Save your heart

Heart attacks are the major cause for death and disability the world over. Dr. H.S. WASIR explains how one can identify and prevent the onset of this dreaded problem.

WHETHER it is an accident, war or disease, the way it is managed is the same - (a) Measures of prevention and (b) if they do occur then to have the latest techniques and tools so as to help in quick recovery and take precautions to avoid their re-occurance.

Prevention of any disease or disaster is best achieved if we know the cause or the factors likely to herald the disaster. Prevention of diseases like small pox, polio, typhoid and tuberculosis has been possible to variable extents through vaccinations and hygienic measures since the causative agents and mode of spread are known. In the case of heart attacks, we do not know the precise cause. Hereditary and environmental factors have often been talked about as the possible reasons, but these can only be called "risk factors" which may make the person more prone to an attack, but their absence does not ensure total freedom.

The main risk factors are: Being over weight, lack of regular exercise, high blood pressure, smoking, high blood cholesterol level and other fats in the blood, diabetes mellitus, being in a constant state of tension, environmental pollution by dioxides of sulphur and nitrogen and carbon monoxide, which comes from vehicular and generator sets exhausts.

The basic underlying pathology for heart attacks (angina, myocardial infarction, heart failure) is the process of atherosclerosis or narrowing of the blood vessels that supply pure (oxygenated) blood to the heart muscle. These are called coronary arteries and hence the disease that is responsible for heart attacks is called Coronary Artery Disease (C.A.D.) or Ischaemic Heart Disease (I.H.D.). The word ischaemia denotes less blood supply that occurs due to the narrowed coronary arteries. Some cases of brain attacks (stroke) also occur due to atherosclerosis involving the arteries to the brains. Measures to prevent atherosclerosisinclude:

Primary prevention of high blood pressure by controlling weight regular exercise, avoiding excess salt, smoking, alcohol and practicing mental relaxation through meditation, music and yoga.

Controlling blood cholesterol and other blood lipid levels under control Lowering blood cholesterol and L.D.L. (Low Density Lipoprotein) lowere the incidence of heart attacks.

Keeping blood sugar and uric acid levels low also helps in preventing atherosclerosis. Regular physical exercise may be the only "medicine" to control mild diabetes mellitus and mild hypertension and a diet without red meat, red beans and alcohol, specially red wine, may help in normalising high blood uric acid.

Preventive measures will help to some extent but it is not possible to eradicate this disease altogether as we do not know its cause. Three main ways in which patients of "heart attack" usually present to their physician or land up in the hospital are:

Angina (chest pain or discomfort) on exertion; angina at rest (unstable angina) and acute heart attack (myocardial Infarction).

When a person complains of pain or discomfort in the chest or on the left side radiating to the arms - more often the left arm - but at times also to the right, back and the jaws, a diagnosis of angina is made. "Angina of effort" is used if the symptoms occur during work of exertion, walking uphill or climbing stairs, specially after meals, and if these symptoms occur at rest, the diagnosis of rest angina or "unstable angina" is made.

In the latter condition, the ECG is usually abnormal but in the former state when symptoms occur only during exertion, the ECG done at rest may be normal. These are the situations where an exercise test (treadmil test) should be done to see the condition of the heart during exertion (exercise). If the exercise ECG is abnormal, it means there is an underlying heart disease which was to be confirmed either by coronary angiography or, in some instances, a Thallium Stress Test first and then angiography.

Every case of chest pain is not due to angina or heart attack. The physician has to look for other causes of angina like valvular heart disease, heart muscle disease, severe anemia or thyroid problems. Detailed physical examination of the patient and blood tests, stress ECG, Thallium and angiography will help establish the correct diagnosis and treatment has to be given accordingly. Basically the treatment of angina consists of:

(a) Avoiding strenuous exertion specially after meals - rather taking about 30-40 minutes rest after meals.

(b) Correction of anaemia, thyroid disorders and any underlying heart muscle disease.

(c) The drugs used after ruling out the above stated diseases - include nitrates, betablockers, calcium channel blockers, ace inhibitors and aspirin - the dosage schedule to be decided by the treating physician. Mental relaxation through meditation, yoga and music and regular physical exercise have a definite established role in the management of angina pectoris.

(d) When the angina is of recent onset, or is occurring at rest or the effort angina of long standing duration does not respond to drug therapy and lifestyle modifications like yoga/meditation and regular exercise practices, such patients must be advised to undergo coronary angiography and if it shows significant obstructions in coronary arteries, such patients should undergo angioplasty with or without stenting or coronary bypass surgery or myocardial laser revascularisation procedures.

Diagnosis of a severe heart attack or acute myocardial infraction is made when a person presents with the symptoms of severe chest discomfort, heaviness in chest or chest pain which may go to back, neck, jaws or the arms, left more than the right, associated with sweating, nausea and at times vomiting, often coming at rest and generally without any relief after taking nitrates. Such a patient should be taken to the nearest heart centre or any hospital dealing with the management of patients with heart attack. Such a centre should have a heart specialist round the clock on duty, a monitoring system for heart status a defibrillator preferably a cath lab for emergency coronary angiography and angioplasty.

The first drug such a patient should be administered is a tablet of aspirin to be chewed followed by administration of clot busters (thrombolytic agents), provided there is no contra indications of these drugs, like a history of bleeding ulcer or any bleeding disorder. Oxygen, sedatives and analgesics such as morphine or pethidine are the standard means of medical management during acute heart attacks.

Some centres equipped with a 24 hour angiographic and intervention set up, would like to take patients with acute heart attack for primary angioplasty and stenting rather than subjecting then to thrombolysis. The rationale for this procedure i sthe certainty of making sure that the blocked artery is fully open which can not be ensured while using clot dissolving agents (thrombolysis).

Bypass surgery is normally done in parients suffering from angina. At times, patients with a heart attack may need open heart surgery for a leaky valve or rupture of portions of heart muscle that may occur as complications after heart attack. For those patients whose hearts have become flabby with very poor ejection power as a result of chronic wide spread coronary disease or primary heart muscle disease, transplant remains the only treatment provided the other organs are in good health.

Gene therapy is yet another exciting field for future treatment of patients with heart disease whereby new blood vessels could be generated by the heart itself following specific gene injections.

Patients must describe at length the details of their symptoms to their physicians. The chief symptoms of heart disease are palpitation, chest pain, breathlessness and undue fatigue.

Physicians must get into the habit of listening with patience to their patients problems and doing a detailed physical examination to detect the underlying cause of their patients symptoms.

Apart from coronary heart disease there are other cardiac and non cardiac disease (anaemia, thyroid problems and gross obesity) which would present with the same symptom of palpitation, breathlessness, fatigue and chest pain like in cases of heart attacks.

Every case of chest pain is not necessarily a case of heart disease and this can be ascertained only by the physican listening carefully to the patient and doing a detailed physical examination.

A person with symptoms of chest pain, palpitation, breathlessness or undue fatigue should not neglect these early warnings of underlying heart disease, get the above described investigations done so that the correct diagnoses of heart disease can be arrived at during early stages and proper treatment advised accordingly so as to prevent any serious eventualities.

The writer is a former professor and Head of Department, Cardiology, at the All India Institute of Medical Sciences, New Delhi.

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