Femoral artery

The femoral artery is the continuation of the external iliac artery and begins as the external iliac artery passes under the inguinal ligament to enter the femoral triangle on the anterior aspect of the upper thigh.

The femoral triangle (Figure 3). The base is formed superiorly by the inguinal ligament, medially by the lateral border of the adductor longus muscle, and laterally by the medial border of the sartorius muscle. The apex is formed by the crossing of the adductor longus by the sartorius muscle. The contents of the femoral triangle, from lateral to medial, are the femoral nerve and its branches, the femoral artery and several of its branches, the femoral vein and its proximal tributaries, and the deep inguinal lymph nodes.

The femoral artery is palpable in the femoral triangle just inferior to the inguinal ligament midway between the anterior superior iliac spine and the pubic symphysis. The femoral artery is easily accessible within the femoral triangle and is the site for insertion of catheters that may extend into the aorta and ultimately into the coronary vessels of the heart. Such catheters are utilized during cardiac catheterization, coronary angiography, and other procedures involving the heart. A cluster of four small branches – superficial epigastric artery, superficial circumflex iliac artery, superficial external pudendal artery, and deep external pudendal artery – originate from the femoral artery in the femoral triangle and supply cutaneous regions of the upper thigh, lower abdomen, and perineum.

The largest branch of the femoral artery in the thigh is the deep artery of the thigh (profunda femoris artery), which originates from the lateral side of the femoral artery in the femoral triangle and is the major source of blood supply to the thigh (Figure 1). The deep artery of the thigh immediately passes posteriorly between the pectineus and adductor longus muscles and then between the adductor longus and adductor brevis muscles, and then travels inferiorly between the adductor longus and adductor magnus , eventually penetrating through the adductor magnus to connect with branches of the popliteal artery behind the knee. The deep artery of the thigh has lateral and medial circumflex femoral branches and three perforating branches.

The femoral artery passes vertically through the femoral triangle and then continues down the thigh in the adductor canal. It leaves the canal by passing through the adductor hiatus in the adductor magnus muscle and becomes the popliteal artery behind the knee. Branches of this artery supply blood to the knee joint and to certain muscles in the thigh and calf. The popliteal artery diverges into the anterior and posterior tibial arteries. The anterior tibial artery passes downward between the tibia and fibula, giving off branches to the skin and muscles in the anterior and lateral regions of the leg. This vessel continues into the foot as the dorsalis pedis artery (dorsal pedis artery), which supplies blood to the foot. The posterior tibial artery, the larger of the two popliteal branches, descends beneath the calf muscles, giving off branches to the skin, muscles, and other tissues of the leg along the way to the foot.

Figure 1. Femoral artery

Figure 2. Femoral Artery and Deep Artery of the Thigh (and its perforating branches)

Figure 3. Femoral Triangle

Femoral artery bypass

Peripheral artery bypass is surgery to reroute the blood supply around a blocked artery in one of your legs. Fatty deposits can build up inside the arteries and block them ¹.

Peripheral arterial disease happens when there is a narrowing of the blood vessels outside of your heart ². The cause of PAD is atherosclerosis. This happens when plaque builds up on the walls of the arteries that supply blood to the arms and legs. Plaque is a substance made up of fat and cholesterol. It causes the arteries to narrow or become blocked. This can reduce or stop blood flow, usually to the legs. If severe enough, blocked blood flow can cause tissue death and can sometimes lead to amputation of the foot or leg.

The main risk factor for peripheral arterial disease is smoking. Other risk factors include older age and diseases like diabetes, high blood cholesterol, high blood pressure, heart disease, and stroke.

Many people who have peripheral arterial disease don’t have any symptoms. If you have symptoms, they may include:

• Pain, numbness, achiness, or heaviness in the leg muscles. This happens when walking or climbing stairs.
• Weak or absent pulses in the legs or feet
• Sores or wounds on the toes, feet, or legs that heal slowly, poorly, or not at all
• A pale or bluish color to the skin
• A lower temperature in one leg than the other leg
• Poor nail growth on the toes and decreased hair growth on the legs
• Erectile dysfunction, especially among men who have diabetes

Peripheral arterial disease can increase your risk of heart attack, stroke, and transient ischemic attack.

Doctors diagnose peripheral arterial disease with a physical exam and heart and imaging tests. Treatments include lifestyle changes, medicines, and sometimes surgery. Lifestyle changes include dietary changes, exercise, and efforts to lower high cholesterol levels and high blood pressure.

Treatment of Peripheral arterial disease

Alternative Names:

• Femoropopliteal bypass;
• Femoral popliteal bypass;
• Aorta-bifemoral bypass;
• Axillo-bifemoral bypass;
• Ilio-bifemoral bypass;
• Femoral-femoral bypass.

A graft is used to replace or bypass the blocked part of the artery. The graft may be a plastic tube, or it may be a blood vessel (vein) taken from your body (most often the opposite leg) during the same surgery.

Peripheral artery bypass surgery can be done in one or more of the following blood vessels:

• Aorta (the main artery that comes from your heart)
• Artery in your hip
• Artery in your thigh
• Artery behind your knee
• Artery in your lower leg
• Artery in your armpit

During bypass surgery of any artery:

• You will receive medicine (anesthesia) so that you do not feel pain. The kind of anesthesia you receive will depend on what artery is being treated.
• Your surgeon will make a cut over the part of the artery that is blocked.
• After moving skin and tissue out of the way, the surgeon will place clamps at each end of the blocked section of artery. The graft is then sewn in place.
• The surgeon will make sure you have good blood flow in your extremity. Then your cut will be closed. You may have an x-ray called an arteriogram to make sure that the graft is working.

If you are having bypass surgery to treat your aorta and iliac artery or your aorta and both femoral arteries (aortobifemoral):

You will probably have general anesthesia. This will make you unconscious and unable to feel pain. Or, you may have epidural or spinal anesthesia instead. The doctor will inject your spine with medicine to make you numb from your waist down.

Your surgeon will make a surgical cut in the middle of the abdomen to reach the aorta and iliac arteries.

If you are having bypass surgery to treat your lower leg (femoral popliteal):

• You may have general anesthesia. You will be unconscious and unable to feel pain. You may instead have an epidural or spinal anesthesia. The doctor will inject your spine with medicine to make you numb from your waist down. Some people have local anesthesia and a medicine to relax them. Local anesthesia numbs just the area being worked on.
• Your surgeon will make a cut in your leg between your groin and knee. It will be near the blockage in your artery.

Why the Procedure is Performed

Symptoms of a blocked peripheral artery are pain, achiness, or heaviness in your leg that starts or gets worse when you walk.

You may not need bypass surgery if these problems happen only when you walk and then go away when you rest. You may not need this surgery if you can still do most of your everyday activities. Your doctor can try medicines and other treatments first.

Reasons for having arterial bypass surgery of the leg are:

• You have symptoms that keep you from doing your everyday tasks.
• Your symptoms do not get better with other treatment.
• You have skin ulcers (sores) or wounds on your leg that do not heal.
• You have an infection or gangrene in your leg.
• You have pain in your leg from your narrowed arteries, even when you are resting or at night.

Before having surgery, your doctor will do special tests to see the extent of the blockage.

Risks of Artery Bypass Surgery

Risks for any anesthesia and surgery are:

• Allergic reactions to medicines
• Breathing problems
• Blood clots in the legs that may travel to the lungs
• Breathing problems
• Heart attack or stroke

Risks for this surgery are:

• Bypass does not work
• Damage to a nerve that causes pain or numbness in your leg
• Damage to nearby organs in the body
• Damage to the bowel during aortic surgery
• Excess bleeding
• Infection in the surgical cut
• Injury to nearby nerves
• Sexual problems caused by damage to a nerve during aortofemoral or aortoiliac bypass surgery
• Surgical cut that opens up
• Need for a second bypass surgery or a leg amputation
• Heart attack
• Death

Before the Procedure

You will have a physical exam and many medical tests.

• Most people need to get their heart and lungs checked before they have peripheral artery bypass.
• If you have diabetes, you will need to see your health care provider to have it checked.

Always tell your provider what medicines you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

• You may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), naprosyn (Aleve, Naproxen), and other similar drugs.
• Ask your provider which drugs you should still take on the day of your surgery.
• If you smoke, you need to stop. Ask your provider for help.
• Always let your provider know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

DO NOT drink anything after midnight the night before your surgery, including water.

On the day of your surgery:

• Take the medicines your provider told you to take with a small sip of water.
• Your provider will tell you when to arrive at the hospital.

After the Procedure

Right after surgery, you will go to the recovery room, where nurses will watch you closely. After that you will go either to the intensive care unit (ICU) or a regular hospital room.

• You may need to spend 1 or 2 days in bed if the surgery involves the large artery in your abdomen called the aorta.
• Most people stay in the hospital for 4 to 7 days.
• After femoral popliteal bypass, you will spend less time or no time in the ICU.

When your provider says it is ok, you will be allowed to get out of bed. You will slowly increase how far you can walk. When you are sitting in a chair, keep your legs raised on a stool or another chair.

Your pulses will be checked regularly after your surgery. The strength of your pulse will show how well your new bypass graft is working. While you are in the hospital, tell your provider right away if the leg that had surgery feels cool, looks pale or pink, feels numb, or if you have any other new symptoms.

You will receive pain medicine if you need it.

Outlook (Prognosis) of Artery Bypass Surgery

Bypass surgery improves blood flow in the arteries for most people. You may not have symptoms anymore, even when you walk. If you still have symptoms, you should be able to walk much farther before they start.

If you have blockages in many arteries, your symptoms may not improve as much. The prognosis is better if other medical conditions such as diabetes are well controlled. If you smoke, it is very important to quit.

1. Peripheral artery bypass – leg. Medline Plus, U.S. National Library of Medicine. https://medlineplus.gov/ency/article/007394.htm
2. Peripheral artery bypass – leg. Medline Plus, U.S. National Library of Medicine. https://medlineplus.gov/peripheralarterialdisease.html

Brachiocephalic artery

The arch of the aorta is 4–5 cm (almost 2 in.) in length and is the continuation of the ascending aorta. Three major elastic arteries originate along the aortic arch (see Figure 2) and they are:

• The Brachiocephalic trunk,
• The Left Common Carotid artery, and
• The Left Subclavian artery.

The first and largest branch from the arch of the aorta is the brachiocephalic trunk. It extends superiorly for a short distance, bending slightly to the right, and posterior to the right sternoclavicular joint, it divides to form the right subclavian artery and right common carotid artery.

There is only one brachiocephalic trunk; the left common carotid and left subclavian arteries arise separately from the aortic arch.

Figure 1. Brachiocephalic artery (brachiocephalic trunk)

Figure 2. Brachiocephalic artery (brachiocephalic trunk) coming off the Aortic arch

Figure 3. Brachiocephalic artery (brachiocephalic trunk) location

Brachiocephalic artery function

The brachiocephalic artery (brachiocephalic trunk) divides to form:

1. Right subclavian artery and
2. Right common carotid artery.

The right subclavian artery supply the upper limbs, chest wall, shoulders, back, brain, and spinal cord with blood. Three major branches arise from the right subclavian artery before they leave the thoracic cavity: (1) a right thyrocervical trunk, which supplies blood to muscles, skin, tissues of neck; thyroid gland, shoulders, and upper back (right side); (2) an right internal thoracic artery, supplying the skin and muscles of chest and abdomen; mammary gland (right
side), pericardium; and (3) a right vertebral artery, which supplies blood to the spinal cord, cervical vertebrae (right side); fuses with left vertebral, forming basilar artery after entering cranium via foramen magnum.

The right common carotid artery originates from the brachiocephalic trunk immediately posterior to the right sternoclavicular joint and is entirely in the neck throughout its course. Both right and left common carotid arteries ascend through the neck, just lateral to the trachea and esophagus, within a fascial compartment (the carotid sheath). They give off no branches as they pass through the neck. Near the superior edge of the thyroid cartilage each common carotid artery divides into its two terminal branches-the external and internal carotid arteries. At the bifurcation, the common carotid artery and the beginning of the internal carotid artery are dilated. This dilation is the carotid sinus and contains receptors that monitor changes in blood pressure and are innervated by a branch of the glossopharyngeal nerve [cranial nerve IX]. Another accumulation of receptors in the area of the bifurcation is responsible for detecting changes in blood chemistry, primarily oxygen content. This is the carotid body and is innervated by branches from both the glossopharyngeal [IX] and vagus [X] nerves.

Figure 4. Brachiocephalic artery major branches and functions

Internal carotid arteries

After its origin, the internal carotid artery ascends toward the base of the skull. It gives off no branches in the neck and enters the cranial cavity through the carotid canal in the petrous part of the temporal bone. The internal carotid arteries supply the cerebral hemispheres, the eyes and the contents of the orbits, and the forehead.

External carotid arteries

The external carotid arteries begin giving off branches immediately after the bifurcation of the common carotid arteries as follows:

• Superior thyroid artery: supplies the thyrohyoid muscle, internal structures of the larynx, sternocleidomastoid and cricothyroid muscles, thyroid gland
• Ascending pharyngeal artery: supplies pharyngeal constrictors and stylopharyngeus muscle, palate, tonsil, pharyngotympanic tube, meninges in posterior cranial fossa
• Lingual artery: Muscles of the tongue, palatine tonsil, soft palate, epiglottis, floor of mouth, sublingual gland
• Facial artery: All structures in the face from the inferior border of the mandible anterior to the masseter muscle to the medial corner of the eye, the soft palate, palatine tonsil, pharyngotympanic tube, submandibular gland
• Occipital artery: Sternocleidomastoid muscle, meninges in posterior cranial fossa, mastoid cells, deep muscles of the back, posterior scalp
• Posterior auricular artery: Parotid gland and nearby muscles, external ear and scalp posterior to ear, middle and inner ear structures
• Superficial temporal artery: Parotid gland and duct, masseter muscle, lateral face, anterior part of external ear, temporal is muscle, parietal and temporal fossae
• Maxillary artery: External acoustic meatus, lateral and medial surface of tympanic membrane, temporomandibular joint, dura mater on lateral wall of skull and inner table of cranial bones, trigeminal ganglion and dura in vicinity, mylohyoid muscle, mandibular teeth, skin on chin , temporalis muscle, outer table of bones of skull in temporal fossa, structures in infratemporal fossa, maxillary sinus, upper teeth and gingivae, infra-orbital skin, palate, roof of pharynx, nasal cavity.

Figure 5. Carotid arteries

What is brachial artery

The brachial artery is a branch of a prominent artery – the subclavian artery that changes its name along its course. After leaving the thoracic cavity and passing over the first rib, each subclavian artery becomes an axillary artery. The axillary arteries supply blood to the muscles of the pectoral region and axilla. The axillary artery crosses the axilla and enters the arm, where it gives rise to the humeral circumflex arteries ¹. These vessels supply structures near the head of the humerus. Beyond this loop, the axillary artery becomes the brachial artery, which supplies blood to the upper limb (see Figure 3).

The brachial artery continues down the medial and anterior sides of the humerus and ends just distal to the elbow, supplying the anterior flexor muscles of the brachium along the way. The brachial artery is the most common site of blood pressure measurement, using an inflatable cuff that encircles the arm and compresses the artery. The deep brachial artery arises from the proximal end of the brachial and supplies the humerus and triceps brachii muscle (see Figure 3). About midway down the arm, it continues as the radial collateral artery ².

Locating the brachial artery in the arm

The brachial artery is on the medial side of the arm in the cleft between the biceps brachii and triceps brachii muscles (Figure 4) . The median nerve courses with the brachial artery, whereas the ulnar nerve deviates posteriorly from the vessel in distal regions.

Figure 1. Origin of brachial artery

Figure 2. Brachial artery

Figure 3. Brachial artery anatomy

Figure 4. Brachial artery location in the arm

Brachial artery blood pressure

The heart is responsible for supplying the organs and tissues of the body with blood. To do this it pumps blood into the large vessels of the circulatory system with every beat. The blood that is pumped into these vessels puts pressure on the walls of the vessels. When the heart muscle contracts during each heartbeat, the pressure rises as well. When measuring blood pressure, there are two different values:

• Systolic blood pressure is taken while the heart muscle is contracting and pumping oxygen-rich blood into the blood vessels.
• Diastolic blood pressure is taken while the muscle is relaxing and refilling with blood.

In clinical use, the term blood pressure usually refers to the pressure in arteries generated by the left ventricle during systole and the pressure remaining in the arteries when the ventricle is in diastole. Blood pressure is usually measured in the brachial artery in the left arm. The device used to measure blood pressure is a
sphygmomanometer. It consists of a rubber cuff connected to a rubber bulb that is used to inflate the cuff and a meter that registers the pressure in the cuff. With the arm resting on a table so that it is about the same level as the heart, the cuff of the sphygmomanometer is wrapped around a bared arm. The cuff is inflated by squeezing the bulb until the brachial artery is compressed and blood flow stops, about 30 mmHg higher than the person’s usual systolic pressure. The technician places a stethoscope below the cuff on the brachial artery, and slowly deflates the cuff . When the cuff is deflated enough to allow the artery to open, a spurt of blood passes through, resulting in the first sound heard through the stethoscope. This sound corresponds to systolic blood pressure, the force of blood pressure on arterial walls just after ventricular contraction. As the cuff is deflated further, the sounds suddenly become too faint to be heard through the stethoscope. This level, called the diastolic blood pressure, represents the force exerted by the blood remaining in arteries during ventricular relaxation. At pressures below diastolic blood pressure, sounds disappear altogether. The various sounds that are heard while taking blood pressure are called Korotkoff sounds.

Digital blood pressure meters are often used on the wrist, but they can also be placed on the finger or upper arm and only have to be activated by pressing a button. They read the blood pressure automatically from variations in the volume of the blood present in the arteries.

When measuring on the wrist it is important to keep the hand level with the heart. Otherwise you can get skewed results. Digital meters can also sometimes be inaccurate and produce unreliable readings – especially in people with certain heart rhythm problems or arteries hardened due to arteriosclerosis.

Blood pressure is measured in units of “millimeters of mercury”; written mmHg for short. Blood pressure measurements are always given in pairs, with the upper (systolic blood pressure) value first, followed by the lower (diastolic blood pressure) value. So someone who has a reading of 132/88 mmHg (often spoken “132 over 88”) has a systolic blood pressure of 132 mmHg and a diastolic blood pressure of 88 mmHg.

It is important to measure blood pressure more than once, because it fluctuates over the course of the day ³. Physical exertion, stress, pain or extreme heat or cold can affect blood pressure, for example. But if blood pressure changes due to any of these things, it is only temporarily high and will then fall back down to normal range quickly.

So, if blood pressure is measured just once and found to be high, it does not automatically mean that it is also permanently too high. A blood pressure reading taken at the doctor’s office can also be misleading: a visit to the doctor makes some people so nervous that their blood pressure rises.

All of this means that to get reliable results it is important to always take readings on different days and while the person is at rest. This means sitting back and relaxing on a chair and waiting about three minutes before taking a measurement so that the circulatory system comes to rest. The upper arm, which is commonly used to take the measurement, should lie on a table at about the same level as the heart while the reading is being done.

Which number is more important ?

Typically, more attention is given to systolic blood pressure (the top number) as a major risk factor for cardiovascular disease for people over 50 ⁴. In most people, systolic blood pressure rises steadily with age due to the increasing stiffness of large arteries, long-term build-up of plaque and an increased incidence of cardiac and vascular disease.

However, elevated systolic or diastolic blood pressure alone may be used to make a diagnosis of high blood pressure. And, according to recent studies, the risk of death from ischemic heart disease and stroke doubles with every 20 mm Hg systolic or 10 mm Hg diastolic increase among people from age 40 to 89 ⁴.

Figure 5. Blood pressure measurement over the brachial artery

What is normal blood pressure, and when is blood pressure considered to be high ?

Blood pressure is always measured on several days and when you are at rest ³. If several of these measurements are too high, you are said to have high blood pressure, even if only one of the two – either the systolic or the diastolic value – is high ³. The medical term for high blood pressure is hypertension. Normal blood pressure in adults is below 140 mmHg for systolic and below 90 mmHg for diastolic.

Normal blood pressure: systolic under 140 mmHg and diastolic under 90 mmHg. However, the normal (optimal) blood pressure range is 120/80 mm Hg. People who exercise regularly and are in good physical condition may have even lower blood pressures. Thus, blood pressure slightly lower than 120/80 may be a sign of good health and fitness.

A person has hypertension if the systolic value is over 140 mmHg, the diastolic value is over 90 mmHg, or if both are too high. High blood pressure itself usually goes unnoticed. Only if it is extremely high can it result in symptoms like dizziness or trouble seeing.

If hypertension remains undetected for a long time and is not treated, the risk of cardiovascular disease such as heart attacks, strokes and heart and kidney failure increases. So if you or your doctor think you have high blood pressure it is important to have your blood pressure checked regularly. If the readings are repeatedly abnormal, there are several different ways of lowering your blood pressure and thereby decreasing the risk of complications.

Table 1. Healthy and unhealthy blood pressure ranges

Note: A diagnosis of high blood pressure must be confirmed with a medical professional. A doctor should also evaluate any unusually low blood pressure readings. Additionally, lower targets may be appropriate for some populations such as African-Americans, the elderly, or patients with underlying issues such as diabetes mellitus or chronic kidney disease.

Prehypertension (early stage high blood pressure)

Prehypertension is when blood pressure is consistently ranging from 120-139/80-89 mm Hg. People with prehypertension are likely to develop high blood pressure unless steps are taken to control it.

Hypertension Stage 1

Hypertension Stage 1 is when blood pressure is consistently ranging from 140-159/90-99 mm Hg. At this stage of high blood pressure, doctors are likely to prescribe lifestyle changes and may consider adding blood pressure medication.

Hypertension Stage 2

Hypertension Stage 2 is when blood pressure is consistently ranging at levels greater than 160/100 mm Hg. At this stage of high blood pressure, doctors are likely to prescribe a combination of blood pressure medications along with lifestyle changes.

Hypertensive crisis

This is when high blood pressure requires emergency medical attention. If your blood pressure is higher than 180/110 mm Hg and you are NOT experiencing symptoms such as chest pain, shortness of breath, back pain, numbness/weakness, changes in vision or difficulty speaking, wait about five minutes and take it again. If the reading is still at or above that level, you should CALL your local emergency number and get help immediately.

A hypertensive (high blood pressure) crisis is when blood pressure rises quickly and severely. There are two types of hypertensive crises — both require immediate medical attention ⁵.

• Hypertensive Urgency

If you get a blood pressure reading of 180/110 or greater, wait about five minutes and try again. If the second reading is just as high, seek immediate medical help. Early evaluation of organ function is critical to determine an appropriate course of action. Your elevated reading may or may not be accompanied by one or more of the following symptoms ⁵:

• Severe headache
• Shortness of breath
• Nosebleeds
• Severe anxiety

Treatment of hypertensive urgency may involve adjusting or adding medications, but rarely requires hospitalization.

• Hypertensive Emergency

Hypertensive emergencies generally occur at blood pressure levels exceeding 180 systolic OR 120 diastolic, but organ damage can occur at even lower levels in patients whose blood pressure had not been previously high.

The consequences of uncontrolled blood pressure in this range can be severe and include ⁵:

• Stroke
• Loss of consciousness
• Memory loss
• Heart attack
• Damage to the eyes and kidneys
• Loss of kidney function
• Aortic dissection
• Angina (unstable chest pain)
• Pulmonary edema (fluid backup in the lungs)
• Eclampsia

Brachial artery injury

Vascular injuries of the upper extremity represent approximately 30% to 50% of all peripheral vascular injuries. The majority of injuries are to the brachial artery, and 90% of injuries are due to penetrating trauma ⁶. The morbidity and mortality rates associated with brachial artery injuries depend on the cause of the injury itself, which vein or tendon is injured, and whether musculoskeletal and nerve injuries are also present. In recent years, the limb salvage rate has reached nearly 100% because of early transport of patients to the hospital, early diagnosis, increased surgical experience, and developments in the treatment of hypovolemic shock and the use of antibiotic therapy ⁷.

Patients with obvious clinical symptoms of brachial artery injuries as detected by physical examination and those in whom Doppler ultrasonography demonstrates a substantial difference in pressure between the right and left brachial arteries should undergo surgical repair without further angiographic examination. Doppler ultrasonography of the upper extremity has been shown to be as specific and sensitive as arteriography in detecting brachial artery injuries ⁸. Normally, the average brachial–brachial Doppler pressure index between the 2 upper extremities is approximately 0.95; it is rarely less than 0.85 ⁹. If uncertainty remains regarding vascular injuries after physical examination and Doppler ultrasonography, angiography may be used to confirm the vascular injury.

Compartmental edema or contusion can impair venous drainage and arterial flow and can cause pressure injuries to the nerves ¹⁰.

Major venous injuries, fractures, and widespread tissue destruction may also influence the long-term function of the extremity ¹¹. Whether primary and secondary nerve repair procedures are helpful is a point of controversy ¹². The rate of functional disability ranges from 27% to 44% when injury to the upper extremity includes nerve injuries ¹³.

Table 2. Signs and Symptoms of Arterial Ischemia among Patients with Traumatic Brachial Artery Injury

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What is heart surgery

Heart surgery can correct problems with the heart if other treatments haven’t worked or can’t be used ¹. The first American open-heart surgery was performed in 1893 by an African-American, Dr. Daniel Hale Williams. Dr. Daniel Williams completed the operation on a young man named James Cornish. He had been rushed to Provident Hospital in Chicago–with a stab wound. Williams repaired the wound with the use of sutures.

Now many heart surgeries are done each year in the United States for various heart problems. Heart surgery is done in a hospital with a team of experts. Cardiothoracic surgeons perform the surgery with other doctors and nurses who help.

How long the surgery takes will depend on the type of surgery you’re having. Coronary artery bypass grafting (CABG), the most common type of heart surgery, takes about 3–6 hours.

Heart surgery is used for both children and adults. This article discusses heart surgery for adults. For more information about heart surgery for children, go to the articles about congenital heart disease.

There are many types of heart surgery. One person’s experience before surgery can be very different from another’s.

Some people carefully plan their surgeries with their doctors. They know exactly when and how their surgeries will happen. Other people need emergency heart surgery. For example, they might be diagnosed with blocked coronary arteries and admitted to the hospital right away for surgery.

If you’re having a planned surgery, your doctors and others on your health care team will meet with you to explain what will happen. They’ll tell you how to prepare for the surgery. You might be admitted to the hospital the afternoon or morning before your surgery.

You may have some tests before the surgery, such as an EKG (electrocardiogram), chest x ray, or blood tests. An intravenous (IV) line will be placed into a blood vessel in your arm or chest to give you fluids and medicines.

A member of your health care team may shave the area where your surgeon will make the incision (cut). Also, your skin might be washed with special soap to reduce the risk of infection.

Just before the surgery, you’ll be moved to the operating room. You’ll be given medicine so that you fall asleep and don’t feel pain during the surgery.

The most common type of heart surgery for adults is coronary artery bypass grafting (CABG). During coronary artery bypass grafting, a healthy artery or vein from the body is connected, or grafted, to a blocked coronary (heart) artery.

The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery. This creates a new path for oxygen-rich blood to flow to the heart muscle. Coronary artery bypass grafting can relieve chest pain and may lower your risk of having a heart attack.

Doctors also use heart surgery to:

• Treat heart failure and coronary heart disease (coronary artery disease)
• Repair or replace heart valves that don’t work well, which control blood flow through the heart
• Repair abnormal or damaged structures in the heart
• Implant medical devices that help control the heartbeat or control abnormal heart rhythms and support heart function and blood flow
• Replace a damaged heart with a healthy heart from a donor (heart transplant)

Traditional heart surgery, often called open-heart surgery, is done by opening the chest wall to operate on the heart. The surgeon cuts through the patient’s breastbone (or just the upper part of it) to open the chest ².

Once the heart is exposed, the patient is connected to a heart-lung bypass machine. The machine takes over the heart’s pumping action and moves blood away from the heart. This allows the surgeon to operate on a heart that isn’t beating and that doesn’t have blood flowing through it.

Another type of heart surgery is called off-pump, or beating heart, surgery. It’s like traditional open-heart surgery because the chest bone is opened to access the heart. However, the heart isn’t stopped, and a heart-lung bypass machine isn’t used. Off-pump heart surgery is limited to coronary artery bypass grafting.

Surgeons can now make small incisions (cuts) between the ribs to do some types of heart surgery. The breastbone is not opened to reach the heart. This is called minimally invasive heart surgery. This type of heart surgery may or may not use a heart-lung bypass machine.

Newer methods of heart surgery (such as off-pump and minimally invasive) may reduce risks and speed up recovery time. Studies are under way to compare these types of heart surgery with traditional open-heart surgery.

The results of these studies will help doctors decide the best surgery to use for each patient.

Outlook for heart surgery

The results of heart surgery in adults often are excellent ². Heart surgery can reduce symptoms, improve quality of life, and improve the chances of survival.

What are the Risks of Heart Surgery ?

Heart surgery has risks, even though its results often are excellent. Risks include ³:

• Bleeding.
• Infection, fever, swelling, and other signs of inflammation.
• A reaction to the medicine used to make you sleep during the surgery.
• Arrhythmias (irregular heartbeats).
• Damage to tissues in the heart, kidneys, liver, and lungs.
• Stroke, which may cause short-term or permanent damage.
• Death. (Heart surgery is more likely to be life threatening in people who are very sick before the surgery.)

Memory loss and other issues, such as problems concentrating or thinking clearly, may occur in some people.

These problems are more likely to affect older patients and women. These issues often improve within 6–12 months of surgery.

In general, the risk of complications is higher if heart surgery is done in an emergency situation (for example, during a heart attack) ³. The risk also is higher if you have other diseases or conditions, such as diabetes, kidney disease, lung disease, or peripheral artery disease ³.

Heart surgery recovery

Recovery in the Hospital

You may spend a day or more in the hospital’s intensive care unit (ICU), depending on the type of heart surgery you have ⁴. An intravenous (IV) needle might be inserted in a blood vessel in your arm or chest to give you fluids until you’re ready to drink on your own.

Your health care team may give you extra oxygen through a face mask or nasal prongs that fit just inside your nose. They will remove the mask or prongs when you no longer need them.

When you leave the intensive care unit (ICU), you’ll be moved to another part of the hospital for several days before you go home. While you’re in the hospital, doctors and nurses will closely watch your heart rate, blood pressure, breathing, and incision site(s).

Recovery at Home

People respond differently to heart surgery. Your recovery at home will depend on what kind of heart problem and surgery you had. Your doctor will tell you how to:

• Care for your healing incision(s)
• Recognize signs of infection or other complications
• Cope with the after-effects of surgery

You also will get information about followup appointments, medicines, and situations when you should call your doctor right away.

After-effects of heart surgery are normal. They may include muscle pain, chest pain, or swelling (especially if you have an incision in your leg from coronary artery bypass grafting, or coronary artery bypass grafting).

Other after-effects may include loss of appetite, problems sleeping, constipation, and mood swings and depression. After-effects usually go away over time.

Recovery time after heart surgery depends on the type of surgery you had, your overall health before the surgery, and any complications from the surgery.

Your doctor will let you know when you can go back to your daily routine, such as working, driving, and physical activity.

Ongoing Care

Ongoing care after your surgery will include checkups with your doctor. During these visits, you may have blood tests, an EKG (electrocardiogram), echocardiography, or a stress test. These tests will show how your heart is working after the surgery.

After some types of heart surgery, you’ll need to take a blood-thinning medicine. Your doctor will do routine tests to make sure you’re getting the right amount of medicine.

Your doctor also may recommend lifestyle changes and medicines to help you stay healthy. Lifestyle changes may include quitting smoking, changing your diet, being physically active, and reducing and managing stress.

Your doctor also may refer you to cardiac rehabilitation (rehab). Cardiac rehab is a medically supervised program that helps improve the health and well-being of people who have heart problems.

Cardiac rehab includes exercise training, education on heart healthy living, and counseling to reduce stress and help you recover. Your doctor can tell you where to find a cardiac rehab program near your home.

Surgical Approaches

Surgeons can use different approaches to operate on the heart, including open-heart surgery, off-pump heart surgery, and minimally invasive heart surgery.

The surgical approach will depend on the patient’s heart problem, general health, and other factors.

Open-Heart Surgery

Open-heart surgery is any kind of surgery in which a surgeon makes a large incision (cut) in the chest to open the rib cage and operate on the heart. “Open” refers to the chest, not the heart. Depending on the type of surgery, the surgeon also may open the heart.

Once the heart is exposed, the patient is connected to a heart-lung bypass machine. The machine takes over the heart’s pumping action and moves blood away from the heart. This allows the surgeon to operate on a heart that isn’t beating and that doesn’t have blood flowing through it.

Open-heart surgery is used to do coronary artery bypass grafting, repair or replace heart valves, treat atrial fibrillation, do heart transplants, and place ventricular assist devices and total artificial hearts.

For this type of surgery, you’ll be given medicine to help you fall asleep. A doctor will check your heartbeat, blood pressure, oxygen levels, and breathing during the surgery.

A breathing tube will be placed in your lungs through your throat. The tube will connect to a ventilator (a machine that supports breathing).

Your surgeon will make a 6- to 8-inch incision (cut) down the center of your chest wall. Then, he or she will cut your breastbone and open your rib cage to reach your heart.

During the surgery, you’ll receive medicine to thin your blood and keep it from clotting. A heart-lung bypass machine will be connected to your heart. The machine will take over your heart’s pumping action and move blood away from your heart.

A specialist will oversee the heart-lung bypass machine. The machine will allow the surgeon to operate on a heart that isn’t beating and that doesn’t have blood flowing through it.

Figure 1. Open-Heart Surgery

Heart-Lung Bypass Machine

You’ll be given medicine to stop your heartbeat once you’re connected to the heart-lung bypass machine. A tube will be placed in your heart to drain blood to the machine.

The machine will remove carbon dioxide (a waste product) from your blood, add oxygen to your blood, and then pump the blood back into your body. Your surgeon will insert tubes into your chest to drain fluid.

Once the bypass machine starts to work, the surgeon will repair your heart problem. After the surgery is done, he or she will restore blood flow to your heart. Usually, your heart will start beating again on its own. Sometimes mild electric shocks are used to restart the heart.

Once your heart has started beating again, your surgeon will remove the tubes and stop the heart-lung bypass machine. You’ll be given medicine to allow your blood to clot again.

The surgeon will use wires to close your breastbone. The wires will stay in your body permanently. After your breastbone heals, it will be as strong as it was before the surgery.

Stitches or staples will be used to close the skin incision. Your breathing tube will be removed when you’re able to breathe without it.

Figure 2. Heart-Lung Bypass Machine

Off-Pump Heart Surgery

Surgeons also use off-pump, or beating heart, surgery to do coronary artery bypass grafting. This approach is like traditional open-heart surgery because the chest bone is opened to access the heart. However, the heart isn’t stopped, and a heart-lung bypass machine isn’t used ⁵. Instead, your surgeon will steady your heart with a mechanical device so he or she can work on it. Your heart will continue to pump blood to your body.

Off-pump heart surgery isn’t right for all patients. Work with your doctor to decide whether this type of surgery is an option for you. Your doctor will carefully consider your heart problem, age, overall health, and other factors that may affect the surgery.

Figure 3. Off-pump coronary artery bypass heart surgery

Minimally Invasive Heart Surgery

For minimally invasive heart surgery, a surgeon makes small incisions (2–3 inches) in the side of the chest between the ribs. This type of surgery may or may not use a heart-lung bypass machine.

Minimally invasive heart surgery is used to do some bypass and maze surgeries. It’s also used to repair or replace heart valves, insert pacemakers or implantable cardioverter defibrillators, or take a vein or artery from the body to use as a bypass graft for coronary artery bypass grafting.

One type of minimally invasive heart surgery that is becoming more common is robotic-assisted surgery. For this surgery, a surgeon uses a computer to control surgical tools on thin robotic arms.

The tools are inserted through small incisions in the chest. This allows the surgeon to do complex and highly precise surgery. The surgeon always is in total control of the robotic arms; they don’t move on their own.

Figure 4. Minimally Invasive Heart Surgery

Heart bypass surgery

Coronary artery bypass grafting or heart bypass surgery is the most common type of heart surgery ⁵. Coronary artery bypass grafting improves blood flow to the heart. Surgeons use coronary artery bypass grafting to treat people who have severe coronary heart disease (coronary artery disease).

Coronary heart disease is a disease in which a waxy substance called plaque builds up inside the coronary arteries. These arteries supply oxygen-rich blood to your heart.

Over time, plaque can harden or rupture (break open). Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. This can cause chest pain or discomfort called angina.

If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. This is the most common cause of a heart attack. Over time, ruptured plaque also hardens and narrows the coronary arteries.

During coronary artery bypass grafting, a healthy artery or vein from the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, goes around) the blocked portion of the coronary artery. This creates a new path for oxygen-rich blood to flow to the heart muscle.

Surgeons can bypass multiple blocked coronary arteries during one surgery.

Figure 5. Coronary artery bypass grafting

Coronary artery bypass grafting isn’t the only treatment for coronary artery disease. A nonsurgical procedure that opens blocked or narrow coronary arteries is percutaneous coronary intervention (PCI), also known as coronary angioplasty or heart stent surgery.

Heart stent surgery

During percutaneous coronary intervention or heart stent surgery, a thin, flexible tube with a balloon at its tip is threaded through a blood vessel to the narrow or blocked coronary artery. Once in place, the balloon is inflated to push the plaque against the artery wall. This restores blood flow through the artery.

During percutaneous coronary intervention, a stent might be placed in the coronary artery to help keep it open. A stent is a small mesh tube that supports the inner artery wall.

Both coronary artery bypass grafting and percutaneous coronary intervention are options, your doctor can help you decide which treatment is right for you.

Figure 6. Heart stent surgery (percutaneous coronary intervention)

Heart ablation surgery

Heart ablation surgery also known as catheter ablation, is a procedure that uses radiofrequency energy (similar to microwave heat) to destroy a small area of heart tissue that is causing rapid and irregular heartbeats ⁶. Destroying this tissue helps restore your heart’s regular rhythm. The procedure is also called radiofrequency ablation.

A catheter with an electrode at its tip is guided through the veins to the heart muscle with real-time, moving X-rays (fluoroscopy) displayed on a video screen. The catheter is placed at the exact site inside the heart where cells give off the electrical signals that stimulate the abnormal heart rhythm. Then a mild, painless radiofrequency energy (similar to microwave heat) is transmitted to the pathway. This destroys carefully selected heart muscle cells in a very small area (about 1/5 of an inch). This procedure takes place in a special hospital room called an electrophysiology lab or a cardiac catheterization lab. It takes 2 to 4 hours ⁶.

Radiofrequency ablation is the preferred treatment for many types of rapid heartbeats (arrhythmias) especially supraventricular tachyarrhythmias.

Why do people have catheter ablation ?

Special cells in your heart create electrical signals that travel along pathways to the chambers of your heart. These signals make the heart’s upper and lower chambers beat in the proper sequence. Abnormal cells may create disorganized electrical signals that cause irregular or rapid heartbeats called arrhythmias. When this happens, your heart may not pump blood effectively and you may feel faint, short of breath and weak. You may also feel your heart pounding.

Medicines to treat rapid and irregular heartbeats work very well for most people. But they don’t work for everyone, and they may cause side effects in some people. In these cases, doctors may suggest catheter ablation. The procedure is used most often to treat a condition called supraventricular tachycardia (SVT), which occurs because of abnormal conduction fibers in the heart. Catheter ablation is also used to help control other heart rhythm problems such as atrial flutter and atrial fibrillation. Catheter ablation destroys the abnormal tissue without damaging the rest of the heart.

What are the risks of catheter ablation ?

There are few risks. The most common problems result from the use of the catheters – long, thin tubes doctors insert into your arteries or veins. Inserting the tubes can occasionally damage your blood vessel or cause bleeding or infection. These problems are rare.

Figure 7. Radiofrequency ablation of the heart

NOTE: During radiofrequency catheter ablation procedure, the tip of a catheter is guided to the area of heart tissue that is producing abnormal electrical signals. Then the catheter emits a pulse of painless radiofrequency energy that destroys the abnormal tissue and corrects the irregular heartbeat.

What happens during catheter ablation ?

A doctor with special training performs the procedure along with a team of nurses and technicians. The procedure is done in a hospital electrophysiology lab or a cardiac catheterization lab.

• A nurse will put an IV (intravenous line) into a vein in your arm so you can get medicine (anesthesia) to prevent pain. You may also get a medicine (sedative) to help you relax but you will be awake throughout the procedure.
• The nurse will clean and shave the area where the doctor will be working. This is usually in your groin.
• The nurse will give you a shot — a local anesthetic — to numb the needle puncture site.
• The doctor will make a needle puncture through your skin and into the blood vessel (typically a vein, but sometimes an artery) in your groin. A small straw-sized tube (called a sheath) will be inserted into the blood vessel. The doctor will gently guide a catheter (a long, thin tube) into your vessel through the sheath. A video screen will show the position of the catheter. You may feel some pressure in your groin, but you shouldn’t feel any pain.
• The doctor inserts several long, thin tubes with wires, called electrode catheters, through the sheath and feeds these tubes into your heart.
• To locate the abnormal tissue causing arrhythmia, the doctor sends a small electrical impulse through the electrode catheter. This activates the abnormal tissue that is causing your arrhythmia. Other catheters record the heart’s electrical signals to locate the abnormal sites.
• The doctor places the catheter at the exact site inside your heart where the abnormal cells are. Then, a mild, painless, radiofrequency energy (similar to microwave heat) is sent to the tissue. This destroys heart muscle cells in a very small area (about 1/5 of an inch) that are responsible for the extra impulses that caused your rapid heartbeats.
• Catheter ablation usually takes 2 to 4 hours. If you have more than one area of abnormal tissue, the procedure will take longer. You can usually go home the same day, or you may have to stay overnight.

What happens after catheter ablation ?

You’ll be moved to a recovery room. The sheath usually stays in your leg for several hours after catheter ablation. During this time, you have to lie flat.

After the doctor or nurse removes the sheath:

• A nurse will put pressure on the puncture site to stop the bleeding.
• You should keep your leg straight for 6 to 8 hours after the doctor or nurse removes the sheath. The nurse will tell you when you can get out of bed.
• The nurse will watch you carefully and check your heartbeat and vital signs (pulse and blood pressure).
• Tell your doctor or nurse right away if you notice any swelling, pain or bleeding at the puncture site, or if you have chest pain.
• Before you leave the hospital, the nurse will give you written instructions about what to do at home.
• Aspirin is often prescribed for 2 to 4 weeks to minimize risk of clot formation at ablation sites.

What happens after you get home ?

Follow the instructions your nurse or doctor gave you. Most people can return to their normal activities on the day after they leave the hospital.

• Don’t drive for 24 hours after you leave the hospital.
• Don’t drink alcohol for 24 hours after you leave the hospital.
• Avoid heavy physical activity for three days. Ask your doctor when you can return to strenuous exercise.
• A small bruise at the puncture site is normal. If the site starts to bleed, lie flat and press firmly on top of it. Have someone call the doctor or hospital.

Call your local emergency number if you notice:

• The puncture site swells up very fast.
• Bleeding from the puncture site does not slow down when you press on it firmly.

Transmyocardial laser revascularization

Transmyocardial laser revascularization is surgery used to treat angina ⁵.

Transmyocardial laser revascularization is most often used when no other treatments work. For example, if you’ve already had one coronary artery bypass grafting procedure and can’t have another one, transmyocardial laser revascularization might be an option. For some people, transmyocardial laser revascularization is combined with coronary artery bypass grafting.

If transmyocardial laser revascularization is done alone, an incision is made on the left breast to expose the heart. Then, a laser is used to drill a series of holes from the outside of the heart into the heart’s pumping chamber.

During transmyocardial laser revascularization, a surgeon uses lasers to make small channels through the heart muscle and into the heart’s lower left chamber (the left ventricle).

It isn’t fully known how transmyocardial laser revascularization relieves angina. The surgery may help the heart grow tiny new blood vessels. Oxygen-rich blood may flow through these vessels into the heart muscle, which could relieve angina.

Figure 8. Transmyocardial laser revascularization

Heart Valve Repair or Replacement Surgery

For the heart to work well, blood must flow in only one direction. The heart’s valves make this possible. Healthy valves open and close in a precise way as the heart pumps blood.

Each valve has a set of flaps called leaflets. The leaflets open to allow blood to pass from one heart chamber into another or into the arteries. Then the leaflets close tightly to stop blood from flowing backward.

Heart surgery is used to fix leaflets that don’t open as wide as they should. This can happen if they become thick or stiff or fuse together. As a result, not enough blood flows through the valve.

Heart surgery also is used to fix leaflets that don’t close tightly. This problem can cause blood to leak back into the heart chambers, rather than only moving forward into the arteries as it should.

To fix these problems, surgeons either repair the valve or replace it with a man-made or biological valve ⁵. Biological valves are made from pig, cow, or human heart tissue and may have man-made parts as well.

To repair a mitral or pulmonary valve that’s too narrow, a cardiologist (heart specialist) will insert a catheter (a thin, flexible tube) through a large blood vessel and guide it to the heart.

The cardiologist will place the end of the catheter inside the narrow valve. He or she will inflate and deflate a small balloon at the tip of the catheter. This widens the valve, allowing more blood to flow through it. This approach is less invasive than open-heart surgery.

Researchers also are testing new ways to use catheters in other types of valve surgeries. For example, catheters might be used to place clips on the mitral valve leaflets to hold them in place.

Catheters also might be used to replace faulty aortic valves. For this procedure, the catheter usually is inserted into an artery in the groin (upper thigh) and threaded to the heart.

In some cases, surgeons might make a small cut in the chest and left ventricle (the lower left heart chamber). They will thread the catheter into the heart through the small opening.

The catheter has a deflated balloon at its tip with a folded replacement valve around it. The balloon is used to expand the new valve so it fits securely within the old valve.

Currently, surgery to replace the valve is the traditional treatment for reasonably healthy people. However, catheter procedures might be a safer option for patients who have conditions that make open-heart surgery very risky.

Figure 9. Heart Valve Repair / Replacement Surgery

Arrhythmia Treatment

An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.

Many arrhythmias are harmless, but some can be serious or even life threatening. If the heart rate is abnormal, the heart may not be able to pump enough blood to the body. Lack of blood flow can damage the brain, heart, and other organs.

Medicine usually is the first line of treatment for arrhythmias. If medicine doesn’t work well, your doctor may recommend surgery. For example, surgery may be used to implant a pacemaker or an implantable cardioverter defibrillator.

A pacemaker is a small device that’s placed under the skin of your chest or abdomen. Wires connect the pacemaker to your heart chambers. The device uses low-energy electrical pulses to control your heart rhythm. Most pacemakers have a sensor that starts the device only if your heart rhythm is abnormal.

An implantable cardioverter defibrillator is another small device that’s placed under the skin of your chest or abdomen. This device also is connected to your heart with wires. An implantable cardioverter defibrillator checks your heartbeat for dangerous arrhythmias. If the device senses one, it sends an electric shock to your heart to restore a normal heart rhythm.

Another arrhythmia treatment is called maze surgery. For this surgery, the surgeon makes new paths for the heart’s electrical signals to travel through. This type of surgery is used to treat atrial fibrillation, the most common type of serious arrhythmia.

Simpler, less invasive procedures also are used to treat atrial fibrillation. These procedures use high heat or intense cold to prevent abnormal electrical signals from moving through the heart.

Figure 10. Implantable cardioverter defibrillator and/or pacemaker

Aneurysm Repair

An aneurysm is a balloon-like bulge in the wall of an artery or the heart muscle. This bulge can occur if the artery wall weakens. Pressure from blood moving through the artery or heart causes the weak area to bulge.

Over time, an aneurysm can grow and burst, causing dangerous, often fatal bleeding inside the body. Aneurysms also can develop a split in one or more layers of the artery wall. The split causes bleeding into and along the layers of the artery wall.

Aneurysms in the heart most often occur in the heart’s lower left chamber (the left ventricle). Repairing an aneurysm involves surgery to replace the weak section of the artery or heart wall with a patch or graft.

Figure 11. Aortic aneurysm repair

Heart Transplant

A heart transplant is surgery to remove a person’s diseased heart and replace it with a healthy heart from a deceased donor. Most heart transplants are done on patients who have end-stage heart failure.

Heart failure is a condition in which the heart is damaged or weak. As a result, it can’t pump enough blood to meet the body’s needs. “End-stage” means the condition is so severe that all treatments, other than heart transplant, have failed.

Patients on the waiting list for a donor heart receive ongoing treatment for heart failure and other medical conditions. Ventricular assist devices or total artificial hearts might be used to treat these patients.

Surgery To Place Ventricular Assist Devices or Total Artificial Hearts

A ventricular assist device is a mechanical pump that is used to support heart function and blood flow in people who have weak hearts.

Your doctor may recommend a ventricular assist device if you have heart failure that isn’t responding to treatment or if you’re waiting for a heart transplant. You can use a ventricular assist device for a short time or for months or years, depending on your situation.

A total artificial heart is a device that replaces the two lower chambers of the heart (the ventricles). You may benefit from a TAH if both of your ventricles don’t work well due to end-stage heart failure.

Placing either device requires open-heart surgery.

Figure 12. Ventricular assist device

Figure 13. Total artificial heart

1. Heart Surgery. Medline Plus, U.S. National Library of Medicine. https://medlineplus.gov/heartsurgery.html
2. Heart Surgery. National Heart, Lung and Blood Institute, Department of Health and Human Services. https://www.nhlbi.nih.gov/health/health-topics/topics/hs/
3. What Are the Risks of Heart Surgery ? National Heart, Lung and Blood Institute, Department of Health and Human Services. https://www.nhlbi.nih.gov/health/health-topics/topics/hs/risks
4. What To Expect After Heart Surgery. National Heart, Lung and Blood Institute, Department of Health and Human Services. https://www.nhlbi.nih.gov/health/health-topics/topics/hs/after
5. Types of Heart Surgery. National Heart, Lung and Blood Institute, Department of Health and Human Services. https://www.nhlbi.nih.gov/health/health-topics/topics/hs/types
6. Ablation for Arrhythmias. American Heart Association. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/PreventionTreatmentofArrhythmia/Ablation-for-Arrhythmias_UCM_301991_Article.jsp

What is blood plasma

How much blood you have depends mostly on your size and weight. A man who weighs about 70 kg (about 154 pounds) has about 5 to 6 liters of blood in his body. Blood is 55% blood plasma and about 45% different types of blood cells. Blood is composed of solid particles (red blood cells, white blood cells, and cell fragments called platelets) suspended in a fluid extracellular matrix called blood plasma. Over 99% of the solid particles present in blood are cells that are called red blood cells (erythrocytes) due to their red color. The rest are pale or colorless white blood cells (leukocytes) and platelets (thrombocytes).

The blood plasma is the clear, straw-colored, liquid portion of the blood in which the cells (red blood cells, white blood cells) and platelets are suspended. It is
approximately 92% water and less than 8% is dissolved substances, mostly proteins, a complex mixture of organic and inorganic biochemicals. Functions of plasma include transporting gases, vitamins, and other nutrients; helping to regulate fluid and electrolyte balance; and maintaining a favorable pH. Blood plasma also contain antibodies to fight infections (part of the immune system), glucose, amino acids and the proteins that form blood clots (part of the hemostatic system)..

Blood plasma contains electrolytes that are absorbed from the intestine or released as by-products of cellular metabolism. They include sodium, potassium, calcium, magnesium, chloride, bicarbonate, phosphate, and sulfate ions. Sodium and chloride ions are the most abundant. Bicarbonate ions are important in maintaining the pH of plasma. Like other plasma constituents, bicarbonate ions are regulated so that their blood concentrations remain relatively stable.

Blood transports a variety of materials between interior body cells and those that exchange substances with the external environment. In this way, blood helps maintain stable internal environmental conditions.

Hemostasis refers to the process that stops bleeding, which is vitally important when blood vessels are damaged. Following an injury to the blood vessels, several actions may help to limit or prevent blood loss. These include vascular spasm, platelet plug formation, and blood coagulation.

Platelets adhere to any rough surface, particularly to the collagen in connective tissue. When a blood vessel breaks, platelets adhere to the collagen underlying the endothelium lining blood vessels. Platelets also adhere to each other, forming a platelet plug in the vascular break. A plug may control blood loss from a small break, but a larger break may require a blood clot to halt bleeding.

Coagulation, the most effective hemostatic mechanism, forms a blood clot in a series of reactions, each one activating the next. Blood coagulation is complex and utilizes many biochemicals called clotting factors. Some of these factors promote coagulation, and others inhibit it. Whether or not blood coagulates depends on the balance between these two groups of factors. Normally, anticoagulants prevail, and the blood does not clot. However, as a result of injury (trauma), biochemicals that favor coagulation may increase in concentration, and the blood may coagulate. The resulting mass is a blood clot, which may block a vascular break and prevent further blood loss. The clear, yellow liquid that remains after the clot forms is called serum. Serum is plasma minus the clotting factors.

Note: Blood is a complex mixture of formed elements in a liquid extracellular matrix, called blood plasma. Note that water and proteins account for 99% of the blood plasma.

Figure 1. Blood composition

Note: Blood consists of a liquid portion called plasma and a solid portion (the formed elements) that includes red blood cells, white blood cells, and platelets. When blood components are separated by centrifugation, the white blood cells and platelets form a thin layer, called the “buffy coat,” between the plasma and the red blood cells, which accounts for about 1% of the total blood volume. Blood cells and platelets can be seen under a light microscope when a blood sample is smeared onto a glass slide.

Blood Plasma Proteins

Blood plasma proteins are the most abundant of the dissolved substances (solutes) in plasma. These proteins remain in the blood and interstitial fluids, and ordinarily are not used as energy sources. The three main types of blood plasma proteins—albumins, globulins, and fibrinogen—differ in composition and function.

Albumins are the smallest plasma proteins, yet account for about 60% of them by weight. Albumins are synthesized in the liver.

Plasma proteins are too large to pass through the capillary walls, so they are impermeant. They create an osmotic pressure that holds water in the capillaries, despite blood pressure forcing water out of capillaries by filtration. The term colloid osmotic pressure is used to describe this osmotic effect due to the plasma proteins. Because albumins are so plentiful, they are an important determinant of the colloid osmotic pressure of the plasma.

By maintaining the colloid osmotic pressure of plasma, albumins and other plasma proteins help regulate water movement between the blood and the tissues. In doing so, the blood plasma proteins help control blood volume, which, in turn, directly affects blood pressure.

If the concentration of plasma proteins falls, tissues swell. This condition is called edema. As the concentration of plasma proteins drops, so does the colloid osmotic pressure. Water leaves the blood vessels and accumulates in the interstitial spaces, causing swelling. A low plasma protein concentration may result from starvation, a protein-deficient diet, or an impaired liver that cannot synthesize plasma proteins.

Globulins make up about 36% of the plasma proteins. They can be further subdivided into alpha, beta, and gamma globulins. The liver synthesizes alpha and
beta globulins, which have a variety of functions. The globulins transport lipids and fat-soluble vitamins. Lymphatic tissues produce the gamma globulins, which are a type of antibody.

Fibrinogen constitutes about 4% of the plasma proteins, and functions in blood coagulation (clotting). Fibrinogen is synthesized in the liver, fibrinogen is the largest of the plasma proteins.

Plasma products and their uses

Plasma products can be grouped into three main types:

• clotting or coagulation factors
• albumin solutions
• immunoglobulins

Coagulation or clotting factors

Coagulation is the name for the complex process of blood clotting. Clotting factors are proteins that work together with platelets to clot blood.

People need clotting factors for their blood to successfully clot. Missing one or more of these factors leads to blood clotting disorders such as haemophilia and Von Willebrand disease.

In the US, hemophilia is commonly treated with ‘recombinant factors’ that are manufactured in a laboratory and do not come from donated plasma.

Other blood clotting disorders that are treated with coagulation factors made from donated plasma.

Albumin

Albumin is the most common protein in blood plasma. It helps to:

• carry substances around the body
• maintain the right amount of fluid circulating in the body

If the circulation is working properly, vital hormones, cells and enzymes are transported to the right parts of the body to do their job.

If it’s not working properly, the circulatory system starts to break down, with serious consequences such as fluids being retained in the cells.

This can be treated by using human albumin solution which makes sure that the right amount of fluid is circulating in the blood stream.

Albumin can also be used to treat people with some types of liver or kidney disease and patients who have suffered burns.

Immunoglobulins

Immunoglobulins are protective antibodies which are produced by the body to fight against invading viruses or bacteria. There are two different types of immunoglobulins, specific and non-specific.

Specific immunoglobulins

Specific immunoglobulins contain high levels of antibody to a particular illness. These are given to people who have been exposed to a specific infection.

Antidotes to tetanus, rabies, chickenpox and hepatitis are all examples of specific immunoglobulins.

For example, a donor who has had chicken pox will have high levels of chicken pox antibodies. So their plasma would be ideal to treat a child with leukaemia who has been exposed to chicken pox.

Non-specific immunoglobulins

Non-specific immunoglobulins contain a wide variety of antibodies. These are given to people:

• who make faulty antibodies, or can’t make their own antibodies
• who are having treatments for diseases like cancer, where the treatment harms their ability to make antibodies

People with a faulty immune system need these products to live. Over 1,000 donations of plasma contribute to a single dose of an immunoglobulin product that contains all the necessary antibodies.

Table 1 summarizes the characteristics of the blood plasma proteins.

Table 1. Blood plasma proteins

Separating plasma products

Plasma is first tested to be sure it’s safe to use, in the same way that whole blood is tested.

Many chemical and physical processes (e.g., spinning and heat treatments) are then carried out to separate the individual proteins. This is known as the fractionation process.

This process is fully automated and takes up to five days to complete.

Solvent or detergent treatment, dry heat treatment, filtration and pasteurization are also used to kill or remove any viruses that may be present.

The finished products are then tested again to make sure they contain the right biological make-up.

Once processing and testing is complete, the products are labeled, coded and packed, ready to be used by hospitals, clinics and doctors’ surgeries.

The total number of products that can be made with plasma fractionation runs into hundreds.

Blood Plasma Gases and Nutrients

The most important blood gases are oxygen (O2) and carbon dioxide (CO2). Blood plasma also contains a considerable amount of dissolved nitrogen, which ordinarily has no physiological function.

The plasma nutrients include amino acids, simple sugars, nucleotides, and lipids, all absorbed from the digestive tract. For example, blood plasma transports glucose from the small intestine to the liver, where it may be stored as glycogen or converted to fat. If blood glucose concentration drops below the normal range, glycogen may be broken down into glucose.

Blood plasma also carries recently absorbed amino acids to the liver, where they may be used to manufacture proteins, or deaminated and used as an energy source.

Blood plasma lipids include fats (triglycerides), phospholipids, and cholesterol. Because lipids are not water-soluble and plasma is almost 92% water, these lipids are carried in the plasma attached to proteins.

Blood Plasma Nonprotein Nitrogenous Substances

Molecules that contain nitrogen atoms but are not proteins comprise a group called nonprotein nitrogenous substances. In plasma, this group includes amino acids, urea, uric acid, creatine and creatinine. Amino acids come from protein digestion and amino acid absorption. Urea and uric acid are products of protein and nucleic acid catabolism, respectively. Creatinine results from the metabolism of creatine. In the skeletal muscle creatine is part of creatine phosphate in muscle tissue, where it stores energy in phosphate bonds.

Blood Plasma Electrolytes

Blood plasma contains electrolytes that are absorbed from the intestine or released as by-products of cellular metabolism. They include sodium, potassium, calcium, magnesium, chloride, bicarbonate, phosphate, and sulfate ions. Sodium and chloride ions are the most abundant. Bicarbonate ions are important in maintaining the pH of plasma. Like other plasma constituents, bicarbonate ions are regulated so that their blood concentrations remain relatively stable.

Blood plasma donation

Plasmapheresis is the standard procedure by which blood plasma is separated from whole blood and collected ¹. Blood flows through a single needle placed in an arm vein, into a machine that contains a sterile, disposable plastic kit. The plasma is isolated and channeled out into a special bag, and red blood cells and other parts of the blood are returned to you through the same needle.

Is Plasmapheresis Safe ?

Absolutely. The machine and the procedure have been evaluated and approved by the Food and Drug Administration (FDA), and all plastics and needles coming into contact with you are used once and discarded ¹. At no time during the procedure is the blood being returned to you detached from the needle in your arm, so there is no risk of returning the wrong blood to you.

Who Is Eligible to Participate in the AB Plasma Program ?

Donors must have blood group AB and must be male, because men lack plasma proteins (antibodies) directed against blood cell elements ¹. Otherwise, eligibility for plasmapheresis procedures is the same as that for whole-blood donation. The interval between consecutive group AB plasmapheresis donations at National Institutes of Health Blood Bank is 1 month.

How Long Does Plasmapheresis Take ?

Plasmapheresis procedures take about 40 minutes, but you should allow another 20 minutes for staff to obtain your medical history ¹.

What is blood plasma used for

Blood plasma is the pale yellow liquid part of whole blood. It is enriched in proteins that help fight infection (part of the immune system) and aid the blood in clotting (part of the hemostatic system). AB plasma is plasma collected from blood group AB donors. It is considered “universal donor” plasma because it is suitable for all recipients, regardless of blood group. Due to its value as a transfusion component, it is sometimes referred to as “liquid gold.”

Blood plasma products available in the United States include fresh frozen plasma and thawed plasma that may be stored at 33.8 to 42.8°F (1 to 6°C) for up to five days ². Blood plasma contains all of the coagulation factors. Fresh frozen plasma infusion can be used for reversal of anticoagulant effects. Thawed plasma has lower levels of factors V and VIII and is not indicated in patients with consumption coagulopathy (diffuse intravascular coagulation) ³.

Blood plasma transfusion is recommended in patients with active bleeding and an International Normalized Ratio (INR) greater than 1.6, or before an invasive procedure or surgery if a patient has been anticoagulated ⁴, ⁵. Blood plasma is often inappropriately transfused for correction of a high INR when there is no bleeding. Supportive care can decrease high-normal to slightly elevated INRs (1.3 to 1.6) without transfusion of plasma. Table 2 gives indications for plasma transfusion ⁴, ⁵, ⁶.

Table 2. Indications for Transfusion of Blood Plasma Products

Cryoprecipitate

Cryoprecipitate is prepared by thawing fresh frozen plasma and collecting the precipitate. Cryoprecipitate contains high concentrations of factor VIII and fibrinogen ². Cryoprecipitate is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy. Indications for cryoprecipitate transfusion are listed in Table 3 ⁷, ⁸. Each unit will raise the fibrinogen level by 5 to 10 mg per dL (0.15 to 0.29 μmol per L), with the goal of maintaining a fibrinogen level of at least 100 mg per dL (2.94 μmol per L) ⁸. The usual dose in adults is 10 units of pooled cryoprecipitate ³. Recommendations for dosing regimens in neonates vary, ranging from 2 mL of cryoprecipitate per kg to 1 unit of cryoprecipitate (15 to 20 mL) per 7 kg ⁷.

Table 3. Indications for Transfusion of Cryoprecipitate

Blood plasma for patients undergoing surgery on the heart or blood vessels

Cardiovascular surgery includes many types of major surgery on the heart and major blood vessels, including procedures such as: heart valve replacements, coronary artery bypass grafts, aortic aneurysm repairs and corrections or congenital abnormalities of the heart. Cardiovascular surgery is associated with a significant risk of bleeding, with 8% of patients losing more than 2 ml/kg/hour of blood postoperatively ⁹. A number of features make patients undergoing cardiovascular surgery more likely to bleed ¹⁰, ¹¹:

• These patients may be taking drugs that predispose towards bleeding, such as aspirin or clopidogrel.

• Patients undergoing major heart surgery will often require a cardiopulmonary bypass, where a circuit is formed by removing the heart from the circulation by passing a catheter into the aorta and the pulmonary artery while a cardiopulmonary bypass machine circulates blood round the body and ensures that it is adequately oxygenated. Heparin is used to prevent the cardiopulmonary bypass circuit from clotting. Heparin is an anticoagulant and can predispose patients to bleeding. When cardiopulmonary bypass is complete, heparin is neutralised with protamine.

• Hypothermia and acidosis during the procedure may also contribute towards excess bleeding.

• Dilution of clotting factors with administration of intravenous fluid; this is a particular problem in the paediatric setting.

• When acute bleeding develops, clotting factors are consumed, resulting in a coagulopathy and predisposing the patient towards further bleeding.

In some cases these patients will have a clearly defined bleeding risk. They may already be haemorrhaging and, if this is the case, treatments to reduce bleeding would be considered therapeutic. Alternatively they may have abnormal blood results, such as a prolonged prothrombin time, suggesting that clotting factors may be deficient. Lastly, in some cases it may be presumed that a coagulopathy may develop and that prophylactic treatment before this event would reduce the risk of bleeding.

Treatment strategies to reduce bleeding include optimising surgical technique to minimise blood loss; antifibrinolytic agents such as tranexamic acid; careful monitoring and neutralisation of heparin; optimising the management of anticoagulant and antiplatelet drugs; and blood components such as fresh frozen plasma ¹².

Fresh frozen plasma obtained from whole blood from blood donors, is a source of procoagulant factors, including fibrinogen and is used for either the treatment or prophylaxis of bleeding ¹³. Many audits indicate that patients undergoing major cardiac and vascular surgery receive a significant proportion of all clinical plasma transfusions. Some studies have reported wide variation in the use of clinical plasma for cardiac surgery and in critical care among centres within the same country ¹⁴.

Fresh frozen plasma contains a number of factors that help blood to clot. The risk of bleeding in open heart surgery or surgery on the main blood vessels in the body is high. Fresh frozen plasma is sometimes administered to these patients to reduce bleeding. It can be administered prophylactically (to prevent bleeding) or therapeutically (to treat bleeding). However, there are risks of side effects from fresh frozen plasma, such as severe allergic reactions or breathing problems ¹⁵.

However a 2015 Cochrane Review found no evidence for the efficacy of fresh frozen plasma for the prevention of bleeding in heart surgery and it found some evidence of an increased overall need for red cell transfusion in those treated with fresh frozen plasma ¹⁵. There were no reported adverse events due to fresh frozen plasma transfusion. Overall the evidence for the safety and efficacy of prophylactic fresh frozen plasma for cardiac surgery is insufficient. The trials focused on prevention of bleeding and did not address prevention of bleeding for patients with abnormal blood clotting or for the treatment of bleeding patients.

Blood plasma for critically ill patients

Plasma transfusions are a frequently used treatment for critically ill patients, and they are usually prescribed to correct abnormal coagulation tests and to prevent or stop bleeding ¹⁶. Plasma transfusions have been used since 1941 ¹⁷. In 2008, 4,484,000 plasma units were transfused in patients in the United States ¹⁸. More than 10% of critically ill patients, both adults and children, receive a plasma transfusion during their hospital stay, making plasma transfusion a frequently used treatment modality ¹⁹, ²⁰, ²¹. In current practice, plasma transfusions are widely used in critical care; they are administered most often to correct abnormal coagulation tests or to prevent bleeding ²².

In situations in which active bleeding is attributable to a coagulation factor deficiency, plasma transfusions can constitute a life-saving intervention by improving coagulation factor deficit ²³, especially in patients requiring massive transfusion ²⁴. Although plasma transfusions are frequently prescribed for critically ill patients, some of the reasons for their use are not supported by evidence from medical research. Some research has found an association of plasma transfusions with worse outcomes, and other studies have suggested that plasma transfusions do not help to return blood to its normal thickness ²⁵.

Blood plasma for chronic inflammatory demyelinating polyradiculoneuropathy

Chronic inflammatory demyelinating polyradiculoneuropathy is a disease that causes progressive or relapsing and remitting weakness and numbness. At least one or two cases per 100,000 of the population and may be as high as 8.9 per 100,000 ²⁶. It is probably caused by an autoimmune process. Chronic inflammatory demyelinating polyradiculoneuropathy is an uncommon disease that causes weakness and numbness of the arms and legs. The condition may progress steadily or have periods of worsening and improvement. Although not proven, chronic inflammatory demyelinating polyradiculoneuropathy is generally considered to be an autoimmune disease caused by either humoral or cell-mediated immunity directed against myelin around individual nerve fibres or Schwann cell antigens which have not been identified ²⁷. In severe cases, the disease affects the actual nerve fibres themselves. There has been debate as to whether people with the clinical features of an acquired demyelinating neuropathy and a systemic disease, such as cancer, diabetes mellitus, systemic lupus erythematosus, and other connective tissue diseases should be categorised as having chronic inflammatory demyelinating polyradiculoneuropathy ²⁸.

Immunosuppressive or immunomodulatory drugs would be expected to be beneficial. According to Cochrane systematic reviews, three immune system treatments are known to help. These are corticosteroids (‘steroids’), plasma exchange (which removes and replaces blood plasma), and intravenous immunoglobulin (infusions into a vein of human antibodies). Moderate- to high-quality evidence from two small trials shows that plasma exchange provides significant short-term improvement in disability, clinical impairment, and motor nerve conduction velocity in chronic inflammatory demyelinating polyradiculoneuropathy but rapid deterioration may occur afterwards ²⁹. Adverse events related to difficulty with venous access, use of citrate, and haemodynamic changes are not uncommon.

Blood plasma for generalised myasthenia gravis

Myasthenia gravis is an autoimmune disease caused by antibodies in the blood which attack the junctions (against the nicotinic acetylcholine receptor) between nerves and muscles they stimulate. Less than five per cent of patients have auto-antibodies to a muscle tyrosine kinase. Myasthenia gravis is characterised by weakness and fatigability of voluntary muscle, which changes over time. Acute exacerbations are life-threatening because they can cause swallowing difficulties or respiratory failure. Historically, with treatment – including thymectomy, steroids, and immunosuppressive drugs – after one to 21 (mean 12) years, 6% of patients went into remission, 36% improved, 42% were unchanged, and 2% were worse ³⁰. In recent years, expert opinion has highlighted the greater efficacy of combined immunosuppressive treatments ³¹. A new subtype of myasthenia is associated with autoantibodies to a muscle specific kinase and these antibodies are also pathogenic on passive transfer ³².

Plasma exchange was introduced in 1976 as a short-term therapy for acute exacerbations of myasthenia gravis ³³. It is thought to work because the exchange removes circulating anti-AChR (anti-acetylcholine receptor) antibodies. However, improvement has also been reported in so-called seronegative myasthenia gravis (where no anti-AChR antibodies can be detected) following plasma exchange ³⁴. A symposium held in 1978 ³⁵, and numerous papers have recognised the short-term benefit of plasma exchanges ³⁶. The use of repeated plasma exchange over a long period in refractory myasthenia gravis has also been reported ³⁷. Plasma exchange is used worldwide for the treatment of myasthenia gravis but despite the published case series and the conferences of experts many questions remains unanswered concerning its efficacy for the treatment of chronic, more or less severe, myasthenia gravis as well as of myasthenic exacerbation or crisis and its efficacy in comparison with other treatments. Few randomised controlled trials have been published ³⁸, ³⁹. Plasma exchange removes these circulating auto-antibodies. Many case series suggest that plasma exchange helps to treat myasthenia gravis. However, two Cochrane Reviews 2002 ⁴⁰ and 2003 ⁴¹, both found no adequate randomised controlled trials have been performed to determine whether plasma exchange improves the short- or long-term outcome for chronic myasthenia gravis or myasthenia gravis exacerbation. However, many case series studies convincingly report short-term benefit from plasma exchange in myasthenia gravis, especially in myasthenic exacerbation or crisis. In severe exacerbations of myasthenia gravis one randomised controlled trial did not show a significant difference between plasma exchange and intravenous immunoglobulin. Further research is need to compare plasma exchange with alternative short-term treatments for myasthenic crisis or before thymectomy and to determine the value of long-term plasma exchange for treating myasthenia gravis.

Blood plasma for the prevention of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome is an iatrogenic, serious and potentially fatal complication of ovarian stimulation which affects 1% to 14% of all in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) cycles ⁴². Ovarian hyperstimulation syndrome may be associated with massive ovarian enlargement, extracellular exudate accumulation combined with profound intravascular volume depletion, ascites, hydrothorax, haemoconcentration, liver dysfunction and renal failure ⁴³. It can lead to cancellation of an IVF cycle and prolonged bed rest or hospitalisation, which may have significant emotional, social, and economic impacts ⁴⁴. Ovarian hyperstimulation syndrome can be classified into an early form that is related to the ovarian response and exogenous human chorionic gonadotrophin (hCG) administration, and is detected three to nine days after hCG administration. A late form of ovarian hyperstimulation syndrome, diagnosed 10 to 17 days later, is due to endogenous hCG ⁴⁵ and is categorised as mild, moderate, severe or life-threatening. The aetiology of ovarian hyperstimulation syndrome is not completely clear at this moment; however the syndrome is strongly associated with serum hCG and certain vasoactive substances ⁴⁶ are not elevated during gonadotropin stimulation in in vitro fertilization (IVF) patients developing ovarian hyperstimulation syndrome (OHSS): results of a prospective cohort study with matched controls. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2001;96:196-201. https://www.ncbi.nlm.nih.gov/pubmed/11384807)).

Blood plasma albumin has both osmotic and transport functions. It contributes about 75% of the plasma oncotic pressure and administration of 50 g human albumin solution will draw more than 800 mL of extracellular fluid into the circulation within 15 minutes ⁴⁷. It has been suggested that the binding and transport properties of human albumin play a major role in the prevention of severe ovarian hyperstimulation syndrome, as albumin may result in binding and inactivation of the vasoactive intermediates responsible for the pathogenesis of ovarian hyperstimulation syndrome. The osmotic function is responsible for maintaining the intra-vascular volume in the event of capillary leakage, thus preventing the sequelae of hypovolaemia, ascites and haemoconcentration ⁴⁸. A 2016 Cochrane Review concluded that there is some eEvidence suggesting that the plasma expanders assessed in this review (human albumin, hydroxyethyl starch and mannitol) reduce rates of moderate and severe ovarian hyperstimulation syndrome in women at high risk. Adverse events appear to be uncommon, but were too poorly reported to reach any firm conclusions ⁴⁸.

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Blood donation rules

Blood donation rules and requirements vary a lot between countries. For example, in the the United States (US) you must be at least 17 years old to donate blood at the National Institutes of Health Blood Bank ¹. In Australia the minimum age to donate blood is 16 years with an upper limit of 70 years of age ². In the US there is no upper age limit for donation ¹.

The temperature of blood in the body is 38° C, which is about one degree higher than body temperature ³. How much blood you have depends mostly on your size and weight. A man who weighs about 70 kg (about 154 pounds) has about 5 to 6 liters of blood in his body.

The volume of blood removed during a donation (450 mL ± 10% of blood) represents only about 10% of the total blood mass of a subject weighing 70 Kg.

Blood is 55% blood plasma and about 45% different types of blood cells. The blood plasma is a light yellow liquid. Over 90% of blood plasma is water, while less than 10% is dissolved substances, mostly proteins. Blood plasma also contains electrolytes, vitamins and nutrients such as glucose and amino acids. Over 99% of the solid particles present in blood are cells that are called red blood cells (erythrocytes) due to their red color. The rest are pale or colorless white blood cells (leukocytes) and platelets (thrombocytes).

Note: Blood is a complex mixture of formed elements in a liquid extracellular matrix, called blood plasma. Note that water and proteins account for 99% of the blood plasma.

Figure 1. Blood composition

Note: Blood consists of a liquid portion called plasma and a solid portion (the formed elements) that includes red blood cells, white blood cells, and platelets. When blood components are separated by centrifugation, the white blood cells and platelets form a thin layer, called the “buffy coat,” between the plasma and the red blood cells, which accounts for about 1% of the total blood volume. Blood cells and platelets can be seen under a light microscope when a blood sample is smeared onto a glass slide.

Blood has three important functions:

• Transportation

The blood transports oxygen from the lungs to the cells of the body, where it is needed for metabolism. The carbon dioxide produced during metabolism is carried back to the lungs by the blood, where it is then exhaled. Blood also provides the cells with nutrients, transports hormones and removes waste products, which the liver, the kidneys or the intestine, for example, then get rid of.

• Regulation

The blood helps to keep certain values of the body in balance. For instance, it makes sure that the right body temperature is maintained. This is done both through blood plasma, which can absorb or give off heat, as well as through the speed at which the blood is flowing. When the blood vessels expand, the blood flows more slowly and this causes heat to be lost. When the environmental temperature is low the blood vessels can contract, so that as little heat as possible is lost. Even the so-called pH value of the blood is kept at a level ideal for the body. The pH value tells us how acidic or alkaline a liquid is. A constant pH value is very important for bodily functions.

• Protection

If a blood vessel is damaged, certain parts of the blood clot together very quickly and make sure that a scrape, for instance, stops bleeding. This is how the body is protected against losing blood. White blood cells and other messenger substances also play an important role in the immune system.

Blood donation eligibility ⁴

You can donate blood if you:

• Are healthy
• Are at least 17 years of age
• Weigh at least 110 pounds (50 kgs). There is no upper weight limit.

The tables below address specific situations affecting donation eligibility.

Table 1. Medical Condition

Medical Condition	Eligibility
Acquired Immune Deficiency Syndrome (AIDS), individuals at high risk and their partners	cannot donate
Colds and flu within 2 days	cannot donate
Diabetes, on or off medication and under control. If well-controlled by diet, oral medication, or insulin, you can donate. *However, the use of insulin made from beef is a cause for permanent deferral.	can donate
Hepatitis or jaundice after age 11	cannot donate
Pregnancy. You cannot donate until six weeks after the conclusion of the pregnancy.	cannot donate
Pregnancy, after delivery, miscarriage, abortion	6-week wait
Menstruation	can donate
Cancer, treatment complete and disease-free; most types	2-year wait

Table 2. Medical Procedures

Medical Procedures	Eligibility
Surgery, without transfusion (except for autologous blood)	can donate
Surgery, with transfusion	1-year wait

Table 3. Vaccinations

Vaccinations	Eligibility
Measles (rubella); measles, mumps, and rubella (MMR); chicken pox (varicella)	1-month wait
Flu	can donate
Hepatitis A or B	can donate

Table 4. Other Possible Restrictions

Other Possible Restrictions	Eligibility
Ear/Body piercing, sterile procedure/equipment used	can donate
Ear/Body piercing, nonsterile procedure/equipment used	1-year wait
Tattooing	1-year wait
Travel outside the United States or Canada	Contact the National Institutes of Health Blood Bank

If you have traveled to other countries

There is a slight risk of exposure to infectious agents outside the United States that could cause serious disease. Donor deferral criteria for travel outside the US are designed to prevent the transmission of three specific organisms from donor to recipient:

• Malaria. Malaria is caused by a parasite that can be transmitted from mosquitoes to humans. It is found in several hundred countries, and is one of the leading causes of death from infectious diseases world-wide. Donors who have traveled to areas listed by the Centers for Disease Control ⁵ as malarial risk areas are deferred for 1 year after their travel ends ¹.

• Bovine Spongiform Encephalopathy (BSE). BSE is commonly referred to as “Mad Cow disease” and is caused by an abnormal, transmissible protein called a prion. In the 1990s, the United Kingdom experienced an epidemic of the disorder in cows, with subsequent cow-to-human transmission, presumably through the food chain. BSE-infected cattle were also detected in other countries in Western Europe. Transfusion-transmission of BSE among donor-recipient pairs has been documented in a handful of cases ¹. Donors who have spent more than three months in the United Kingdom from 1980-1996, and donors who resided in Western Europe for greater than five years since 1980, are permanently deferred from blood donation ⁶.

Other blood donation restrictions

• If you have low Hemoglobin (Hb) or anemia, female donors must have a hemoglobin level of at least 12.5g/dL and male donors are required to have a minimum level of 13.0g/dL. The deferral is 30 days for both whole blood and apheresis donations. The most common reason for low hemoglobin is iron deficiency, and you will be given information about maintaining a healthy iron balance.
• If you have sickle cell disease, you cannot donate if you have sickle cell disease. You should not donate whole blood if you have sickle cell trait, because your blood will clog the filter that is applied to whole blood units. You can donate platelets if you are a sickle cell trait carrier.
• If you have received a blood transfusion, you must wait one year to donate.
• You cannot donate if you are currently experiencing severe allergy symptoms.

• Taking antibiotics,  you can donate 24 hours after the last dose if you have no further signs of infection. You may donate while taking antibiotics for acne.
• You cannot donate while taking narcotics to relieve pain.
• You may donate blood while taking nonnarcotic pain relievers.
• Aspirin interferes with platelet function and should be discontinued prior to platelet donation as follows. You cannot donate platelets if you have taken aspirin in the last 48 hours.
  • Special Caution: Many medications contain aspirin, so check the container carefully before making a platelet donation,
• Nonaspirin: You can donate platelets if you have taken ibuprofen or other nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDS).
• You can donate if you had skin cancer (basal cell or squamous cell) or cervical cancer in situ and the surgical site is completely healed.
• If you had another type of cancer, you can donate two years after the date of surgery or other definitive therapy, as long as your doctor informs you that there is no evidence of persistent or recurrent cancer.
• You are permanently deferred if you had leukemia or lymphoma.
• If you have a cold or the flu, you can donate once you have been symptom-free for 48 hours.
• If you have had dental work, there is a 24-hour waiting period after a routine cleaning and a 72-hour wait after extractions, root canals, or oral surgery.
• If you have epilepsy, you can donate if you have been seizure free for at least one week.
• If you have high blood pressure, you can donate if your blood pressure is controlled by medication.
• If you have low blood pressure, you can donate with low blood pressure.
• If you have heart disease or had a heart attack, in some situations, you may donate if you have heart disease or have had a heart attack. Contact the National Institutes of Health Blood Bank ⁷ for more details.
• If you have had angioplasty, you will need to contact the National Institutes of Health Blood Bank ⁷ for more details.
• If you had major surgery, you must wait until you have completely recovered and returned to normal activity before donating.
• If you have had hepatitis, you cannot donate if you have had hepatitis after age 11.
• If you received the hepatitis vaccine, you can donate if you have received the hepatitis vaccine (a series of three vaccinations).
• You must wait one year if you received Hepatitis B Immune Globulin or if you experienced a needlestick injury contaminated with untested blood.
• If you have herpes, you cannot donate with herpes or a cold sore when the lesions are active. You can donate if the lesions are dry and almost healed.
• If you have had malaria, you may donate if you have been asymptomatic of malaria for more than 3 years while residing in a non-endemic country.

Benefits of blood donation

There is no substitute for human blood. Human blood cannot be manufactured. People are the only source of blood. Much of the medical care of an National Institutes of Health patient depends on the steady supply of blood from healthy, caring individuals like yourself. No miracle of modern medicine can help the patients who need blood if blood is not available. The blood you donate at the National Institutes of Health Blood Bank is used to support the many patients who come from all over the world to receive treatment.

Blood in the umbilical cord at birth is rich in stem cells that can be used to treat a variety of disorders, including leukemias, sickle cell disease and other hemoglobin abnormalities, and certain inborn errors of metabolism. The United States and the United Kingdom have public umbilical cord blood banks that provide stem cells for free. For many illnesses it is more effective to receive donor stem cells, because receiving one’s own could reintroduce the disease.

Types of Blood Donations

You can make the following types of donations:

Blood components for transfusion

• Whole blood
• Red cells by apheresis
• Platelets by apheresis
• Granulocytes by apheresis
• AB Plasma by apheresis

Hemochromatosis donations

Hemochromatosis is a relatively common inherited condition in which the body absorbs excess iron. Over many years, iron overload can develop, with deposition of excess iron in body tissues and organs. Disabling arthritis, glandular failure, and severe liver disease can occur if the disorder is not treated. The treatment is phlebotomy therapy, or removal of 1 unit (1 pint) of blood every 1 – 16 weeks, depending on the level of iron overload. One pint of blood contains 250 mg of iron. Serial frequent phlebotomy sessions are a highly effective way to lower body iron levels. The National Institutes of Health Blood Bank has a protocol for treatment of hemochromatosis by phlebotomy therapy, which uses a simple and easy method to determine the pace of therapy.

The blood units removed therapeutically may be made available for transfusion into others if the donor (the hemochromatosis subject) meets standard blood donor eligibility criteria. Phlebotomy therapy and medical care for hemochromatosis are offered free of charge to all study participants. All persons with hemochromatosis are eligible for participation in this study, regardless of whether they meet blood donor criteria.

Hemochromatosis patients participating in the NIH Blood Bank Hemochromatosis Donor Program may donate:

• Whole blood
• Double red cells

Blood components for laboratory research use

Donated blood is never wasted. It is used every day of the year to treat patients who are participating in the medical treatment and research programs of the National Institutes of Health. If your blood is not required for immediate use, it may be frozen and stored. Fractions of blood that cannot be used for transfusion are used for research. Occasionally, the blood you give may not be required for a patient here but may be sent to another hospital, where it can be used to help save a life.

What is Whole Blood ?

Whole blood consists of red blood cells, white blood cells, and platelets suspended in a protective yellow liquid known as plasma. Most patients receiving transfusions do not need all of these elements.

Red blood cells have no nucleus, in contrast to many other cells. Each red blood cell contains hemoglobin, which can transport oxygen. In tiny blood vessels in the lung the red blood cells pick up oxygen from inhaled air and carry it through the bloodstream to all parts of the body. When they reach their goal, they release it again. The cells need oxygen for metabolism, which also creates carbon dioxide as a waste product. The red blood cells then pick up the carbon dioxide and transport it back to the lung. There we exhale it when we breathe out.

Red blood cells can also pick up or release hydrogen and nitrogen. When picking up or releasing hydrogen they help to keep the pH level of the blood steady; by releasing nitrogen the blood vessels expand, and blood pressure falls. Red blood cells have a life cycle of about 120 days. When they are too old or damaged they are broken down in the bone marrow, spleen or liver.

All solid parts of the blood originate from common parent cells, the so-called stem cells. In adults blood cells are produced mainly in the bone marrow. The various blood cells develop in several stages from stem cells to blood cells or blood platelets. White blood cells such as lymphocytes do not mature only in the bone marrow, but also in the lymph nodes. When the cells are completed, they are released into the bloodstream. In addition to these mature cells, the blood still contains a small number of precursor cells.

Figure 2. Blood cell development. A blood stem cell goes through several steps to become a red blood cell, platelet, or white blood cell

Certain messenger substances regulate the production of blood cells. The hormone erythropoietin, which is produced in the kidneys, promotes the production of red blood cells, while so-called cytokines stimulate the production of white blood cells.

One pint (473 ml) of whole blood is usually processed by a spinning method into:

• Red blood cells, which carry the oxygen needed by patients who are anemic;
• Platelets: Platelets are small cells that help the blood to clot. Manufactured in the bone marrow and stored in the spleen, their job is to rush to the site of an injury. Once there, they form a barrier, help the damaged organ or blood vessel stop bleeding, and give the body a chance to begin healing. Platelets needed by patients who are bleeding.
• Plasma: Plasma is the pale yellow liquid part of whole blood, in which the cellular elements are suspended. It is enriched in proteins that help fight infection and aid the blood in clotting. AB plasma is plasma collected from blood group AB donors. It is considered “universal donor” plasma because it is suitable for all recipients, regardless of blood group. Due to its value as a transfusion component, it is sometimes referred to as “liquid gold.” Plasma is transfused to patients whose blood is not clotting.

Therefore, one donation of whole blood can treat three different patients!

Used for:

• Cancer, blood diseases, haemophilia, anaemia, heart disease, stomach disease, kidney disease, childbirth, operations, blood loss, trauma, burns.

Is it Safe to Give Whole Blood ?

Absolutely. Many safeguards are taken to assure that no harm comes to you during or after donation. First, we obtain a medical history and check your blood pressure, pulse, and temperature to assure that you are in good health. We take a small sample of blood from your finger to confirm that you have an ample number of red cells to share. All equipment used to collect your blood is sterile and disposable. After donation, we provide delicious snacks and drinks.

Who is Eligible to Give Whole Blood?

Please see detailed description of donor criteria above (Tables 1-4 plus eligibility criteria and restrictions).

How often can you donate whole blood ?

You must wait 56 days between whole-blood donations to allow the number of red blood cells in your body to return to a predonation level.

How long does blood donation take ?

15 minutes to donate, 45 minutes for the appointment.

How Do You Arrange to Donate ?

You can contact the National Institutes of Health Blood Bank ⁷ for more details.

What is Donating Red Cells by Apheresis

Double Red Cell Apheresis (DRCA) is a procedure that allows a donor to give 2 units of red cells at the same time. This is done by a procedure called “apheresis,” which separates whole blood into component parts such as red blood cells, platelets, and plasma ⁸. To remove red cells, a needle is placed in your arm, and the blood flows into a sterile, disposable plastic kit installed in a machine designed specifically for this purpose. As blood enters the machine, the bowl is spinning at high speed. This causes the components of the blood to separate so that the red blood cells can be siphoned into a blood bag. Plasma and other parts of the blood are then returned to you through the same needle. The process is repeated to collect 2 units of red blood cells.

Is Double Red Cell Apheresis Safe ?

Absolutely. The machine and the procedure have been evaluated and approved by the Food and Drug Administration (FDA), and all plastics and needles coming into contact with you are used once and discarded ⁸. At no time during the procedure is the blood being returned to you detached from the needle in your arm, so there is no risk of returning the wrong blood to you.

What Are The Double Red Cell Apheresis Donor Requirements ?

Because you will be losing more red blood cells than usual during this procedure, donor criteria differ from those for whole blood donation:

Men

• Minimum weight – 130 pounds (59 kgs)
• Minimum height – 5’1″

Women

• Minimum weight – 150 pounds (68 kgs)
• Minimum height – 5’5″

Donors must have a slightly higher red cell count, specifically, a fingerstick hemoglobin level of at least 13.3 gm/dL. To assure that you do not become anemic, the interval between Double Red Cell Apheresis and subsequent blood donation is 4 months ⁸.

How Long Does Double Red Cell Apheresis Procedure Take ?

The time required to remove 2 units of reds cells is about 45 minutes ⁸. Because you’ll be with us longer, there will be time to watch TV, read, or just chat with staff and other donors. Every effort will be made to make the experience relaxing and enjoyable.

What is Donating Platelets by Apheresis

Plateletpheresis is the standard procedure by which platelets are separated from whole blood, concentrated, and collected ⁹. To remove platelets, a needle is placed in each arm. Blood flows through a needle into a machine that contains a sterile, disposable plastic kit specifically designed for this purpose. The platelets are isolated and channeled out into a special bag, and red blood cells and other parts of the blood are returned to you through a needle in the opposite arm. There is also a plateletpheresis procedure that can be performed with a single needle.

Is Plateletpheresis Safe ?

Absolutely. The machine and the procedure have been evaluated and approved by the Food and Drug Administration, and all plastics and needles coming into contact with you are used once and discarded ⁹. At no time during the procedure is the blood being returned to you detached from the needle in your arm, so there is no risk of returning the wrong blood to you.

Who Is Eligible to Give Platelets ?

The interval between consecutive platelet donations at National Institutes of Health Blood Bank is 1 month. However, because the body replaces platelets within a few days, you are allowed to give more frequently when you are donating for a relative or for a patient who responds particularly well to your platelets. In addition to standard donor eligibility requirements, platelet donors should refrain from taking aspirin for 48 hours prior to donation.

How Long Does Plateletpheresis Take ?

Plateletpheresis procedures take about 90 minutes ⁹, but you should allow another 30 minutes for staff to obtain your medical history.

What is Plasmapheresis ?

Plasmapheresis is the standard procedure by which plasma is separated from whole blood and collected ¹⁰. Blood flows through a single needle placed in an arm vein, into a machine that contains a sterile, disposable plastic kit. The plasma is isolated and channeled out into a special bag, and red blood cells and other parts of the blood are returned to you through the same needle.

Is Plasmapheresis Safe ?

Absolutely. The machine and the procedure have been evaluated and approved by the Food and Drug Administration (FDA), and all plastics and needles coming into contact with you are used once and discarded ¹⁰. At no time during the procedure is the blood being returned to you detached from the needle in your arm, so there is no risk of returning the wrong blood to you.

Who Is Eligible to Participate in the AB Plasma Program ?

Donors must have blood group AB and must be male, because men lack plasma proteins (antibodies) directed against blood cell elements ¹⁰. Otherwise, eligibility for plasmapheresis procedures is the same as that for whole-blood donation. The interval between consecutive group AB plasmapheresis donations at National Institutes of Health Blood Bank is 1 month.

How Long Does Plasmapheresis Take ?

Plasmapheresis procedures take about 40 minutes, but you should allow another 20 minutes for staff to obtain your medical history ¹⁰.

What is Granulocytes by Apheresis

A granulocyte is a type of white blood cell which fights bacteria and fungi. Patients with bone marrow failure syndromes, or those undergoing chemotherapy or marrow transplantation, often do not make enough of their own granulocytes to prevent serious infections. Such patients may benefit from a course of granulocyte transfusions.

What is Granulocytapheresis ?

Granulocytapheresis is the process by which granulocytes are collected from a healthy donor ¹¹. Similar to plateletpheresis, blood is withdrawn from a vein and directed into a machine that contains a sterile disposable kit. Granulocytes are separated by a spinning process and concentrated in a plastic bag. The remaining parts of the blood are returned to the donor through a second needle.

Is Granulocytapheresis Safe ?

Yes. The machine and the procedure used for granulocyte collection are approved by the Food and Drug Administration, and all plastics and needles coming into contact with the donor are discarded after use ¹¹. Two medications are given to the donor the day before collection to boost the donor’s granulocyte count. These medications are approved for donor use under an NIH protocol.

Who Is Eligible to Give Granulocytes ?

Granulocyte donors are healthy, unpaid volunteers between the age of 18 and 75 who meet the criteria for blood and platelet donors described below ¹¹. Granulocyte donors must meet some additional criteria described in the protocol. Granulocyte donors should refrain from taking aspirin for 48 hours prior to donation.

How Long Does Granulocytapheresis Take ?

Giving granulocytes with use of an apheresis machine takes about 2.5 hours, which is slightly longer than a plateletpheresis donation ¹¹. The donor has enough time to enjoy a full-length movie.

Blood donation side effects

Blood donors normally tolerate the donation very well, but occasionally adverse reactions of variable severity may occur during or at the end of the collection. The adverse reactions that occur in donors can be divided into local reactions and systemic reactions. In a small study involving 4,906 donors (3,716 male and 1,190 female), only 63 donors (1.2% of all the volunteers) suffered some kind of adverse reaction: 59 (1.08% of the subjects) had mild reactions (agitation, sweating, pallor, cold feeling, sense of weakness, nausea), and only 4 (3 males and 1 female, 0.2%) had more severe disorders, including vomiting, loss of consciousness, and convulsive syncope.

The statistical probability of an episode of complete loss of consciousness was equivalent to an incidence of 0.1%, that is, one case every 1,000 donors ¹².

Of the 63/4,906 (1.2%) donors who had adverse reactions to blood donation, only 40 (0.8%) were administered oral vasopressors (a drug or other agent which causes the constriction of blood vessels), while the other 23 (0.4%) recovered from the vasovagal reaction simply from being placed in the antishock position. Of the 63 donors who had a vasovagal reaction, only 18 (0.36%) were given crystalloid solutions, while less than five (0.1%) required additional therapy with cortisone ¹². In no case was re-animation based on oxygen therapy or administration of adrenaline needed.

The greatest number of reactions occurred during or after donations of whole blood, with there being fewer after donations of other blood components.

Local reactions

Local reactions occur predominantly because of problems related to venous access ¹². They are usually haematomas due to extravasation from the veins, caused by incorrect placement of the needle during the venipuncture. Pain, hyperaemia and swelling may develop at the site of the extravasation. Other local events include pain due to slight trauma to the subcutaneous nerve endings. In most cases, however, these are banal complications that do not require any treatment. Local phlebitis and thrombophlebitis are more serious complications than the foregoing, but are very rare.

Systemic reactions

The systemic reactions, in contrast to the local reactions, can be divided into mild or severe. In most cases, they are vasovagal reactions than can be triggered by the pain of the venipuncture, by the donor seeing his or her own blood, by the donor seeing another donor unwell, by the anxiety and state of tension of undergoing the donation, etc. The systemic reactions are characterised by the appearance of pallor, sweating, dizziness, gastrointestinal disorders, nausea, hypotension, and bradycardia. Therapeutic intervention must be swift, otherwise this clinical picture, typical of a vasovagal reaction, will progress into an episode of syncope, of variable severity, which may or may not be complicated by the onset of tonic-clonic muscle spasms (convulsive syncope), accompanied by vomiting and loss of sphincter control.

Systemic reactions can occur during apheresis procedures, which require the use of anticoagulants such as acid-citrate-dextrose for the collection of the blood component ¹². This anticoagulant can cause hypocalcaemia, because of chelation. The lowered concentration of calcium ions leads to episodes of paraesthesia of the lips, oral cavity and limbs. These symptoms resolve after interruption of the apheresis procedure, although it may sometimes be necessary to use a therapeutic intervention, such as the administration of calcium gluconate. Much more rarely, tremor, muscle spasms, hypotension, tachycardia, arrhythmia, convulsions and tetany develop.

There are rare reports of acute intoxication due to overdoses of acid-citrate-dextrose ¹³. Another rare complication, that can occur during apheresis procedures, is severe arrhythmias ¹².

Figure 3. Frequency of the symptoms occurring in donors during or immediately after the donation

Note: The donor population analysed consisted of 4,906 donors (3,716 male and 1,190 female). In total, 3,983 (81%) voluntaries have donated whole blood, 851 (17%) plasma from apheresis, 64 (1.3%) experienced multicomponent donation, and 8 (0.1%) were donors of plasma-platelet apheresis in the year from 24^th October, 2005 to 24^th April 2006.

Blood Transfusions

Early attempts to transfer blood from one person to another produced varied results. Sometimes, the recipient improved. Other times, the recipient suffered a blood transfusion reaction in which the red blood cells clumped, obstructing vessels and producing great pain and organ damage.

Eventually scientists determined that blood is of differing types and that only certain combinations of blood types are compatible. These discoveries led to the development of procedures for typing blood. Today, safe transfusions of whole blood depend on two blood tests—“type and cross match.” First the recipient’s ABO blood type and Rh status are determined. Following this, a “cross match” is done of the recipient’s serum with a small amount of the donor’s red blood cells that have the same ABO type and Rh status as the recipient. Compatibility is determined by examining the mixture under a microscope for agglutination, the clumping of red blood cells. Agglutination (“clumping”) is a reaction between antigens and specific antibodies. This is what happens when antigens on mismatched donated red blood cells react with antibodies in plasma.

Blood Antigens and Antibodies

An antigen, is any molecule that triggers an immune response, the body’s reaction to invasion by a foreign substance or organism. When the immune system encounters an antigen not found on the body’s own cells, it will attack, producing antibodies. In a transfusion reaction, antigens (agglutinogens) on the surface of the donated red blood cells react with antibodies (agglutinins) in the plasma of the recipient, resulting in the agglutination of the donated red blood cells.

A mismatched blood transfusion quickly produces telltale signs of agglutination—anxiety, breathing difficulty, facial flushing, headache, and severe pain in the neck, chest, and lumbar area. Red blood cells burst, releasing free hemoglobin. Liver cells and macrophages phagocytize the hemoglobin, converting it to bilirubin, which may sufficiently accumulate to cause the yellow skin of jaundice. Free hemoglobin reaching the kidneys may ultimately cause them to fail.

Only a few of the 32 known antigens on red blood cell membranes can produce serious transfusion reactions. These include the antigens of the ABO group and those of the Rh group. Avoiding the mixture of certain kinds of antigens and antibodies prevents adverse transfusion reactions.

ABO Blood Group

The ABO blood group is based on the presence (or absence) of two major antigens on red blood cell membranes—antigen A and antigen B. A and B antigens are carbohydrates attached to glycolipids projecting from the red blood cell surface. A person’s erythrocytes have on their surfaces one of four antigen combinations: only A, only B, both A and B, or neither A nor B.

A person with only antigen A has type A blood. A person with only antigen B has type B blood. An individual with both antigens A and B has type AB blood. A person with neither antigen A nor B has type O blood. Thus, all people have one of four possible ABO blood types—A, B, AB, or O. The resulting ABO blood type is inherited. It is the consequence of DNA encoding enzymes to synthesize A or B antigens on erythrocytes in one of these four combinations.

• In the United States, the most common ABO blood types are O (47%) and A (41%). Rarer are type B (9%) and type AB (3%). These percentages vary in subpopulations and over time, reflecting changes in the genetic structure of populations.

Antibodies that affect the ABO blood group antigens are present in the plasma about two to eight months following birth, as a result of exposure to foods or microorganisms containing the antigen(s) that are not present on the individual’s red blood cells. Specifically, whenever antigen A is absent in red blood cells, an antibody called anti-A is produced, and whenever antigen B is absent on cells, an antibody called anti-B is produced. Therefore, individuals with type A blood have anti-B antibody in their plasma; those with type B blood have anti-A antibody; those with type AB blood have neither antibody; and those with type O blood have both anti-A and anti-B antibodies (Figure 4 and Table 5). The antibodies anti-A and anti-B are large and do not cross the placenta. Thus, a pregnant woman and her fetus may be of different ABO blood types, but agglutination in the fetus will not occur.

An antibody of one type will react with an antigen of the same type and clump red blood cells; therefore, such combinations must be avoided. The major concern in blood transfusion procedures is that the cells in the donated blood not clump due to antibodies in the recipient’s plasma. For this reason, a person with type A (anti-B) blood must not receive blood of type B or AB, either of which would clump in the presence of anti-B in the recipient’s type A blood. Likewise, a person with type B (anti-A) blood must not receive type A or AB blood, and a person with type O (anti-A and anti-B) blood must not receive type A, B, or AB blood.

Type AB blood does not have anti-A or anti-B antibodies, so an AB person can receive a transfusion of blood of any other type. For this reason, individuals with type AB blood are called universal recipients. However, type A (anti-B) blood, type B (anti-A) blood, and type O (anti-A and anti-B) blood still contain antibodies (either anti-A and/or anti-B) that could agglutinate type AB cells if transfused rapidly.

Consequently, even for AB individuals, using donor blood of the same type as the recipient is best (Table 6). Type O blood has neither antigen A nor antigen B. Therefore, theoretically this type could be transfused into persons with blood of any other type. Individuals with type O blood are called universal donors. Type O blood, however, does contain both anti-A and anti-B antibodies. If type O blood is given to a person with blood type A, B, or AB, it should be transfused slowly so that the recipient’s larger blood volume will dilute the donor blood, minimizing the chance of an adverse reaction.

Figure 4. ABO Blood Types and Antibodies (different combinations of antigens and antibodies distinguish blood types)

Table 5. Antigens and Antibodies of the ABO Blood Group

Table 6. Preferred and Permissible Blood Types for Transfusions

Rh Blood Group

The Rh (Rhesus) blood group was named after the rhesus monkey in which it was first studied. In humans, this group includes several Rh antigens (factors). The most prevalent of these is antigen D, a transmembrane protein.

If the Rh antigens are present on the red blood cell membranes, the blood is said to be Rh-positive. Conversely, if the red blood cells do not have Rh antigens, the blood is called Rh-negative. The presence (or absence) of Rh antigens is an inherited trait. Anti-Rh antibodies (anti-Rh) form only in Rh-negative individuals in response to the presence of red blood cells with Rh antigens. This happens, for example, if an individual with Rh-negative blood receives a transfusion of Rh-positive blood. The Rh antigens stimulate the recipient to begin producing anti-Rh antibodies. Generally, this initial transfusion has no serious consequences, but if an individual with Rh-negative blood—who is now sensitized to Rh-positive blood—receives another transfusion of Rh-positive blood some months later, the donated red cells are likely to agglutinate.

A similar situation of Rh incompatibility arises when an Rh-negative woman is pregnant with an Rh-positive fetus. Her first pregnancy with an Rh-positive fetus would probably be uneventful. However, if at the time of the infant’s birth (or if a miscarriage occurs) the placental membranes that separated the maternal blood from the fetal blood during the pregnancy tear, some of the infant’s Rh-positive blood cells may enter the maternal circulation. These Rh-positive cells may then stimulate the maternal tissues to produce anti-Rh antibodies. If a woman who has already developed anti-Rh antibodies becomes pregnant with a second Rh-positive fetus, these antibodies, called hemolysins, cross the placental membrane and destroy the fetal red blood cells. The fetus then develops a condition called erythroblastosis fetalis, or hemolytic disease of the fetus and newborn.

Erythroblastosis fetalis is extremely rare today because obstetricians carefully track Rh status. An Rh-negative woman who might carry an Rh-positive fetus is given an injection of a drug called RhoGAM at week 28 of her pregnancy and after delivery of an Rh-positive baby. Rhogam is a preparation of anti-Rh  antibodies, which bind to and shield any Rh-positive fetal cells that might contact the woman’s cells and sensitize her immune system. RhoGAM must be given within 72 hours of possible contact with Rh-positive cells—including giving birth, terminating a pregnancy, miscarrying, or undergoing amniocentesis (a prenatal test in which a needle is inserted into the uterus).

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5. Explore Travel Health with the CDC Yellow Book. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/page/yellowbook-home
6. Bovine Spongiform Encephalopathy (BSE) Questions and Answers. U.S. Food and Drug Administration. https://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ucm111482.htm
7. National Institutes of Health Blood Bank. https://clinicalcenter.nih.gov/blooddonor/index.html
8. Red Cells by Apheresis. National Institutes of Health Blood Bank. https://clinicalcenter.nih.gov/blooddonor/donationtypes/red_cells.html
9. Platelets by Apheresis. National Institutes of Health Blood Bank. https://clinicalcenter.nih.gov/blooddonor/donationtypes/platelets.html
10. AB Plasma Donor Program. National Institutes of Health Blood Bank. https://clinicalcenter.nih.gov/blooddonor/donationtypes/ab_plasma.html
11. Granulocytes by Apheresis. National Institutes of Health Blood Bank. https://clinicalcenter.nih.gov/blooddonor/donationtypes/granulocytes.html
12. Crocco A, D’Elia D. Adverse reactions during voluntary donation of blood and/or blood components. A statistical-epidemiological study. Blood Transfusion. 2007;5(3):143-152. doi:10.2450/2007.0005-07. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2535889/
13. Winters JL. Complications of donor apheresis. J Clin Apher. 2006;21:132–41. https://www.ncbi.nlm.nih.gov/pubmed/15880355

What are heart valves ?

Your heart is a strong muscle about the size of the palm of your hand. Your body depends on the heart’s pumping action to deliver oxygen- and nutrient-rich blood to the body’s cells. When the cells are nourished properly, the body can function normally. Just like an engine makes a car go, the heart keeps your body running. The heart has two pumps separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. The left side of the heart receives the oxygen-rich blood from the lungs and pumps it to the body.

The heart has four chambers ¹, two on the right and two on the left:

• Two upper chambers are called atrium (two is called an atria). The atria collect blood as it flows into the heart.
• Two lower chambers are called ventricles. The ventricles pump blood out of the heart to the lungs or other parts of the body.

The heart also has four valves that open and close to let blood flow from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart in only one direction when the heart contracts (beats). The four heart valves are:

• Tricuspid valve, located between the right atrium and right ventricle
• Pulmonary or pulmonic valve, between the right ventricle and the pulmonary artery. This artery carries blood from the heart to the lungs.
• Mitral valve, between the left atrium and left ventricle
• Aortic valve, between the left ventricle and the aorta. This aorta carries blood from the heart to the body.

Each valve has a set of flaps (also called leaflets or cusps). The mitral valve has two flaps; the others have three. Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries. Then they shut to keep blood from flowing backward. Blood flow occurs only when there’s a difference in pressure across the valves, which causes them to open. Under normal conditions, the valves permit blood to flow in only one direction.

The heart four chambers and four valves and is connected to various blood vessels. Veins are blood vessels that carry blood from the body to the heart. Arteries are blood vessels that carry blood away from the heart to the body.

The heart pumps blood to the lungs and to all the body’s tissues by a sequence of highly organized contractions of the four chambers. For the heart to function properly, the four chambers must beat in an organized way.

When the heart’s valves open and close, they make a “lub-DUB” sound that a doctor can hear using a stethoscope ².

• The first sound—the “lub”—is made by the mitral and tricuspid valves closing at the beginning of systole. Systole is when the ventricles contract, or squeeze, and pump blood out of the heart.
• The second sound—the “DUB”—is made by the aortic and pulmonary valves closing at the beginning of diastole. Diastole is when the ventricles relax and fill with blood pumped into them by the atria.

Figure 1. The anatomy of the heart valves

Figure 2. Top view of the 4 heart valves

Figure 3.  Normal heart blood flow

Figure 4. Heart valves function

Heart valves function

Blood Flow

• The Right Side of Your Heart

In figure 3 above, the superior and inferior vena cavae are shown in blue to the left of the heart muscle as you look at the picture. These veins are the largest veins in your body.

After your body’s organs and tissues have used the oxygen in your blood, the vena cavae carry the oxygen-poor blood back to the right atrium of your heart.

The superior vena cava carries oxygen-poor blood from the upper parts of your body, including your head, chest, arms, and neck. The inferior vena cava carries oxygen-poor blood from the lower parts of your body.

The oxygen-poor blood from the vena cavae flows into your heart’s right atrium.  From the right atrium, blood is pumped into the right ventricle. And then from the right ventricle, blood is pumped to your lungs through the pulmonary arteries (shown in blue in the center of figure 3).

Once in the lungs, the blood travels through many small, thin blood vessels called capillaries. There, the blood picks up more oxygen and transfers carbon dioxide to the lungs—a process called gas exchange.

The oxygen-rich blood passes from your lungs back to your heart through the pulmonary veins (shown in red to the left of the right atrium in figure 3).

• The Left Side of Your Heart

Oxygen-rich blood from your lungs passes through the pulmonary veins (shown in red to the right of the left atrium in figure 3 above). The blood enters the left atrium and is pumped into the left ventricle.

From the left ventricle, the oxygen-rich blood is pumped to the rest of your body through the aorta. The aorta is the main artery that carries oxygen-rich blood to your body.

Like all of your organs, your heart needs oxygen-rich blood. As blood is pumped out of your heart’s left ventricle, some of it flows into the coronary arteries (shown in red in figure 3).

Your coronary arteries are located on your heart’s surface at the beginning of the aorta. They carry oxygen-rich blood to all parts of your heart.

For the heart to work well, your blood must flow in only one direction. Your heart’s valves make this possible. Both of your heart’s ventricles have an “in” (inlet) valve from the atria and an “out” (outlet) valve leading to your arteries.

Healthy valves open and close in exact coordination with the pumping action of your heart’s atria and ventricles. Each valve has a set of flaps called leaflets or cusps that seal or open the valve. This allows blood to pass through the chambers and into your arteries without backing up or flowing backward.

1. American Heart Association. About Arrhythmia. http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/About-Arrhythmia_UCM_002010_Article.jsp
2. Centers for Disease Control and Prevention. Division of Birth Defects and Developmental Disabilities. Congenital Heart Defects (CHDs). https://www.cdc.gov/ncbddd/heartdefects/index.html

What is a heart transplant ?

Heart transplant is surgery that removes a diseased heart and replaces it with a healthy heart from a deceased donor to improve your quality of life and increase your lifespan ¹. Most heart transplants are done on patients who have end-stage heart failure, a condition in which your heart is severely damaged or weakened, and on people who have failed other treatment options. End-stage heart failure may be caused by conditions such as coronary heart disease, viral infections, or hereditary conditions ¹. In rare instances, heart transplant may be performed at the same time as lung transplant in patients who have severe heart and lung disease.

The first human heart transplantation was performed on 3 December 1967 by a South African doctor, Dr Christiaan Barnard at Groote Schuur Hospital, Cape Town, South Africa. The annual number of transplants only began to grow substantially from the 1980s, declining again after 1996 due to the shortage of donor hearts. Heart transplants are now the the third most common organ transplant operation in the U.S. ². Meanwhile, more than 73,000 heart transplants have been performed worldwide ³.

Heart transplant recipient survival rates vary based on a number of factors. A 2014 report by the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients stated that the overall survival rate in the U.S. is about 88 percent after one year and about 75 percent after five years ⁴.

Most people who receive a heart transplant enjoy a high quality of life. Depending on your condition, you may be able to return to many of your daily life activities, such as returning to work, participating in hobbies and sports, and exercise. Discuss with your doctor what activities are appropriate for you.

Some women who have had a heart transplant can become pregnant. However, discuss with your doctor if you’re considering having children after your transplant ⁴. You’ll likely need medication adjustments before becoming pregnant, as some medications can cause pregnancy complications ⁴.

You may be eligible for heart transplant surgery if you have severe heart disease leading to heart failure that does not respond to other treatments.

In adults, heart failure can be caused by several conditions, including:

• A weakening of the heart muscle (cardiomyopathy)
• Coronary artery disease
• Heart valve disease
• A heart problem you’re born with (congenital heart defect)
• Dangerous recurring abnormal heart rhythms (ventricular arrhythmias) not controlled by other treatments
• Amyloidosis
• Failure of a previous heart transplant

In children, heart failure is most often caused by either a congenital heart defect or a cardiomyopathy.

Another organ transplant may be performed at the same time as a heart transplant (multiorgan transplant) in people with certain conditions at select medical centers. Multiorgan transplants include:

• Heart-kidney transplant. This procedure may be an option for some people with kidney failure in addition to heart failure.
• Heart-liver transplant. This procedure may be an option for people with certain liver and heart conditions.
• Heart-lung transplant. Rarely, doctors may suggest this procedure for some people with severe lung and heart diseases, if the conditions aren’t able to be treated by only a heart transplant or lung transplant.

If you are otherwise healthy enough for surgery, you will be placed on the National Organ Procurement and Transplantation Network’s (OPTN) waiting list ⁵. This national network handles the organ-sharing process for the United States ⁵. If a match is found, you will need to have your heart transplant surgery right away.

Heart transplant surgery will be done in a hospital. You will have general anesthesia and will not be awake during the surgery. You will receive medicine through an intravenous (IV) line in your arm. A breathing tube connected to a ventilator will help you breathe. A surgeon will open your chest, connect your heart’s arteries and veins to a heart-lung bypass machine, and remove your diseased heart. The body’s arteries and veins will be taken off the bypass machine and reconnected to the healthy donor heart. The heart transplant is complete after the surgeon closes your chest.

After the surgery, you will recover in the hospital’s intensive care unit (ICU) and stay in the hospital for up to three weeks. During your recovery, you may start a cardiac rehabilitation program. Before leaving the hospital, you will learn how to keep track of your overall health; monitor your weight, blood pressure, pulse, and temperature; and learn the signs of heart transplant rejection and infection. For the first three months after leaving the hospital, you will return often for tests to check for infection or rejection of your new heart, to test your heart function, and to make sure that you are recovering well.

Practicing good hygiene, obtaining routine vaccines, and making healthy lifestyle choices are very important after a heart transplant to reduce your risk of infection. Regular dental care is also important. Your doctor or dentist may prescribe antibiotics before any dental work to prevent infection. Following your doctor’s advice will help you recover and stay as healthy as possible.

Heart transplant has some serious risks.

Complications of surgery

Heart transplant surgery requires open heart surgery, which carries the risk of many complications ⁶, including:

• Bleeding
• Infection
• Blood clots
• Heart attack
• Stroke
• Death

Risks of having a heart transplant

Although receiving a donor heart can save your life, having a heart transplant has many risks. Risks include:

• Primary graft dysfunction happens when the donor heart fails and cannot function ¹. This is the most frequent cause of death for the first month after transplant.

• Rejection of the donor heart. One of the most significant risks after a heart transplant is your body rejecting the donor heart. Your immune system also may reject your new heart. Rejection is most likely to occur within six months after the transplant ¹.

Your immune system will see your donor heart as a foreign object that’s not supposed to be in your body. Your immune system will try to attack your donor heart. Although all people who receive a heart transplant receive immunosuppressants — medications that reduce the activity of the immune system — about 10 percent of heart transplant recipients still have some signs of rejection that need treatment during the first year after transplantation. This is often effectively treated with medication. You will need to take these medicines for the rest of your life to suppress your immune system and help prevent your body from rejecting your new heart ¹.

Usually the rejection is without any symptoms and requires only an adjustment of medications. If you miss doses of medications, however, the rejection can be severe and very serious. It’s important that you follow the instructions as explained by your doctors.

To determine whether your body is rejecting the new heart, you’ll have frequent heart biopsies to test your heart tissue during the first year after your transplant. After the first year, the number of biopsies is significantly reduced.

• Problems with your coronary arteries. After your transplant, it’s possible the walls of the arteries in your heart (coronary arteries) could thicken and harden, leading to cardiac allograft vasculopathy (CAV). Cardiac allograft vasculopathy is a common and serious complication of heart transplant. Cardiac allograft vasculopathy is an aggressive form of atherosclerosis that over months or a few years can quickly block the heart’s arteries and cause the donor heart to fail ¹. Over time, your new heart may fail due to the same reasons that caused your original heart to fail. Some patients who have a heart transplant that fails may be eligible for another transplant.

Your doctor may recommend annual tests after your transplant to monitor your coronary arteries for cardiac allograft vasculopathy.

• Medication side effects. The immunosuppressants you’ll need to take for the rest of your life may cause kidney damage and other problems. Other complications of these medications can include high blood pressure, high cholesterol, diabetes and osteoporosis a condition in which your bones become thin and weak.

• Cancer. Immunosuppressants can also increase your cancer risk. Taking these medications can put you at a greater risk of skin cancer, non-Hodgkin’s lymphoma and other solid tumors. Regular checkups are necessary to detect the development of cancer.

• Infection. Immunosuppressants decrease your ability to fight infection. Some heart transplant recipients may develop an infection that requires them to be admitted to the hospital during the first year after their transplant. The risk of infection decreases over time as the amount of immunosuppressant medication is decreased.

Despite these risks, heart transplant has a good success rate that has improved over many decades of research. Recent survival rates are about 85 percent at one year after surgery, with survival rates decreasing by about three to four percent each additional year after surgery because of serious complications ¹. Mechanical circulatory support, possibly from left ventricular assist devices, may be an alternative to heart transplant. But more research is needed to determine long-term survival rates for these new devices.

What is Heart Failure and What Causes it ?

There are two main reasons for heart problems.

1. One is caused by plaque building up in the arteries of the heart. This is called coronary artery disease.
2. The other is caused by disease of the heart muscle. This condition is called idiopathic cardiomyopathy. Doctors do not know what causes it.

In both cases, as the heart grows weaker, it is less able to pump oxygen-rich blood through the body. As it tries harder to pump blood, it grows larger. Doctors call this an enlarged heart. After a while, the enlarged heart has to work so hard that it just wears out. Soon it cannot pump even the smallest amount of blood.

A weak, enlarged heart can cause you to feel short of breath and tired, even when you are quiet, such as when resting or at night in bed. Your feet, legs, and stomach may swell, and you may feel sick to your stomach and not feel like eating.

How is Heart Failure Treated ?

There are several options for treating heart failure. Your doctors will first try medical therapy. In some cases, medicines alone can success fully treat heart failure.
If needed, your doctor may use other methods of treatment. These are:

• Pacemakers. These devices are used to treat a heart that beats too slowly. Some of the newer pacemakers are even better at helping the heart pump as it should.
• Angioplasty. This is a procedure that opens clogged arteries.
• Repair the heart valve. This procedure can often make your heart function much better. If doctors cannot repair the valve, they may be able to replace it with an artificial (man-made) valve.
• Cardiac size reduction. During this procedure, your doctor removes a piece of the heart muscle from an enlarged heart. This makes your heart smaller, which allows it to pump more efficiently and vigorously.

Contraindications for heart transplant

Contraindications are ⁷:

• irreversible pulmonary hypertension/elevated pulmonary vascular resistance;
• active systemic infection;
• active malignancy or history of malignancy with probability of recurrence;
• inability to comply with complex medical regimen;
• severe peripheral or cerebrovascular disease and irreversible dysfunction of another organ, including diseases that may limit prognosis after heart transplantation.

Ultimately, your transplant team will determine if you are a candidate for a heart transplant.

Ventricular assist devices

For some people who can’t have a heart transplant, another option may be a ventricular assist device. A ventricular assist device is a mechanical pump implanted in your chest that helps pump blood from the lower chambers of your heart (ventricles) to the rest of your body.

Ventricular assist devices are commonly used as a temporary treatment for people waiting for a heart transplant. These devices are increasingly being used as a long-term treatment for people who have heart failure but aren’t eligible for a heart transplant. A left ventricular assist device (LVAD) is implanted under your skin. It helps pump blood from the left ventricle of your heart and on to the rest of your body. A control unit and battery pack are worn outside your body and are connected to the LVAD through a port in your skin. If a ventricular assist device doesn’t help your heart, doctors may sometimes consider a total artificial heart — a device that replaces the ventricles of your heart — as an alternative short-term treatment while you’re waiting for a heart transplant.

Figure 1. Left ventricular assist device

Before a heart transplant

There are five steps to getting a heart transplant ⁸. Your transplant team will:

Decide if you need a new heart. Decide if you are healthy enough to receive a new heart. Prepare you for your operation. This can take a long time, and there is no guarantee that a heart will be found. Perform a heart transplant operation. Help you stay healthy after your operation.

Step 1. Your Transplant Team Decides If You Need a New Heart

Many heart diseases get worse very slowly. Sometimes one treatment will work where another did not. Because of this, the transplant center will first determine which therapy is best for your condition.

Sometimes a new drug or therapy can improve your heart condition. The transplant center will do its best to make sure you have every chance to get better and live longer with your own heart before they recommend a heart transplant.

Step 2. Your Transplant Team Decides If You Are Healthy Enough to Receive a New Heart

Before you have a heart transplant, a team of health care professionals will talk to you about what may happen if you get a new heart. What happens can depend on your physical health, your mental health, and how easy it will be for you to get the transplant medicines you will need.

There are four parts to this phase.

1. First you will visit a transplant center. You, your doctor, a nurse, or a social worker can schedule this visit. Your doctor’s office will send your medical records to the transplant center before your appointment. Your records should show that you are taking your medicine properly and are on a restricted diet. Your records will also confirm that you have no medical conditions that can keep you from receiving a transplant.
2. During this visit, your physical health will be evaluated. The transplant team will do a complete evaluation of your physical health. They may do more tests to evaluate your: heart kidneys and gallbladder stomach, esophagus, and intestines lungs bladder teeth and gums brain and nervous system prostate, if you are a man breasts and cervix, if you are a woman The transplant team may order other tests as well.
3. Then, your mental health will be evaluated. You may need to see a social worker or psychologist to make sure you are not addicted to alcohol or drugs. It is also important to make sure you have no emotional problems that can interfere with your health.
4. Finally, you will see an insurance specialist. An insurance specialist will review your insurance to make sure your policy covers the transplant operation and the medicines you will need after your transplant.

If the transplant team decides you are a good candidate for the operation, they will work with you to find a new heart.

Step 3. Your Transplant Team Prepares You for Your Operation

This step involves finding a new heart for you. Sometimes this can take a long time. How long it takes depends on your body size, your blood type, and how sick you are.

While waiting for your operation, you will have regular visits with your doctor and transplant team. They will monitor your health, and they will work with you to make sure you are eating and exercising properly. You need to let them know of any changes in your health.

Step 4. Your Transplant Team Performs a Heart Transplant Operation

Transporting donor organs for transplant

A heart transplant usually needs to occur within four hours of organ removal for the donor organ to remain usable. As a result, hearts are offered first to a transplant center close by, then to centers within certain distances of the donor hospital.

You’ll need to remain in close contact with the transplant team and let them know if you have any changes to your health. Make sure the transplant center has phone numbers to be able to contact you anytime. The transplant center needs to be able to reach you 24 hours a day.

When you’re notified that a potential organ is available, you and your transplant team have a limited amount of time to consider whether to accept the donation. You’ll be expected to travel to the transplant hospital immediately after being notified of the potential donation. You’ll usually need to be prepared to get to the hospital within three hours.

As much as possible, you should generally make travel plans ahead of time. Some heart transplant centers provide private air transportation or other travel arrangements. Have a suitcase packed with everything you’ll need for your hospital stay, as well as an extra 24-hour supply of your medications.

Once you arrive at the hospital, your doctors and transplant team will conduct a final evaluation to determine if the donor heart is suitable for you and if you’re ready to have surgery. If your doctors and transplant team decide that the donor heart isn’t appropriate for you or surgery isn’t appropriate for you, you may not be able to have the transplant.

The Procedure

When the right heart is found, the nurse coordinator will call you and you will go to the hospital. The transplant doctors will check the donor heart while you are being evaluated. You will be given medications before and during the operation to prevent your body from rejecting the new heart. If the donated heart is the right match for you, you will be taken to the operating room and put to sleep with an anesthetic.

A transplant surgeon will prepare your chest cavity so your heart can be removed. At the same time, the new heart will be removed from the donor and sent to your hospital. This heart will be placed in your chest through the opening in your chest cavity. This is called a sternotomy.

There are two very different surgical approaches to heart transplantation: the orthotopic and the heterotopic approach ². Because the length of this surgery is different for every patient, families should talk with the surgeon about what to expect.

1. Orthotopic Approach. The more common of the two procedures, the orthotopic approach, requires replacing the recipient heart with the donor heart. After the donor heart is removed, preserved and packed for transport, it must be transplanted into the recipient within four to five hours. The recipient receives general anesthesia and is placed on a bypass machine to oxygenate the blood while the heart transplant is being performed. After the recipient’s heart is removed, the donor heart is prepared to fit and implantation begins.
2. Heterotopic Approach. Heterotopic transplantation, also called “piggyback” transplantation, is accomplished by leaving the recipient’s heart in place and connecting the donor heart to the right side of the chest. The procedure is rare compared to orthotopic transplantation and is advantageous because the new heart can act as an assist device if complications occur. Your physician can explain why this approach may better suit your needs.

Most heart transplant surgeries are done with a method called orthotopic ⁸. Your heart is removed, and the donor heart is sewn in place. Once the new heart is in place, the donor’s main arteries – the aorta and pulmonary arteries – are sewn to yours ⁸.

Figure 2. Heart transplant procedure

After the operation, you will be taken to a special unit for recovery. You will stay in the hospital until your doctor feels you are ready to go home. How long you stay will depend on your health and how well your new heart is working. It will also depend on how quickly and easily you learn to take care of your new heart.

Transplant Medicines

After your operation, you will take strong medicines to keep your body from rejecting your new heart. Your immune system protects you from foreign invaders, and your body will think the new heart is a foreign invader. So your immune system will try to reject your new heart. This can damage it. Because of this, you will take immunosuppressants (im-u-no-su-pres-ants), also called anti-rejection medicines. These drugs suppress the immune system enough to keep your transplanted heart healthy.

That’s why these medicines are called immunosuppressants or anti-rejection drugs. Your body will remember that the heart once belonged to someone else, so you will need to take these drugs for as long as you have the transplant.

Step 5. Your Transplant Team Helps You Stay Healthy After Your Operation

It is very important that you keep yourself healthy after your transplant. Here are a few important reminders:

• After you leave the hospital, make sure you go to the transplant center often. Also be sure you go to all your doctor appointments. This very is important!
• You will only have to do this for a few months.
• Take your medicines properly. This is extremely important!
• Watch your weight and be sure to get some exercise on a regular basis.
• Be sure to tell the staff at the transplant center if you have problems keeping your appointments or taking your medicines.

Your Doctor Appointments

If your body begins to reject your new heart, you may not know it. Some patients may have signs, but most do not recognize them. If your body is rejecting the new heart, your doctors and nurses will know it. This is why it is so important to go to all your medical appointments. Your health care providers watch closely for signs of rejection and side effects from the medications. But, they must examine you and test your blood to know for sure.

Your doctor and transplant staff will watch for these signs:

• Rejection: The risk of rejection never goes away. You will always need anti-rejection drugs. Your doctor may lower the dosage, but you should never skip or stop taking the drugs. A biopsy of the heart is the best way to know if your body is rejecting your new heart. Your doctors will do this many times for the first year after your transplant. After that, they will biopsy your heart, but less often.
• Infection: Immunosuppressant drugs can increase the chance of getting infections. These infections can be treated. However, you need to tell your doctor if you have a fever, unusual pain, or any other new feelings. The risk of infection will go down when your doctor lowers the dosage.
• High blood pressure: High blood pressure is a common problem after transplant. It can damage your new heart and cause strokes and heart attacks.
• Diabetes Mellitus: Anti-rejection medications can cause diabetes. If you had diabetes before your transplant, you may find it harder to control your blood sugar level after your transplant.
• High cholesterol: Your anti-rejection medication can also cause high cholesterol. There are some medications called statins that control cholesterol and help prevent rejection because they also control inflammation.
• Heart disease: Some forms of heart disease can come back in the transplanted heart. Your doctor and transplant staff will monitor you for signs of this problem.
• Cancer: Anti-rejection drugs can raise the risk of getting cancer, especially blood cancer and skin cancer. Although blood cancer, called lymphoma, can be fatal, your doctor can lower the risk by lowering the dose of anti-rejection drugs. Your transplant team will suggest getting screened for cancer early and on a regular basis. They will recommend you regularly: get a colonoscopy, a mammogram, a pap smear, or prostate exam. And see a dermatologist.
• Osteoporosis: This is thinning of the bones. Being ill, eating a poor diet, being inactive, or taking prednisone and other anti-rejection drugs can cause osteoporosis. Your doctor will most likely order a bone density test and may put you on drugs that prevent osteoporosis.
• Cataracts: Prednisone (a steroid medication) and other drugs can cause cataracts, which are cloudy spots on the lens of your eye. You cannot prevent cataracts, but they can be surgically removed. Your doctor will ask you to see an eye doctor (ophthalmologist) at least once a year to get checked for cataracts and glaucoma. Glaucoma is pressure in the eye that can damage your vision.
• Kidney disease: The main medicines used to treat rejection, and many of the medicines used to treat infection, can hurt your kidneys. Your doctors will try to make sure you have enough medicine to prevent rejection of your new heart, but not so much that it hurts the kidneys. Sometimes this is hard to do. If you are older, or if your kidneys have already been injured by illness or medications, you may have permanent kidney damage. This can cause your feet to swell and your body to retain fluid. You may feel very tired and not feel well overall. Kidney disease is a serious problem. You will need to go for regular blood tests. These tests make sure the levels of your anti-rejection medications are not too high or too low.

Heart transplant list

Getting On The Heart Transplant List

For most transplant candidates, the first step in receiving a transplant is to get on national transplant waiting list:

• the OPTN (Organ Procurement & Transplantation Network) ⁵ or
• the UNOS (United Network for Organ Sharing) ⁹

The Organ Procurement and Transplantation Network (OPTN) ⁵ secure transplant information database contains all national data on the candidate waiting list, organ donation and matching, and transplantation ⁵. This system is critical in helping organ transplant institutions match waiting candidates with donated organs. Institutions also rely on the database to manage time-sensitive, life-critical data of all candidates, before and after their transplants. The Organ Procurement and Transplantation Network (OPTN) is an official U.S. Government web site managed by the Health Resources and Services Administration, U.S. Department of Health & Human Services ⁵.

The National Waiting List

The waiting list is a computer database that contains medical information on every person who is waiting for any type of organ transplant in the U.S. and Puerto Rico. You will not have a number ranking for transplant based on all the other persons who are waiting for your organ. You also will not move up or down each time someone receives a transplant.

Here are the necessary steps to get on the national waiting list:

• Your physician must give you a referral.
• Contact a transplant hospital. Learn as much as possible about the 200+ transplant hospitals in the United States and choose one based on your needs, including insurance, location, finances and support group availability.
• Schedule an appointment for an evaluation and find out if you are a good candidate for transplant.
• During the evaluation, ask questions to learn as much as possible about that hospital and its transplant team.
• If the hospital’s transplant team determines that you are a good transplant candidate, they will add you to the national waiting list.

Your transplant hospital will notify you within 10 days to inform you about your date of listing. If you have questions about your status on the list, you should ask the team at your transplant hospital.

All transplant candidates who do not have the option of a living donor (and even some who do) usually wait for some length of time because there are not enough donor organs for all who need them.

Organ Type and Waiting Time

Most candidates, except those with living donors, wait for an organ due to the shortage of donor organs. Because each candidate’s situation is unique, waiting times can vary, depending on a number of factors, such as those described below. To better understand what influences waiting time, talk with your transplant team.

What determines who will be offered an organ?

Depending on the organ, there are many considerations. These include but are not limited to:

• age
• blood type
• medical urgency
• waiting time
• geographic distance between donor and recipient
• size of the donor organ in relation to the recipient
• type of organ needed

How does organ type affect waiting times ?

Heart Allocation

Physicians assign a status code to individuals waiting for a heart transplant. This code indicates how medically urgent it is that you receive a transplant. In addition, the system allocates hearts locally first, and then in a specific sequence by zone. Please see the OPTN/UNOS Allocation of Thoracic Organs Policy for details ¹⁰.

Lung Allocation

All candidates waiting for a lung will be grouped together, regardless of whether they are waiting for a single lung or a double lung. If one lung is allocated to a patient needing a single lung transplant, the other lung will be then allocated to another patient waiting for a single lung transplant. In addition, the system allocates thoracic organs locally first, and then in a specific sequence by zone. Please see the OPTN/UNOS Allocation of Thoracic Organs Policy for details ¹⁰.

Heart/Lung Allocation

If you are waiting for heart-lung transplant, you will be registered on the individual UNOS Patient Waiting lists for both the heart and the lung. When the patient is eligible to receive a heart, the lung will be allocated to the heart-lung candidate from the same donor. When the patient is eligible to receive a lung, the heart shall be allocated to the heart-lung candidate from the same donor isolated. In addition, thoracic organs are allocated locally first, and then in a specific sequence by zone. Please see the OPTN/UNOS Allocation of Thoracic Organs Policy for details ¹⁰.

Other Options to Consider

Multiple Listing

As addressed in the OPTN/UNOS Policy ¹⁰, patients may be listed at more than one transplant center. Being listed at more than one transplant center does not guarantee that an organ will become available faster than if you are listed at one transplant center. In addition, you probably would not benefit from listing at multiple centers in the same local allocation area. This is because waiting time priority is first calculated among candidates at all hospitals within the local donation area, not for each hospital individually.

It’s important to note that some transplant programs may not accept multiple-listed patients. Others may set their own requirements for multiple-listed candidates.

If you choose to multiple list, your primary care physician should contact your centers of choice so that you may be evaluated as a transplant candidate, as you did with your primary evaluation. Read a detailed brochure here now ¹¹.

Transferal of Waiting Time

As addressed in the OPTN/UNOS Policy ¹⁰, patients may transfer their primary waiting time from one transplant center to another center. This transfer may be necessary for a number of reasons, such as a change in the transplant candidate’s health insurance or if the candidate has moved. Read a detailed brochure here now ¹¹.

Living Donation

Living donor transplants are a viable alternative for patients in need of new organs. Learn more about living donation here ¹².

Kidney paired donation is a type of living donation that is a transplant option for recipients who have a willing and able living donor but are an incompatible match due to blood or tissue type. Learn more paired donation here ¹³.

People You Should Know

Your Transplant Team

Many people at the transplant center work to make your transplant as successful as possible. It’s important that you know who each of these people are and what they will be doing to help you through your transplant. You will need to feel comfortable talking to them and asking them questions about your health and/or status concerning transplantation.

Your transplant team will include all or some of the following people:

• Transplant Coordinator. Usually a registered nurse, who will be your main contact and will work with you and other members of your transplant team to coordinate your care.
• Transplant Surgeon. The doctor who will evaluate your present condition, make recommendations, and ultimately perform your transplant surgery.
• Transplant Physician. This doctor, whether a nephrologist, hepatologist, cardiologist or other specialist, will assist the surgeon in evaluating your need for transplantation and help with your care.
• Transplant Financial Coordinator. The financial coordinator has detailed knowledge of financial matters and hospital billing methods. This person works with social workers to determine how you can best afford the cost of your transplant.
• Insurance Case Manager. Often your first point of contact, the insurance case manager helps navigate the specifics of insurance coverage.
• Social Worker. Most transplant programs are staffed with social workers who are ready to help you. Transplant social workers can assist transplant candidates and their families with a variety of helpful resources, including the development of a financial plan. They can also help address psycho-social issues and determine your needs and help you understand and cope with basic problems associated with your illness.
• Dietician. As an integral part of the transplant team, the registered dietitian develops nutrition therapy to patients before and after transplantation. Educating patients about maintaining a healthy weight and minimizing side effects of anti-rejection drug therapy ensures optimal nutrition status and improves transplant outcomes.

Questions to Ask Your Transplant Team

Patients usually have many questions about transplantation and their health as they go through the transplant process. In addition to financial questions, below is a list of issues and concerns you may want to discuss with your transplant team. Be sure to write your questions down and bring them to the appointment. You might also want to bring a trusted friend or family member with you and ask them to take notes.
Questions about Your Evaluation

• What should I bring with me?
• What should I do to prepare for the appointment?
• Does your center offer parking permits or overnight accommodations?
• What does the evaluation and testing process include? How does it affect whether I am put on the list?

Before the transplant

• Who will tell me and my family about the transplant process?
• Can I tour the transplant center?
• What other options do I have besides transplantation?
• What are the risks of transplantation?
• What are the benefits of transplantation?
• What are the transplant success rates at this hospital?
• How many transplants do you perform at this hospital each year?
• How long has this hospital been doing transplants?
• What is involved in the evaluation and testing process?
• How do my test results affect whether or not I am put on the list?
• How long is the local waiting list?
• How do you decide whether you will accept an organ offered to me?
• Who are the members of the transplant team and what are their jobs?
• How many attending surgeons are available to do my type of transplant?
• Do I need to stay close to the transplant hospital while I am put on the waiting list?
• How soon must I be at the transplant hospital after being called?
• Is there a special nursing unit for transplant patients?
• Will the transplant center team advise my local health care providers of my care requirements?
• Will I be asked to take part in research studies?

After the transplant

• What is the length of hospitalization after my transplant?
• Do I need to stay close to the hospital post-transplant? If so, for how long?
• What is the usual immunosuppressive treatment?
• What follow-up examinations and tests will I undergo? How frequently?
• Will I need to return to the transplant center if I have complications?
• What medications will I take after I leave the hospital and how much will they cost?

Financial Questions

• How much will the transplant cost? How much will I have to pay?
• What part of the transplant cost is covered by my insurance?
• What if my insurance does not pay for medications?
• What financial coverage is accepted by this hospital?
• What happens if my financial coverage runs out?

Questions about Living Donation

• Does the hospital do living donor transplants?
• What types of living donor transplants does the center do?
• Is a living donor transplant a choice in my case? If so, where can the living donor evaluation occur?
• What are the costs if I have a living donor?

Heart Transplant Cost

Financing a transplant raises many questions and concerns for patients and their families. The first step in developing a financial strategy is to figure out how much of your costs insurance will cover. Your financial coordinator or social worker can help. Then you can begin to explore other funding sources.

Most patients use a combination of sources. Some patients can finance the transplant procedure through their primary insurance coverage and use savings and other private funds to pay for other expenses. Many patients work with community fundraising groups to complete their transplant financial strategy.

Questions to Ask Your Transplant Financial Coordinator

• How much will the transplant cost ? How much will I have to pay ?
• What financial coverage does the hospital accept (such as Medicare, Medicaid, private insurance, etc) ?
• What happens if my financial coverage runs out ?
• Will the costs vary if I have a living donor ?

Questions to Ask Your Insurance Company

• Will my insurance cover me throughout the transplantation process?
• Am I covered for a transplant right now, or do I have to wait a certain period of time (pre-existing exclusion clause)? If yes, how long?
• Do I need authorization (approval) before I have a transplant?
• Do I need to notify you when I am admitted to the hospital? How soon after I am admitted?
• Do I need a second opinion? If so, who will pay for it?
• What do I do if I run out of insurance money?
• How are the costs of the transplant applied to my deductible?
• What happens if I change jobs or lose my job? Will it affect my insurance?
• How can I cut down on insurance expenses to make sure my coverage lasts as long as I need it?
• What pre- and post-transplant tests are covered? Do I need to go to a certain facility for these tests to be covered?
• Are expenses for food, housing and transportation covered while I wait for my transplant?
• How much coverage will I receive for post-transplant medications? What is the co-pay amount?

Questions to Ask When Choosing a Fundraising Organization

• Are you a 501(C)(3) (tax-exempt) organization? If so, can people who donate to my fund use the amount of money they donate as an income tax deduction?
• What type of account will be used?
• How can I find out how much money is in my account?
• Who has access to my funds?
• Are there any additional fees?
• What are my options if I don’t receive a transplant or don’t need all the money?
• Can I talk to other patients you have helped?
• Who should I call if I have questions or problems?
• What is the process of paying my bills with these funds?
• Will you check my bills for accuracy?
• What other services do you have available?
• Can you refer me to other sources for financial help?

Transplant Costs

The cost of a transplant, including preliminary testing, the surgery itself and post-operative recovery costs vary across the country and depend on the hospital and organ type. These costs start to add up, even before your transplant. Therefore, patients commonly rely on several sources to help pay for their medical and non-medical costs of pre- and post-transplantation.

Medical Costs

Medical costs include:

• insurance deductibles
• insurance co-pays
• pre-transplant evaluation and testing
• surgery
• fees for the recovery of the organ from the donor
• follow-up care and testing
• additional hospital stays for complications
• fees for surgeons, physicians, radiologist, anesthesiologist and recurrent lab testing
• anti-rejection and other drugs, which can easily exceed $2,500 per month
• rehabilitation

Non-Medical Costs

Non-medical costs include:

• food, lodging and long distance phone calls for you and your family
• transportation, to and from your transplant center, before and after your transplant
• plane travel to get to your transplant hospital quickly
• child care
• lost wages if your employer does not pay for the time you or a family member spends away from work
• If your transplant center is not close to your home, lodging close to the center before and after your surgery. Some centers offer free or low-cost hospitality houses for you and your family.

Table 1. Estimated U.S. Average 2011 Billed Charges Per Transplant

Funding Sources

Common funding sources to help with the costs of transplants include:

• Private Health Insurance
• COBRA Extended Employer Group Coverage
• Health Insurance Marketplace
• Medicare
• Medicare Prescription Drug Plans
• MediGap Plans
• State Health Insurance Assistance Programs
• Medicaid
• Charitable Organizations
• Advocacy Organizations
• Fundraising Campaigns
• TRICARE (Formerly Champus) and Veterans Administration (VA)
• State “High Risk” Insurance Pool

Note: This information is only a brief summary and is not intended to provide complete information. Ask your transplant financial team and your insurance provider or employee benefits officer for the latest information or help.

Private Health Insurance

You or your family may have health insurance coverage through an employer or a personal policy. Although many insurance companies offer optional coverage for transplant costs, the terms and benefits of insurance vary widely. Read your policy carefully and contact your insurance company if you have questions about how much of your costs they will pay, including your lab tests, medications and follow-up care after you leave the hospital.

Some insurance questions to consider:

• Is my transplant center in-network with my insurance company?
• If my transplant center is out-of network, do I have an out-of-network benefit for transplant?
• What deductibles will apply?
• What are my co-payments for doctor visits, hospitalizations and medications?
• Does my plan require prior authorization?
• Who needs to get prior authorization?
• Does my plan have a lifetime maximum or “cap” for transplant services?
• Do any pre-existing-condition requirements

Regardless of how much your insurance covers, you are responsible for any costs not paid by your insurance, unless you have made other arrangements. If you are responsible for paying any or all of your insurance premiums, be sure to pay them on time so that you do not lose your insurance.

Transplant center social workers and financial coordinators can also help you with the information you need. They can contact your insurance company to check on your benefits and explain your coverage in more detail.

Insurance “Caps”

Many insurance policies state a total amount of money that will pay out in your lifetime, also referred to as a “cap.” After the insurance company pays this amount, they are not required to pay additional benefits. Some policies also put a cap on how much they will pay for a particular procedure or treatment, such as a transplant or the total amount of drugs per year. Even after the actual transplant, the ongoing cost of care may exceed the cap. Because the amount of the cap varies greatly depending on the individual policy, it is important to be familiar with the terms of your insurance cap and keep track of how your insurance dollars are spent.

Experimental and Investigative Procedures

If your transplant center asks you to be involved in any experimental procedures or studies, be sure to ask your center or insurance company if your insurance policy will cover the payment. It is important to know that you do not have to agree to be involved in any experimental procedures or investigational studies. If you still have questions, contact your employer’s benefits office or your state insurance commissioner.

Tips

• Keep copies of all medical bills, insurance forms and payments (or canceled checks).
• Ask your insurance company about pre-certification or using a specific provider.
• Follow the rules set forth by your insurance company so that your benefits will not be decreased.
• Always keep a log (who you talked to, date and time and questions answered) of your conversations with anyone in the hospital’s billing office or your insurance company.
• Make sure to keep your transplant center informed about your insurance, especially if you have more than one insurance company.

COBRA Extended Employer Group Coverage

If you are insured by an employer group health plan and you must leave your job or reduce your work hours, you may qualify for extended coverage through COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985). This federal law requires certain group health plans to extend coverage for 18 to 36 months after benefits end. This requirement is limited to companies employing 20 or more people. You pay the full cost of the premiums for the group health plan. Learn more by contacting your employer’s benefits office or visit the federal Department of Labor web site ¹⁴.

Health Insurance Marketplace

Also known as the health insurance “exchange,” the marketplace is a set of government-regulated and standardized health care plans in the United States. Learn more at Healthcare.gov ¹⁵.

Medicare

Medicare is a federal health insurance program available to people who are 65 or older, disabled or have end stage renal disease (ESRD).

Medicare, like most private insurance plans, does not always pay 100% of your medical expenses. In most cases, it pays hospitals and health providers according to a fixed fee schedule, which may be less than the actual cost. You must pay deductibles and other expenses. Medicare currently offers coverage for transplant of:

• kidneys
• kidney-pancreas
• pancreas, either after a kidney transplant or for certain indications

If you already have Medicare due to age or disability, Medicare also covers other transplants:

• heart, in certain circumstances
• lung
• heart-lung
• liver, including transplants necessitated by hepatocellular carcinoma (HCC)
• intestines

To receive full Medicare benefits for a transplant, you must go to a Medicare-approved transplant program. These programs meet Medicare criteria for the number of transplants they perform and the quality of patient outcomes.

If you have questions about Medicare eligibility, benefits, or transplant programs, contact your local Social Security office, or Medicare at or www.medicare.gov ¹⁶.

Medicare Prescription Drug Plans

Medicare Part D covers costs for prescription drugs. To get this coverage you must choose and join a Medicare drug plan. For more information visit www.medicare.gov ¹⁶.

MediGap Plans

Many people on Medicare also choose to buy a private “Medigap” policy to pay for costs not covered by Medicare. Check with a local insurance agent or go to www.medicare.gov ¹⁶.

State Health Insurance Assistance Program

The State Health Insurance Assistance Program (SHIP) is a national program that offers one-on-one counseling and assistance to people with Medicare and their families. Your transplant social worker or financial coordinator can provide information on your state’s SHIP program.

Medicaid

Medicaid is a federal and state government health insurance program for certain low-income individuals. Each state determines criteria for:

• eligibility
• benefits
• reimbursement rates

Most Medicaid programs only cover transplants performed in their state, unless there are no centers that can transplant that organ. For more information, contact your local human services department or the financial coordinator at your transplant center.

Charitable Organizations

Charitable organizations offer a range of support, from providing information about diseases, organs and transplants, to encouraging research into these diseases and treatments.

Also, although it is very unlikely that one organization can cover all of the costs for an individual patient, some organizations provide limited financial assistance through grants and direct funding. For example, an organization may only be able to help with direct transplant costs, food and lodging or medication costs.

Advocacy Organizations

Advocacy organizations advise transplant patients on financial matters. If you agree to a financial arrangement with an advocacy organization, it is important to make sure that the funds are available in a manner that suits your needs. You may even want legal assistance in reviewing a written agreement before signing. Your bank can also help you review the arrangement.

Every advocacy organization should be able to provide supporting information and background documentation to prove they are legally recognized to help those in need. Brochures and other background information should never serve as substitutes for these documents. Ask advocacy organizations to provide you with copies of the following documents:

• a current federal or state certification as a charitable, non-profit organization
• a current by-laws, constitution and/or articles of incorporation
• a financial statement for the preceding year, preferably one that
• an audit report from an independent organization
• references

Fundraising Campaigns

Public fundraising is often used to help cover transplant expenses not paid by medical insurance. Before you begin seeking donations, it may be necessary to check with your city/county governments, legal advisor or transplant team about the many legal and financial laws and guidelines.

If you decide to use public fundraising as a way to cover your expenses, you may want to contact local newspapers, radio or television stations to help support your cause. In addition, try to enlist the support of local merchants and other sponsors to promote or contribute to your events. Your friends, neighbors, religious groups, local chapters of volunteer or service groups and other community groups may also be able to help.

It is also very important to understand that the funds you raise only be used for your transplant-related expenses and donated money sometimes has to be counted as taxable income. In cases in which money must be counted as income, you may lose your Medicaid eligibility.

TRICARE and Veterans Administration

Government funding for families of active-duty, retired, or deceased military personnel may be available through TRICARE. TRICARE standard may share the cost of most organ transplants and combinations. TRICARE also covers living donor kidney, liver, and lung transplants. Patients must receive pre-authorization from the TRICARE medical director and meet TRICARE selection criteria. Pre-authorization is based on a narrative summary submitted by the attending transplant physician. For more information about TRICARE, contact the health benefits advisor at your nearest military health care facility, call the TRICARE Benefits Service Branch or learn more here ¹⁷.

State “High Risk” Insurance Pool

Many states offer a high-risk health insurance pool to provide access to coverage to individuals with serious pre-existing medical conditions. Typically the premiums are higher, and the coverage may be more limited. Ask your transplant center social worker or financial coordinator if your state has a high-risk insurance pool or learn more at www.Healthinsurance.org ¹⁸.

Financial Resources Directory

Because many patients cannot afford to pay for the full cost of organ transplant surgery, or even a small insurance deductible amount, using their personal funds, it is common for patients explore other options to help them fund their procedure.

The following organizations may provide financial assistance to transplant candidates or recipients and their families. This is a sample listing and should not be interpreted as a comprehensive list or an endorsement. Ask your transplant financial team for the latest information or help.

For a full financial resources directory listings ¹⁹ go here: https://transplantliving.org/before-the-transplant/financing-a-transplant/directory/

Selecting A Hospital

You do have choices when it comes to hospital care. The most important consideration in any choice is the individual’s specific situation. Each patient has different needs, preferences and desires that need to be taken into account when selecting an appropriate hospital.

When choosing a transplant center, patients should carefully consider these factors:

• The experience of the transplant team and support personnel. It is always important to know how much experience a hospital has with the type of care you need.
• The cost of the procedure and related items. The cost of a transplant, including preliminary testing, the surgery itself and post-operative recovery costs vary across the country by hospital and organ type.
• Insurance coverage. Although many insurance companies offer coverage for transplant costs, the terms and benefits of insurance policies vary widely. Some insurance companies establish network agreements with certain transplant centers; the insurer may pay a higher proportion of costs for centers within their network. In addition, many transplant centers have different policies about the types of insurance they accept for the type of transplant you need.
• Geographical proximity to the program. The travel time to the transplant center is important when you are waiting for an organ and is a key factor considered in organ distribution.
• The quality and availability of pre- and post-transplant services. Offering a comprehensive system of support services to meet the special needs of patients and their families is important. Education and emotional support can help you feel informed about your health care decisions.
• A commitment to keeping up with technologic advances. It may be important to identify if a transplant center has a commitment to technology and the latest procedures, both which offer assurance that a program is continually growing.
• Multicultural sensitivity. Does the transplant center have bilingual staff members and/or access to translators if needed? Regardless of treatment, patients should always feel understood and informed throughout the treatment process.
• Availability of friends and family for assistance. More and more, family members and friends are needed to help with the patient’s care as an outpatient.

Support Services

Common support services to help with recovering from a transplant include:

• vocational rehabilitation
• social security coverage for the disabled
• Americans with Disabilities Act (ADA)

Note: This information is only a brief summary and is not intended to provide complete information. Ask your transplant financial team and your insurance provider or employee benefits officer for the latest information or help.

Vocational Rehabilitation

Vocational rehabilitation provides assistance to individuals who cannot return to work after an injury or illness. It helps individuals achieve suitable employment or enhance their ability to function independently at home and in the community. Federal and state governments fund each state’s department of vocational rehabilitation, which, depending on the individual, may provide the following types of services:

• evaluation to determine job skills, abilities and attitudes, which includes medical, psychological and vocational testing
• development of an individualized rehabilitation plan, including long-range vocational goals, intermediate objectives to achieve vocational goals, the process for evaluating progress, rehabilitation equipment, client assistance (including financial services) and post-employment services
• vocational rehabilitation training and assistance, including training in the activities of daily living, physical and occupational therapy, use of physical aids or devices, such as artificial limbs or wheelchairs and skills training for the specific type of work (classroom instruction, individual tutoring and simulated work)
• job-seeking skills, such as preparing a résumé or handling job interviews
• placement with an employer and/or on-the-job training
• services to help your family adjust to your disability
• transportation to rehabilitation activities

Eligibility Requirements

You may be eligible if:

• You have a physical or mental condition that makes it difficult for you to work.
• You would be able to return to work after receiving rehabilitation.
• You need these services to be able to prepare for, start or maintain gainful employment.

Applying for Vocational Rehabilitation

You must complete an application and be evaluated for eligibility. You should start rehabilitation as soon as possible, after you are discharged from the hospital to protect your disability coverage. Your transplant social worker can help you apply or you can contact the agency yourself.

Social Security Coverage for the Disabled

The Social Security Administration’s two disability programs, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI), are for individuals whose medical conditions prevent them from working. Both of these programs should be used as a move towards improving your economic condition.

Social Security Disability Insurance (SSDI)

• covers individuals who are working and paying Social Security taxes
• can be collected while you are involved in an approved rehabilitation program

Supplemental Security Income (SSI)

• makes monthly payments to disabled individuals with few assets and low incomes
• requires no waiting period

Eligibility Requirements

If you are eligible for SSDI or SSI, you may receive benefits until you are able to work again on a regular basis. Certain members of your family may also qualify for benefits.

Under this program:

• You must file a formal application.
• You must be unable to perform any work for which you are qualified.
• Your disability must be expected to last at least a year or result in death.
• You must have earned enough work credits when you were able to work (SSDI only).
• You may file an appeal if you are turned down the first time you apply, but believe that you qualify.

Applying for Disability

Even if another insurer or government agency has ruled that you are disabled, you must still meet Social Security requirements in order to receive Social Security benefits. Contact the Social Security Administration ²⁰ or your transplant financial team to apply for these programs. It is also important to consider the following points when applying:

• Apply as soon as you become disabled.
• You may apply by telephone, mail or in person at any Social Security office.
• Ask your social worker for help in applying.
• You cannot collect benefits until your sixth full month of disability.
• You may be able to qualify retroactively (dating back to the disabling event).
• During the 60 to 90 day claims process, Social Security will be gathering your medical information and assessing your ability to work.
• If you meet the initial requirements for disability, the Social Security office will send your application to your state’s Disability Determination Service for a formal evaluation.
• Reviewers will gather information from your doctors about your medical condition, history and treatment, as well as your ability to perform normal work activities.
• You may need to take a physical examination for further assessment.
• If additional testing is required, Social Security will pay for these expenses.
• You will receive written notice about your claim.

Review Periods and Termination of Benefits

Your case will be reviewed periodically to see if you are still disabled. Your benefits will end if:

• you work on a regular basis and earn an average of $500 or more a month; or
• your medical condition improves and you are no longer considered disabled (unless you are in a vocational rehabilitation program).

Work Incentives

In effort to help you move from dependency on benefits to self-sufficiency, work incentives protect your entitlement to cash payments and/or Medicaid or Medicare protection, until you can support yourself. Also, because you can still receive Social Security benefits if you attempt to work, it is important to call your Social Security Administrator and ask about work incentives and how they affect your benefits. The following points will provide you with a basic overview of work incentives:

• You may work for up to nine “trial” months (when your earnings are more than $200 in one month) over a five-year period. After nine trial months, Social Security will evaluate your work.
• Generally, if your earnings average $500 a month or less, you will continue to receive benefits.
• If you earn more than $500 a month on average, you will receive benefits for three more months.
• If you are still defined as disabled, you may receive a monthly benefit for any month that your earnings fall below $500, for up to 36 months.
• You must make Social Security aware of any special expenses you must pay in order to work. These expenses will be subtracted from your earnings to calculate your monthly earnings. These expenses include things like medications, travel costs related to your job, and some medical costs.

Americans with Disabilities Act

The Americans with Disabilities Act (ADA) of 1990 prohibits discrimination against people with disabilities who wish to work. The Act applies to private companies, state and local governments and employment agencies and labor unions that employ 15 or more workers for more than 20 weeks, but does not cover all employers. The ADA specifically excludes drug and alcohol abuse among the disabilities it covers, but it does protect those who have stopped using illegal drugs and have enrolled in or completed a drug rehabilitation program.

Eligibility Requirements

To be protected under the ADA, you must:

• have a physical or mental impairment that restricts one or more major life activities; and
• be able to perform the essential functions of your current job or a job that your are seeking, either with or without “reasonable” accommodations from your employer.

Employer Responsibilities

Reasonable Accommodations

Employers are required to make reasonable accommodations for disabled workers, such as:

• changing work schedules as necessary
• providing restructured job duties and/or reassigning disabled workers to other positions
• improving access to work facilities for disabled persons
• constructing new devices (such as a wheelchair ramp) or modifying existing ones to assist disabled workers, and
• modifying job examinations, training materials or policies as appropriate

Exceptions

If you have not made your employer aware of your disability, they will be under obligation to accommodate you. Also, employers may not have to provide an accommodation if they can prove it would pose an undue hardship to the business.

Patient Rights

Although pre-employment drug testing is allowed, ADA regulations do not allow an employer to take a medical examination before you are considered for employment. However, the Act does allow a routine medical examination after a job offer has been made and before employment begins for all new employees.

In a job interview, you may only be asked about your disability if the company can prove that the questions relate directly to the necessities of the job and meet certain other considerations.

Filing a Claim

To report a potential ADA violation, contact your local Equal Employment Opportunity Commission office, listed under “United States Government” in the telephone book. By law, an employer cannot retaliate against anyone filing a claim or participating in an investigation.

1. National Institutes of Health. National Heart, Lung and Blood Institute. Heart Transplant. https://www.nhlbi.nih.gov/health/health-topics/topics/ht
2. Transplant Living. A service of the United Network for Organ Sharing. Heart Transplant. https://transplantliving.org/before-the-transplant/about-the-operation/heart/
3. Registry of the International Society for Heart and Lung Transplantation: twenty-third official adult heart transplantation report–2006. Taylor DO, Edwards LB, Boucek MM, Trulock EP, Waltz DA, Keck BM, Hertz MI, International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2006 Aug; 25(8):869-79. https://www.ncbi.nlm.nih.gov/pubmed/16890107/
4. Mayo Foundation for Medical Education and Research. Heart transplant results. http://www.mayoclinic.org/tests-procedures/heart-transplant/details/results/rsc-20206368
5. Organ Procurement & Transplantation Network. https://optn.transplant.hrsa.gov/
6. Mayo Foundation for Medical Education and Research. Heart transplant risks. http://www.mayoclinic.org/tests-procedures/heart-transplant/details/risks/cmc-20206285
7. De Jonge N, Kirkels JH, Klöpping C, et al. Guidelines for heart transplantation. Netherlands Heart Journal. 2008;16(3):79-87. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2266869/
8. American Society of Transplantation. Getting a New Heart: Information for Patients about Heart Transplant. https://www.myast.org/patient-information/patient-education-brochures/patient-information-about-heart-transplant
9. United Network for Organ Sharing. https://www.unos.org/
10. Organ Procurement & Transplantation Network. OPTN policies are rules that govern operation of all member transplant hospitals, organ procurement organizations (OPOs) and histocompatibility labs in the U.S. https://optn.transplant.hrsa.gov/governance/policies/
11. United Network for Organ Sharing. Multiple Listing and Waiting Time Transfer. http://www.unos.org/wp-content/uploads/unos/Multiple_Listing.pdf
12. United Network for Organ Sharing. Living Donation. https://transplantliving.org/living-donation/
13. United Network for Organ Sharing. Paired Donation. https://transplantliving.org/living-donation/types/paired-donation/
14. United States DEPARTMENT OF LABOR. https://www.dol.gov/
15. HealthCare. https://www.healthcare.gov/
16. Medicare. https://www.medicare.gov/
17. TRICARE. https://tricare.mil/
18. Healthinsurance.org https://www.healthinsurance.org/obamacare/risk-pools/
19. https://transplantliving.org/before-the-transplant/financing-a-transplant/directory/
20. The United States Social Security Administration. https://www.ssa.gov/

Human heart

Your heart is a strong muscle about the size of the palm of your hand. Your body depends on the heart’s pumping action to deliver oxygen- and nutrient-rich blood to the body’s cells. When the cells are nourished properly, the body can function normally. Just like an engine makes a car go, the heart keeps your body running. The heart has two pumps. The stronger pump uses arteries to send blood with oxygen away from the heart, throughout the body. The other pump uses veins to bring blood back to the heart and sends it to the lungs to get more oxygen. An electrical system in the heart controls the heart’s pumps (the heart beat or pulse).

How the Heart Works

The heart has two sides, separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. The left side of the heart receives the oxygen-rich blood from the lungs and pumps it to the body.

The heart has four chambers ¹, two on the right and two on the left:

• Two upper chambers are called atrium (two is called an atria). The atria collect blood as it flows into the heart.
• Two lower chambers are called ventricles. The ventricles pump blood out of the heart to the lungs or other parts of the body.

The heart also has four valves that open and close to let blood flow from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart in only one direction when the heart contracts (beats). The four heart valves are:

• Tricuspid valve, located between the right atrium and right ventricle
• Pulmonary or pulmonic valve, between the right ventricle and the pulmonary artery. This artery carries blood from the heart to the lungs.
• Mitral valve, between the left atrium and left ventricle
• Aortic valve, between the left ventricle and the aorta. This aorta carries blood from the heart to the body.

Each valve has a set of flaps (also called leaflets or cusps). The mitral valve has two flaps; the others have three. Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries. Then they shut to keep blood from flowing backward. Blood flow occurs only when there’s a difference in pressure across the valves, which causes them to open. Under normal conditions, the valves permit blood to flow in only one direction.

The heart four chambers and four valves and is connected to various blood vessels. Veins are blood vessels that carry blood from the body to the heart. Arteries are blood vessels that carry blood away from the heart to the body.

The heart pumps blood to the lungs and to all the body’s tissues by a sequence of highly organized contractions of the four chambers. For the heart to function properly, the four chambers must beat in an organized way.

When the heart’s valves open and close, they make a “lub-DUB” sound that a doctor can hear using a stethoscope ².

• The first sound—the “lub”—is made by the mitral and tricuspid valves closing at the beginning of systole. Systole is when the ventricles contract, or squeeze, and pump blood out of the heart.
• The second sound—the “DUB”—is made by the aortic and pulmonary valves closing at the beginning of diastole. Diastole is when the ventricles relax and fill with blood pumped into them by the atria.

Arteries

The arteries are major blood vessels connected to your heart.

• The pulmonary artery carries blood from the right side of the heart to the lungs to pick up a fresh supply of oxygen.
• The aorta is the main artery that carries oxygen-rich blood from the left side of the heart to the body.
• The coronary arteries are the other important arteries attached to the heart. They carry oxygen-rich blood from the aorta to the heart muscle, which must have its own blood supply to function.

Veins

The veins also are major blood vessels connected to your heart.

• The pulmonary veins carry oxygen-rich blood from the lungs to the left side of the heart so it can be pumped to the body.
• The superior and inferior vena cavae are large veins that carry oxygen-poor blood from the body back to the heart.

Blood Flow

• The Right Side of Your Heart

In figure 3 above, the superior and inferior vena cavae are shown in blue to the left of the heart muscle as you look at the picture. These veins are the largest veins in your body.

After your body’s organs and tissues have used the oxygen in your blood, the vena cavae carry the oxygen-poor blood back to the right atrium of your heart.

The superior vena cava carries oxygen-poor blood from the upper parts of your body, including your head, chest, arms, and neck. The inferior vena cava carries oxygen-poor blood from the lower parts of your body.

The oxygen-poor blood from the vena cavae flows into your heart’s right atrium.  From the right atrium, blood is pumped into the right ventricle. And then from the right ventricle, blood is pumped to your lungs through the pulmonary arteries (shown in blue in the center of figure 3).

Once in the lungs, the blood travels through many small, thin blood vessels called capillaries. There, the blood picks up more oxygen and transfers carbon dioxide to the lungs—a process called gas exchange.

The oxygen-rich blood passes from your lungs back to your heart through the pulmonary veins (shown in red to the left of the right atrium in figure 3).

• The Left Side of Your Heart

Oxygen-rich blood from your lungs passes through the pulmonary veins (shown in red to the right of the left atrium in figure 3 above). The blood enters the left atrium and is pumped into the left ventricle.

From the left ventricle, the oxygen-rich blood is pumped to the rest of your body through the aorta. The aorta is the main artery that carries oxygen-rich blood to your body.

Like all of your organs, your heart needs oxygen-rich blood. As blood is pumped out of your heart’s left ventricle, some of it flows into the coronary arteries (shown in red in figure 3).

Your coronary arteries are located on your heart’s surface at the beginning of the aorta. They carry oxygen-rich blood to all parts of your heart.

For the heart to work well, your blood must flow in only one direction. Your heart’s valves make this possible. Both of your heart’s ventricles have an “in” (inlet) valve from the atria and an “out” (outlet) valve leading to your arteries.

Healthy valves open and close in exact coordination with the pumping action of your heart’s atria and ventricles. Each valve has a set of flaps called leaflets or cusps that seal or open the valve. This allows blood to pass through the chambers and into your arteries without backing up or flowing backward.

Figure 1. The anatomy of the heart

Figure 2. The anatomy of the heart chambers

Figure 3. Normal heart blood flow

The Heart’s Electrical System

The heart’s electrical system controls the rate and rhythm of the heartbeat.

With each heartbeat, an electrical signal spreads from the top of the heart to the bottom. As the signal travels, it causes the heart to contract and pump blood.

Your heart’s electrical system controls all the events that occur when your heart pumps blood ³. The electrical system also is called the cardiac conduction system. If you’ve ever seen the heart test called an EKG (electrocardiogram), you’ve seen a graphical picture of the heart’s electrical activity.

Your heart’s electrical system is made up of three main parts:

1. The Sinoatrial (SA) node, located in the right atrium of your heart
2. The Atrioventricular (AV) node, located on the interatrial septum close to the tricuspid valve
3. The His-Purkinje system, located along the walls of your heart’s ventricles

A heartbeat is a complex series of events. These events take place inside and around your heart. A heartbeat is a single cycle in which your heart’s chambers relax and contract to pump blood. This cycle includes the opening and closing of the inlet and outlet valves of the right and left ventricles of your heart.

Each heartbeat has two basic parts: diastole and systole. During diastole, the atria and ventricles of your heart relax and begin to fill with blood.

At the end of diastole, your heart’s atria contract (atrial systole) and pump blood into the ventricles. The atria then begin to relax. Your heart’s ventricles then contract (ventricular systole), pumping blood out of your heart.

Each electrical signal begins in a group of cells called the sinus node or sinoatrial (SA) node. The SA node is located in the heart’s upper right chamber, the right atrium. In a healthy adult heart at rest, the SA node fires off an electrical signal to begin a new heartbeat 60 to 100 times a minute. In a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA node sometimes is called your heart’s natural pacemaker. Your pulse, or heart rate, is the number of signals the SA node produces per minute.

The signal is generated as the vena cavae fill your heart’s right atrium with blood from other parts of your body. The signal spreads across the cells of your heart’s right and left atria.

From the SA node, the electrical signal travels through special pathways in the right and left atria. This causes the atria to contract and pump blood through the open valves from the atria into heart’s two lower chambers, the ventricles.

The electrical signal then moves down to a group of cells called the atrioventricular (AV) node, located between the atria and the ventricles. Here, the signal slows down just a little, allowing your heart’s right and left ventricles time to finish filling with blood.

The electrical signal then leaves the AV node and travels along a pathway called the bundle of His. This pathway divides into a right bundle branch and a left bundle branch. The signal goes down these branches to the ventricles, causing them to contract and pump blood to the lungs and the rest of the body.

From the bundle of His, the signal fibers divide into left and right bundle branches through the Purkinje fibers. These fibers connect directly to the cells in the walls of your heart’s left and right ventricles.

The signal spreads across the cells of your ventricle walls, and both ventricles contract. However, this doesn’t happen at exactly the same moment.

The left ventricle contracts an instant before the right ventricle. This pushes blood through the pulmonary valve (for the right ventricle) to your lungs, and through the aortic valve (for the left ventricle) to the rest of your body.

As the signal passes, the walls of the ventricles relax and await the next signal.

This process continues over and over as the atria refill with blood and more electrical signals come from the SA node.

A problem with any part of this process can cause an arrhythmia. For example, in atrial fibrillation, a common type of arrhythmia, electrical signals travel through the atria in a fast and disorganized way. This causes the atria to quiver instead of contract.

Figure 4. The heart’s electrical system

How to keep your heart healthy

Heart disease also called cardiovascular disease, is the number one killer in the U.S. Heart disease is also a major cause of disability. The most common cause of heart disease is narrowing or blockage of your coronary arteries also called coronary artery disease, the coronary arteries are the blood vessels that supply blood to your heart. A buildup of fatty deposits or plaques in your arteries (also known as atherosclerosis) is the most common cause of coronary artery disease. Atherosclerosis is not part of normal aging and can be serious. Unhealthy lifestyle habits, such as a poor diet, lack of exercise, being overweight and smoking, can lead to atherosclerosis. Coronary artery disease happens slowly over time. It’s the major reason people have heart attacks. Other kinds of heart problems may happen to the valves in the heart or the heart may not pump well and cause heart failure. Some people are born with heart disease also known as congenital heart disease.

Heart disease describes a range of conditions that affect your heart. Heart diseases include:

• Blood vessel disease, such as coronary artery disease
• Heart rhythm problems (arrhythmias)
• Heart defects you’re born with (congenital heart defects)
• Heart valve disease
• Disease of the heart muscle
• Heart infection

Many forms of heart disease can be prevented or treated with healthy lifestyle choices.

Risk factors are conditions or habits that increase your risk of developing a disease. The following are risk factors that can increase your chance of developing heart disease and cardiovascular disease:

• High blood cholesterol (hypercholesterolemia). High levels of cholesterol in your blood can increase the risk of plaque formation and atherosclerosis.
• High blood pressure (hypertension). Uncontrolled high blood pressure can result in hardening and thickening of your arteries, narrowing the vessels through which blood flows. Blood pressure is considered high if it stays at or above 140/90 mmHg over time. If you have diabetes or chronic kidney disease, high blood pressure is defined as 130/80 mmHg or higher. (The mmHg is millimeters of mercury—the units used to measure blood pressure.)
• Diabetes. Diabetes increases your risk of heart disease. Both conditions share similar risk factors, such as obesity and high blood pressure.
• Insulin resistance. This condition occurs if the body can’t use its own insulin properly. Insulin is a hormone that helps move blood sugar into cells where it’s used for energy. Insulin resistance may lead to diabetes.
• Obesity or being overweight. Excess weight typically worsens other heart disease risk factors.
• Metabolic syndrome. Metabolic syndrome is the name for a group of risk factors that raises your risk for coronary heart disease and other health problems, such as diabetes and stroke.
• Smoking. Nicotine tightens your blood vessels, and carbon monoxide can damage their inner lining, making them more susceptible to atherosclerosis. Heart attacks are more common in smokers than in nonsmokers.
• Poor diet. A diet that’s high in fat, salt, sugar and cholesterol can contribute to the development of heart disease. A healthy diet can help reduce your risk of developing coronary heart disease and stop you gaining weight, reducing your risk of diabetes and high blood pressure.
• Physical inactivity. Lack of exercise also is associated with many forms of heart disease and some of its other risk factors as well.
• Ethnicity
• Family history. A family history of heart disease increases your risk of coronary artery disease, especially if a parent developed it at an early age (before age 55 for a male relative, such as your brother or father, and 65 for a female relative, such as your mother or sister).
• Air pollution. Air pollution is harmful to your heart and circulation. Research shows that air pollution can affect your heart and circulation by:
  • damaging the inside walls of your blood vessels, causing them to become narrower and harder
  • restricting the movement of your blood vessels, which can increase your blood pressure and add to the strain on your heart
  • making your blood more likely to clot
  • affecting the normal electrical functioning of your heart which could cause abnormal heart rhythms
  • causing small changes to the structure of your heart like those that are seen in the early stages of heart failure.
  • This damage can contribute to the development of new health problems, or put people with existing heart and circulatory conditions at increased risk of events like a heart attack or stroke.
• Poor dental health. It’s important to brush and floss your teeth and gums often, and have regular dental checkups. If your teeth and gums aren’t healthy, germs can enter your bloodstream and travel to your heart, causing endocarditis.
• Stress. Unrelieved stress may damage your arteries and worsen other risk factors for heart disease. Research suggests that an emotionally upsetting event, particularly one involving anger, can serve as a trigger for a heart attack or angina in some people. Stress can contribute to high blood pressure and other heart disease risk factors. Some of the ways people cope with stress—drinking alcohol, using other substances, smoking, or overeating—are not healthy ways to manage stress.
• Drug abuse
• Excessive use of alcohol or caffeine. Heavy drinking can damage the heart muscle and worsen other coronary heart disease risk factors. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day.
  
• Age. Growing older increases your risk of damaged and narrowed arteries and a weakened or thickened heart muscle. Genetic or lifestyle factors cause plaque to build up in your arteries as you age. In men, the risk for coronary heart disease increases starting at age 45. In women, the risk for coronary heart disease increases starting at age 55.
• Sex. Men are generally at greater risk of heart disease. The risk for women increases after menopause.
• Preeclampsia. Preeclampsia (high blood pressure during pregnancy) can occur during pregnancy. The two main signs of preeclampsia are a rise in blood pressure and excess protein in the urine. Preeclampsia is linked to an increased lifetime risk of heart disease, including coronary heart disease, heart attack, heart failure, and high blood pressure. Preeclampsia (high blood pressure during pregnancy) is a risk factor that you can’t control. However, if you’ve had the condition, you should take extra care to monitor your blood pressure and try to lower other heart disease risk factors.
• Mental health problems. Some common mental health conditions include:
  • Depression, which is a long-lasting low mood disorder
  • Anxiety disorders such as social anxiety disorder, phobias and post-traumatic stress disorder (PTSD)
  • Personality disorders such as paranoia, borderline personality disorder and obsessive-compulsive disorder (OCD)
  • Bipolar disorder (BPD), previously called manic depression, which causes extreme and unpredictable mood changes
  • Psychosis and schizophrenia, which is when a person experiences an altered state of reality

The good news is many heart and cardiovascular diseases are caused by risk factors that can be controlled, treated or modified.

Complications of heart disease include:

• Heart failure. One of the most common complications of heart disease, heart failure occurs when your heart can’t pump enough blood to meet your body’s needs. Heart failure can result from many forms of heart disease, including heart defects, cardiovascular disease, valvular heart disease, heart infections or cardiomyopathy.
• Heart attack. A blood clot blocking the blood flow through a blood vessel that feeds the heart causes a heart attack, possibly damaging or destroying a part of the heart muscle. Atherosclerosis can cause a heart attack.
• Stroke. The risk factors that lead to cardiovascular disease can also lead to an ischemic stroke, which happens when the arteries to your brain are narrowed or blocked so that too little blood reaches your brain. A stroke is a medical emergency — brain tissue begins to die within just a few minutes of a stroke.
• Aneurysm. A serious complication that can occur anywhere in your body, an aneurysm is a bulge in the wall of your artery. If an aneurysm bursts, you may face life-threatening internal bleeding.
• Peripheral artery disease. When you develop peripheral artery disease, your extremities — usually your legs — don’t receive enough blood flow. This causes symptoms, most notably leg pain when walking (claudication). Atherosclerosis also can lead to peripheral artery disease.
• Sudden cardiac arrest. Sudden cardiac arrest is the sudden, unexpected loss of heart function, breathing and consciousness, often caused by an arrhythmia. Sudden cardiac arrest is a medical emergency. If not treated immediately, it results in sudden cardiac death.

You can help reduce your risk of heart disease by taking steps to control factors that put you at greater risk:

• Control your blood pressure. Ask your doctor for a blood pressure measurement at least every two years. He or she may recommend more frequent measurements if your blood pressure is higher than normal or you have a history of heart disease. Optimal blood pressure is less than 120 systolic and 80 diastolic, as measured in millimeters of mercury (mm Hg).
• Lower your cholesterol. Ask your doctor for a baseline cholesterol test when you’re in your 20s and then at least every five years. You may need to start testing earlier if high cholesterol is in your family. If your test results aren’t within desirable ranges, your doctor may recommend more-frequent measurements. Most people should aim for a low-density lipoprotein (LDL or “bad” cholesterol) level below 130 milligrams per deciliter (mg/dL), or 3.4 millimoles per liter (mmol/L). If you have other risk factors for heart disease, you should aim for an LDL level below 100 mg/dL (2.6 mmol/L). If you’re at very high risk of heart disease — if you’ve already had a heart attack or have diabetes, for example — aim for an LDL level below 70 mg/dL (1.8 mmol/L).
• Keep diabetes under control. If you have diabetes, tight blood sugar control can help reduce the risk of heart disease.
• Don’t smoke. Smoking is a major risk factor for heart disease, especially atherosclerosis. One of the best things you can do for your heart is to stop smoking or using smokeless tobacco. Quitting is the best way to reduce your risk of heart disease and its complications. Even if you’re not a smoker, be sure to avoid secondhand smoke. Chemicals in tobacco can damage your heart and blood vessels. Cigarette smoke reduces the oxygen in your blood, which increases your blood pressure and heart rate because your heart has to work harder to supply enough oxygen to your body and brain. There’s good news though. Your risk of heart disease starts to drop in as little as a day after quitting. After a year without cigarettes, your risk of heart disease drops to about half that of a smoker. No matter how long or how much you smoked, you’ll start reaping rewards as soon as you quit.
• Don’t drink or limit your alcohol intake. Alcohol can cause abnormal heart rhythms, high blood pressure, damage to your heart muscle and other diseases such as stroke, liver problems and some cancers. Alcohol is also high in calories so it can lead to weight gain. It also lowers your inhibitions which might mean you find it harder to stick to your healthy eating plans when you have been drinking. If you are trying to lose weight, cut down on alcohol. Drinking more than the recommended amount of alcohol can have a harmful effect on your heart and general health.
• Get enough exercise. Regular, daily physical activity can lower your risk of heart disease. Physical activity helps you achieve and maintain a healthy weight and control diabetes, high cholesterol and high blood pressure — all risk factors for heart disease. If you have a heart arrhythmia or heart defect, there may be some restrictions on the activities you can do, so talk to your doctor. Exercise at least 30 to 60 minutes most days of the week. If you haven’t been active for a while, you may need to slowly work your way up to these goals, but in general, you should aim for at least:
  • 150 minutes a week of moderate aerobic exercise, such as walking at a brisk pace
  • 75 minutes a week of vigorous aerobic activity, such as running
  • Two or more strength training sessions a week
  • Even shorter bouts of activity offer heart benefits, so if you can’t meet those guidelines, don’t give up. Just five minutes of moving can help, and activities such as gardening, housekeeping, taking the stairs and walking the dog all count toward your total. You don’t have to exercise strenuously to achieve benefits, but you can see bigger benefits by increasing the intensity, duration and frequency of your workouts.
• Get enough good-quality sleep. Quality sleep is good for your heart. It can be a challenge to make time for good sleep, but it’s important. For two weeks try to get 8 hours of good, quality sleep each night. Yes, each person’s sleep needs vary slightly, but eight is a good number to shoot for.
• Eat healthy foods. A heart-healthy diet based on fruits, vegetables and whole grains — and low in saturated fat, salt (sodium), cholesterol and added sugar — can help you control your weight, blood pressure and cholesterol.
• Maintain a healthy weight. Being overweight increases your risk of heart disease. A body mass index (BMI) of less than 25 and a waist circumference of 35 inches (88.9 centimeters) or less is the goal for preventing and treating heart disease.
• Reduce and manage stress. Reduce stress as much as possible. Practice techniques for managing stress, such as muscle relaxation and deep breathing.
• Get treatment for depression. Being depressed can increase your risk of heart disease significantly. Talk to your doctor if you feel hopeless or uninterested in your life.
• Practice good hygiene. Regularly wash your hands and brush and floss your teeth to keep yourself well.
• Get regular medical checkups. Early detection and treatment can set the stage for a lifetime of better heart health.

Lifestyle factors for healthy heart

Following a healthy lifestyle can help you and your children prevent or control many coronary heart disease risk factors. Because many lifestyle habits begin during childhood, parents and families should encourage their children to make heart healthy choices. For example, you and your children can lower your risk of coronary heart disease if you maintain a healthy weight, follow a healthy diet, do physical activity regularly, and don’t smoke.

Strong studies make it possible to link reductions in risk to these habits. Following a healthy lifestyle may prevent over 80% of cases of coronary artery disease ⁴, ⁵, 50% of ischemic strokes ⁶, 80% of sudden cardiac deaths ⁷ and 72% of premature deaths related to heart disease ⁸. In other words, a healthy lifestyle is a good investment in a longer, healthier life.

Table 1. Lifestyle factors for healthy heart

Footnotes:

*The Strategic Planning Task Force of the American Heart Association committee selected 5 aspects of diet to define a healthy dietary score. The score is not intended to be comprehensive. Rather, it is a practical approach that provides individuals with a set of potential concrete actions. A comprehensive rationale is set forth in the text of this document, and a comprehensive set of nutrition recommendations is provided in the 2006 Nutrition Guidelines ⁹, ¹⁰, ¹¹.

†Untreated values.

Changes to Your Heart With Age

Aging can cause changes in the heart and blood vessels. For example, as you get older, your heart can’t beat as fast during physical activity or stress as when you were younger. However, the number of heart beats per minute (heart rate) at rest does not change as you age ¹³.

Many of the problems older people have with their heart and blood vessels are really caused by disease, not by aging. For example, an older heart can normally pump blood as strong as a younger heart; less ability to pump blood is caused by disease. But, changes that happen with age may increase a person’s risk of heart disease. The good news is there are things you can do to delay, lower, or possibly avoid or reverse your risk.

A common problem related to aging is “hardening of the arteries,” called arteriosclerosis. This problem is why blood pressure goes up with age.

Age can cause other changes to the heart ¹³. For example:

• Blood vessels can become stiffer, and some parts of the heart wall will thicken to help with blood flow.
• Your heart valves may become thicker and stiffer, causing leaks or problems with pumping blood out of the heart.
• The size of the sections of your heart may increase.

Other factors, such as thyroid disease or chemotherapy, may weaken the heart muscle. Things you can’t control, like your family history, might also increase your risk of heart disease. But even so, leading a heart-healthy lifestyle might help you avoid or delay serious illness ¹⁴.

Blood Pressure

As you get older, it is important for you to have your blood pressure checked regularly, even if you are healthy. You may feel fine, but if not treated, high blood pressure can lead to stroke and problems with your heart, eyes, and kidneys. Exercise and reducing salt in your diet can help, but often medication is needed to manage high blood pressure and the related problems.

Normal Blood Pressure

Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps blood ¹⁵. Your blood pressure is determined both by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure. High blood pressure, sometimes called hypertension, happens when this force is too high. A blood pressure reading is given in millimeters of mercury (mm Hg). Mercury was used in the first accurate pressure gauges and is still used in medicine today as the standard unit of measurement for pressure. Health care workers check blood pressure readings the same way for children, teens, and adults. They use a gauge, stethoscope or electronic sensor, and a blood pressure cuff. With this equipment, they measure:

• Systolic Pressure (top number): blood pressure when the heart beats while pumping blood.
• Diastolic Pressure (bottom number): blood pressure when the heart is at rest between beats.

Normal blood pressure for adults is defined as a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg. It is normal for blood pressures to change when you sleep, wake up, or are excited or nervous. When you are active, it is normal for your blood pressure to increase. However, once the activity stops, your blood pressure returns to your normal baseline range.

Typically, more attention is given to systolic blood pressure (the first number) as a major risk factor for cardiovascular disease for people over 50. In most people, systolic blood pressure rises steadily with age due to the increasing stiffness of large arteries, long-term buildup of plaque and an increased incidence of cardiac and vascular disease. However, either an elevated systolic or an elevated diastolic blood pressure reading may be used to make a diagnosis of high blood pressure. According to recent studies, the risk of death from ischemic heart disease and stroke doubles with every 20 mm Hg systolic or 10 mm Hg diastolic increase among people from age 40 to 89.

Blood pressure normally rises with age and body size. Newborn babies often have very low blood pressure numbers that are considered normal for babies, while older teens have numbers similar to adults.

Abnormal Blood Pressure

Abnormal increases in blood pressure are defined as having blood pressures higher than 120/80 mmHg. You can have high blood pressure for years without any symptoms. Uncontrolled high blood pressure increases your risk of serious health problems, including heart attack and stroke. Fortunately, high blood pressure can be easily detected. And once you know you have high blood pressure, you can work with your doctor to control it.

The following table outlines and defines high blood pressure severity levels. The ranges in the table are blood pressure guides for adults who do not have any short-term serious illnesses. People with diabetes or chronic kidney disease should keep their blood pressure below 130/80 mmHg.

Although blood pressure increases seen in prehypertension are less than those used to diagnose high blood pressure, prehypertension can progress to high blood pressure and should be taken seriously. Over time, consistently high blood pressure weakens and damages your blood vessels, which can lead to complications.

Table 3. Stages of High Blood Pressure in Adults

Footnote: Healthy and unhealthy blood pressure ranges. A hypertensive crisis (high blood pressure crisis) is when blood pressure rises quickly and severely with readings of 180/120 or greater.

The consequences of uncontrolled blood pressure in this range can be severe and include:

• Stroke
• Loss of consciousness
• Memory loss
• Heart attack
• Damage to the eyes and kidneys
• Loss of kidney function
• Aortic dissection
• Angina (unstable chest pain)
• Pulmonary edema (fluid backup in the lungs)
• Eclampsia

An elevated reading may or may not be accompanied by one or more of the following symptoms:

• Severe headache
• Shortness of breath
• Nosebleeds
• Severe anxiety

High blood pressure Prevention

High blood pressure can often be prevented or reduced by eating healthily, maintaining a healthy weight, taking regular exercise, drinking alcohol in moderation and not smoking.

Healthy diet

Cut down on the amount of salt in your food and eat plenty of fruit and vegetables. The Healthy Eating highlights the different types of food that make up our diet, and shows the proportions we should eat them in to have a well-balanced and healthy diet.

Salt raises your blood pressure. The more salt you eat, the higher your blood pressure. Aim to eat less than 1.5 g (1500 mg) of salt a day, which is about half a teaspoonful. A lower sodium level — 1,500 milligrams (mg) a day — is appropriate for people 51 years of age or older, and individuals of any age who are black or who have hypertension, diabetes or chronic kidney disease.

Otherwise healthy people can aim for 2,300 mg a day or less. While you can reduce the amount of salt you eat by putting down the saltshaker, you generally should also pay attention to the amount of salt that’s in the processed foods you eat, such as canned soups or frozen dinners.

Eating a low-fat diet that includes lots of fiber – such as wholegrain rice, bread and pasta – and plenty of fruit and vegetables also helps lower blood pressure. Aim to eat five portions of fruit and vegetables every day.

Tips for a lower-salt diet

Too much salt can raise your blood pressure, which puts you at increased risk of health problems such as heart disease and stroke. But a few simple steps can help you to cut your salt intake.

Salt (Sodium) Equivalents

Sodium chloride or table salt is approximately 40 percent sodium. It’s important to understand just how much sodium is in salt so you can take measures to control your intake. These amounts are approximate.

• 1/4 teaspoon salt = 575 mg sodium
• 1/2 teaspoon salt = 1,150 mg sodium
• 3/4 teaspoon salt = 1,725 mg sodium
• 1 teaspoon salt = 2,300 mg sodium

Sodium Sources

Sodium can be sneaky. Taking control of your sodium means checking labels and reducing preservatives. Other foods to be aware of include:

• Processed foods
• Natural foods with a higher-than-average sodium content, including cheese, seafood, olives and some legumes
• Table salt, sea salt and kosher salt (sodium chloride)
• Some over-the-counter drugs
• Some prescription medications

You don’t have to add salt to food to be eating too much – 75% of the salt we eat is already in everyday foods such as bread, breakfast cereal and ready meals.

A diet that is high in salt can cause raised blood pressure, which currently affects more than one third of adults in the US.

High blood pressure often has no symptoms, and it is estimated that in America about one in every three people who have high blood pressure don’t know it. But if you have it, you are more likely to develop heart disease or have a stroke.

Heart rate

Your heart rate, or pulse, is the number of times your heart beats per minute. Normal heart rate varies from person to person. Knowing yours can be an important heart-health gauge.

According to the National Institute of Health, the average resting heart rate:

• for children 10 years and older, and adults (including seniors) is 60 – 100 beats per minute
• for well-trained athletes is 40 – 60 beats per minute.

As you age, changes in the rate and regularity of your pulse can change and may signify a heart condition or other condition that needs to be addressed.

The best places to find your pulse are the:

• wrists
• inside of your elbow
• side of your neck
• top of the foot

Figure 5. Radial artery at the wrist and taking a radial pulse

To get the most accurate reading, put your finger over your pulse and count the number of beats in 60 seconds.

How to take your pulse at the wrist:

• Take your pulse on the inside of your wrist, on the thumb side.
• Use the tips of your first two fingers (not your thumb) to press lightly over the blood vessels on your wrist.
• Count your pulse for 10 seconds and multiply by 6 to find your beats per minute.

Your resting heart rate is the heart pumping the lowest amount of blood you need because you’re not exercising. If you’re sitting or lying and you’re calm, relaxed and aren’t ill, your heart rate is normally between 60 (beats per minute) and 100 (beats per minute).

But a heart rate lower than 60 doesn’t necessarily signal a medical problem. It could be the result of taking a drug such as a beta blocker. A lower heart rate is also common for people who get a lot of physical activity or are very athletic. Active people often have lower heart rates because their heart muscle is in better condition and doesn’t need to work as hard to maintain a steady beat.

Moderate physical activity doesn’t usually change the resting pulse much. If you’re very fit, it could change to 40 beats per minute. A less active person might have a heart rate between 60 and 100 beats per minute. That’s because the heart muscle has to work harder to maintain bodily functions, making it higher.

How Other Factors Affect Heart Rate

• Air temperature: When temperatures (and the humidity) soar, the heart pumps a little more blood, so your pulse rate may increase, but usually no more than five to 10 beats a minute.
• Body position: Resting, sitting or standing, your pulse is usually the same. Sometimes as you stand for the first 15 to 20 seconds, your pulse may go up a little bit, but after a couple of minutes it should settle down.
• Emotions: If you’re stressed, anxious or “extraordinarily happy or sad” your emotions can raise your pulse.
• Body size: Body size usually doesn’t change pulse. If you’re very obese, you might see a higher resting pulse than normal, but usually not more than 100.
• Medication use: Medications that block your adrenaline (beta blockers) tend to slow your pulse, while too much thyroid medication or too high of a dosage will raise it.
• Energy drinks.
• Caffeine in beverages and foods.

How do you get your heart rate on target during exercise ?

When you work out, are you doing too much or not enough ?

There’s a simple way to know: Your target heart rate helps you hit the bull’s eye.

This table shows estimated target heart rates for different ages.

• Your maximum heart rate is about 220 minus your age.

In the age category closest to yours, read across to find your target heart rate. Heart rate during moderately intense activities is about 50-69% of your maximum heart rate, whereas heart rate during hard physical activity is about 70% to less than 90% of the maximum heart rate.

The figures are averages, so use them as general guidelines.

Important Note: A few high blood pressure medications lower the maximum heart rate and thus the target zone rate. If you’re taking such medicine, call your physician to find out if you need to use a lower target heart rate.

If your heart rate is too high, you’re straining. So slow down. If it’s too low, and the intensity feels “light” or “moderate/brisk,” you may want to push yourself to exercise a little harder.

During the first few weeks of working out, aim for the lower ranger of your target zone (50 percent) and gradually build up to the higher range (85 percent). After six months or more, you may be able to exercise comfortably at up to 85 percent of your maximum heart rate.

Table 2. Target heart rate during exercise

Best foods for heart health

A healthy diet can help protect your heart, improve your blood pressure and cholesterol, and reduce your risk of type 2 diabetes. A heart-healthy eating plan includes:

• Vegetables and fruits
• Beans or other legumes
• Lean meats and fish
• Low-fat or fat-free dairy foods
• Whole grains
• Healthy fats, such as olive oil

The following foods are the foundation of a heart-healthy eating plan:

• Vegetables such as leafy greens (spinach, collard greens, kale, cabbage), broccoli, and carrots
• Fruits such as apples, bananas, oranges, pears, grapes, and prunes
• Whole grains such as plain oatmeal, brown rice, and whole-grain bread or tortillas
• Fat-free or low-fat dairy foods such as milk, cheese, or yogurt
• Protein-rich foods:
• Fish high in omega-3 fatty acids (salmon, tuna, and trout)
• Lean meats such as 95% lean ground beef or pork tenderloin or skinless chicken or turkey
• Eggs
• Nuts, seeds, and soy products (tofu)
• Legumes such as kidney beans, lentils, chickpeas, black-eyed peas, and lima beans
• Oils and foods high in monounsaturated and polyunsaturated fats:
• Canola, corn, olive, safflower, sesame, sunflower, and soybean oils (not coconut or palm oil)
• Nuts such as walnuts, almonds, and pine nuts
• Nut and seed butters
• Salmon and trout
• Seeds (sesame, sunflower, pumpkin, or flax)
• Avocados
• Tofu

Research shows that the best foods that protect your heart and blood vessels, include the following:

• Fruits and Vegetables. Current World Health Organization (WHO) recommendations for fruit intake combined with vegetable intake are a minimum 400 g/day ¹⁸. A recent meta-analysis indicated that the intake of 800 g/day of fruit was associated with a 27% reductions in relative risk of cardiovascular disease ¹⁹.
• Fatty fish (Omega-3 fatty acids). Omega-3 fatty acid is a polyunsaturated fatty acid that must be obtained through dietary intake from fish as well as other types of seafood as it is not produced naturally in the human body ²⁰. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are essential fatty acids present in omega-3 ²¹. Fatty fish such as salmon, sardines and mackerel are abundant sources of omega-3 fatty acids, healthy unsaturated fats that have been linked to lower blood levels of beta-amyloid—the protein that forms damaging clumps in the brains of people with Alzheimer’s disease. Omega-3 fatty acids are thought to help keep your blood vessels healthy and to help to reduce blood pressure. Research into this style of eating has shown a reduced risk of developing problems such as type 2 diabetes, high blood pressure and raised cholesterol, which are all risk factors for heart disease ²². The American Heart Association recommends eating 2 servings of fish (particularly fatty fish) per week. A serving is 3.5 ounce cooked, or about ¾ cup of flaked fish. Fatty fish like salmon, mackerel, herring, lake trout, sardines and albacore tuna are high in omega-3 fatty acids ²³. Eating oily fish is a nutritious choice which can form part of the Mediterranean diet (more bread, fruit, vegetables, fish and less meat, and replacing butter with unsaturated fat spreads). Researchers have also found that people who closely follow a traditional Mediterranean style diet are more likely to live a longer life and also are less likely to become obese. Try to eat fish at least twice a week, but choose varieties that are low in mercury, such as salmon, cod, canned light tuna, and pollack. If you’re not a fan of fish, ask your doctor about taking an omega-3 supplement, or choose terrestrial omega-3 sources such as flaxseeds, avocados, and walnuts. Plant sources of omega-3 fatty acids include flaxseed, oils (olive, canola, flaxseed, soybean), nuts and other seeds (walnuts, butternut squash and sunflower). Replacements for vegans/vegetarians exist that are not supplements, but the evidence is not as robust for plant sources of omega-3 fatty acids.
• Berries. Researchers credit the high levels of flavonoids in berries with the benefit ²⁴. Flavonoids, the natural plant pigments that give berries their brilliant hues, also help improve memory, research shows. Berries contain a particularly high amount of flavonoids called anthocyanidins that are capable of crossing the blood brain barrier and localizing themselves in the hippocampus, an area of the brain known for memory and learning. Epidemiological evidence has established strong inverse associations between flavonoid-rich fruit (e.g. strawberries, grapefruit) and coronary heart disease mortality in cardiovascular disease-free postmenopausal women after multivariate adjustment ²⁵. In a 20-year study of over 16,000 older adult women (aged ≥70 years), those who ate the most blueberries and strawberries had the slowest rates of cognitive decline by up to two-and-a-half years ²⁴.
• Walnuts. Nuts are excellent sources of protein, fat-soluble vitamin E and healthy fats, and one type of nut in particular might also improve memory. A 2015 study from UCLA linked higher walnut consumption to improved cognitive test scores. Walnuts are high in a type of omega-3 fatty acid called alpha-linolenic acid (ALA). Diets rich in alpha-linolenic acid and other omega-3 fatty acids have been linked to lower blood pressure and cleaner arteries. That’s good for both the heart and brain.
• Meat-free meals. Heart-healthy eating encourages consuming meat sparingly. Beans, lentils and soybeans, which pack protein and fiber, make a worthy substitute. They’ll keep you full and are rich in B vitamins, which are important for brain health. In one study analyzing the diets of older adults, those who had the lowest intakes of legumes had greater cognitive decline than those who ate more.

The American Heart Association suggests these daily amounts:

• Vegetables – canned, dried, fresh and frozen vegetables; 5 servings
• Fruits – canned, dried, fresh and frozen fruits; 4 servings
• Whole grains – barley, brown rice, millet, oatmeal, popcorn and whole wheat bread, crackers and pasta; 3-6 servings
• Dairy – low fat (1%) and fat-free dairy products; 3 servings
• Proteins – eggs, fish, lean meat, legumes, nuts, poultry and seeds; 1-2 servings. Eat a variety of fish at least twice a week, especially fish containing omega-3 fatty acids (for example, salmon, trout and herring).
• Oils – polyunsaturated and monounsaturated canola, olive, peanut, safflower and sesame oil; 3 tablespoons
• Limit – sugary drinks, sweets, fatty meats, and salty or highly processed foods
• Choose foods with less salt (sodium) and prepare foods with little or no salt. To lower blood pressure, aim to eat no more than 2,300 milligrams of sodium per day. Reducing daily intake to 1,500 mg is desirable because it can lower blood pressure even further.
• Limit saturated fat and trans fat and replace them with the better fats, monounsaturated and polyunsaturated. If you need to lower your blood cholesterol, reduce saturated fat to no more than 5 to 6 percent of total calories. For someone eating 2,000 calories a day, that’s about 13 grams of saturated fat.
• Avoid – partially hydrogenated oils, tropical oils, and excessive calories
• Replace – highly processed foods with homemade or less-processed options
• If you drink alcohol, drink in moderation. That means no more than one drink per day if you’re a woman and no more than two drinks per day if you’re a man.

Carbohydrate

Carbohydrate (starch) is the body’s main energy (fuel) source. Starch is broken down to produce glucose which is used by your body for energy.

Starchy foods are an important part of the healthy diet. They should make up about a third of all the food that you eat. You don’t have to avoid or restrict them because they are ‘fattening’. Instead, be aware of the total amount of starch that you eat. Cutting out one food group, such as carbohydrate can cause dietary imbalance. Starchy foods include bread, potatoes, rice and pasta. Wholegrain options are healthier choices.

Fiber rich foods help your gut to function properly and have many other health benefits. Studies have shown that people who are overweight or obese tend to lose weight if they include plenty of high fiber, starchy carbohydrate in their diets.

Sugar

Sugar is a type of carbohydrate. Like starch, it breaks down into glucose, to provide energy for your body. ‘Free’ sugars are often added to foods during manufacture and include refined sugars such as sucrose (table sugar). This kind of sugar is also found naturally, in unsweetened fruit juices, and in syrups and honey.

Excess consumption of free sugars is linked to the risk of obesity, type 2 diabetes and tooth decay. Many of the free sugars that you consume, are in sugary drinks. A regular can of cola for instance, can contain the equivalent of seven teaspoons of sugar (35g). The guidance about free sugar consumption suggests a daily limit of 30g. This is equivalent to six teaspoons.

The natural sugars found in milk and in whole fruits and vegetables are not free sugars and do not need to be restricted in the same way.

Fruit and vegetables

Fruit and vegetables contain high levels of ‘micronutrients’. These include vitamins, minerals and antioxidants. Micronutrients are essential to the body’s many biochemical processes.

Fruit and vegetables are often high in fiber. They are generally low in calorie and they taste good. The current Dietary Guidelines for Americans recommends at least five portions of different fruit and vegetable per day ²⁶. Like carbohydrate, fruit and vegetable should account for about one third of what you eat, per day. Dried, frozen, tinned, as well as fresh, fruit and veg are all included. One portion of pulses (baked beans, lentils, dried peas) can also count towards your five a day.

Dietary fiber

Fiber comes from plant-based foods, including fruits, vegetables and wholegrains. Dietary fiber is the part of plants that you eat but which doesn’t get digested in your small intestine. Instead, it is completely or partially broken down (fermented) by bacteria in your large intestine. Once broken down in your large intestine, it has been suggested that dietary fibers increase the beneficial bacteria in your gut. This improves your immune system. Fibre includes carbohydrates called polysaccharides and resistant oligosaccharides. Recent research suggests that fiber should be categorized by its physical characteristics; how well it dissolves (solubility), how thick it is (viscosity) and how well it breaks down (fermentability). Some commonly known terms are described below:

• Soluble fiber including pectins and beta glucans is found in foods like fruit and oats.
• Insoluble fiber including cellulose is found in wheat bran and nuts.
• Resistant starch is a soluble fiber that is highly fermentable in the gut. It gets broken down by good bacteria to produce short chain fatty acids (SCFAs). Resistant starch is naturally present in some foods such as bananas, potatoes, grains and pulses.
• Prebiotics are types of carbohydrate that only our gut bacteria can feed upon. Some examples are onions, garlic, asparagus and banana

Fibre is essential for your gut to work normally. It increases good bacteria which supports your immunity against inflammatory disorders and allergies. A high fiber diet seems to reduce the risk of chronic diseases such as heart disease, type 2 diabetes and bowel cancer.

Eating a range of dietary fiber can:

• Improve the diversity of your microbiota
• Improve constipation and lactose intolerance
• Enhance immunity
• Reduce inflammation in your gut

For example, high quality randomized controlled trials have shown that eating oat bran leads to lower blood pressure and lower total cholesterol.

Benefits of a high-fiber diet:

• Normalizes bowel movements. Dietary fiber increases the weight and size of your stool and softens it. A bulky stool is easier to pass, decreasing your chance of constipation. If you have loose, watery stools, fiber may help to solidify the stool because it absorbs water and adds bulk to stool.
• Helps maintain bowel health. A high-fiber diet may lower your risk of developing hemorrhoids and small pouches in your colon (diverticular disease). Studies have also found that a high-fiber diet likely lowers the risk of colorectal cancer. Some fiber is fermented in the colon. Researchers are looking at how this may play a role in preventing diseases of the colon.
• Lowers cholesterol levels. Soluble fiber found in beans, oats, flaxseed and oat bran may help lower total blood cholesterol levels by lowering low-density lipoprotein, or “bad,” cholesterol levels. Studies also have shown that high-fiber foods may have other heart-health benefits, such as reducing blood pressure and inflammation.
• Helps control blood sugar levels. In people with diabetes, fiber — particularly soluble fiber — can slow the absorption of sugar and help improve blood sugar levels. A healthy diet that includes insoluble fiber may also reduce the risk of developing type 2 diabetes.
• Aids in achieving healthy weight. High-fiber foods tend to be more filling than low-fiber foods, so you’re likely to eat less and stay satisfied longer. And high-fiber foods tend to take longer to eat and to be less “energy dense,” which means they have fewer calories for the same volume of food.
• Helps you live longer. Studies suggest that increasing your dietary fiber intake — especially cereal fiber — is associated with a reduced risk of dying from cardiovascular disease and all cancers.

Good sources of dietary fiber include:

• Pulses (like lentils and peas) and beans and legumes (think navy beans, small white beans, split peas, chickpeas, lentils, pinto beans)
• Fruits and vegetables, vegetables such as carrots, broccoli, green peas, and collard greens; fruits especially those with edible skin (like pears and apples with the skin on) and those with edible seeds (like berries)
• Nuts—try different kinds (pumpkin seeds, almonds, sunflower seeds, pistachios and peanuts are a good source of fiber and healthy fats, but be mindful of portion sizes, because they also contain a lot of calories in a small amount!)
• Whole grains such as:
  • Quinoa, barley, bulgur, oats, brown rice and farro
  • Whole wheat pasta
  • Whole grain cereals, including those made from whole wheat, wheat bran and oats

Choose fiber rich foods from a variety of sources including wholegrains, fruit and vegetable, nuts and seeds, beans and pulses. When you read food labels check for the grams of fiber per serving or per 100g. Foods that are naturally high in fiber and contain at least 3 grams per 100 gram are often labeled as a “good source,” and foods labeled as “excellent source” contain more than 5 grams of fiber per serving.

Depending on your age and sex, adults should get 25 to 31 grams of fiber a day ²⁷. Older adults sometimes don’t get enough fiber because they may lose interest in food.

• Men over the age of 50 should get at least 38 grams of fiber per day.
• Women over the age of 50 should get 25 grams per day.
• Children ages 1 to 3 should get 19 grams of fiber per day.
• Children between 4 and 8 years old should get 25 grams per day.
• Girls between 9 and 18 should get 26 grams of fiber each day. Boys of the same age range should get between 31 and 38 grams of fiber per day.

You may wish to see a dietitian if you:

• are unsure about how much and/or what types of fiber you currently have in your diet
• suffer with constipation or diarrhea (e.g. irritable bowel syndrome [IBS])
• have a condition which can restrict your fiber intake (e.g. inflammatory bowel disease)

Keep in mind that if you haven’t been eating a lot of foods high in fiber on a daily basis, it’s important to increase your intake slowly to allow your body to adjust. A sudden increase in eating foods high in fiber (especially foods with added fiber or when using supplements) can cause gas, bloating or constipation. Be sure you are drinking enough water too, because fiber needs water to move through your body.

Protein

Protein is vital. It is your body’s main building block. Animal products such as meat, fish, eggs and dairy are good sources of dietary protein. Meat and fish also provide your body with a form of iron (heme), which is easy to absorb. Fish also contains essential fatty acids (e.g, Omega-3).

Protein also comes from foods of plant origin. Pulses, nuts, and seeds are all high in protein. Pulses are a very good meat alternative, whether or not you are vegetarian or vegan.

Cutting back on consumption of red meat (beef, lamb, goat, pork) especially, is better for your health and for the environment: current advice is to have no more than 300g of red meat per week. Try to avoid processed meats such as bacon, salami, hot dogs, ham. Consumption of these cured meat products has been linked to a much higher risk of certain gut cancers.

Dairy

Dairy products and calcium-fortified alternatives are your body’s main source of calcium, which is necessary for the growth, development and maintenance of healthy bones and teeth. Dairy products and alternatives are also a source of protein. Milk, cheese, cream and milk-based sauces and yogurts can have a high saturated fat content. Fat reduced options are recommended, and small quantities.

Fats

Fats also known as lipids, is an essential nutrient (a primary storage form of energy, a kilojoule-dense nutrient) your body need for energy and to help your gut absorb vitamins A, D, E and K from foods. Fat has twice as many calories as proteins or carbohydrates. There are nine calories (37kJ) in every gram of fat, regardless of what type of fat it is. Fats are more energy-dense than carbohydrates and proteins, which provide four calories (17kJ) per gram. Dietary fat also plays a major role in your cholesterol levels. You need some fat in your diet but not too much. There are different types of fats, some are “good” and some are “bad”, however, you should try to avoid “bad” fats. When it comes to dietary fat, what matters most is the type of fat you eat. Contrary to past dietary advice promoting low-fat diets, newer research shows that healthy fats are necessary and beneficial for health.

Healthy fats are unsaturated. They keep cholesterol levels within a healthy range, reduce your risk of heart problems and may be good for the skin, eyes and brain. Unsaturated fats are the best choice for a healthy diet.

Unhealthy fats are saturated and trans fats, which can raise levels of ‘bad’ cholesterol and increase the risk of heart disease. Multiple studies have linked high levels of saturated fat with cognitive decline. A diet that is higher in unsaturated fats and lower in saturated fats is linked to better cognition.

• Saturated fats such as butter, solid shortening, and lard. Eating foods that contain saturated fats raises the level of cholesterol in your blood. High levels of LDL cholesterol (low-density lipoprotein or “bad” cholesterol) in your blood increase your risk of heart disease and stroke. The American Heart Association recommends aiming for a dietary pattern that achieves 5% to 6% of calories from saturated fat. For example, if you need about 2,000 calories a day, no more than 120 of them should come from saturated fat. That’s about 13 grams of saturated fat per day ²⁸.
• Trans fats also known as trans fatty acids or “partially hydrogenated oils”. These are found in vegetable shortenings, some margarines, crackers, cookies, snack foods, and other foods made with or fried in partially hydrogenated oils. By 2018, most U.S. companies will not be allowed to add partially hydrogenated oils to food.

“Bad” fats, such as artificial trans fats and saturated fats, are guilty of the unhealthy things all fats have been blamed for—weight gain, clogged arteries, an increased risk of certain diseases, and so forth. Large studies have found that replacing saturated fats in your diet with unsaturated fats and omega-3 fatty acids can reduce your risk of heart disease by about the same amount as cholesterol-lowering drugs. Since fat is an important part of a healthy diet, rather than adopting a low-fat diet, it’s more important to focus on eating more beneficial “good” fats and limiting harmful “bad” fats. For good health, the majority of the fats that you eat should be monounsaturated or polyunsaturated. Eat foods containing monounsaturated fats and/or polyunsaturated fats such as canola oil, olive oil, safflower oil, sesame oil or sunflower oil instead of foods that contain saturated fats and/or trans fats.

For years you’ve been told that eating fat will add inches to your waistline, raise cholesterol, and cause a myriad of health problems. When food manufacturers reduce fat, they often replace it with carbohydrates from sugar, refined grains, or other starches. Your body digests these refined carbohydrates and starches very quickly, affecting your blood sugar and insulin levels and possibly resulting in weight gain and disease ²⁹. But now scientists know that not all fat is the same. Research has shown that unsaturated fats are good for you. Healthy fats play a huge role in helping you manage your moods, stay on top of your mental game, fight fatigue, and even control your weight. These fats come mostly from plant sources. Cooking oils that are liquid at room temperature, such as canola, peanut, safflower, soybean, and olive oil, contain mostly unsaturated fat. Nuts, seeds, and avocados are also good sources. Fatty fish—such as salmon, sardines, and herring—are rich in unsaturated fats, too. You should actively make unsaturated fats a part of your diet. Of course, eating too much fat will put on the pounds too. Note also that by swapping animal fats for refined carbohydrates—such as replacing your breakfast bacon with a bagel or pastry—won’t have the same benefits. In fact eating refined carbohydrates or sugary foods can have a similar negative effect on your cholesterol levels, your risk for heart disease, and your weight. Limiting your intake of saturated fat can still help improve your health—as long as you take care to replace it with good fat rather than refined carbs. In other words, don’t go no fat, go good fat.

Healthy-eating tips:

• Use olive oil in cooking.
• Replace saturated fats with unsaturated fats; for example, use avocado, tahini, nut or seed butter instead of dairy butter.
• Eat fish, especially oily fish, twice a week.
• Consume legume- or bean-based meals twice a week.
• Snack on nuts or add them to your cooking.
• Throw avocado in salads.
• Choose lean meats and trim any fat you can see (including chicken skin).
• Use table spreads that have less than 0.1g of trans fats per 100g.

Saturated fats

Saturated fats are fat molecules that are “saturated” with hydrogen molecules. Saturated fats are normally solid at room temperature. Saturated fats occur naturally in many foods — primarily meat and dairy foods (butter, cream, full-fat milk and cheese). Beef, lamb, pork on poultry (with the skin on) contain saturated fats, as do butter, cream and cheese made from whole or 2% milk. Plant-based foods that contain saturated fats include coconut, coconut oil, coconut milk and coconut cream, cooking margarine, and cocoa butter, as well as palm oil and palm kernel oil (often called tropical oils). Saturated fats are also found in snacks like chips, cakes, biscuits and pastries, and takeaway foods. Consuming more than the recommended amount of saturated fat is linked to heart disease and high cholesterol.

The American Dietary Guidelines recommend that:

• men should not eat more than 30g of saturated fat a day
• women should not eat more than 20g of saturated fat a day
• children should have less

For people who need to lower their cholesterol, the American Heart Association recommends reducing saturated fat to less than 6% of total daily calories. For someone eating 2,000 calories a day, that’s about 11 to 13 grams of saturated fat ²⁸.

Examples of foods with saturated fat are:

• fatty beef,
• lamb,
• pork,
• poultry with skin,
• beef fat (tallow),
• meat products including sausages and pies,
• lard and cream,
• butter and ghee,
• cheese especially hard cheese like cheddar,
• other dairy products made from whole or reduced-fat (2 percent) milk,
• cream, soured cream and ice cream,
• some savory snacks, like cheese crackers and some popcorns,
• chocolate confectionery,
• biscuits, cakes, and pastries

In addition, many baked goods and fried foods can contain high levels of saturated fats. Some plant-based oils, such as palm oil, palm kernel oil, coconut oil and coconut cream, also contain primarily saturated fats, but do not contain cholesterol.

Unsaturated Fats

If you want to reduce your risk of heart disease, it’s best to reduce your overall fat intake and swap saturated fats for unsaturated fats. Unsaturated fats are in fish, such as salmon, trout and herring, and plant-based foods such as avocados, olives and walnuts. Liquid vegetable oils, such as soybean, corn, safflower, canola, olive and sunflower, also contain unsaturated fats.

There are 2 types of unsaturated fats: monounsaturated and polyunsaturated. Unsaturated fats help reduce your risk of heart disease and lower your cholesterol levels.

• Polyunsaturated fats such as omega-3 and omega-6 fats are found in fish, nuts, and safflower and soybean oil.
• Monounsaturated fats are found in olive and canola oil, avocado, cashews and almonds.

Monounsaturated fats have one (“mono”) unsaturated carbon bond in the molecule. Polyunsaturated fats have more than one (“poly,” for many) unsaturated carbon bonds. Both of these unsaturated fats are typically liquid at room temperature.

Eaten in moderation, both kinds of unsaturated fats may help improve your blood cholesterol when used in place of saturated and trans fats.

Polyunsaturated fats

Polyunsaturated fats are simply fat molecules that have more than one unsaturated carbon bond in the molecule, this is also called a double bond. Oils that contain polyunsaturated fats are typically liquid at room temperature but start to turn solid when chilled. Olive oil is an example of a type of oil that contains polyunsaturated fats.

There are 2 main types of polyunsaturated fats: omega-3 and omega-6. Oils rich in polyunsaturated fats also provide essential fats that your body needs but can’t produce itself – such as omega-6 and omega-3 fatty acids. You must get essential fats through food. Omega-6 and omega-3 fatty acids are important for many functions in the body. A deficiency of essential fatty acids—either omega-3s or omega-6s—can cause rough, scaly skin and dermatitis ³⁰.

Polyunsaturated fats can help reduce bad cholesterol levels in your blood which can lower your risk of heart disease and stroke. Polyunsaturated fats also provide nutrients to help develop and maintain your body’s cells. Oils rich in polyunsaturated fats also contribute vitamin E to the diet, an antioxidant vitamin most Americans need more of.

Foods high in polyunsaturated fat include a number of plant-based oils, including:

• soybean oil
• corn oil
• sunflower oil

Other sources include some nuts and seeds such as walnuts and sunflower seeds, tofu and soybeans.

Omega-6 fats are found in vegetable oils, such as:

• rapeseed
• corn
• sunflower
• some nuts

Omega-3 fats are found in oily fish, such as:

• kippers
• herring
• trout
• sardines
• salmon
• mackerel

The American Heart Association also recommends eating tofu and other forms of soybeans, canola, walnut and flaxseed, and their oils. These foods contain alpha-linolenic acid (ALA), another omega-3 fatty acid.

Polyunsaturated fats (PUFAs) are frequently designated by their number of carbon atoms and double bonds. Alpha-linolenic acid (ALA), for example, is known as C18:3n-3 because it has 18 carbons and 3 double bonds and is an omega-3 fatty acid. Similarly, eicosapentaenoic acid (EPA) is known as C20:5n-3 and docosahexaenoic acid (DHA) as C22:6n-3. Omega-6 fatty acids (omega-6s) have a carbon–carbon double bond that is six carbons away from the methyl end of the fatty acid chain. Linoleic acid (LA) known as C18:2n-6 and arachidonic acid (AA) known as C20:4n-6 are two of the major omega-6s.

The human body can only form carbon–carbon double bonds after the 9th carbon from the methyl end of a fatty acid ³¹. Therefore, alpha-linolenic acid (ALA) and linoleic acid (LA) are considered essential fatty acids, meaning that they must be obtained from the diet ³². Alpha-linolenic acid (ALA) can be converted into eicosapentaenoic acid (EPA) and then to docosahexaenoic acid (DHA), but the conversion (which occurs primarily in the liver) is very limited, with reported rates of less than 15% ³³. Therefore, consuming EPA and DHA directly from foods and/or dietary supplements is the only practical way to increase levels of these fatty acids in the body.

Alpha-linolenic acid (ALA) is present in plant oils, such as flaxseed, soybean, and canola oils ³³. Docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are present in fish, fish oils, and krill oils, but they are originally synthesized by microalgae, not by the fish. When fish consume phytoplankton that consumed microalgae, they accumulate the omega-3s in their tissues ³³.

Some researchers propose that the relative intakes of omega-6s and omega-3s—the omega-6/omega-3 ratio—may have important implications for the pathogenesis of many chronic diseases, such as cardiovascular disease and cancer ³⁴, but the optimal ratio—if any—has not been defined ³⁵. Others have concluded that such ratios are too non-specific and are insensitive to individual fatty acid levels ³⁶. Most agree that raising eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) blood levels is far more important than lowering linoleic acid (LA) or arachidonic acid levels.

Currently, most clinicians do not assess omega-3 status, but it can be done by measuring individual omega-3s in plasma or serum phospholipids and expressing them as the percentage of total phospholipid fatty acids by weight ³⁷. Experts have not established normal ranges, but mean values for serum or plasma phospholipid eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) among U.S. adults not taking omega-3 supplements are about 3%–4% ³⁷. Plasma and serum fatty acid values, however, can vary substantially based on an individual’s most recent meal, so they do not reflect long-term dietary consumption ³⁸.

It is also possible to assess omega-3 status via analysis of erythrocyte fatty acids, a measurement that reflects longer-term intakes over approximately the previous 120 days ³⁹. The “omega-3 index” proposed by Harris and von Schacky reflects the content of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) in erythrocyte membranes expressed as a percentage of total erythrocyte fatty acids ⁴⁰. This index can be used as a surrogate for assessing tissue levels of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) ⁴¹. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) typically comprise about 3%–5% of erythrocyte fatty acids in Western populations with low fish intakes. In Japan, where fish consumption is high, erythrocyte eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) levels are about twice those of Western populations ³³.

Table 1. Alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) content of selected foods

Footnotes: *Except as noted, the U.S. Department of Agriculture (USDA) database does not specify whether fish are farmed or wild caught. **The USDA database does not specify whether beef is grass fed or grain fed.

Essential Fatty Acids

Essential Fatty Acids such as omega-3 oils are ‘essential’ because your body can’t make them and you have to obtain them from your food. Essential Fatty Acids are found in the skin of white fish but also in the flesh of oily fish such as fresh and tinned salmon, mackerel, sardines and fresh tuna. Advice for fish eaters is to have one portion of oily fish, and one portion of white fish per week.

Essential Fatty Acids can also be found in some plant oils such as flaxseed, rapeseed and soya but there is not as much in these oils as there is in fish and seafood.

Omega-3 fatty acids

Omega-3 fatty acids (omega-3s) are a type of polyunsaturated fat and have a carbon–carbon double bond located three carbons from the methyl end of the chain (see Figure 6). Omega-3 fatty acids, sometimes referred to as “n-3s,” are present in certain foods such as flaxseed and fish, as well as dietary supplements such as fish oil. Omega-3 fatty acids are especially beneficial to your health. Omega-3s play important roles in the body as components of the phospholipids that form the structures of cell membranes ³⁰. There are different types of omega-3s: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are found in fish and algae and have the most health benefits, while alpha-linolenic acid (ALA) comes from plants and is a less potent form of omega-3, although the body does convert ALA to EPA and DHA at low rates. Alpha-linolenic acid (ALA) contains 18 carbon atoms, whereas eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) are considered “long-chain” omega-3s because EPA contains 20 carbons and DHA contains 22 ⁴¹.

Docosahexaenoic acid (DHA), in particular, is especially high in the retina, brain, and sperm ³³. In addition to their structural role in cell membranes, omega-3s (along with omega-6s) provide energy for the body and are used to form eicosanoids. Eicosanoids are signaling molecules that have similar chemical structures to the fatty acids from which they are derived; they have wide-ranging functions in the body’s cardiovascular, pulmonary, immune, and endocrine systems ³¹. Higher concentrations of EPA and DHA than arachidonic acid tip the eicosanoid balance toward less inflammatory activity ⁴².

Research has shown that a diet rich in omega-3 fatty acids may help to:

• Prevent and reduce symptoms of depression, ADHD, and bipolar disorder.
• Protect against memory loss and dementia.
• Reduce the risk of heart disease, stroke, and cancer.
• Ease arthritis, joint pain, and inflammatory skin conditions.
• Support a healthy pregnancy.
• Battle fatigue, sharpen your memory, and balance your mood.

Fish the best source of omega-3 (high in EPA and DHA):

• Anchovies
• Herring
• Salmon
• Mackerel
• Sardines
• Trout
• Tuna
• Mussels
• Oysters
• Halibut

Vegetarian sources of omega-3s (high in ALA):

• Algae such as seaweed (high in EPA and DHA)
• Eggs (small amounts of DHA)
• Flaxseeds and flaxseed oil
• Chia seeds
• Canola and soybean oil
• Walnuts
• Mayonnaise
• Edamame
• Beans (refried, kidney, etc.)
• Brussels sprouts
• Kale
• Spinach

Fish is a good source of protein and omega-3 fatty acids, which are good for your heart. Research has shown that omega-3 fatty acids can reduce your risk of heart disease and stroke. A 2020 Cochrane review ⁴³ of 86 randomized controlled trials published between 1968 and 2019 found that 0.5 g/day to more than 5 g/day omega-3 fatty acids for 12 to 88 months in a total of 162,796 participants reduced serum triglyceride levels by about 15% and slightly decreased rates of cardiovascular mortality and coronary heart disease events. However, the omega-3 fatty acids supplements did not affect all-cause mortality, cardiovascular events, stroke, or arrhythmia. The authors of several earlier meta-analyses and systematic reviews, as well as a 2016 report from the Agency for Healthcare Research and Quality, concluded that omega-3 fatty acids supplements do not appear to significantly reduce the risk of most cardiovascular events ⁴⁴. Many of these analyses ⁴⁵, however, but not all ⁴⁶, did find that omega-3s reduce the risk of cardiac death.

The American Heart Association recommends eating 2 servings of fish (particularly fatty fish) per week. A serving is 3.5 ounce (100 g) cooked, or about ¾ cup of flaked fish. Fatty fish like salmon, mackerel, herring, lake trout, sardines and albacore tuna are high in omega-3 fatty acids. For people with existing coronary heart disease, such as a recent heart attack (myocardial infarction), the American Heart Association recommends approximately 1 gram/day EPA plus DHA, preferably from oily fish; however, supplements could also be considered under the direction of a physician ⁴⁷. The American Heart Association does not recommend omega-3 supplements for people who do not have a high cardiovascular disease risk.

While omega-3s are best obtained through food, there are many omega-3 and fish oil supplements available. A typical fish oil supplement provides about 1,000 mg fish oil, containing 180 mg EPA and 120 mg DHA, but doses vary widely ⁴⁸. If you need to substantially lower your triglycerides, your doctor may recommend prescription fish oil, which has been concentrated to contain about 900 mg of EPA plus DHA per capsule. Cod liver oil supplements provide vitamin A and vitamin D in addition to omega-3s. For strict vegetarians or vegans, as well as obtaining ALA from food sources, look for capsules containing DHA and EPA extracted from algae, the original source of omega-3s for fish. Although seafood contains varying levels of methyl mercury (a toxic heavy metal) ⁴⁹, omega-3 supplements have not been found to contain this contaminant because it is removed during processing and purification ⁵⁰.

Some types of fish may contain high levels of mercury, PCBs (polychlorinated biphenyls), dioxins and other environmental contaminants. Levels of these substances are generally highest in older, larger, predatory fish and marine mammals.

The benefits and risks of eating fish vary depending on a person’s stage of life.

Children and pregnant women are advised by the U.S. Food and Drug Administration (FDA) to:

• Avoid eating those fish with the potential for the highest level of mercury contamination (such as shark, swordfish, king mackerel or tilefish).
• Eat a variety of fish and shellfish that are lower in mercury (such as canned light tuna, salmon, pollock, catfish).
• Check local advisories about the safety of fish caught by family and friends in local lakes, rivers and coastal areas.

For middle-aged and older men and postmenopausal women, the benefits far outweigh the potential risks when the amount of fish eaten is within the recommendations established by the FDA and Environmental Protection Agency.

Eating a variety of fish will help minimize any potentially adverse effects due to environmental pollutants. Five of the most commonly eaten fish or shellfish that are low in mercury are shrimp, canned light tuna, salmon, pollock, and catfish. Avoid eating shark, swordfish, king Mackerel, or tilefish because they contain high levels of mercury.

Cholesterol

Dietary fat plays a major role in your cholesterol levels. Cholesterol is a type of fat, a wax-like substance that your body needs to function properly that comes from foods such as eggs and is also found in your blood mostly made by your body in your liver. In and of itself, cholesterol isn’t bad. But when you get too much of it, it can have a negative impact on your health. The 2 main types of cholesterol are:

1. “Good” cholesterol or HDL (high-density lipoprotein) cholesterol. “Good” HDL cholesterol has a positive effect by taking cholesterol from parts of the body where there’s too much of it to the liver, where it’s disposed of.
   
2. “Bad” cholesterol or LDL (low-density lipoprotein) cholesterol.

High levels of LDL cholesterol (low-density lipoprotein or “bad” cholesterol) can increase your risk of heart disease. The key is to keep your LDL levels low and HDL high, which may protect against heart disease and stroke. High levels of LDL cholesterol (low-density lipoprotein or “bad” cholesterol) can clog arteries and low HDL (high-density lipoprotein or “good” cholesterol) can be a marker for increased cardiovascular risk. However, eating foods that contain any type of cholesterol won’t actually raise your body’s cholesterol levels. Rather than the amount of cholesterol you eat, the biggest influence on your cholesterol levels is the type of fats you consume. Eating saturated or trans fats is far more likely to give you high cholesterol. So instead of counting cholesterol, it’s important to focus on replacing bad fats with good fats.

LDL (bad) cholesterol

LDL (low-density lipoprotein) cholesterol is considered the “bad” cholesterol, because it contributes to fatty buildups in arteries (atherosclerosis). This narrows the arteries and increases the risk for heart attack, stroke and peripheral artery disease. Your body naturally produces all the LDL cholesterol you need. Eating foods containing saturated fats and trans fats causes your body to produce even more LDL — raising the level of “bad” cholesterol in your blood.

HDL (good) cholesterol

HDL (high-density lipoprotein) cholesterol can be thought of as the “good” cholesterol because a healthy level may protect against heart attack and stroke. HDL carries LDL (bad) cholesterol away from the arteries and back to the liver, where the LDL is broken down and passed from the body. But HDL cholesterol doesn’t completely eliminate LDL cholesterol. Only one-third to one-fourth of blood cholesterol is carried by HDL.

Trans fats

Avoid trans fat. Trans fats also known as trans fatty acids or “partially hydrogenated oils”, are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid, so they ‘behave’ like a saturated fat. There are two broad types of trans fats found in foods: naturally-occurring and artificial trans fats. Naturally-occurring trans fats are produced in the gut of some animals and foods made from these animals (e.g., milk and meat products) may contain small quantities of these fats. Artificial trans fats (or trans fatty acids) are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid.

Trans fats increase the levels of ‘bad’ LDL cholesterol and decreases the levels of ‘good’ HDL cholesterol in your body, which increases your risk of developing heart disease and stroke. Trans fats is also associated with a higher risk of developing type 2 diabetes. Trans fats can be found in many foods such as in butter, margarine (in small amounts), deep-fried and processed foods like doughnuts, cakes and pastries. Baked goods, such as pastries, pizza dough, frozen pizza, pie crust, cookies, biscuits, and crackers also can contain trans fats.

Since 2006, the FDA has required trans fat content to be listed on the Nutrition Facts panel of packaged foods. In recent years, many major national fast-food chains and casual-dining restaurant chains have announced they will no longer use trans fats to fry or deep-fry foods.

The American Heart Association recommends that adults who would benefit from lowering LDL cholesterol eliminate trans fat from their diet.

To find the amount of trans fats in a particular packaged food, look at the Nutrition Facts panel. Companies must list any measurable amount of trans fat (0.5 grams or more per serving) in a separate line in the “Total Fat” section of the panel, directly beneath the line for “Saturated Fat.” This means if a food package states 0 grams of trans fats, it might still have some trans fats if the amount per serving is less than 0.5 g. You can also spot trans fats by reading ingredient lists and looking for the ingredients referred to as “partially hydrogenated oils.”

Salt

Salt or sodium is a mineral that’s essential for life. Table salt is a combination of two minerals — about 40% sodium and 60% chloride. Salt or sodium is regulated by your kidneys, and it helps control your body’s fluid balance. It also helps send nerve impulses and affects muscle function. High levels of salt in your diet can increase blood pressure. High blood pressure is known as the “silent killer” because its symptoms are not always obvious. It’s one of the major risk factors for heart disease, the No. 1 killer worldwide. Ninety percent of American adults are expected to develop high blood pressure over their lifetimes. Because high blood pressure is an important risk factor for stroke, and strokes are detrimental to cognitive health, excessive salt intake is harmful for your brain health. There is a well-established relationship between consuming high levels of sodium and risk of stroke. In Japan, a public health education intervention in the 1960s showed the effectiveness of dietary interventions to reduce sodium intake. A 50% reduction in salt in the diet was associated with an 85% reduction in mortality caused by stroke.

Most of the salt that you eat is added to processed foods. More than 70% of the sodium you consume comes from packaged, prepared and restaurant foods. The rest of the sodium in the diet occurs naturally in food (about 15 percent) or is added when we’re cooking food or sitting down to eat (about 11 percent). Current recommendations from the Dietary Guidelines for Americans are to limit sodium intake to 2,300 milligrams (mg) a day, which amounts to about one teaspoon of salt. The American Heart Association recommends an ideal limit of no more than 1,500 mg per day for most adults. On average, Americans eat more than 3,400 milligrams of sodium each day — much more than the American Heart Association and other health organizations recommend. Because the average American eats so much excess sodium, even cutting back by 1,000 milligrams a day can significantly improve blood pressure and heart health. One estimate suggested that if the U.S. population dropped its sodium intake to 1,500 mg/day (1/2 teaspoon salt), overall blood pressure could decrease by 25.6%, with an estimated $26.2 billion in health care savings. Another estimate projected that achieving this goal would reduce cardiovascular disease deaths by anywhere from 500,000 to nearly 1.2 million over the next decade.

Here are the approximate amounts of sodium in a given amount of salt:

• 1/4 teaspoon salt = 575 mg sodium
• 1/2 teaspoon salt = 1,150 mg sodium
• 3/4 teaspoon salt = 1,725 mg sodium
• 1 teaspoon salt = 2,300 mg sodium

The body needs only a small amount of sodium (less than 500 milligrams per day) to function properly. That’s a mere smidgen — the amount in less than ¼ teaspoon. Very few people come close to eating less than that amount. Plus, healthy kidneys are great at retaining the sodium that your body needs.

Best heart healthy diet

The typical, contemporary Western diet (high in salt, sugar, excess calories, and saturated fats) is not good for the heart. Eating a heart-healthy diet benefits both your body and your heart. In general, best diet for your heart and arteries is lower in saturated fats. Research in the area of the relationship between diet and your heart point to the benefits of two diets in particular: the DASH (Dietary Approaches to Stop Hypertension) diet and the Mediterranean diet. A plant-based diet that is rich in a variety of fruits and vegetables, particularly green-leafy vegetables and berries, is associated with better heart health. Specific foods (such as olive oil), and particular nutritional supplements (including phenolic compounds like curcumin and quercetin) that may also prove effective for Alzheimer’s disease prevention. These diets can help reduce heart disease and may also be able to reduce risk of dementia.

• Dietary Approaches to Stop Hypertension (DASH) diet
  • The DASH diet aims to reduce blood pressure by:
    • Eating foods that are low in saturated fat, total fat and cholesterol, and high in fruits, vegetables and low-fat dairy.
    • Consuming whole grains, poultry, fish and nuts.
    • Decreasing your intake of saturated fats, red meats, sweets, sugared beverages and sodium.
• Mediterranean diet
  • The Mediterranean diet incorporates different principles of healthy eating that are typically found in the areas bordering the Mediterranean Sea.
    • Focusing on fruit, vegetables, nuts and grains.
    • Replacing butter with healthy fats, like olive oil.
    • Limiting red meat.
    • Using herbs to flavor food rather than salt.
    • Eating fish and poultry at least twice a week.

Mediterranean diet

“Mediterranean diet” is a generic term based on the traditional eating habits in the countries bordering the Mediterranean Sea ⁵¹. There’s not one standard Mediterranean diet. At least 16 countries border the Mediterranean. Eating styles vary among these countries and even among regions within each country because of differences in culture, ethnic background, religion, economy, geography and agricultural production ⁵². However, there are some common factors. Mediterranean diet is low in saturated fat and high in fiber ⁵³.

A Mediterranean-style diet typically includes:

• plenty of fruits, vegetables, bread and other grains, potatoes, beans, nuts and seeds are eaten daily and make up the majority of food consumed;
• olive oil as a primary fat source, may account for up to 40% of daily calories; and
• small portions of cheese or yogurt are usually eaten each day, along with a serving of fish, poultry, or eggs.

Fish and poultry are more common than red meat in the Mediterranean diet. The Mediterranean diet also centers on minimally processed, plant-based foods. Wine may be consumed in low to moderate amounts, usually with meals. Fruit is a common dessert instead of sweets.

Main meals consumed daily should be a combination of three elements: cereals, vegetables and fruits, and a small quantity of legumes, beans or other (though not in every meal). Cereals in the form of bread, pasta, rice, couscous or bulgur (cracked wheat) should be consumed as one–two servings per meal, preferably using whole or partly refined grains. Vegetable consumption should amount to two or more servings per day, in raw form for at least one of the two main meals (lunch and dinner). Fruit should be considered as the primary form of dessert, with one–two servings per meal. Consuming a variety of colors of both vegetables and fruit is strongly recommended to help ensure intake of a broad range of micronutrients and phytochemicals. The less these foods are cooked, the higher the retention of vitamins and the lower use of fuel, thus minimizing environmental impact.

The Mediterranean Diet is associated with a lower incidence of mortality from all-causes ⁵⁴ and is also related to lower incidence of cardiovascular diseases ⁵⁵, type 2 diabetes ⁵⁶, certain types of cancer ⁵⁷, and neurodegenerative diseases ⁵⁸. The Mediterranean diet is now recognized as one of the most healthy food patterns in the world.

Year after year, the Mediterranean diet comes out on top in the U.S. News and World Report annual ranking of best diets. The Mediterranean diet is also touted as one of the healthiest by many health organizations and dietitians ⁵⁹.

A Mediterranean-style diet is a healthy dietary pattern that:

• emphasizes vegetables, fruits, whole grains, beans and legumes;
• includes low-fat or fat-free dairy products, fish, poultry, non-tropical vegetable oils and nuts; and
• limits added sugars, sugary beverages, sodium, highly processed foods, refined carbohydrates, saturated fats, and fatty or processed meats.

This style of eating can play a big role in preventing heart disease and stroke and reducing risk factors such as obesity, diabetes, high cholesterol and high blood pressure. There is some evidence that a Mediterranean diet rich in virgin olive oil may help the body remove excess cholesterol from arteries and keep blood vessels open.

The Mediterranean Diet is characterized by ⁶⁰:

1. An abundance of plant food (fruit, vegetables, breads, cereals, potatoes, beans, nuts, and seeds);
2. Minimally processed, seasonally fresh, locally grown foods;
3. Desserts comprised typically of fresh fruit daily and occasional sweets containing refined sugars or honey;
4. Olive oil (high in polyunsaturated fat) as the principal source of fat;
5. Daily dairy products (mainly cheese and yogurt) in low to moderate amounts;
6. Fish and poultry in low to moderate amounts;
7. Up to four eggs weekly;
8. Red meat rarely; and
9. Wine in low to moderate amounts with meals.

Here are some things you can do to switch from a traditional Western-style diet to a more Mediterranean way of eating.

• Dip bread in a mix of olive oil and fresh herbs instead of using butter.
• Add avocado slices to your sandwich instead of bacon.
• Have fish for lunch or dinner instead of red meat. Brush it with olive oil, and broil or grill it.
• Sprinkle your salad with seeds or nuts instead of cheese.
• Cook with olive or canola oil instead of butter or oils that are high in saturated fat.
• Choose whole-grain bread, pasta, rice, and flour instead of foods made with white flour.
• Add ground flaxseed to cereal, low-fat yogurt, and soups.
• Cut back on meat in meals. Instead of having pasta with meat sauce, try pasta tossed with olive oil and topped with pine nuts and a sprinkle of Parmesan cheese.
• Dip raw vegetables in a vinaigrette dressing or hummus instead of dips made from mayonnaise or sour cream.
• Have a piece of fruit for dessert instead of a piece of cake.
• Use herbs and spices instead of salt to add flavor to foods.

DASH diet

DASH stands for Dietary Approaches to Stop Hypertension is similar to a Mediterranean-type diet ⁶¹. DASH diet is an eating plan that is based on research studies sponsored by the National Heart, Lung, and Blood Institute ⁶². The DASH diet is a lifelong approach to healthy eating that’s designed to help treat or prevent high blood pressure (hypertension). The DASH diet encourages you to reduce the sodium in your diet and eat a variety of foods rich in nutrients that help lower blood pressure, such as potassium, calcium and magnesium and eating foods that are low in saturated fat, total fat, and cholesterol, and high in fruits, vegetables, and low fat dairy foods ⁶³.

DASH Diet is a flexible and balanced eating plan that helps you create a heart-healthy eating style for life.

The DASH diet eating plan requires no special foods and has no hard-to-follow recipes. It simply calls for a certain number of daily servings from various food groups to provide your daily and weekly nutritional goals. The Dietary Approaches to Stop Hypertension (DASH) diet recommends ⁶⁴:

• Grains and grain products: 7–8 servings per day, more than half of which are whole-grain foods
• Fruits: 4–5 servings per day
• Vegetables: 4–5 servings per day
• Low-fat or non-fat dairy foods: 2–3 servings per day
• Lean meats, fish, poultry: 6 or less servings or fewer per day
• Nuts, seeds, and legumes: 4–5 servings per week
• Added fats and oils: 2–3 servings per day
• Sweets: 5 or less servings per week
• Salt (sodium): 1,500 milligrams (mg) sodium lowers blood pressure even further than 2,300 mg sodium daily.
• Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel and palm oils
• Limiting sugar-sweetened beverages and sweets.

The DASH diet eating plan includes vegetables, whole grains, poultry, fish, and nuts, and has low amounts of fats, red meats, sweets, and sugared beverages. It is also high in potassium, calcium and magnesium, as well as protein and fiber. The number of servings depends on the number of calories you’re allowed each day. Your calorie level depends on your age, sex, the amount of lean body mass (muscular, athletic, average or overweight), height and, especially, how active you are. Think of this as an energy balance system—if you want to maintain your current weight, you should take in only as many calories as you burn by being physically active. If you need to lose weight, eat fewer calories than you burn or increase your activity level to burn more calories than you eat.

The DASH dietary approach has been shown to lower blood pressure, but little has been published regarding weight loss ⁶¹. In fact, a systematic review and meta-analysis on observational prospective studies on the effects of Dietary Approaches to Stop Hypertension (DASH)-style diet, showed that the DASH diet can significantly protect against cardiovascular diseases, coronary heart disease, stroke, and heart failure risk by 20%, 21%, 19% and 29%, respectively ⁶⁵, ⁶⁶.

Blood pressure is usually measured in millimeters of mercury (mmHg) and is recorded as two numbers—systolic pressure (as the heart beats) “over” diastolic pressure (as the heart relaxes between beats)—for example, 120/80 mmHg. Both numbers in a blood pressure test are important, but for people who are age 50 or older, systolic pressure gives the most accurate diagnosis of high blood pressure. Systolic pressure is the top number in a blood pressure reading. It is high if it is 140 mmHg or above ⁶⁷.

High blood pressure is blood pressure higher than 140/90 mmHg and prehypertension is blood pressure between 120/80 and 139/89 mmHg. Prehypertension means that you don’t have high blood pressure now, but are likely to develop it in the future unless you adopt the healthy lifestyle. High blood pressure is dangerous because it makes your heart work too hard, hardens the walls of your arteries, and can cause the brain to hemorrhage or the kidneys to function poorly or not at all. If not controlled, high blood pressure can lead to heart and kidney disease, stroke and blindness.

Being overweight or obese increases your risk of developing high blood pressure. In fact, your blood pressure rises as your body weight increases. Losing even 10 pounds can lower your blood pressure and losing weight has the biggest effect on those who are overweight and already have hypertension. Overweight and obesity are also risk factors for heart disease. And being overweight or obese increases your chances of developing high blood cholesterol and diabetes—two
more risk factors for heart disease.

The original DASH trial ⁶⁸ consisted of 459 subjects with systolic blood pressures <160 mm Hg and diastolic blood pressures between 80 and 95 mm Hg. For three weeks, all participants were fed a control diet low in fruits, vegetables, and dairy products, and with a fat content typical of an American diet (37% of daily caloric intake). During the following eight weeks, the participants were randomized to one of three diets: the control diet, a diet rich in fruits and vegetables, or the DASH Diet.

The DASH Diet was not low in sodium (salt), but still reduced blood pressure. A meta-analysis of 56 randomized, controlled trials that included over 3,500 participants did not support universal sodium restriction, but instead only recommended dietary sodium restriction in the elderly ⁶⁹.

The DASH Diet reduced systolic blood pressure by 5.5 mm Hg and diastolic blood pressure by 3.3 mm Hg, as compared with controls. Subgroup analysis showed that African Americans and those with hypertension had the greatest reduction in blood pressure ⁶⁸ . The DASH diet results might be applied to a larger group due to the heterogeneous population: half of the participants were women, 60% were African American, and 37% had household incomes of <$30,000 per year. One limitation of applying the DASH Diet to the general population is that the study was carried out in a very controlled setting, where all the meals were prepared for the subjects, and thus no comments may be made regarding attrition rates for the diet.

By following the DASH diet, you may be able to reduce your blood pressure by a few points in just two weeks. Over time, your systolic blood pressure could drop by eight to 14 points, which can make a significant difference in your health risks.

Salt or sodium is a mineral that’s essential for life. Table salt is a combination of two minerals — about 40% sodium and 60% chloride. Salt or sodium is regulated by your kidneys, and it helps control your body’s fluid balance. It also helps send nerve impulses and affects muscle function. High levels of salt in your diet can increase blood pressure. High blood pressure is known as the “silent killer” because its symptoms are not always obvious. It’s one of the major risk factors for heart disease, the No. 1 killer worldwide. Ninety percent of American adults are expected to develop high blood pressure over their lifetimes. Because high blood pressure is an important risk factor for stroke, and strokes are detrimental to cognitive health, excessive salt intake is harmful for your brain health. Most of the salt that you eat is added to processed foods. More than 70% of the sodium you consume comes from packaged, prepared and restaurant foods. The rest of the sodium in the diet occurs naturally in food (about 15 percent) or is added when we’re cooking food or sitting down to eat (about 11 percent). The American Heart Association recommends no more than 2,300 milligrams (mg) a day and moving toward an ideal limit of no more than 1,500 mg per day for most adults. On average, Americans eat more than 3,400 milligrams of sodium each day — much more than the American Heart Association and other health organizations recommend. Because the average American eats so much excess sodium, even cutting back by 1,000 milligrams a day can significantly improve blood pressure and heart health. One estimate suggested that if the U.S. population dropped its sodium intake to 1,500 mg/day (1/2 teaspoon salt), overall blood pressure could decrease by 25.6%, with an estimated $26.2 billion in health care savings. Another estimate projected that achieving this goal would reduce cardiovascular disease deaths by anywhere from 500,000 to nearly 1.2 million over the next decade.

Here are the approximate amounts of sodium in a given amount of salt:

• 1/4 teaspoon salt = 575 mg sodium
• 1/2 teaspoon salt = 1,150 mg sodium
• 3/4 teaspoon salt = 1,725 mg sodium
• 1 teaspoon salt = 2,300 mg sodium

The body needs only a small amount of sodium (less than 500 milligrams per day) to function properly. That’s a mere smidgen — the amount in less than ¼ teaspoon. Very few people come close to eating less than that amount. Plus, healthy kidneys are great at retaining the sodium that your body needs.

Table 2. Daily Nutrient Goals Used in the DASH Studies (for a 2,100 Calorie Eating Plan)

Footnote: 1,500 mg sodium* was a lower goal tested and found to be even better for lowering blood pressure. It was particularly effective for middle-aged and older individuals, African Americans, and those who already had high blood pressure. The American Heart Association recommends no more than 2,300 milligrams (mg) a day and moving toward an ideal limit of no more than 1,500 mg per day for most adults. On average, Americans eat more than 3,400 milligrams of sodium each day — much more than the American Heart Association and other health organizations recommend. Because the average American eats so much excess sodium, even cutting back by 1,000 milligrams a day can significantly improve blood pressure and heart health.

Abbreviations: g = grams; mg = milligrams

Exercise and Physical Activity

Exercise and physical activity are good for just about everyone. The American Heart Association recommends adults get at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity (or a combination of both), preferably spread throughout the week. Any activity is better than none. Even light-intensity activity can offset the serious health risks of being sedentary. Moderate to vigorous aerobic exercise is best. Your heart will beat faster, and you’ll breathe harder than normal. As you get used to being more active, increase your time and/or intensity to get more benefits. Include moderate- to high-intensity muscle-strengthening activity (like resistance or weight training) at least twice a week.

Staying active can help you:

• Keep and improve your strength so you can stay independent
• Have more energy to do the things you want to do and reduce fatigue
• Improve your balance and lower risk of falls and injuries from falls
• Manage and prevent some diseases like arthritis, heart disease, stroke, type 2 diabetes, osteoporosis, and 8 types of cancer, including breast and colon cancer
• Sleep better at home
• Reduce levels of stress and anxiety
• Reach or maintain a healthy weight and reduce risk of excessive weight gain
• Control your blood pressure
• Possibly improve or maintain some aspects of cognitive function, such as your ability to shift quickly between tasks or plan an activity
• Perk up your mood and reduce feelings of depression

Research has shown that exercise is not only good for your physical health, it also supports emotional and mental health. You can exercise with a friend and get the added benefit of emotional support. So, next time you’re feeling down, anxious, or stressed, try to get up and start moving.

Physical activity can help:

• Reduce feelings of depression and stress, while improving your mood and overall emotional well-being
• Increase your energy level
• Improve sleep
• Empower you to feel more in control

In addition, exercise and physical activity may possibly improve or maintain some aspects of cognitive function, such as your ability to shift quickly between tasks, plan an activity, and ignore irrelevant information.

Most people tend to focus on one type of exercise or activity and think they’re doing enough. Research has shown that it’s important to get all 4 types of exercise:

1. Endurance
2. Strength
3. Balance
4. Flexibility.

Each one has different benefits. Doing one kind also can improve your ability to do the others, and variety helps reduce boredom and risk of injury. No matter your age, you can find activities that meet your fitness level and needs.

The Department of Health and Human Services  recommends these exercise guidelines for most healthy adults:

1. AEROBIC activity. Get at least 150 minutes a week of moderate aerobic activity — such as brisk walking, swimming or mowing the lawn — or 75 minutes a week of vigorous aerobic activity — such as running or aerobic dancing. You can also do a combination of moderate and vigorous activity. It’s best to do this over the course of a week.
2. STRENGTH training. Strength train at least twice a week. Consider free weights, weight machines or activities that use your own body weight — such as rock climbing or heavy gardening. The amount of time for each session is up to you.

Endurance exercises

Endurance activities, often referred to as aerobic, increase your breathing and heart rates. These activities help keep you healthy, improve your fitness, and help you perform the tasks you need to do every day. Endurance exercises improve the health of your heart, lungs, and circulatory system. They also can delay or prevent many diseases that are common in older adults such as diabetes, colon and breast cancers, heart disease, and others.

Physical activities that build endurance include:

• Brisk walking or jogging
• Yard work (mowing, raking)
• Dancing
• Swimming
• Biking
• Climbing stairs or hills
• Playing tennis or basketball

Increase your endurance or “staying power” to help keep up with your grandchildren during a trip to the park, dance to your favorite songs at a family wedding, and rake the yard and bag up leaves. Build up to at least 150 minutes of activity a week that makes you breathe hard. Try to be active throughout your day to reach this goal and avoid sitting for long periods of time.

Safety tips

• Do a little light activity, such as easy walking, before and after your endurance activities to warm up and cool down.
• Listen to your body: endurance activities should not cause dizziness, chest pain or pressure, or a feeling like heartburn.
• Be sure to drink liquids when doing any activity that makes you sweat. If your doctor has told you to limit your fluids, be sure to check before increasing the amount of fluid you drink while exercising.
• If you are going to be exercising outdoors, be aware of your surroundings.
• Dress in layers so you can add or remove clothes as needed for hot and cold weather.
• To prevent injuries, use safety equipment, such as a helmet when bicycling.

Strength exercises

Some people call using weight to improve your muscle strength “strength training” or “resistance training.” Your muscular strength can make a big difference. Strong muscles help you stay independent and make everyday activities feel easier, like getting up from a chair, climbing stairs, and carrying groceries. Keeping your muscles strong can help with your balance and prevent falls and fall-related injuries. You are less likely to fall when your leg and hip muscles are strong.

Some people choose to use weights to help improve their strength. If you do, start by using light weights at first, then gradually add more. Other people use resistance bands, stretchy elastic bands that come in varying strengths. If you are a beginner, try exercising without the band or use a light band until you are comfortable. Add a band or move on to a stronger band (or more weight) when you can do two sets of 10 to 15 repetitions easily. Try to do strength exercises for all of your major muscle groups at least 2 days per week, but don’t exercise the same muscle group on any 2 days in a row. Below are a few examples of strength exercises:

• Lifting weights
• Carrying groceries
• Gripping a tennis ball
• Overhead arm curl
• Arm curls
• Wall push-ups
• Lifting your body weight
• Using a resistance band

Safety tips:

• Don’t hold your breath during strength exercises and breathe regularly.
• Breathe out as you lift or push, and breathe in as you relax.
• Talk with your doctor if you are unsure about doing a particular exercise.

Balance exercises

Balance exercises help prevent falls, a common problem in older adults that can have serious consequences. Many lower-body strength exercises also will improve your balance. Balance exercises include:

• Tai Chi, a “moving meditation” that involves shifting the body slowly, gently, and precisely, while breathing deeply.
• Standing on one foot.
• The heel-to-toe walk.
• The balance walk.
• Standing from a seated position.

Safety tips:

• Have a sturdy chair or a person nearby to hold on to if you feel unsteady.
• Talk with your doctor if you are unsure about a particular exercise.

Flexibility exercises

Stretching can improve your flexibility. Moving more freely will make it easier for you to reach down to tie your shoes or look over your shoulder when you back your car out of the driveway. Flexibility exercises include:

• The back stretch exercise
• The inner thigh stretch
• The ankle stretch
• The back of leg stretch

Safety tips:

• Stretch when your muscles are warmed up.
• Stretch after endurance or strength exercises.
• Don’t stretch so far that it hurts.
• Always remember to breathe normally while holding a stretch.
• Talk with your doctor if you are unsure about a particular exercise.

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