The fit, muscular Anthony Robinson doesn’t look like a man who would be lying in a hospital bed, contemplating the idea of a heart transplant, but the 46-year-old personal trainer said he was doing just that over one weekend last February.
Then came Monday and in walked Dr. Munir Janmohamed with news that heart failure doesn’t always require such invasive procedures anymore. Janmohamed, part of a growing subspecialty of cardiologists, knows how to optimize a broad spectrum of therapies from medication to implanted medical devices and on up to transplant.
“I have all these tools in my belt,” Janmohamed said. “When I saw Anthony for the first time ... I was a little concerned. I would see why a patient might think they might need a heart transplant in future, but the first step is going through medication therapy.”
Heart failure occurs when the heart cannot pump enough blood and oxygen to support other organs in the body, and that may result from conditions such as blocked arteries, a viral infection, heart muscle damage or an abnormal heartbeat. Sometimes, the cause remains a mystery, as is the case for Robinson, Janmohamed said.
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Robinson said that, for most of his life, he had been the guy who saw a doctor only once a year for an annual checkup. Last February, though, he got sidelined for a short time by the flu virus, he said.
Once Robinson felt better, he said, he returned to the gym but felt really tired. He took his dog out for a walk near his home in midtown Sacramento, he said, but he felt so exhausted he had a hard time getting back home.
“I was thinking it would just get better, but I noticed it wasn’t getting better,” Robinson said. “I checked my heart rate with an app on my phone, and my heart was beating at 155 beats a minute nonstop, so I made an appointment with my primary care.”
The doctor’s assistant took his vitals and then told him to get to a hospital right away, Robinson said, and even though he felt a little better, he went over to Mercy General Hospital in east Sacramento. The waiting room in the emergency department was packed with people who had the flu, Robinson recalled, but as soon the staff took his vitals, he got pulled to the front of the line.
After an electrocardiogram revealed an abnormal heart rhythm, Robinson said, doctors decided to stop and restart his heart to see whether that might fix the problem. It didn’t. He was admitted to the hospital and put through a battery of tests that showed his arteries were clear, he said, but his heart rhythm continued to be troubling.
Nurses asked him whether he wanted to speak to a chaplain, Robinson said, and he knew then that something was seriously wrong. The doctor on duty came and told him they were going to try medication but that his next step might very well be some type of implanted heart pump to assist with circulation or even a heart transplant. A specialist would confer with him on Monday, the physician said.
Robinson said he thought: “OK, this is how I go out?”
But after speaking with Janmohamed, Robinson was determined to do what was needed to overcome his heart problem. No one is certain why it developed, he said, but Janmohamed told him that he thought he could manage his condition by taking three medications daily and eliminating salt and caffeine from his diet.
“I was at risk of sudden cardiac death (in the beginning), so I had to wear a life vest, which is a portable defibrillator that you have to wear like a bra with a battery pack,” Robinson said.
Over the course of several months, Janmohamed said, he tweaked the dosages on Robinson’s medication to get the cocktail that provided the best chances for Robinson’s recovery. Janmohamed consults with a number of other cardiologists whose patients need just that sort of expertise.
A graduate of the Sacramento Waldorf School in Fair Oaks, Janmohamed trained in cardiovascular medicine at the Fresno campus of UC San Francisco, before going to the university’s San Francisco hospital for a fellowship in advanced heart failure and transplant cardiology. There are only 71 such programs training cardiologists in this subspecialty, compared with 210 cardiology programs.
The subspecialty has grown over the last decade, Janmohamed said, as an aging U.S. population has seen an increasing number of people with failing hearts. Janmohamed said he chose this work because he gets to know patients intimately over years of treatment and because he has a broad spectrum of treatments.
“You can start early on with (prescription-drug) therapy, and then later in their journey, maybe they need a defibrillator or something, and if they have other symptoms, sometimes they may need some sort of...surgical implant pump, followed by a heart transplant,” he said. “You can see patients all along the spectrum. Sometimes, it’s medication, and sometimes, they need something more invasive.”
Many patients are surprised to learn that the medication he’s providing is actually to regulate hormone production, Janmohamed said, but the body releases an overabundance of certain types of hormones when a person has heart failure. Those hormones actually can cause more damage to heart muscle, he said, and certain medications are designed to bring those hormone levels back to normal and, by doing so, lower blood pressure.
People whose hearts are failing typically don’t experience the classic chest pain of a heart attack. Rather, Janmohamed said, they are more likely to feel shortness of breath, fatigue or exhaustion, and swelling in the legs or abdomen. One of the things patients often tell Janmohamed, he said, is that they sleep sitting up because they have trouble breathing when lying down.
When treating a patient, Janmohamed said, he will typically send them for cardiac rehab workouts and other tests to assess heart muscle response and other physical reactions. Sometimes, patients think their heart failure diagnoses means they must give up their regular exercise regimens or avoid adding exercise to their routines, Janmohamed said, but nothing could be further from the truth.
Robinson, for instance, is back to doing his regular workouts.
“My heart is really strong,” Robinson said. “I feel good. I can do everything. I can work out. I can push myself in interval training.”