REFLECTIONS ON CARDIAC FAILURE

ON CARDIAC FAILURE

A PUZZLING DIAGNOSIS

No diagnosis can be as puzzling as that of cardiac failure. Although it carries a prognosis equal to or even graver than some cancers (50% mortality in 5 years) (see table below), it is not really taken as seriously, and does not quite send the same shudder through a patient’s back than if a diagnosis of cancer was announced.


It is a diagnosis that ought to be based on an echocardiogram assessing the ventricle’s ejection systolic fraction (in the case of the more common systolic cardiac failure – pump failure, rather than diastolic failure – failure of relaxation), but it is not infrequent to have patients talk about this diagnosis or their GPs having these patients on failure medication when no echocardiogram has been performed. As pointed out by Hobbs et al (2005) in the BMA publication, ‘The ABC of Heart Failure’, “Heart failure is a difficult condition to diagnose clinically, and hence many patients thought to have heart failure by their general practitioners may not have any demonstrable abnormality of cardiac function on objective testing” (p.37). The situation is similar to that of COPD, a diagnosis that should be based on spirometry, which is rarely done.

In any case, cardiac failure is the end point of all cardiovascular disease. The heart is not like the liver, brain or kidney. It serves one and only one function – that of pumping blood around. If one can understand cardiac failure fully, half of cardiology is mastered. As Thomas Lewis, the father of modern cardiology put it in 1933, “The very essence of cardiovascular medicine is the early detection of heart failure”.

The easiest way to think about the causes of cardiac failure is to think about the various components necessary for normal function, and to give a relevant problem.

1. Broad anatomy – congential heart disease, HOCM
2. Specific anatomy – pericarditis, pericardial effusion, cardiac tampade (pericardium); myocarditis, cardiomyopathy (myocardium), endocarditis, myxomas (endocardium), valvular heart disease (valves)
3. Electricity – arrhythmias of all types
4. Muscular function – e.g. genetic muscle problems (such as Duchenne muscle dystrophy and Friedrich’s ataxia), problems of the biochemical milieu (e.g. calcium and potassium problems)
5. Venous return – e.g. excessive fluid (pregnancy, iatrogenic).
6. Arterial and fuel supply – coronary artery disease, beriberi, hypoxia in all its causes (e.g. COPD, PE, pneumonia, anaemia)
7. Afterload – aortic and pulmonary stenosis, mitral and tricuspid regurgitation, Paget’s disease of bone (where, in severe Paget's disease (i.e. with more than 15% skeletal involvement), the heart works harder to pump blood to affected bones.)

Of course, some of these causes are intertwined; for example, coronary artery disease leads to muscular (contractile) dysfunction, and restrictive pericarditis and cardimyopathy can cause diastolic (failure of relaxation) muscular dysfunction.

ABC PITA

• Aortic & other valvular heart disease
• Arrhythmias
• Beriberi
• Coronary artery disease
• Cardiomyopathy and myocarditis
• Congenital heart disease
• Pulmonary infection
• Paget’s disease
• Pregnancy
• Infective endocarditis
• Thyrotoxicosis
• Anaemia
FIGURE 1 – The causes of heart failure; those in italics cause mainly acute heart failure, which can be recalled by MEAT:

• Massive MI (or complicated) / Myocarditis
• Endocarditis / Embolism
• Arrhythmia (may be due to HOCM or other)
• Toxins e.g. beta-blockers, verapamil

The last point, about toxins is extremely interesting. One of the revolutions of modern cardiology is the observation, as we will see later, that in the non-acute scenario, beta blockers are actually beneficial in heart failure. This is contrary to what most of us have learnt in medical school – where we were led to believe that beta blockers are an absolute no-no in heart failure.


When any of these insults take their toll on the heart, the compensatory mechanisms start to operate, with the aim of reversing the damage caused. Gradually however, these mechanisms are overwhelmed and worse heart and, eventually other organ failure, ensues. The following diagram illustrates the compensatory mechanisms that take place to help the heart while it is failing:


It is the kindness of God that He has established within most organs such compensatory mechanisms. Single organs, like the liver (as we will see in the section of cirrhosis and liver failure), have, as Graeme Alexander, a hepatologist based in Cambridge writes, “an extraordinary degree of redundancy, requiring only 20% of hepatocytes to function effectively” (Reckless, p.224). God has also endowed it with compensatory mechanisms too (as we will see). But he has not endowed the heart muscle with excess number of cells, for the simple reason that if that were the case, the heart will show be less efficient, as we see in the hypertrophied heart.

He has given us two lungs, and two kidneys with lots of reserve tissue, for the same reason. Reflecting on this matter, and the blessings and kindness of compensatory mechanisms, without which, death will be a much earlier occurrence, and the fact that we are yet to invent a machine that repairs or compensates for itself after the slightest damage (for example, every car in England needs an MOT every three years for a new car and every year for a car older than three years old; imagine if each one of us needed a full check up in that fashion!), I can only remember God’s words, “O man! What hath made thee careless concerning thy Lord, the Bountiful, Who created thee, then fashioned, then proportioned thee?” (82:6).

In the next few chapters we will talk about some of those causes. For now let us look at heart failure as it is, beginning with a brief look at two of its famous victims.

GAUSS AND CHARLES DARWIN – VICTIMS OF CARDIAC FAILURE

One of the best things about the latest edition of the Oxford Handbook of Clinical Medicine, by Longmore et al (2004), the bedside bible of medical students and junior doctors, is the fact that it introduces some of the heroes of other specialties to them, people who, in the midst of a busy working life, would be unquestionably forgotten. This is no place to survey the biographical details of these greats, but it will be an opportunity for me to highlight some of them that I feel to be of possible interest and with a good message.

Among the people who I recall to have been mentioned in the OHCM (seventh edition) are Karl Friedrich Gauss and Charles Darwin, in widely different places.



Both Gauss and Darwin lived at around the same time, in the 19th century, and both have been immortalised in the daily lives of German and British citizens, being on the back of the ten German Marks (before the ‘Euro’ arrived) and English Pounds notes respectively (the latter, somewhat unfairly, displacing the great Charles Dickens). There is no doubt about who is the more famous of the two, but in my opinion, there can be little doubt as to who was the greater of the two. Both Gauss and Darwin were victims of heart failure, with the latter’s suffering definitely being the more interesting one from the medical historian’s point of view.

While it is unclear what exactly caused Gauss’s heart to fail (although he did live until he was 76 – and aging is a major risk factor for heart failure [to quote Eugene Braunwald, the world’s most renowned cardiologist, “Heart failure…appears to be the only common cardiovascular condition that is increasing in prevalence and incidence..Since heart failure is more common in the elderly, its prevalence is likely to increase as the population ages” (Harrison’s, p.1319)]), Charles Darwin could well have suffered from Chagas’ disease, which leads, as we discuss in the later section on myocarditis, to cardiac failure (if untreated). Darwin, as is well known, did much of his ‘evolution research’ in South America, and it is only natural that some may postulate he suffered from this type of infection-related disease, which may lead to cardiac failure. Peter Salwen wrote an article on this issue in The New York Times, on Thursday, June 15, 1989, to popularise this notion:

“As a naturalist aboard the frigate Beagle, Darwin spent five happy, strenuous years exploring some of the wildest places on earth. But once back in England, his health declined horribly. He suffered extreme lassitude and gastrointestinal pain, nausea, vomiting, sleeplessness and, ultimately, a fatal heart disease. Forced to give up field work and social life, he lived out the rest of his 71 years as a reclusive semi-invalid. Not a few contemporaries dismissed Darwin's illness as hypochondria; later writers generally assumed it was psychosomatic, probably a reaction to an autocratic father or to the supposed theological implications of his theory of natural selection. But science, belatedly, has vindicated Darwin. As Professor Saul Adler of the Hebrew University, Jerusalem, a distinguished expert in tropical diseases, pointed out, Darwin had more than once met up with Triatima infestans, the "assassin bug," while in South America. One encounter, in a village at the foot of the Argentine Andes, he described vividly in The Voyage of the Beagle: "At night I experienced an attack (for it deserves no less a name) of the Benchuca, a species of Reduvius, the great black bug of the Pampas. It is most disgusting to feel soft wingless insects, about an inch long, crawling over one's body. Before sucking they are quite thin but afterwards they become round and bloated with blood.". T. infestans, is now known to be the principal carrier of Chagas' disease, and though the trypanosome itself was not identified until decades after Darwin's death, his symptoms match the clinical portrait of chronic Chagas' disease. With hindsight, it seems clear that it was this protozoan, and not inner doubts or guilt that reduced a vigorous adventurer to a frail, prematurely aged man who for 40 years (as his son put it) "never knew one day of the health of ordinary men."”

It must be stated that all of this is speculation, and the cause of Charles Darwin’s ill health remains an interesting source of debate.

While Darwin endured his numerous symptoms for many years, Gauss suffered from ill physical health for a relatively shorter time, and indeed knowing this would highlight a very important, often forgotten aspect of cardiac failure which we mentioned before – that it carries a poor prognosis . Eric Temple Bell described this ill health of the ‘Prince of Mathematicians’ towards the end of his chapter of that name in his book ‘Men of Mathematics’:

“With the opening of the new year, he began to suffer greatly from an enlarged heart and shortness of breath, and symptoms of dropsy appeared. Nevertheless he worked when he could, although his hand cramped and his beautifully clear writing broke at last. The last letter he wrote was to Sir David Brewster on the discovery of the electric telegraph. Fully conscious almost to the end he died peacefully, after a severe struggle to live, early on the morning of February 23, 1855, in his seventy eighth year. He lives everywhere in mathematics”

Gauss was a fascinating person. While public awareness of Darwin is greater, because of the impact of his theory of evolution, I really wish Gauss was better known. Intellectually he is far superior and sharper than Darwin, and if belief in God and the afterlife is an index of a greater human being who is more likely to be successful on the Day of Judgement (as we are told on numerous occasions in the Holy Books), then Gauss is also a greater human being. Darwin is one of the icons of atheism, the man who, in the words of Richard Dawkins, made it possible to be “an intellectually fulfilled atheist”. If atheism and neglect of God and reason is the cause of the world’s ills, as I firmly believe and expressed in the introductory chapter, then Darwin must be ranked as one of its greatest sinners.

By contrast, Gauss was a man of great religious zeal, who placed the greatest emphasis on the big questions of life. He wrote in a famous letter, “There are questions on whose answers I would place an infinitely higher value than on the mathematical, for example concerning ethics, concerning our relationship to God, concerning our destiny and our future, but the solution lies quite unattainable above us and quite outside the area of science” (Dunnington, p.298). In the same work, Dunnington, author of the best biography of Gauss in the English language, stated that, “The unshakable idea of personal continuance after death, the firm belief in a last regulator of things, in an eternal, just, omniscient, omnipotent God, formed the basis of (Gauss’) religious life, which harmonized completely with his scientific research”.

Gauss was also one of the first (some regard him as the first) men to be involved in the creation of non-Euclidean geometry. He thus opened a door that had been locked for two thousand years. Everyone thought the foundations of geometry were established and would not be altered – it takes someone of great genius to change this belief and prove that is not the entire truth. And to know that he had first contemplated this in his early teens makes it all the more incredible! As described by Eric Temple Bell:

“The rigor which Gauss imposed analysis gradually overshadowed the whole of mathematics…and mathematics after Gauss became a totally different thing from the mathematics of Newton, Euler and Lagrange. In the constructive sense, Gauss was a revolutionist. Before his schooling was over the same critical spirit which left him dissatisfied with the binomial theorem had caused him to question the demonstrations of elementary geometry. At the age of twelve he was already looking askance at the foundations of Euclidean geometry; by sixteen he had caught his first glimpse if a geometry other than Euclid’s”

The relevance of this point is that no-where, not even in mathematics, can certainty be attained, let alone in the world of science and medicine.

Thus, from learning about Darwin and Gauss’s stories there are a few lessons that could be forgotten:

1. Infections can cause cardiac failure; people are under the impression that cardiac failure is always the consequence of a chronic atherosclerotic process
2. Cardiac failure carries a poor prognosis; it killed Gauss within a year.
3. Cardiac failure can cause depression; this is very possible in Gauss
4. Certainty is impossible in even our most sacred notions; faith is an inevitable prerequisite for inner peace.
5. Mathematicians are among the biggest believers in God (as highlighted in a not unrecent ‘Nature’ journal poll), and Gauss was one of them. It almost goes to say, God is a logical necessity.

THE CLINICAL PRESENTATION OF CARDIAC FAILURE

Anyone who has seen a patient with congestive cardiac failure will be saddened by the sight of that patient, just like the sight of human being with a broken heart would. Acute heart failure, as one cardiologist remarks, “remains one of the most dramatic presentations of all for the admitting doctor”.

The cardiac failure is no ordinary patient. He presents and represents to hospital frequently, in desperate need of medical attention, often for medication that can only be given intravenously, since his often long list of oral medications is often inadequate. It is this, and not just the medication and the rehabilitation, they need, that make them to the NHS, only the second most expensive group of patients to treat (after stroke victims).

Because of this, their folders, like their hearts and ankles, are often swollen. I am reminded of the poem that Nicholas sang in Tolstoy’s ‘War and Peace’:

“At night time in the moon's fair glow
How sweet, as fancies wander free,
To feel that in this world there's one
Who still is thinking but of thee!

That while her fingers touch the harp
Wafting sweet music o'er the lea,
It is for thee thus swells her heart,
Sighing its message out to thee...

A day or two, then bliss unspoilt,
But oh! till then I cannot live!...”

They are so near to death, with their swollen hearts, that without active intervention, they cannot live.

He (and increasingly she) is gasping for his breath, swollen and tired. He or she may have features of the cause or consequences. Regarding the former, an interesting observation is made by John Larkin, who writes in his book Cynical Acumen, “We often ask patients if their dyspnoea is worse in any particular position (e.g. lying down). This ‘orthopnoea’ has been largely hijacked by the cardiologists as a major pointer towards pulmonary oedema …left ventricular failure…cardiac dyspnoea. But to be honest, most dyspnoeas are worse when lying flat. Asthma certainly is. That funny coughing/breathless thing you get with a virus in winter (may be a mild version of asthma itself) seems to be. And any time you watch some athlete finish a marathon or the 10000 metres and lie flat on the ground, they’re pretty quick to get themselves up again and continue their recovery in at least a seated position. So pretty much any dyspneoa is worse when lying flat.” Orthopnea is not unique to cardiac failure, but is frequently still asked about.

Breathlessness occurs mainly due to vascular congestion, which reduces pulmonary oxygenation and diminished lung compliance, increasing the work of breathing and adding to the feeling of breathlessness. In addition, there is reduced cardiac output to the periphery, triggering the symptom.

The swelling is due to right sided failure, and occurs due to the systemic hydrostatic venous pressure exceeding the systemic oncotic venous pressure. At later stages, hepatic congestion and failure occur and contribute by reduced albumin synthesis. Because of this ‘fluid overload’ and the inability to get rid of it naturally, the patient often puts on a lot of weight, and indeed daily weight is one of the important steps in the management of all patients who present with acute heart failure; a Framingham criterion for diagnosis of CCF is weight loss of > 4.5 kg over 5 days treatment.

Tiredness is due to the lack of cardiac output and increase in proportion of deoxygenated haemoglobin. What makes things even worse is that even though the patient is fatigued, he is unable to sleep comfortably (if the cardiac failure is bad enough) because of the orthopnea, and occasional ‘paroxysmal nocturnal dyspnea’, defined as “sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing”. This further contributes to his sensation of fatigue. The fatigue is futher exacerbated by a lack of appetite (which is due to hepatic congestion, due to right heart failure). The following summarises the features of the heart failure patient:

• Acute breathlessness in pulmonary oedema (acute LVF)
• Chronic over many months or years otherwise
• Associated with fatigue, anorexia (correlates with hepatic congestion and RHF), sleep disturbance (PND).
• May have weight gain or weight loss;
• Ankle swelling (if RHF), beats (palpitations) possible due to tachycardia, chest pain (IHD or AS), dizziness and syncope (AS), exercise intolerance
• Exacerbated by lying flat (orthopnea), made better by sitting up afterward
• Severity assesses by NYHA: (I) No limitation of physical activity (II) Slight limitation (III) Less than ordinary activity (IV) Present at rest (V)

The physical examination of patients with cardiac failure usually, though not invariably, shows an unwell; breathless patient who is sitting up. All or none of the vital signs (‘the obs’) may be deranged; the blood pressure may be high (pointing to hypertension as a cause) or low (pointing to a seriously failing pump) – if the patient is hypotensive he may be in cardiogenic shock, which needs the most urgent attention. The patient’s urine output may then be in jeopardy, due to reduced renal perfusion. He is usually tachycardic (one of the consequences of compensation).

But the most prominent vital sign derangement is the fast respiratory rate; tachypneic, with reduced oxygen saturations, due to the increased proportion of deoxygentated haemoglobin. The patient’s temperature is usually irrelevant, except in cases of fulminant infective endocarditis related CCF. Not also that pulmonary oedema due to acute heart failure, is a risk factor for pneumonia, which may cause the patient’s fever.

Other signs include jaundice (in hepatic congestion due to right heart failure); anaemia (may exacerbate heart failure (high output)), central cyanosis and oedema (pitting bilateral dependent oedema, ascites, facial swelling). The patient’s face may be recalled by remembering the three colours of the Bosnians flag - white, yellow and blue.

The specific cardiovascular examination may reveal any of the following:

• Clubbing in IE and congenital cyanotic heart disease
• Splinter haemorrhages in IE
• Peripheral cyanosis in CHF
• Oslers nodes in IE
• Tar stains in IHD-related CHF.
• Tendon xanthomata in IHD related CHF
• Pulse – tachycardia or other abnormality; collapsing pulse in AR; BP may be high or low – note the pulse pressure as may provide clues to aortic valvular heart disease.
• JVP may be raised in RHF
• Face may show xanthelasma, corneal arc or other dysmorphisms (e.g. Paget’s)
• Inspection  Scars (indicating possible previous valvular or coronary problems)
• Palpation  Apex beat displaced; may be SHIT. Thrills (‘purring of a cat’)in stenotic valvular heart disease. Parasternal heave is indicative of right ventricular hypertrophy.
• Auscultation  Heart sound abnormalities; Added sounds – S3 (ventricular gallop) is the single most reliable sign of left heart failure revealed during physical examination (Myers, 2000). Murmurs. Inspiratory crackles.
• Other  Sacral oedema; hepatomegaly.

The mechanism of the third and fourth heart sounds is as follows:

“Patients in sinus rhythm and heart failure often have an S4…produced as left atrial systole propels volume into the left ventricle just prior to ventricular systole. In congestive heart failure, the left ventricle is non-compliant and the S4 probably results from the reverberation of the blood ejected from the left atrium into the left ventricle. An S3, which occurs early in diastole, probably is the single most reliable sign of left heart failure revealed during physical examination. The S3 occurs during rapid filling of the left ventricle. Increased left atrial pressure, which propels the blood forward with increasing force and non-compliance of the left ventricle are two important factors in the production of this extra sound”.

There is a very important point about the physical examination in patients with cardiac failure, and that is that it, as cardiologists everywhere testify, “has serious limitations as many patients, particularly those with less severe heart failure, have few abnormal signs. In addition, some physical signs are difficult to interpret and, if present, may occasionally be related to causes other than heart failure.” The following table illustrates this fact:



Thus, if one suspects cardiac failure, due to the presentation of the patient, or his predisposing factors, one should proceed to investigations. The following table summarises the symptoms and signs of cardiac failure nicely:



INVESTIGATIONS

These are aimed at diagnosis, the causes, and the consequences (LATER):

• Liver impairment
• Arrhythmias (e.g. VF, VT, AF) / Acidosis
• Thromboembolism
• Electrolyte disturbance (hyponatraemia, hypokalaemia)
• Renal failure / Regurgitation (mitral, tricuspid)



The proper diagnosis of cardiac failure rests on the echocardiogram (showing reduced ejection fraction < 60%) plus the presence of symptoms, as illustrated by the guidelines of the European Society of Cardiology. Brain natriuretic peptide is released in excess in patients in the compensatory phase of cardiac failure, and can be used as a screening test in breathless patients. In the primary care setting, it is suggested by NICE guidelines that a normal ECG and a normal BNP is sufficient to exclude a diagnosis of heart failure. The discovery of brain natriuretic peptide has been a great revelation over the past ten years of heart failure research, as it has opened up new avenues for treatment, as we shall soon see.

The CXR in cardiac failure may reveal signs of PLUCK or ABCDE, especially in pulmonary oedema:

ABCDE

 Alveolar oedema
 Kerley B lines (interstitial oedema)
 Cardiomegaly
 Dilated upper lobe vessels
 Pleural Effusion

PLUCK

 Pleural effusion
 Lung disease
 Upper lobe venous dilatation
 Cardiomegaly
 Kerley B-lines

Kerley B-lines are always mentioned, but I personally find them difficult to decipher on a CXR in the present of so much shadowing. They are named after Sir Peter Kerley, an Irish radiologist. Less frequently mentioned are Kerley A and C lines, but they do exist. I will not bore you with the details, which may be found elsewhere.

The chest X-rays below highlight most of these features:




The investigations of the LATER consequences are the following:

 U & Es
 LFTs
 ECG
 ABGs
 CXR – to check for pulmonary oedema
 Echocardiogram
 Doppler US and D-dimer

The investigations for cause are the following (ABC-PITA):

 Aortic stenosis & other valvular heart disease  echocardiography
 Arrhythmias  ECG; 24 hr tape
 Beriberi (most common cause of CHF in non-Western world)
 Coronary artery disease  ECG, ETT, Angiography, Cardiac enzymes
 COPD  CXR ; lung function tests
 Congenital heart disease  Echocardiography
 Virology - if viral myocarditis is suspected (e.g. antecedent history of flu-like illness)
 FBC (anaemia)
 TFTs (thyrotoxicosis)
 ALP & bone radiology (Paget’s)
 Blood cultures (IE)



MANAGEMENT OF CARDIAC FAILURE

The management of heart failure carries the same four principles of management – recalled by the 4Cs:

 Conservative management
 Cause
 Complications
 Checking the fluid balance, U & Es and weight.

The conservative management aspect is where the elements of ‘POSSET’, which we will talk about in a later section, apply. Under cardiac failure we also discuss the following principles:

 All chronic diseases have societies; in the case of cardiac failure (a chronic condition in the majority of cases), education and referring the patient to the patient is useful.

 All major cardiovascular diseases, and especially cardiac failure require a SAFE Weight - Salt reduced, Smoking stop, Alcohol stop, Fats reduce, Exercise increase, Weight loss.

 Also, consider cardiac rehabilitation for all major CVS disease. As described by SIGN, “Cardiac rehabilitation is the process by which patients with cardiac disease, in partnership with a multidisciplinary team of health professionals, are encouraged and supported to achieve and maintain optimal physical and psychosocial health… It is primarily concerned with rehabilitation following myocardial infarction (MI) or coronary revascularisation, but also addresses the rehabilitation needs of patients with angina or heart failure”.

 For chronic diseases like cardiac failure, there is a need to vaccinate.



They are all important measures, and highlight the need for a multidisciplinary approach in the treatment of the disease. The need to stop alcohol consumption is another excellent point in favour of the advice of God regarding it. The need to vaccinate is based on the fact that pulmonary oedema, a consequence of heart failure, is a risk factor for chest infection including pneumonia.

The drugs that CCF patients use are targeted at both causes and consequences. It is not uncommon to see patients on antihypertensive medication, or other drugs aiming to reduce the risk of cardiovascular disease (e.g. statins, aspirin).

All the treatments that are classically thought of as ‘heart failure treatments’ aim to treat the consequences of heart failure, especially oppose the vicious circle of neurohormonal activation. None of them can be regarded as curative (except of course if one regards cardiac transplantation as a cure, which can be done with a stretch of the imagination). The main treatments used are ABCD:

• ACE-inhibitors
• Beta blockers (e.g. bisoprolol, carvedilol)/ Beta agonists
• CPAP / Cardiac transplantation
• Diuretics (including spironolactone) /Dilators (e.g. nitrates)/ Digoxin



Spironolactone is useful in severe heart failure, and carries prognostic benefit. It is the ACE-inhibitors and beta blockers that actually carry a prognostic benefit. The reason for this is unclear but has been established through a number of clinical trials. In the case of spironolactone and ACE-I, “it probably reflects both improved potassium and magnesium
conservation (both are antiarrythmic) and reversal of fibrosis in the myocardium by aldosterone”.

ACUTE HEART FAILURE

In the acute setting, the management of acute left ventricular failure provides one of the most rewarding problems for the doctor on take to tackle. Provided the basics of ABC (Airway, Breathing, Circulation) & MOVE (Monitor, Oxygen, Venous access, ECG and Expert help) are covered, one needs to commence LMNOP:

• Lasix (furosemide) 40 mg IV; repeat up to 120 mg
• Morphine (1 mg boluses; repeat up to 5 mg) / Metoclopramide 10 mg IV
• Nitrates (if systolic BP >100; 2 sprays sublingual GTN followed by GTN infusion 4-10 mg/h)
• Oxygen (100%)
• Position (sit up)

As this is an emergency, the patient should be monitored closely with strict bed rest. It is important to use morphine cautiously as it may cause respiratory depression. Inotropes are needed in severe heart failure, and if the picture is of cardiogenic shock, CVP monitoring, intraarterial and right heart pressure monitoring is appropriate in either an ITU or CCU setting.

The following advice, by a prominent cardiologist, R Swanton, is an excellent summary of how to approach the heart failure patient best:

1. Oral therapy only in combination:

 Frusemide (+ amiloride or spironolactone) if hypokalaemic.
 ACE inhibitor, especially if hypertensive.
 Long-acting nitrate once or twice daily (see p. 122).
 Digoxin if in AF, large heart on CXR or audible S3.
 Warfarin if large heart or in AF.

2. The systolic arterial pressure and renal function will dictate the dose of ACE inhibitor possible and whether the patient will tolerate other vasodilators such as nitrates. The aim should always be to maximize the vasodilator therapy and to use the minimal amount of diuretics possible. However, some patients will need quite vigorous diuretic therapy to cope with systemic oedema. Spironolactone 25–50 mg t.d.s. is very useful in this situation. Start with 25 mg daily if the patient is already on an ACE inhibitor (see p. 185).

3. For refractory oedema not responding to increasing doses of intravenous frusemide,
consider:

 Two-dimensional echocardiography to exclude pericardial collection or constriction
 Fluid restriction to 1500 or even 1000 mL daily;
 A frusemide drip at 1 mg/min for 4 h;
 Oral metolazone 2.5 mg up to 10 mg daily;
 Low-dose dopamine through a central line 5–10mgm/kg/min;
 Haemofiltration.

There are many problems associated with the drugs mentioned above; none of them are free of side effects. In addition, as explained by one pharmacology book:

“There is some tension between these two objectives (to reduce morbidity, to reduce mortality), in that the action of diuretic and vasodilator drugs, which temporarily improve symptoms, can jeopardize survival. There is a further tension between the needs of treating the features of forwards failure, or low output, and backwards failure, or the congestive features. The principal symptom of a low cardiac output, fatigue, is difficult to quantify, and patients have tended to have their treatment tailored more to the consequences of venous congestion.”

This is where the surgeon, the one closest to giving the patient a cure, comes in. Among his artillery are ventricular assist devices and of course, cardiac transplants. They provide the best results, but they may have serious complications.

CARDIAC TRANSPLANTATION

The heart transplant must be regarded as one of the greatest achievements of the twentieth century. Historians voting on the ‘Learning Channel’ put this as the 41st greatest achievement, ahead of the electron microscope and insulin. Attempts began soon after the great Alexis Carrel succeeded in doing a few kidney transplants in dogs and cats.

“Let no man who hopes to retain the respect of his medical brethren dare to operate on the human heart” – remarked Theodor Billroth, the greatest surgeon of the 19th century. Within 70 years of his making that remark, South African cardiothoracic surgeon Christiaan Bernard achieved dared to operate and the heart, and succeeded – showing that there are no limits to human progress. One can imagine the awe in Bernard’s eyes when he transplanted his first heart, “… stood there for a few moments, watching, then stood back and said, 'It works.’”! Although the successes of early transplants were brief, limited mainly by transplant rejection, this was later alleviated (though not entirely) with the advent of the immunosuppressive drugs, chiefly cyclosporin and tacrolimus.

There are a few points that I would like to make with regards to cardiac transplantation, aside from the indications, and contraindications listed in the table below:



With the advent of interventional cardiology, there is deep fear among cardiothoracic surgeons that they may be made redundant, or confined solely to the management of valvular heart disease, which in any case is becoming less prevalent thanks to the decline of rheumatic fever, its main culprit. As put by Reckless and Dwight in the cardiology chapter of the excellent book, ‘An Insider's Guide to the Medical Specialties’,

“One almost feels sorry for the cardiothoracic surgeon, who having completed one of the most demanding and onerous training programmes around, is now rather less the NHS lynchpin than they may have anticipated…both their NHS and private practices are drying up due to a combination of the herds of interventional cardiologists stepping heavily on their toes and Government waiting list targets. In recent years, it has come to be widely accepted that coronary artery bypass grafting and angioplasty offer similar prognostic and symptomatic benefit in multivessel disease.”

What cardiac transplantation does is completely allay any fears of the demise of cardiothoracic surgery. He, and increasingly she, will always be needed; this is because of the rise in expectations of patients with regards to treatment. At some point in the future side effects and the less efficacy of drugs (compared to surgery) will become a reason for patients to sway the treatment of heart failure in the direction of the surgeon. This is already noted by the rising demand for donor hearts in recent years. Unfortunately, because of the lack of donors, those demands may be met with failure.

Having solved the scientific problem of transplant rejection with some of the cleverest creations of the pharmaceutical industry, and the technical details involving this most difficult of operations, the rate limiting step to transplants is the kindness of human beings, and the availability of donor hearts (Bailey and Love, p.831). This is yet another example of how there is a huge gap between our science and ethics, and how our age will probably be immortalised in history as the age of scientific reason, and ethical unreason.

What are the reasons for this lack of donors one wonders? There are many reasons, but one of them must surely be a religious opposition to transplants. This is particularly the case with Muslims. Many of them argue that transplants are unacceptable, since the “human body does not belong to an individual person, but belongs to its creator”. How can we manipulate creation in that fashion they argue? This is the viewpoint of many of their outspoken speakers. For instance, the ‘Ramadhan Foundation’, the UK's leading Muslim youth organisation based in Manchester published the following article, just over 6 months ago:

The Ramadhan Foundation is strongly opposed to the Prime Minister’s proposal to go ahead and assume organ donation when someone dies without opting out. This is a dangerous precedent and we would strongly oppose any attempt to push this policy change through.

In a free country people should be free to decide whether they wish to be organ donors, assuming consent is dangerous and not akin to the free values we often talk about in this country.

From an Islamic perspective we are totally against this policy – our faith totally forbids the taking of organs after death. We therefore oppose this attempt to change a policy that will impact not just on Muslims but on other faiths too.

The Prime Minister talks about a debate and we are ready to contribute to this, we will not however agree that this is a policy change that is needed. It is clear that from a personal perspective Muslims oppose this idea; however there is clearly a failing in the Government policy to try to encourage this sort of thing.

Mr. Muhammad Umar, Chairman of the Foundation comments:

“The Ramadhan Foundation is strongly opposed to Prime Minister’s intentions to introduce this policy of presumed organ donation, our faith Islam totally forbids the giving of organ donation after death. We therefore join other religious communities in speaking out against this policy.

In a free country people should be able to choose if they wish to consent, it is not the role of Government to decide to assume consent without the individual’s views and wishes taken into consideration.

British Muslims will campaign against this infringement of our freedom to practice our faith”

Needless to say, as a result of practices like this, and the encouragement of ‘other religious organisations to do so’, hundreds of thousands of people who may benefit from transplants needlessly die.

It is interesting to note that the opinion with regards to transplants is different according to where the Islamic scholar one speaks to comes from. A R Gatrad makes this point clearly in a BMJ publication on the issue:

“As organ transplantation has not been explicitly dealt with in the Koran or the Hadith, there is a difference of opinion among the ulamas. Those from Arab countries consider it permissible, but those from the Indian subcontinent believe that organ transplantation is not permissible because human life is sacred; the human body is entrusted to an individual and thus does not belong to him or her; and transplantation can lead to illegal trade in organs and the poor would suffer.”

Those in Arab countries appear to express an opinion akin to that of the scholars consulted by the UK Transplant Organisation to see what the Islamic opinion on transplants is, which is expressed in full on their website:

“One of the basic aims of the Muslim faith is the saving of life. This is a fundamental aim of the Shariah and Allah greatly rewards those who save others from death. Violating the human body, whether living or dead, is normally forbidden in Islam. The Shariah, however, waives this prohibition in a number of instances: firstly in cases of necessity; and secondly in saving another person's life. It is this Islamic legal maxim al-darurat tubih al-mahzurat (necessities overrule prohibition) that has great relevance to organ donation.

"Whosoever saves the life of one person it would be as if he saved the life of all mankind. (5:32).

"If you happened to be ill and in need of a transplant, you certainly would wish that someone would help you by providing the needed organ," (said) Sheikh Dr MA Zaki Badawi, Principal, Muslim College, London

The Muslim Law (Shariah) Council of Great Britain resolved that:

 The medical profession is the proper authority to define signs of death
 Current medical knowledge considers brain stem death to be a proper definition of death
 The council accepts brain stem death as constituting the end of life for the purpose of organ transplantation
 The council supports organ transplantation as a means of alleviating pain or saving life on the basis of the rules of the Shariah
 Muslims may carry donor cards
 The next of kin of a dead person, in the absence of a donor card or an expressed wish to donate their organs, may give permission to obtain organs from the body to save other people's lives
 Organ donation must be given freely without reward
 Trading in organs is prohibited.

“Whosoever helps another will be granted help from Allah.” (Prophet Muhammed (pbuh).

Muslim scholars of the most prestigious academies are unanimous in declaring that organ donation is an act of merit and in certain circumstances can be an obligation. These institutes all call upon Muslims to donate organs for transplantation:

 The Shariah Academy of the Organisation of Islamic Conference (representing all Muslim countries)
 The Grand Ulema Council of Saudi Arabia.
 The Iranian Religious Authority
 The Al-Azhar Academy of Egypt”

What can we say about practises such as those that render the dead earth more worthy of a human heart than another human being? It is an extremely abhorrent thing for ‘religious’ men to dictate people’s choices in that manner. Given, it is unethical to remove one’s organs without his or her consent, or if they attempt to sell their organs in order to survive; these are strictly ethical issues which ‘religious men’ can interfere with if they so wish. But as to the permissibility or prohibition of tranplants they should have no say.

The argument that the human being ‘does not own his heart’, that God owns his body is invalid, because the human heart, no matter where it is (whether in the donor or recipient), still belongs to God, who is in no need of anything, let alone the human heart:

“Say: O God! Owner of Sovereignty! Thou givest sovereignty unto whom Thou wilt, and Thou withdrawest sovereignty from whom Thou wilt. Thou exaltest whom Thou wilt, and Thou abasest whom Thou wilt. In Thy hand is the good. Lo! Thou art Able to do all things” (3:26)

“O ye men! It is ye that have need of Allah: but Allah is the One Free of all wants, worthy of all praise” (35:15)

Religious scholars who prohibit transplants based on this are stopping a lot of good; and therefore are failing with regard to the concept ‘enjoining the good, and forbidding the wrong’. They are stopping many families in whom a member may be brain dead, and who would like to see that “good can come after the death of a relative, that some part of the relative will go on living, giving new life to another person” (OHCM, p.6), all because they wish that heart to rot away rather than another human being to benefit from it. And furthermore to base their ideas on ‘religion’ is a crime on religion that does not forbid good things. It is for this reason that I think the ‘Arab’ viewpoint more humane and therefore truthful.

However, the problems do not stop here. Even those who accept the permissibility of transplants express a preference for hearts from ‘Muslim’ donors. “Organs are accepted from a non-Muslim only if not available from a Muslim,” said the supreme head of the Islamic School of Jurisprudence in Egypt in a discussion on the issue published in the BMJ a few years ago.

This too is unacceptable. Hearts and all other organs for that matter, do not have a religion, or if one were to take a mystical look on the matter, all things (other than the human being, in whom the choice of worship is optional) glorify Him, and hence are ‘Muslim’:

"The seven heavens and the Earth, and all beings therein, extol His glory: there is not a thing but celebrates His praise; but you do not understand how they praise Him! Verily He is Oft-Forbearing, Most Forgiving!" (17:44)

So, there is no point making that distinction, as it slows down the transplantation process, if a needy patient is out on the hunt for a ‘Muslim’ heart (whatever that is), when a ‘non-Muslim’ one is readily available (it would be interesting to know their opinions on a Muslim donating his or her heart to a non-Muslim).

I conclude this section with a request that this ugly ‘control’ of ‘religious’ men (who quite honestly lack the expression of the spirit of religion in much of what they say and do) should stop. They cannot enforce their personal opinions upon others, or encourage others to uphold them, and imbue them with a religious slant. They cannot treat human beings unequally based on faith. It is unfair on the religion firstly, and most importantly, on patients in need of transplants.

ISLAM AND CARDIAC TRANSPLANTS – THE FIRST TRANSPLANT

The last point that I would like to make with regards to this topic is what can be regarded as the most famous cardiac transplant report ever. It is not that of Louis Washkensky, (who was Bernaard’s first transplant recipient) or Tony Heusmann (who is famous for having the longest lasting cardiac transplant, dying after 29 years of the transplant).

The case is that of the Prophet Muhammad (PBUH). Many Muslims world over believe he was the first transplant case (and probably the only case of auto-transplant in history). This is reported in some of the earliest biographies of the Prophet, as well as that compendium of reported Prophetic sayings, ‘Sahih Al-Bukhari’ (Volume 1, Book 8, Number 345).

This is story as it is told in the popular biography, ‘When The Moon Split’, by Safiur Rahman Al Mubarakpuri (as well as his other major work, ‘The Sealed Nectar’):

“Anas bin Malik relates that one day as Muhammad was playing with some children near Haleemah’s house, Jibreel (the angel Gabriel) appeared and made Muhammad lie down. He then opened up the boy’s chest, took out his heart, and extracted a lump of flesh from it, saying, “This is the portion of Satan in you”. Then he put Muhammad’s heart in a golden tray filled with Zamzam water, washed it and replaced it in his chest. The other children ran to Haleemah in terror crying that Muhammad had been killed. When they reached Muhammad they found him alive, his face pale from shock. Anas later said that he saw the scar on the Prophet’s chest where it had been sewn back together” (p.24).

Another biography relates the story thus:

“Before Muhammad reached the age of three that the following event is said to have happened. It is told that Muhammad was playing in a yard behind the encampment of the tribe with Halimah's son when the latter ran back to his parents and said, "Two men dressed in white took my Qurayshi brother, laid him down, opened his abdomen, and turned him around." It is also reported that Halimah said, -"my husband and I ran towards the boy and found him standing up and pale. When we asked what happened to him, the boy answered, "Two men dressed in white came up to me, laid me down, opened my abdomen and took something I know not what away." The parents returned to their tent fearing that the child had become possessed. They therefore returned him to Makkah to his mother. Ibn Ishaq reported a hadith issuing from the Prophet after his commission confirming this incident. But he was careful enough to warn the reader that the real reason for Muhammad's return to his mother was not the story of the two angels but, as Halimah was to report to Muhammad's mother later on, the fact that a number of Abyssinian Christians wanted to take Muhammad away with them once they had seen him after his weaning. According to Halimah's report, the Abyssinians had said to one another, "Let us take this child with us to our country and our king, for we know he is going to be of consequence." Halimah could barely disengage herself from them and run away with her protege. This story is also told by al Tabari, but he casts suspicion on it by reporting it first at this early year of Muhammad's age as well as later, just before the Prophet's commission at the age of forty.”

Often the following verse is given as evidence for this incident, "Had we not ‘nashrah laka sadrak’ literally, "opened your chest"] and dissipated your burden which was galling your back."(94:1-3)

What are we to make of it? In my opinion, it is could not have happened, and that such stories should be dumped into the dustbin of mythology, and replaced by something more rational and intelligible.

Stories like these are the fuel for Christian and other criticism of Islam. They are used to highlight the irrationality of Islamic belief. Does our religion need this, at a time when the actions of a small minority of unwise Muslims are the everyday highlight of the Western media? Why should we put off well meaning people who are aiming to find the truth with such nonsensical stories that have no basis in the Quran, or reason, and cannot be proven? The presence of a story in the Bukhari is no proof that it actually took place. It is very difficult to admit this, and many Muslims will find it impossible to say that a book that is so cherished may not be truthful. We are conditioned from our youth to think that the Quran as well as the books of Hadith are untarnished. As one of the finest Islamic thinkers of our time, Muhammad Shahroor, Emeritus Professor of Civil Engineering in Damascus University, remarked, “It is easier to build a skyscraper or a tunnel under the sea than to teach people how to read the books with their own eyes. They have been used to reading them with borrowed eyes for hundreds of years”.

What is more is that an irrational attitude and belief in nonsense is encouraged and indeed felt to be compulsory by some Islamic scholars. For instance, we read the following in one of the most popular and otherwise quite outstanding Islamic books of our times, ‘An Introduction to the Sciences of the Quran’ by Yassir Qadhi:

“The Qur’an is not the only miracle that was given to the Prophet (PBUH). Among his other miracles was the splitting of the moon in half, the increase of adequate amount of food to a very large quantity, the speaking of stones, animals and trees to him, and the sprouting of water from his hands when the Companions were short of it…There exist detailed narrations concerning these events, and the Muslims must believe in them… These miracles of a surety occurred…”

How is this acceptable in the 21st century, the age of science and reason? It is unacceptable that Qadhi and others feel we must believe in these things, otherwise, I presume he would not regard us as Muslims any more. Would he but consider how a non-Muslim is being asked, through these very statements, to sacrifice the rational mind that he or she is using to discover the truth? How offputing would it be to come across a comment like that? It is hoped that Qadhi and others who express his opinion realise that there is more harm than good in his statements, which he should withdraw or correct.

Bertrand Russell once wrote about a very similar frame of mind exhibited by the Communists, in his ‘Theory and Practice of Bolshevism’. His words apply perfectly in this context:

“This habit, of militant certainty about objectively doubtful matters, is one from which, since the Renaissance, the world has been gradually emerging, into that temper of constructive and fruitful scepticism which constitutes the scientific outlook. I believe the scientific outlook to be immeasurably important to the human race. If a more just economic system were only attainable by closing men's minds against free inquiry, and plunging them back into the intellectual prison of the middle ages, I should consider the price too high.”

Rather than an economic system, substitute religious system, and it is a perfect statement.

Skepticism is necessary in this age to refine Islam and promote it as the most rational of religions, to make it appeal to the mind of those supposedly living in the most rational of ages. We have to accept, as Muslims, that the only untarnished book is the Quran. Muslims should recall that this is a promise of preservation from God. Did He not say, “We have sent down the Reminder, and We will preserve it.” (15: 9)? It would also be helpful to remember that we Muslims believe that the Torah and the Bible, were tampered with. ("So woe to those who write the "scripture" with their own hands, then say, "This is from Allaah," in order to exchange it for a small price. Woe to them for what their hands have written and woe to them for what they earn."(4:46)). If those divine books were corrupted, is it beyond the realms of possibility that the Bukhari and the likes of it have also been corrupted or included corrupt statements in the first place? I don’t think so.

Should we deprive people of the great beauty of Islam (submission to God) because we insist on submitting our minds to mythology that has no grounds whatsoever except that someone wrote it in a book. Should we deprive people of it because of this undue literalism of ‘religious’ men without a strain of foresight or imagination? I think not.



But if this is the case, how can we interpret the above verse (94:1)?

It is worthwhile pointing out that the above interpretation of the verse is not the only one among established Quran translators and commentators. For instance, Ghulam Sarwar translates it as, “(Muhammad), have We not comforted your heart?”. Others translate is as, “Did We not relieve your chest?”, or “Did We not expand your chest? (Endowed you with resilience, understanding and a heart and mind to accomplish the ‘impossible’)”.

Muhammad Asad, author of what in my opinion is the best translation of the Quran (one that is unfortunately banned by the Saudis for its ‘rationalist leanings’!), following his translation comments:

“I.e., "the burden of thy past sins, which are now forgiven" (Tabari, on the authority of Mujahid, Qatadah, Ad-Dahhak and Ibn Zayd). In the case of Muhammad, this relates apparently to mistakes committed before his call to prophethood (ibid.), and is obviously an echo of 93:7 - 'Has He not found thee lost on thy way, and guided thee?

Muhammad Ali’s commentary on this verse however, is certainly the best one available however, as he links it with another revealing verse in the Quran:

“The expanding of the breast is also mentioned in Moses’ prayer in 20:25: “My Lord, expand my breast for me”. The same words occur also in 6:125: “So whomsoever Allåh intends to guide, He expands his breast for Islåm”. As opposed to this, it is added, “And whomsoever He intends to leave in error, He makes his breast strait and narrow”.

“There is a report according to which Gabriel opened the breast of the Holy Prophet while he was yet a boy in charge of his nurse, and washed his heart; the authenticity of this has been questioned on critical grounds (Rz). But even that criticism is due to a misconception, for the same incident is related to have taken place again, when the Holy Prophet was entrusted with his Divine mission. The incident was therefore evidently a kashf, or a clear vision. AH says: “The expanding of the breast signifies its illumination with wisdom and its vastness for the reception of what was to be revealed to him”. Råghib gives a similar explanation, viz., its expansion with Divine light and tranquillity. The expansion of the breast stands, in one word, for the greatness of the heart of the Prophet.”

As for established commentators, this is the possibility raised by many, such as Sayyid Qutb, in his ‘In the Shade of the Quran’:

“"Have We not lifted up your heart, and relieved you of your burden which weighed down your back? And have We not given you high renown?" This suggests that the Prophet was troubled in his soul for some reason concerning the message he was entrusted with, and the obstacles in its way and the plots against it. These verses also suggest that the difficulties facing his mission weighed heavily on his heart and made him feel that he urgently needed help and backing. Hence came this comforting address and delightful discourse.”

As for established biographers, both Muhammad Al-Ghazzali and Muhammad Hasanyn Haykal make the same point in their much respected biogaphies of the Prophet. The former comments on the above story:

“If evil were the secretions of a gland in the body and could be prevented by stopping the secretions, or if good were a substance that could be poured into an aeroplane to make them fly, then I should say the literal sense of the words should be taken. Evil and good are beyond the physical, however, and in fact, it is obvious that it has more to do with the spiritual side of people. If it is a matter concerning the limits within which the soul has to operate or in other words, if the study takes us to the point where we must discover the means by which the soul motivates its outer covering of flesh and blood, then it is no use pursuing it since this is beyond our capacity of discovery”

Haykal devotes a nice section to the story in his biography, ‘The Life of Muhammad’ which I shall quote in full:

“Orientalists and many Muslim scholars do not trust the story and find the evidence therefore spurious. The biographies agree that the two men dressed in white were seen by children hardly beyond their second year of age which constitutes no witness at all and that Muhammad lived with the tribe of Banu Sa'd in the desert until he was five. The claim that this event had taken place while Muhammad was two and a half years old and that Halimah and her husband returned the child to his mother immediately thereafter contradicts this general consensus. Consequently, some writers have even asserted that Muhammad returned with Halimah for the third time. The Orientalist, Sir William Muir, refuses even to mention the story of the two men in white clothes. He wrote that if Halimah and her husband had become aware of something that had befallen the child, it must have been a sort of nervous breakdown, which could not at all have hurt Muhammad's healthy constitution. Others claim that Muhammad stood in no need of any such surgery as God had prepared him at birth for receiving the divine message. Dermenghem believes that this whole story has no foundation other than the speculative interpretations of the following Qur'anic verses

"Had we not revived your spirit [literally, "opened your chest"] and dissipated your burden which was galling your back."[Qur'an, 94:1-3]

Certainly, in these verses the Qur'an is pointing to something purely spiritual. It means to describe a purification of the heart as preparation for receipt of the divine message and to stress Muhammad's over-taxing burden of prophethood.

Those Orientalists and Muslim thinkers who take this position vis-à-vis the foregoing tradition do so in consideration of the fact that the life of Muhammad was human through and through and that in order to prove his prophethood the Prophet never had recourse to miracle-mongering as previous prophets had done. This finding is corroborated by Arab and Muslim historians who consistently assert that the life of the Arab Prophet is free of anything irrational or mysterious and who regard the contrary as inconsistent with the Qur'anic position that God's creation is rationally analyzable, that His laws are immutable, and that the pagans are blameworthy because they do not reason.”

These beliefs are far more tenable and intelligible than the narrow literalism of Qadhi and other literalists. I understand there may be several objections to much of what I said above.

Firstly, Haykal’s use of ‘orientalist’ research to justify his version of the story. As is clear to everyone, even before the days of Edward Said who created the discipline of ‘Orientalist studies’, the Orientalists have several agendas on their mind, most importantly, highlighting the superiority of Western civilisation over that of the ‘Orient’.

However, this does not mean we ought to discard all that the ‘Orientalists’ say, since they have said much that is good and truthful to the religion. For instance, for hundreds of years people have been told about the destruction of the great library of Alexandria which was the biggest library in the Ancient world, putting the blame on the Muslims:

“Several historians told varying accounts of a Muslim army led by Amr ibn al 'Aas sacking the city in 642 after the Byzantine army was defeated at the Battle of Heliopolis, and that the commander asked the caliph Umar what to do with the library. He gave the famous answer: "They will either contradict the Koran, in which case they are heresy, or they will agree with it, so they are superfluous." The Arabs subsequently burned the books to heat bathwater for the soldiers. It was also said that the Library's collection was still substantial enough at this late date to provide six months' worth of fuel for the baths”

However, it was the Orientalists, and not the Muslim scholars, who dismissed this idea as a myth:

“While the first Western account of the supposed event was in Edward Pococke's 1663 translation of History of the Dynasties, it was dismissed as a hoax or propaganda as early as 1713 by Fr. Eusèbe Renaudot. Over the centuries, numerous succeeding scholars have agreed with Fr. Renaudot's conclusion, including Alfred J. Butler, Victor Chauvin, Paul Casanova and Eugenio Griffini. More recently, in 1990, noted Middle East scholar Bernard Lewis argued that the original account is not true.”

It was Sigrid Hunke, the late German orientalist who “presented documentary evidence in her book “Allah is Completely Different”, proving that the Arabs entered Alexandria in the year 642 A.D. and that there had been no library in Egypt then, since the library had been burned and destroyed centuries before that date. She also added that there were no public baths in Egypt during that era. Sigrid Hunbke stated that the old library annexed to the academy founded by Ptolomy the First (Soter) about the year 300 B.C. was burned in the year 47 B.C. when Julius Caesar besieged the city. The library was later rebuilt by Cleopatra, who furnished it with books from Bergamun”.

It is things like this that make even a most vehement critique of orientalism, like Abû Imân Abd al-Rahmân Robert Squires, writing at the end of his essay on, ‘Orientalism, Misinformation and Islam’, “Regardless of the flawed, biased and even devious approach of many Orientalists, they too can have their moments of candour”.

Second, my objection to belief in ‘other miracles’ of the Prophet (PBUH). My personal belief is that the Quran is the only ‘miracle’ that the Prophet (PBUH) has been given to convince us of the truthfulness of his message. I have no objection to those who think otherwise, although I believe it does render the person believing in those other ‘miracles’ to be more prone to the harms of superstition and irrationality, two problems that all rational Arabs are only too well acquainted with.

But I cannot be so naïve as to believe that the Prophet (PBUH) sought the splitting of the moon for example, or the ‘multiplication of food’ or ‘multiplication of water’ etc to convince us of his message; I repeat with Francis Bacon, “God never wrought miracles to convince atheism, because his ordinary works convince it.

His ordinary works, as in the Quran, and the universe with all that is in it, all its natural laws and rhythm, all declare the truthfulness of Islam and the justice of submitting to Him.

If indeed God gave the prophet (PBUH) those other miracles that are often talked about, He (SWT) would be admitting a deficiency of the tools that He is using to convince those who do not witness those miracles. On the day of judgement, we would then have the excuse, ‘O God, but we didn’t see the moon split like our elders did. Why did you not show us that miracle’?

I believe the age of reason began with the Prophet (PBUH); the miracles that were given to the other prophets came at a time when reason had not taken its full form. That is the reason why the miracle of the Prophet (PBUH) came in written form, addressing the highest form of intellect, as opposed to that of the other prophets (PBUT), which ranged from Noah’s ark to Jesus’s giving sight to the blind.

Belief in miracles is a great burden, for it entails that we abandon the most precious thing we have; indeed, it means the abandonment of what makes us human – the power of rational thought. But God’s works are all ‘miraculous’, in the sense that they are beyond the capacity of human beings to even fully comprehend them, let alone emulate them. This is the sense in which Thomas Paine understood it:

“In the same sense that everything may be said to be a mystery, so also may it be said that everything is a miracle, and that no one thing is a greater miracle than another. The elephant, though larger, is not a greater miracle than a mite, nor a mountain a greater miracle than an atom. To an almighty power, it is no more difficult to make the one than the other, and no more difficult to make millions of worlds than to make one. Everything, therefore, is a miracle, in one sense, whilst in the other sense, there is no such thing as a miracle. It is a miracle when compared to our power and to our comprehension, if not a miracle compared to the power that performs it.”

Thus, the Written and Unwritten books of God are the miracles that We have. The only reason why I believe in the miracles of the other prophets is that they were mentioned in His last revelation. There is no other reason to believe them whatsoever, for if a miracle has been revaled to a certain people, and not revealed to any other, it is a miracle to that people only. It is a miracle to the first people only, and hearsay to every other, and consequently they are not obliged to believe it.
It is a contradiction in terms and ideas, to call anything a miracle that comes to us at second-hand, either verbally or in writing. Miracles are necessarily limited to the first communication- after this, it is only an account of something which that person says was a miracle made to them; and though the first people may find themselves obliged to believe it, it cannot be incumbent on me to believe it in the same manner; for it was not a miracle made to me, and I have only their word for it that it was made to them.

Thus, we cannot be obliged, as Qadhi tries, to believe those other miracles of the Prophet (PBUH). Indeed, I would go as far as say that belief in such miracles will mean disbelief in the truthfulness of God’s message. The Quran tells us:

“They say, 'We will not believe thee till thou makest a spring to gush forth from the earth for us, or till thou possessest a garden of plants and vines, and thou makest rivers to gush forth abundantly all amongst it, or till thou makest heaven to fall, as thou assertest, on us in fragments, or thou bringest God and the angels as a surety, or till thou possessest a house of gold ornament, or till thou goest up into heaven; and we will not believe thy going up till thou bringest down on us a book that we may read. Say: 'Glory be to my Lord. Am I aught BUT A MORTAL, a Messenger?' (17:90-93)

“Not before this didst thou recite any Book, or inscribe it with thy right hand, for then those who follow falsehood would have doubted. Nay; rather it is signs, clear signs (ayatun bayyinatun) IN THE BREASTS of those who have been given knowledge; and none denies Our signs but the evildoers. They say, 'Why have signs (ayatun) not been sent down upon him from his Lord?' Say: 'The signs (al-ayatu) are only with God, and I am only a plain warner.' What, is it not SUFFICIENT for them that We have sent down upon thee the Book that is recited to them? Surely in that is a mercy, and a reminder to a people who believe (29:48-51)”

“The unbelievers say, 'Why has a sign (ayatun) not been sent down upon him from his Lord?' Thou art ONLY a warner, and a guide to every people” (13:7)

“Then, it may be that you will give up part of what is revealed to you and your breast will become straightened by it because they say: Why has not a treasure been sent down upon him or an angel come with him? You are ONLY a warner; and Allah is custodian over all things” (11:12)”

Thus, as one commentator states, “if Muhammad did perform miracles then this falsifies the sufficiency of the Quran”.

I will leave the last word on this matter with Muhammad Asad:

“This highly elliptic sentence has a fundamental bearing on the purport of the Qur'an as a whole. In many places the Qur'an stresses the fact that the Prophet Muhammad, despite his being the last and greatest of God's apostles, WAS NOT EMPOWERED TO PERFORM MIRACLES similar to those with which the earlier prophets are said to have reinforced their verbal messages. His ONLY miracle was and is the Qur'an itself - a message perfect in its lucidity and ethical comprehensiveness, destined for all times and all stages of human development, addressed not merely to the feelings but also to the minds of men, open to everyone, whatever his race or social environment, and bound to remain unchanged forever”

Belief in miracles in the age of reason is the sacrifice of reason itself, which of course would be beneficial to a despotic leadership, for obvious reasons, but not to the freedom of thought, and delight in rationality, that true submission to God entails.

BNP – IS HEART FAILURE AN ENDOCRINE CONDITION

We mentioned in the previous section on investigations brain natriuretic peptide (BNP), and its potential value in the diagnosis of cardiac failure. This is a matter of great interest – since it has paved the way for the creation of a drug, called nesiritide, which has been approved for clinical use in the USA, and is currently being explored by NICE in the UK.
This drug has been shown in some clinical trials to be of prognostic benefit, better than nitrates with fewer side effects. It has been known for some time now, as it gets mention in Swanton’s ‘Pocket Consultant Cardiologist’ under ‘future possibilities’:


Although the name suggests otherwise, human BNP, has nothing to do with the brain (if you excuse the pun). It was originally identified in extracts of pig’s brains, but in humans it is produced mainly in the ventricles. The name has stuck however.

What the discovery of BNP allows for is, as outlined above, the ability to use a simple blood test to help confirm a suspected diagnosis of cardiac failure when the availability of echocardiography is limited. It also allows for a more accurate prediction of prognosis – as stated by Professor Eugene Braunwald, “Elevated circulating concentrations of ANP and particularly BNP correlate with a poor prognosis in heart failure” (Braunwald, p.1318). Finally, it could potentially lead to a revolution in the understanding of heart failure, converting it into a potential endocrine condition.

It has always been known that hormones play a big part in heart failure, and indeed many of the drugs used in its treatment aim to manipulate them. But for someone to suggest that heart failure could well be “A State of Brain Natriuretic Peptide Deficiency or Resistance or Both”, as the title of a recently published article in the prestigious Journal of the American College of Cardiology suggests, is quite extraordinary (J Am Coll Cardiol, 2007; 49:1089-1091). In this fascinating article, Professor Horng H. Chen, a Minnesota cardiologist argued that because, “In both experimental and human HF, investigations have supported the hypothesis that the synthetic capacity of the cardiac myocytes may be overwhelmed in severe HF relative to the demands of the system, leading to a state of relative deficiency”, and “..both human severe HF and animal models of severe HF are characterized by an attenuated biological response to endogenous and exogenous natriuretic peptides. Indeed, it has been suggested that the diminished response to the cardiac natriuretic peptides play an important role in the pathophysiology of sodium retention and systemic and renal vasoconstriction observed in severe HF, thus contributing to disease progression”, heart failure may be likened to the most common endocrine condition, diabetes. He concludes, “This paradigm of combined deficiency and resistance to an endogenous hormone is similar to diabetes mellitus, where there is insulin deficiency in type I diabetes mellitus and insulin resistance in type II diabetes mellitus.”

This is a fascinating area, which I am sure will only grow with time. Nesiritide (Natrecor) is yet to be approved in the BNF, and I hope, that if it were as beneficial as its American creator Scios makes it out to be in its pretty powerful adverts that are scattered all over American medical journals, showing a picture of a bold old man on his hospital bed sinking in water, with the headline “Relief from dyspnea can’t come soon enough – Reach for Natrecor for rapid relief from dyspnea” – that the words of H G Wells never ring true, the man who famously remarked, “In England, we have come to rely upon a comfortable time-lag of fifty years or a century intervening between the perception that something ought to be done and a serious attempt to do it.


And finally if indeed, it is eventually regarded to be, at least to a small extent, an endocrine condition, than the intelligent design of the heart will extend to the level of the endocrine systems, the balance of hormones which we will discuss in the endocrinology section of this work.