This cartoon succinctly depict all the options we have in our fight against end stage heart failure .We know , a failing heart is often compared to a sick , aged and tired horse.
Image courtesy Heart Physiology: From Cell to Circulation :Lionel H. Opie Lippincott Williams & Wilkins, 2004
1.Don’t whip the horse (Except in emergency)
- Avoid all Inotropics ( Doubutamine and Milrinone were shown to improve quality of life marginally but with dramatic reduction in quantity of life ! However , the same thing does not apply for Digoxin as it is the the only Inotropic with a soothing para-sympathetic comfort !
- Please be reminded, CRT wires could act as “multiple whip equivalents” right inside the heart , especially in advanced class 3 or just recovered class 4 patients. Beware!
2.Unload the horse
Vasodilators
- ACEI/ARBS
3.Slow the horse
- Never exert too much (Not more than 70% of capacity)
- Beta blockers
- Ivabradine (Slow the sinus node and expect a reduction in MVO2 )
4.Change the horse
- Heart transplant may be the best solution
5.Switch to an Artificial Horse(Tractor )
- ie LV assist device
6.Finally try to heal the horse (Still largely in research labs!)
- Genetic engineering
- Tissue repairing
- Stem cells
- Holistic and spiritual healing etc (Has really worked in few )
Dr.S.Venkatesan MD 
Leave a Reply