Care for and with the heart

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(This article is a translation. Find the original piece on the website or in the PanEssay paper)


Last week they were finally back again: our interns! After being absent for multiple months, everyone was feeling relieved and happy, but most of all cautious. We had made a plan in advance to give the interns enough physical space, but also enough space to learn. This space turned out to be available and in the first week the interns already got to know the ins and outs of acute cardiology.


I personally went back in time, into my memory. The summer of 1986 was when I started my internships in the UMCG, which was then the AZG, at the old Intern Clinic that has since fallen to the wrecking ball of demolition. After a start of four weeks at the general internal clinic I went on to cardiology. And I felt right at home. A really nice supervisor worked there, and because of the holidays we were missing the ward physician for some weeks. This meant that you really had to get working as an intern. The head of the department, professor Henk Lie, gave us personal bedside teaching and got us interested in getting more into depth with cardiology. He assigned my colleague intern and I the ‘’class patients’’; the class-department was the territorium of the heads of the (sub)departments, the doctors assistants. Interns were not usually welcome here. 


Cardiology made a great impression on me during this internship, but there is one experience that I will never forget. In the second week one of our patients with heart failure was quickly getting worse. When we saw him in the morning he was already very short of breath, but not long after the start of the afternoon it became terminal. Because there were no other treatment options, all that was left to us was Tender Love and Care. Just before visiting hour he passed away, with just two interns by his side that he had met only a few days ago.


A year and a half later during my semi-physician internship at the same department, the treatment of heart failure had already changed.  Patients were admitted to start on ACE-inhibitors. Carefully, a start was made with low dose captopril two days after the (temporary) stopping of diuretics, and a pilot needle and frequent checking of the blood pressure. A response with severe hypotension was not uncommon. In that same period, we began carefully with placebo controlled studies with metoprolol. A controversial study, because until then beta blockers had been contraindicated during treatment of heart failure. Because of another study we were doing, we now know better. Both medications didn't just mean a large improvement on mortality statistics and the Kaplan-Meier curve of heart failure patients, numbers that we as doctors are bombarded with, but also in the quality of life of the patients. Personally I noticed that the life of my grandfather in Canada was getting much better. From an almost home- and chairbound life, he could walk through his garden again and even do light labour there. He could attend the family picnic once again. 

And all that after the start of ACE-inhibitors and beta blockers.


After that many improvements have been made in the treatment of heart failure. I was doing research myself on the effects of heart revalidation in patients with heart failure. When the assumption used to be that heart patients have to spend the rest of their life taking it easy, we now know that in these patients, as in others, rest weakens the muscle.


A period followed where attention was paid to the technical treatment with, for example, implantable defibrillators, special pacemakers (biventricular pacing), and these past years also the treatment with a left ventricular assist device (LVAD), which we can use to pretty successfully treat patients with severe heart failure at the moment. 

Heart transplants can be delayed and the functionality of these patients is strongly improved. Especially now that we have gained access these past years to our new drug options. According to study results that were published during the ESC congress, we seem to be at the forefront of a new medicamental revolution in the treatment of heart failure. 


When considering all this, one can feel like the sky is the limit. But this is not the case, and it never will be. There will always be patients with heart failure, where just like in the summer of 1986 treatment options have been exhausted. And the care that is needed for them is perhaps not the most spectacular, but it is for us doctors no less important. I am happy to look around our department and see increasing attention for diligent and personal care in the terminal phase of heart failure. In our department my colleague Jenifer Coster tirelessly keeps going, and luckily she is not alone. Not only in the department but internationally as well. During the ESC congress there was not only attention for technical improvements and breakthroughs in the area of drug treatment, but also for discussing the human factor. With the diverse treatment options of heart failure we should never forget to include Tender Love and Care. 


By Wybe Nieuwland, cardiologist at the UMCG, and chairperson of the exam committee.