Getting to the heart of the matter

Fifteen to 20 million Indians suffer a heart attack every year, out of which 30 per cent die within a few minutes. The relatively high incidence of premature heart disease before a victim is forty is a disturbing feature. DR. V. CHOCKALINGAM outlines steps to lead a healthy life.

Mr. A., a 25-year-old engineering graduate, suffered a massive heart attack. He was a Type-A personality; a person who smoked heavily and who had financial problems.

Mrs. S, a 36-year-old, was another victim. She had diabetes, was over weight and came from a environment where there were familial conflicts.

THESE are not isolated cases and in such cases the solution lies in prevention.

First, let us get to know the heart.

It is usually the size of one's fist and weighs about 400 grams. It starts beating even before birth and continues to work without rest as long as we live. It beats 72 times a minute. For the heart to function oxygen is most important. It is carried by the blood through the coronary arteries, (the blood vessels supplying the heart musculature are called the Myocardium). The two coronary arteries arise from the root of the aorta, the great artery from the heart. As the blood leaves the heart and enters the aorta, it first supplies the coronary arteries.

The amount of oxygen the heart muscle needs and the oxygen supply by the coronary arteries is always in balance. As the oxygen level of the heart increases - with exercise, emotion and eating - oxygen supply also increases in proportion. When the oxygen demand and supply are not in balance, it causes a heart attack. This is the result of the coronary arteries being obstructed which results in reduced blood supply to the Myocardium.

In the initial stages, heart trouble manifests itself as Angina Pectoris, that is severe central or left sided chest pain. As the disease advances, it results in myocardial infarction or a heart attack.

Myocardial infarction - coronary artery disease (CAD) - tops the list of the world's killer diseases. Indians are at four times more risk than Europeans and Americans and 20 times at more risk than Japanese. Fifteen to 20 million Indians suffer a heart attack every year, out of which 30 per cent die within a few minutes. The relatively high incidence of premature CAD before a victim is 40 is a disturbing feature.

The main predisposing and precitating factors (risk factors) are:

1. Mental stress and strain - Type A personalities who are ambitious, competitive and in a constant struggle with the environment.

2. Smoking: Smokers are five times at greater risk. Unfortunately, there has been an increase in the prevalence of smoking in the recent past while the trend world-wide is to shun it.

3. Blood cholesterol: There are four components of cholesterol, i.e. total cholesterol, Triglycerides, Low Density Lipoprotein (LDL) and high density lipoprotein (HDL). The elevation of the first three components is responsible for the blockage of coronary arteries. On the other hand, HDL (good cholesterol) prevents a heart attack. Hepatic endogenous cholesterol synthesis is increased by stress, smoking and alcohol.

4. High blood pressure - greater than 140/90 mm Hg.

5. Diabetes Mellitus - elevated "blood sugar".

6. Obesity, especially abdominal - apple type.

7. A sedentary lifestyle and genetics.

Each risk factor increases the incidence of CAD two-fold and when in combination, several-fold.

A heart attack manifests itself in the following manner. The person may feel an obstruction over the chest area, which gives rise to the expression Maradaippu (Tamil). The pain may be comprehensive or constrictive in nature occurring at the centre of the chest behind the breast bone. The pain is usually precipitated by exertion, over eating and emotion and lasts from 10 minutes to hours. It may radiate to the left shoulder, left arm and sometimes to the right shoulder, to the back and to the abdomen or to the neck and jaws, often being mistaken for flatulance. The person may feel giddy, sweat, have palpitations and experience difficulty in breathing. A person with such complaints should immediately contact a doctor or go to a hospital. Ten per cent of such victims may have a painless or a "silent heart attack", common among diabetics, hypertensives, alcoholics and those above 75 years.

Most often a heart attack occurs between 5 a.m. and 8 a.m. - circadian rhythm. This is due to increased catecholamine secretion in response to planning too many things in a hurry.

The first four to six hours of a "heart attack" are very important (the golden hour). Drugs like thrombolytic (streptokinase) and aspirin improve heart function. For the first two or three days, patients are observed in the intensive care unit and then discharged. Medicines mainly act by increasing the supply of blood to the heart, preventing a further narrowing of blood vessels and regulating heart function.

Heart attack patients must regulate their dietary habits, avoiding ghee, butter, cheese, coconut oil, egg yolk (yellow), nuts, cream, liver, brain and kidney (meat). They may have greens, vegetables, onion, garlic, lean fish and the white of an egg. Boiled or steamed foods should be given preference over fried foods especially fast foods.

Gingelly oil and sunflower oil must be used in cooking. Vegetables oils, to a certain extent, not only prevent the elevation of fat in the blood but also bring down elevated fat levels.

One should not eat till full. After each meal one should rest for an hour. While getting up, the person must sit for a minute and should not carry heavy weights. When climbing steps the person must do it slowly as the heart has to work at least 10 times more.

In some patients, the heart rate may be reduced from 72 per minute to 30-40 per minute, and this may result in chest pain, giddiness, loss of consciousness, fits and even sudden death.

Temporary/permanent implantation of pace makers which regulate the heart rate, can help such patients. Pace makers are usually kept below the left collar bone underneath the skin and connected to the heart by a pacing electrode catheter.

Primary prevention - strategies to avoid development of CAD - curtailing risk factors.

Secondary prevention - steps to overcome/avert recurrence of CAD.

Tertiary prevention - prevention of complications of CAD.

Personality alterations

Try to be cheerful and content.

Learn to relax while at work.

Live a life in peace with one-self and one's surroundings.

No smoking

Abrupt, permanent and total cessation of smoking - in any form - is very important.

Tobacco smoke contains nearly 270 organic compounds like nitrogen and oxides, carbon monoxide and carbon dioxide. The culprit is nicotine. Nicotine mobilises adrenaline and nor-adrenaline from adrenal medulla and myocardium. It increases the heart rate, blood pressure, cardiac output and myocardial oxygen demand. It also increases myocardial irritability and induces ventricular premature beats, ventricular tachycardia and even sudden death.

At the same time, it reduces oxygen supply to the myocardium by producing coronary constriction. Nicotine also increases free fatty acids, total cholesterol, blood sugar and coagulability. Smoking results in angina known as tobacco angina. Non-smokers and near smokers (passive smokers) may experience these effects.

If transient, coronary spasm results in spastic angina. If it is prolonged for a few more minutes, it results in spastic infarction and even sudden death. Younger individuals, Type A personalities and smokers often suffer from coronary spasm.

HDL cholesterol, more than 50 mgm per cent in the blood, prevents heart attack. It can be increased by (a) losing weight (b) doing regular aerobic exercises (c) stopping smoking (d) meditation, yogasana and a change in one's attitude.

Alcohol as a risk factor

Even though alcohol increases HDL cholesterol, the beneficial effect is lost as it increases three components of bad cholesterol, an elevation of blood pressure and directly damaging the heart muscle (alcoholic cardiomyopathy).

Exercise

The benefits of gradual aerobic exercises like brisk walking, cycling and swimming are:

Mental relaxation

A feeling of well-being

An increase in HDL (good) cholesterol and a decrease in Total cholesterol, LDL and Triglycerides.

Control over obesity, high blood pressure and diabetes.

The development of intra and inter coronary collaterals - "Natural by-pass".

Further, certain yogasanas, meditation and stress relieving therapy are also very useful.

Start now: By 30 years, everyone should start controlling high blood cholesterol levels, blood sugar and hypertension. Drug therapy is needed for only the few who are not able to control these factors with regular exercise, diet adjustments and weight reduction.

Myocardial revascularisation procedures like coronary by pass surgery, angioplasty and stenting are all only temporary relief for CAD and not a cure. Modification in one's lifestyle are aimed at preventing the formation of a block - primary prevention which effectively controls and arrests the further progress of the block-secondary prevention. Recent studies by Dr. Dean Ornish, U.S., have shown that it results in the regression of the block by six months to a year.

Heart attack patients need no longer to worry and can lead a normal active life.

In conclusion, modifications in a person's lifestyle play a very important role in CAD.

The writer is Professor of Cardiology and Chief Cardiologist, Madras Medical College and General Hospital, Chennai.

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