I guess over a period of time one has to learn to distance one's emotions from one's profession. This is what allows me to do what I do well. The guileless smile of a young patient though never fails to move me and always brings a smile to my face. Whatever the stresses and frustrations of work may be it reminds me why I do what I do.

9. What to expect when admitted for cardiac catheterisation?

What to expect when admitted for cardiac catheterisation?

If you have been told that your child needs to have a cardiac catheterisation procedure here’s what you can expect. Firstly, the procedure is usually straight forward and low risk. So do not worry.

There are broadly two types of catheterisation procedures; diagnostic and therapeutic. Diagnostic cardiac catheterisation allows the doctor to come to a better understanding of what the problem is with the heart. It allows measurement of pressures in the various chambers of the heart and blood vessels. Also, a special dye (contrast) is injected and X-rays are performed to give further information about the heart problem. Although a fairly good understanding of the problem can be obtained with just echocardiography, diagnostic cardiac catheterisation is sometimes required prior to surgery in some patients to get finer details.             

                                         

Interventional cardiac catheterisation is carried out to close holes, unblock valves or blood vessels without surgery using a key-hole approach. This requires specialized skills and should be carried out only by well-trained individuals. The advantages of this approach are as follows

·         Minimally invasive

·         Less pain

·         Quicker recovery (usually overnight stay in hospital)

·         No scar

Usually the patient is admitted on the day of the procedure (in the morning) and advised to stay ‘nil by mouth’ (fasting) for at least 4 hours prior to the procedure. This is not just for solid foods but also for milk. Sips of water can be allowed until 2 hours prior to the procedure. Some basic blood tests have to be performed prior to the procedure to make sure that there are no signs of infection and that the kidneys are working normally. Once these test results are available and the patient has been fasting for at least 4 hours he/she can be taken for the procedure.

The procedure is carried out in the Catheterisation Laboratory or Cath Lab which is a room which contains all the equipment necessary to carry out the procedure safely. There are heart monitors, X-ray equipment and emergency equipment available in the Cath Lab. Usually for most catheterisation procedures there is no need to put the patient on a breathing machine. Some sleep medication is given through a drip and this is enough to keep the patient asleep and free of pain during the procedure. Sometimes in more complex procedures there might be a need to ventilate the patient (using a breathing machine). This is however only brief and can be stopped at the end of the procedure allowing the patient to breathe on his or her own.

After the procedure the patient has to lie still for around 4 hours. This can be difficult in small children and there needs to be good monitoring of the patient after the procedure. The patient can have sips of water initially (usually once they become awake) and care has to be taken to avoid vomiting which can sometimes happen post procedure. Once the patient has tolerated liquids he can take solid food. After a brief overnight stay in hospital the patient can be discharged the following morning after assessment.