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5StepstoDetectandManageaHeartAttack

©2007,Dr.AnjaliAroraISBN978-81-207-3247-6

Allrightsarereserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystemortransmitted,inanyformorbyanymeans,mechanical,photocopying,recordingorotherwise,withoutpriorwritten

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Theauthorwishestothankallacademicians,scientistsandwriterswhohavebeenasourceofinspiration.

Introduction

Theword “heart attack”with reference to any person having suffered it,makes one sit up.Heartattackoccursdue toblockageornarrowingof thearteries, that supplyblood to theheartmuscles.Every person thinks it cannot affect him. It can only occur to the person next door. A famouscardiologistoncesaid that ifanymansuffers froma“heartattack”before theageof80years,hislifestylehas tobeblamed.Man should survive till 100years ifhedoesnot abusehisphysical andmentalhealth.

01.YourHeart:HowMuchDoYouKnowAboutIt?Your

Answer the following questions to find out how much you know about your heart and itsfunctioning.

1.Wheredoestheheartnormallylie?

a.Ontherightsideofthechestb.Moretotheleftc.Inthecentreofthechest(mediastinum)

2.Wheredoweexperiencetheheartbeattobethestrongest?

a.Inthecentreoftheheartb.Alittleontheleftsidec.Alittleontherightsideofthechest

3.Theheartissuppliedbloodthrougharteries,knownas

a.Capillariesb.Coronariesc.Carotids

4.Thechestisoftenexaminedbythedoctorsthroughaninstrumentcalled

a.Sphygmomanometerb.Stethoscopec.Angioscope

5.Theproceduretostudythebloodvesselsoftheheartis

a.Arteriographyb.Angiographyc.Venography

Themoretimesyouanswer(b),themoreyouarecorrectandseemtoknowaboutyourheart.

Pain

Cardiac Non-cardiacTightness Sharp(notsevere)Pressure Knife-likeWeight StabbingConstriction LikeastitchAche LikeaneedleDull PrickingfeelingSqueezingfeeling ShootingSoreness ReproducedbypressureorpositionCrushing Canwalkaroundwithit‘Likeaband’ ContinuousBreathless(tightness)

02.YourHeartAndItsArteries(Coronaries)TheHeart

Theheartliesinthecentreandmoretowardstheleftofthechestinanareacalledthemediastinum.Astheheartistiltedslightlytotheleftyoufeelthebeatofyourheartontheleftsideattheapex.Herethebeatissupposedtobethestrongest.

Theheartisaboutthesizeofafistandweighslessthanapound.Itispinkishgreyincolourandismainlymadeupofmusclecalledmyocardium.It ishollowanddivided intoa leftandarightside.Eachsidehastwochambers,theoneaboveisknownastheatriumandtheonebelow,ventricle.

Theheartpumpslife-sustainingbloodthroughthebody.Therightsideoftheheartsuppliesbloodtothelungs,whiletheleft,thestrongerside,suppliesbloodtotherestofthebody.Oxygenandglucosearesupplied to thebody.Carbondioxideandwastegasescollected in thebloodarepassedinto theright atrium and via the right ventricle and pulmonary artery, are pumped out through the lungs.Bloodfromthelungstakesinoxygenwhichisbreathedinbyrespiration.Thisbloodgoestotheleftatriumandthentotheleftventriclewhereitispumpedoutfromaortatotherestofthebody.

SomeFactsabouttheHeart

Theheartbeatsapproximately100,000timeseachday.About7000litresofbloodflowsthroughtheheart.

Like other parts of the body, the heart receives its food (oxygen and nutrients, e.g. glucose)throughasystemofarteries,knownascoronaries.Thechancesofasmokersufferingfromaheartattackare three timesmoreascomparedtoanon-smoker.Onquitting,theriskiscuttohalfinaboutayear ’stime.After10yearsyouroddsnearlyreturntonormal.

CoronaryArteries

Normalcoronaryarteriesaresimilartoclearpipesandpossesssmoothlinings.Therefore,theflowof blood through these arteries is smooth and free. Risk factors like high cholesterol, smoking,diabetesandhighbloodpressurecandamagetheliningofthearteries.

HeartAttack

Heartattackoccurswhen there isa totalblockageofacoronaryartery.Heartattack,unlikeanginalastslonger.Itisapainofmoreintensityandisnotrelievedbyrestormedication.Heartattackcausesdamagetotheheartmuscle,whichispermanent.

Medicationoftenrelievesthesymptomsofangina.Differenttypesofdrugsareavailable,buttheyallhaveonepurpose–toreducethecontractionandrateoftheheart.Allmedicationshavepossiblesideeffects,whichifneededcanbediscussedwithyourdoctor.

PlaqueFormation

Plaque is a fatty substance in the blood (like cholesterol)which often builds up in and around thesmootharterialmuscles.Clotformingplateletscanaccumulateonthis.Duetotheformationof theplaque,blockageofthevesselsstarts,restrictingthebloodflow.

Theatherosclerosisplaquecanblockapartorwholeofthe“affected”arteryand“atherosclerosis”istheresult.Thepartialblockageofoxygenrichbloodtotheheartoftenresultsinchestpain(angina).

Whentheblockageistotal,itcanresultinaheartattack.

03.HardeningOfTheArteries(Atherosclerosis)Hardening

Angina

Anginaisasymptomofcoronaryarterydisease.Progressivenarrowingofthearteries,duetoplaqueformationsuppliesinadequateoxygenrichbloodtotheheartmuscle,duringexerciseorstress.Thiscondition is called “ischaemia”.When ischaemia of the heartmuscle occurs, “angina” is the painsignalfromtheheartaskingforrest.

AnginaPectoris

Itmeanschestpain.Thispainisoftennotconfinedtothechest.Itisoftenareferredorradiatingpainintheupperbody,leftarm,jaworupperback.Thepaincanalsoshowsymptomslikeheavinessinchestorindigestion.

An anginal attack normally lasts for less than fiveminutes. The effects of ischaemia on the heartmusclearereversibleanddonotresultinthedeathofcells.Ananginalattackcanberelievedbyrestandmedication.

DiagnosingAngina

Certaintestshavetobeconducted,besidesthemedicalevaluation.

MedicalEvaluation

Diagnosis of angina can be made on the basis of your medical history. The relation of yoursymptomstoyourphysicalactivityoremotionalstress,identifytheriskfactorsforatherosclerosis.Alsocertain laboratory tests,a restingelectrocardiogramandchestX-rayareneeded tohelpmakethediagnosisofyourdisease.

MedicalHistory

Yourpatternofdiscomfortorpainalongwithareviewofyourmedicalhistorywillhelpyourdoctormakeaprovisionaldiagnosisofangina.

Theprioritywillbegiventothenatureofyourdiscomfortorpain.Itslocation(site),whatbringsitonandwhatrelievesit.Yourriskfactorswillbeidentifiedbyyourdoctor(overweight,smoker,etc).Yourfamilyhistorywillbeassessed–whatkindofillnessesdoyouhaveinthefamily,etc.

WomenandHeartDisease

Manywomenexperienceshortboutsofrecurrentchestpain(angina),butroutinetestslikeECGpickupnoabnormality.

Recentresearchbasedona10yearmulticentrestudyintheUnitedStateshasstatedthatwomenshouldbeexaminedunder“Women’sIschaemicSyndromeEvaluation”orWISE.Women’spathophysiologyisdifferentfromthatofmen.

Women have blood vessels of smaller diameter as compared to men. Blockage in minor vessels(microvascular disease) deprive theheart of oxygen, causing a condition called ischaemia.Over atimeischaemiaincreasestheriskofaheartattack.Theseminorblockagesintheminorvesselsandcapillariesarenotevenpickeduponanangiogram.

Inthecaseofpremenopausalwomen,duetothepresenceofestrogenhormone,stressECGtoocangive a false test. For women suffering from chest pain and having a clear angiogram, therecommendationisofastressechoorstressthallium.

04.AnginaAndAHeartAttack01.Angina–NotAHeartAttack,ConfirmationOfDiagnosis

It isnecessary toplaceanoxygendemandon theheart to stimulate theconditionswhichnormallyprecedeaheartattack.Usingcertainspecial studies,evidenceof ischaemia isnoted.Conductionoffurthertestscanalsolocatepreciselythesiteofanarterialblockage.

StressElectrocardiogramorTreadmillTest

Thestresselectrocardiogramstimulates thoseconditionswhichareprevalentprecedingananginalattack.Earlysignsofischaemiaaredetectable.Thetestisperformedonatreadmillorbicycle(undersupervision).

StressEchography

Ultrasoundwavesaredirectedatthechest.Thesewavesbounceofftheheart’swallandvalves.

Ananalysisofthesereboundingwaveshelpsuswiththecalculationsofthesize,shapeandmovementofthestructureswithintheheart.

Twoechoesareusually taken–oneof theheartat restand theotherof theheartunderstress (e.g.afterthepatientexercisesonatreadmill).Acomparisonbetweenthetwoimageshelpsdetectareasoftheheartnotreceivingenoughblood.

TheLimitationsofthisTest

Thelimitationsoftheultrasoundarethattheresolutionoftheultrasoundisnothighenoughtoseethearteries.Wecanonlydetectandhighlightthebigchangeinstructures,e.g.thatoftheheartchamberandheartmuscles.

Somepeoplemaybegeneticallymoreprone toheart disease thanothers.Still, there areplentyofwaystoreduceyourriskfactors.

Thecomprehensivetreatmentofangina–forthepreventionofheartattackincludeseliminatingorreducingtheriskfactors.

StopSmoking:Smokingisknowntocontributetocoronaryarterydisease.Throwawayyourpackofcigarettes.It’snevertoolatetostop.

LoseWeight:Lessweightinthebodymeanslessstrainonyourheart.Avoidfatandfattyproducts(redmeat,friedfood,dairyproducts),sugarandsweetfoods(cakes,pastries,jalebi,halwas).Loweryourcholesterollevelsandotherlipidsinthebody.Thismayhelpslowdowntheformationoffattydepositsandhardeningofthearteries.

Exercise:Takeguidancefromyourdoctorforafitnessprogramme.Aregularexerciseprogrammewillhelpyouloseweightandimproveyourbodyfitness.Youwillfeelgoodonceyouhaveadjustedtotheexerciseregime.

Reduce Your Stress: Take small breathers at work, eg. getting up for a glass of water or juststretchingyourlegsafterfinishingapartofyourjob.Try“stressbustingexercises”.

MeditationandYoga:Meditationandyogaareothertoolstorelaxyourbody.Ifyouhadachangeinyour angina pattern recently or your discomfort or pain is not relieved by medication and rest,consultyourdoctor.

02.MedicalTreatmentForAngina

Anti-anginalmedicationisprescribedtoreduceyourheart’sworkload.Themedicationcanbe:-

Nitrates

Nitratecontainingmedicationshavebeenusedforyearsandgivepromptrelieftotheanginapatient.Nitratesaresmalltabletswhichcanbekeptunderthetongue,chewedorswallowed.Theymayalsocomeinsprayform.

Action:Nitrateseasethestrainontheheartbyreducingthebloodpressure.

Longactingnitrates includepatchesplacedon theskin.Thesepatchesareavailable tohelppreventanginalattacksbeforetheyoccur.

BetaBlockers

Action:Theyactbydirectlyreducingtheheart’sdemandforoxygen.Theyachievethisbyslowingdowntherateofheartandreducingtheforceofcontractionoftheheartmuscles.

Theoxygensupply,whichwouldbe limitedbyblockages, remainsadequate for theslowermusclecontractionandacomparativerestingheart.Theseareusedforlong-termanginalpatients.

CalciumChannelBlockers

Theyareusedforthelong-termanginaltreatment.

Action: They reduce the oxygen demand by slowing down the heart’s activity. This helps thenarrowedcoronaryvesselstorelaxandwiden.Thustheoxygensupplytotheheartincreasesandatthesametimetheheart’sdemandforoxygendecreases.

Angina

Anginaisawarningandifyoudonot treat it, thefuture isnotbright!Youareheadingforaheartattack.

03.HeartAttack

Intheliningofthecoronaryartery,abloodclotformsonthetopofaplaque.Thiscausesblockageofthatartery.Thebloodfullofoxygenrequiredfortheheartmuscles(myocardium)isblockedoff.Thisleadstostarvationofthatportionoftheheartmuscles.Asaresult,thispartoftheheartmusclein the left ventricle (mostly) gets severely damaged or dies. This is known as infarction. As thisoccursinthemyocardiumormuscle, it ismedicallytermedasMyocardialInfarction(MI)orheartattack.

Comparedtoangina,heartattacklastslongerandisnotrelievedbymedicationorrest.

WomenandHeartAttack

Heartattack inwomenison therise.Onereasonfor thiscanbe thatmorewomenareentering thepreviouslymale dominated world of business, industry and also the irregular working schedules.Also,stress,tension,unhealthyeatinghabits,smoking,alcoholandlackofexercisehavecomeintoplay.

Scientifically, it has been proven that after menopause women become more susceptible to heartdisease.Lackofestrogen(femalehormone)isresponsibleforthis.

CoronaryArteryDiseaseandYourFamilyHistory

Ifamemberofyourimmediatefamilyhasdevelopedheartdisease,youarepronetotherisktwiceasmuchastherestofthepopulation.

Genetic and environment differencesdetermine thedifferences in our appearance andhealth.Yourriskishigherifyourrelativehaddevelopedcoronarydiseaseatanearlyage.“Earlyage”isbeforeagee.g.,55inmenand65inwomen.Thisfollowsageneralruleingenetics:Theearlieradiseaseoccurs, thegreater is the influenceofgenes inyour life.Whileyourgeneticswill determineyourbaseline likelihood for thedisease,many factors in lifewillmodify this risk.As inmostcommondiseases,coronaryarterydiseaseresultsfromaninteractionbetweengenesandenvironment.

SymptomsofaHeartAttack

Apowerfulcrushingpainhitsthechest.Thispainseemstoflowfromthechesttotheleftarm,back,shoulder and heart. The patient experiences a cold, clammy sweat. Occasionally, vomiting due toseverepaincanoccur.Somepeoplebecomeunconscious.

Urgentmedicalassistance is required.Call foryournearestdoctoror rush thepatient toanursinghomeorahospitalnearesttoyou.

SilentHeartAttack

It isoftenmistaken for anusualboutof indigestion.About25%of theheart attacksoccurringare“silent”. These silent heart attacks damage the heart muscles. Sometimes no noticeable symptomsoccur.

HelpontheOnsetofaHeartAttack

Immediatelyaftertheonsetofaheartattack,thepersonneedstobemadecomfortable.Placethepersoninasupine(straightlying)position.Loosenoutanytightclothing(collar,belt,shirtcuffs,shoes).Ifbreathingseemstohavestopped,startcardiopulmonaryresuscitation(mouthtomouthbreathing).Next,callmedicalhelp,asadvisedearlier.

CardiopulmonaryResuscitation(CPR)

CPRisthetechniqueformaintainingthepulmonaryfunctionoftheheartandthebreathingfunctionofthelungs(ontheirfailing).Torestorecirculation,medicalhelpisneeded.Tokeepaheartattackvictim alive it may be necessary to keep the circulation of blood (using external massage) and

artificialbreathing(throughmouthtomouthrespiration)goingtill theexperthelparrives.Callfortheambulanceandhelp.Atthesametimestartwithcardiopulmonaryresuscitation.

04.TechniqueAppliedForCPR(ForDifferentConditionsALittleVariationHasToBeObserved)

Ifthepatientisunconsciousbutstillbreathingwithapulse,turnthepatientonhisside.Seethatvomitingdoesnotobstructhisbreathing.If the pulse can be felt and you feel that the patient’s breathing has stopped,mouth tomouthartificialresuscitationshouldbestartedimmediately.

Thepatientshouldbemadetolieonhisback.Anyvomitorartificialteethshouldberemovedbeforethetechniqueisstarted.

Kneelingbythesideofthepatient,pinchthepatient’snosewithonehand.Takeadeepbreathin.Nowplaceyour lipsover thepatient’smouthandforciblybreatheout intohismouth toaerate the lungs(kissoflife).Atthesametimewithyourotherhandkeepthechinofthepatientpulledup(toavoidobstructionfromthetongue).

ToConfirmAdequateRespiration

See if thepatient’s chestmovesoutwards,while you are breathing into thepatient. If it is not theneitheryouarenotsealingthepatient’snoseorlipsaroundthemouth.

IfyoufindnopulsealongwithCPR,startcardiacmassage.

Keepkneelingatthesideofthepatient.Placeyourhandsoneontopoftheotherwithyourfingersinterlockedoverthelowerendofthepatient’sbreastbone.Keepingyourelbowsstraightandbringingtheweightofyourbodydirectlyoveryourhands,pressdownsharplyforaboutaninch.

Thisprocedurecanbeconductedbyasinglepersonortwopeople.

BreathingProcedure

Startthekissoflife.Threequickbreathsfirst.Observeandchecktheriseandfallofthechest.Lookatthepupilsoftheeyes.Checktheheartbeat.Incaseofnoheartbeat,startmassagingtheheart.

CPRCycle

No.ofNo.ofNo.ofpumpshelpers No.ofbreaths No.ofpumpsforheartmassage1 2 30

In two person CPR the person pumping the chest stops, while the other gives mouth to mouthbreathing.

Assoonastheambulancearrivesorthepatientreachesthehospital,earlydefibrillation(ifneeded)starts.Fastadvancedlifesupportthroughmedicationandotheraidsaretheanswertosurvivalandagoodrecovery.

ToDetectaHeartAttack

Youmayhavehadasilentheartattackorhavesufferedfromonesometimeback.Sowouldyouliketohave tests conducted to checkyourself out for coronary arterydisease?Somedirect or indirecttestscanhelpyoudiagnoseyourcondition,eg.Electrocardiogram(ECG).Oftensilentheartattacksshowupduringexercisestresstests.

Electrocardiogram(ECG)

Thistestmeasurestheelectricalactivityoftheheart.TherestingECGisusuallynormalinpatientsofangina who have no other heart problem. It can however, provide evidence of a prior heartattack/attacksofwhichyoumaynotbeawareof.

ItsLimitation:AnECGcandetectthesignoftrouble,butitcannotprovideavisualmapoftheheart.Italsocannotidentifyastowheretherealheartproblemlies.

BloodTests

Abloodsample iscollected,afteranovernightfastingof12hrs(i.e.notevenacupof teaor limewater,etc.). Ifyouhaveeatenat8pmyour samplewillbecollectedbetween8:00am to10:00am.Someofthebloodteststobeconductedwillbeforlipids(cholesterolandotherfats),bloodsugar,uricacidtodiagnosecertainconditionslikehighlipids,diabetesandotherriskfactorsforcoronaryarterydisease.

X-ray

Remember,everychestpainisnotofangina.SpecialX-raystudiesmaybeprescribedbyyourdoctortoidentifyconditionscausingsimilarsymptomsasthatofangina.Gallbladderinflammation,hiatushernia / bulging of the stomach into the chest cavity or neck pain and certain lung conditions cancauseachessimilartothatofangina.

ThalliumTest

It is oneof the testswhich confirms the diagnosis of coronary artery disease. In this procedure, asmall amount of radioactive thallium is injected into a vein during exercise, while the heart is

monitored by the electrocardiogram (ECG). Thallium is rapidly taken up by contracting heartmuscles.ATVscreenrevealstheimagesoftheareasintheheartwherethereisnothalliumuptake.Thisisanindicationofcoronarycirculationimpairment.

ItsLimitation:Thistestexposesthepatienttosmallamountsofradiation.

WallMotionStudy

Asimilartesthelpsdetermineifthereisanimpairmentofheartcontraction.

CoronaryAngiogram(Angiography)

To visualise or see the amount of the blockage a procedure called angiography is used in thecoronaryarteries.Alongthincatheterisinsertedintoanarteryinthegroinorarmandpassedintothe entrance of the coronary arteries. An X-ray sensitive dye is then injected into the coronarycirculation.ThroughaTVscreenyoucanlocate

theblockagesandafilmcanbemadetodocumenttheirlocationsandtheextentofblockage.Localanaesthesiaisrequiredforthisprocedure.Anovernightstayinthehospitalmayberequired.

05.Assessment

The reports of your testswill take a day to be delivered to you.Your doctorwill assess all your

reports and tell you which kind of treatment procedure you require depending upon if you aresufferingfromangina,haveablock/blocksinyourcoronariesorhavesufferedaheartattack.

ScanningtheHeart(Throughotherchoices)

At one time only the stethoscope and later the electrocardiogramwere the tools to diagnose hearttrouble. Today the latest X-ray, magnetic and ultrasound scans are available for picturing threedimensionalandmovingpicturesoftheheart.

CardiacCTforCalciumScoring

Computedtomography,alsoknownasCTorCATscanning,usesaspecialmachinetoobtainmultipleX-rayimagesofanypartofthebody.

CardiacCTforcalciumscoring isanon-invasivewayofobtaining informationabout the locationandextentofcalcifiedplaque in thecoronaryarteries—(thevessels thatsupplyoxygen-containingbloodtotheheartwall).Plaqueisabuild-upoffatandothersubstances,includingcalcium,whichintime can narrow the arteries or even close off blood flow to the heart. The resultmay be painfulanginainthechestoraheartattack.Calciumisamarkerofcoronaryarterydisease.ThefindingsoncardiacCT,expressedasacalciumscore,mayhelpdecidewhatmeasurescanbetakentoavoidtheseevents.Anothernameforthistestiscoronaryarterycalciumscoring.

ThegoalofcardiacCTforcalciumscoring is todetectcoronaryarterydisease(CAD)atanearlystage when there are no symptoms and to determine its severity. The procedure is most oftensuggestedformenover45yearsandwomenabove55yearsorpostmenopausalwomen.

Procedure:During a computed tomography (CT) scan, the rotating gantry emitsX-rays that passthroughthepartofthebodybeingexamined—inthiscasetheheartandcoronaryarteries.Theresultis that theX-ray beam follows a spiral path. The recorded images are reconstructed by computerusingaspecialsoftwareprogram.RecentlydevelopedspiralCTscanners(likethenew64sliceCTscanner)producehigh-qualityimagesinlessthan10seconds.Thisisespeciallyimportantforelderlypatientsandthosewhocannotholdtheirbreathfortherequiredtime.

A negative cardiac CT scan that shows no calcification within the coronary arteries suggests thatatheroscleroticplaqueisminimalatmost,andthatthechanceofcoronaryarterydiseasedeveloping

CalciumScore PresenceofPlaque0 Noevidenceofplaque1-10 Minimalevidenceofplaque11-100 Mildevidenceofplaque

101-400 Moderateevidenceofplaque

Over400 Extensiveevidenceofplaque

over the next two to five years is very low. A positive test means that coronary artery disease is

presentevenifyouhavenosymptoms.Theamountofcalcification,expressedasascore,mayhelptopredictthelikelihoodofamyocardialinfarction(heartattack)inthecomingyears.

Results: You may be given the results directly from the interpreting radiologist. You could alsoreceiveyourresultsfromyourprimarycarephysicianorcardiologist.

TheNew64SliceCTScanner

This scanner has unprecedented resolution and speed, therefore it is able to diagnose aorticdissectionsandpulmonaryembolism.

Procedure:Thepatientismadetoliedownandinjectedwithacontrastagenttohighlighttheheart’sbloodvessels.Thepatientstandsinthescanner.

Thedetectorarrayrecords theX-rays.Eachspiral loopcreatesasliceof theheartcomparedto64thinslices.Thespiralslicesarereconstructedinto

hundredsof2Dimages.Thedoctor ’scomputerprocessestheslicesandthencreatesa3Dcomposite,whichcanshowthepumpingactionoftheheart.

ItsLimitations:Even thescannedpicturescannot showyoueverything.Also, it isbecomingclearthatalltheplaqueformedinsideacoronaryarterymaynotbedangerous.Someappeartobestableanddonothavemuchgrowth.Otherscontainfatandinflammatoryproteins,whicharemostlikelytorupture,triggeringaheartattack.

06.HeartDiseaseAndPsychosomaticDisorders

YourPersonality

There isanassociationbetweenaTypeApersonalityandheartdisease.ThepersonwithaTypeApersonalityjuggleswithevents,believesindoingtwoormorethingsatthesametime,isambitious,anxiousandimpatient.Heorshewantsthingsinlifetomovefast.TypeApersonalitiesbesidesbeinganxiouscanbeangry, tense,pressurisedandcompetitive.Theyare twiceas likely todevelopheartdiseaseascomparedtoTypeBpersonality.

Along with these personalities comes the modern era of competitive working, fast foods andsedentarylifestyles.Alsoaddedtoit,isthepartytime.Manyofuslabelitas“contacttime”.Thereforethe body and mind are not relaxed, but working overtime. At all working hours the whole body

systemisactiveandmaybesubconsciously too,whilesleeping.Doyourealise thepressureoneisputtingononeself?Howlongwillitlast?Willyounotcrackdown?

Depression

Depression is another area precipitating heart disease.Research shows that depression can triggerheartproblems.Safeguardingmentalhealthisalsoimportantforheartattacksurvivors.Itwasseenthatdepressedheartattackpatientsweremorethantwiceaslikelytodieorhaveheartproblemsinthetwoyearsfollowingaheartattack.

Perhaps, the most important way to deal with psychosomatic problems is to prevent heartdisease.

Psychologistsinsistthatitisourattitudeandemotionswhichneedtobetackled.Hereareafewtipstohelpyouachievethis:

Writedownwhatupsetsyou.Noteyourattitudetowardsthingsthatdisturbyou.Takeawaynegativethoughtsfromyourmind,thinkofsomethingpleasantorpositive.Controlyouranger.Articulatewhatyoufeel.Don’tbottleuptoomuchinside.Discussyourproblemswithpeopleclosetoyou(friendsorrelatives).Trysolvingthempositively.Hearsoothingmusic.

Somepeople,whendepressedorupsethaveatendencytoovereat.Theybecomeobese.Tryandcutdownontoomanysweetsandcarbohydrates.Ifyoufeellikeeating,combinesomeofthemwithsalads,fruits,etc.Trytorelaxandmeditate.Takenicelongwalksandexerciseregularly.

Stressmanagementskillsalsohelprecogniseandreduceemotionaloverreactions.

TreatmentforaHeartAttack

MedicationBalloonAngioplastyCoronaryArteryBypass

RoboticHeartSurgeryChelationTherapyStemCellTherapy(stillunderresearch)

Medication

Onceyourheartattackisdiagnosed,yourtreatmentbeginsimmediately.

Somedrugsaretobeadministeredtoapatientimmediatelyafteraheartattack.Theyareeffectiveifgivenwithin4-6hrsof aheart attack.They areknown todisintegrate (breakdown) theblood clot,blockingthearteryandbloodflowtotheheart.Ifadministeredontime,thesedrugscankeeptheheartmuscledamagetoaminimumandcansaveaperson’slife.

Medication is to be given and continued as soon as possible after a heart attack. The medicationincludedcanbe:

Aspirin

Heparin

ThrombolyticTherapy(clotbusters)

OtherAntiplateletDrugs

Combinationoftheabove

Coronaryarterydiseaseisusuallyfirstmanagedwithmedication.Ifthisoptiondoesnotwork,otheralternativeslikecoronaryangioplastyorcoronarybypassproceduresareconductedonyou.

Remember these procedures help treat your disease. To remain healthy and not get into repeatedcoronaryproblems,youwillneed to reduceyour risks.Alongwith thisaproperdietandexerciseregimenisessential.

Shortlyafteraheartattackthestatusofyourheart,arteriesandtheamountoftheheartdamagedhasto be assessed. In some cases, procedures like angioplasty or stents are used to open up blockedarteries. These procedures are often combined with thrombolytic therapy to open up narrowedarteries.Atthesametimeclotsblockingthosearteriesarebroken.

BalloonAngioplastyorPercutaneousTransluminalCoronaryAngioplasty(PTCA)

After assessing your reports and having studied your angiogram your doctor will evaluate thenumber,typeandsiteofblockages.Hemightoptforanangioplasty.

Angioplasty is conducted under local anaesthesia. A balloon tipped catheter is inserted into thefemoral(fromthegroin)artery.ThiscatheterisslowlyfedintothecoronaryarteryunderconstantX-rayguidance.Theballoonat the tipof thecatheter is insufflatedat the siteof theblockage.As theballoon expands under high pressure, the opening of the blocked artery widens in most cases,relievingtheobstruction.Thepurposeofthisballoonistocompresstheplaque,plasteringitasathinlayeralongthewallofthevessel.Thisclearsthelumenpermittinganincreasedflowofblood.Thisis also called “Balloon Angioplasty”. The balloon is then deflated and the catheter removed. Theprocedurenormallytakeslessthananhour.Ittakesonlyonedayofhospitalrecovery.

RegularFollowUp

Onceyougetenrolled into the treatmentprogramme,a regularevaluation isnecessary tomonitoryourprogress.Theeffectivenessofyourmedicationneedstobemonitoredandifrecoveryisnottoyourdoctor ’s satisfaction,your treatmentprogrammemayneed tobe assessedand rescheduled. Ifyou notice any change in the pattern or intensity of your anginal episodes, inform your doctor.Reducingyourriskfactors,whereverpossible,couldleadtoacomfortableandproductivelife.

Stents

Inthepastfewyears,stentshavebeenintroducedduringanangioplastytowidennarrowedarteries.Astentisawiremeshtubeusedtopropopenanarteryduringangioplasty.Thestentiscollapsedtoasmalldiameterandputoveraballooncatheter.Itisthenmovedintotheareaoftheblockage.Withtheballooninflation,thestentexpands.Thestentisleftinthebloodvesseltopreventitfromnarrowing.Over a period of time, it gets covered with tissue from the inner lining of the coronary artery.Antiplateletmedicationisgiventostoptheformationofablootclotinthenewlyopenedartery.Thestent stays in thearterypermanently,helping it to remainopen. It also improvesblood flow to theheartmusclesandrelievessymptomslikechestpain.

CoronaryArteryBypass

Bypasssurgerymaybenecessarytoincreasebloodflowtotheheart.Duringthissurgery,aveinisremoved from the person’s leg (graft) and is used as a detour around the blocked portion of theaffected coronary branch or branches. The surgeon therefore constructs an alternate route for theblood.

Anotherbypassmethod is inwhich the internalmammaryartery (carryingblood tochestwallandother structures) is linked to the coronary artery. Three or four coronary artery branches can bebypassedduringthesamesurgery.Asthegraftsarefromthepatient’sownbodytherearenoneoftherejection problems associated with heart transplant. Most patients undergoing a coronary arterybypasssurgery,experiencerelieffromtheirsymptoms.

Bypasssurgeryusuallyrequiresaweeks’stayinthehospitalandanotherthreemonthsforcompleterecovery.Remember,surgeryisnotacureforatherosclerosis.Itisjustamechanicalcorrection.Topreventatherosclerosisinyournewartery,reduceyourriskfactors.Thiscanhelpyouslowdowntheprogressionofcoronaryarterydisease.

Robotically-assisted heart surgery is the latest advance in trying to move open heart surgicalprocedurestothecategoryofminimallyinvasivesurgery.Thishelpstominimisetheextentandthetraumaofcardiacsurgeryasmuchaspossible.

Robotically-assistedEndoscopicHeartSurgery

Athreearmedrobotisplacedapproximately8feetfromthepatient.Threesmallincisionsaremadebetweentheribs.Twoforinsertionofinterchangeableinstrumentsandanotherforathincylindricalvideo camera (endoscope). The surgeon manipulates the surgical instruments with the help of acomputer. An endoscope is passed through a tiny incision in the chest wall, and two surgicalinstrumentsarepassedthroughadditionalsmallincisions.Thesurgeonviewstheimageprovidedbythe endoscope on a computer screen. The surgeonmanipulates them via a computer console. Thecomputer interprets the surgeon’s handmovements and causes the surgical instruments to respondaccordingly.

Thistechniquehasbeenlimitedtosinglebypassgraftsintheleftanteriordescendingcoronaryartery(theLAD).TheLADis locatedon thefrontof theheart,and therefore is relativelyaccessible. It ispredictedthatwithadvancesintechnology,multiplegraftswithroboticassistancewillbepossible.

Robotic procedures have been successfully performed, for instance, in mitral valve repair, inrepairing atrial septal defects (ASD) and in repairing patent ductus arteriosus (PDA). Withtechnologicaladvancements,roboticprocedureswillbeappliedtomostotherformsofheartsurgery.

ChelationTherapy

This form of therapy is not approved by theAmericanHeartAssociation. It is used in alternativemedicine.Itisaprocesswhichinvolvesundesirableionicmaterial(byinfusion)toberemovedfromthe body. An organic compound having suitable chelating process is used for this. The infusionneededisofEDTA(EthyleneDiamineTetraaaceticAcid).

Chelationtherapyisusedforthetreatmentofatherosclerosis.

ChelationTreatment

Reducesoxidationoflipidsandlipoproteins.Helpsremovecalciumandcopperionsfromthebloodstream.Helpssmootheningofarterywallduetohealingofcellsthatlinethearteries.Canimprovebloodflowinthearteriessubstantially.EDTAalongwithothernutrientsareknowntomopupfreeradicalsandhelpinthestabilityofcellmembrane.

StemCellTherapy

It is one of themost promising research being conducted in theworld today. It can help those inwhomconventionaldrugsarenotofmuchhelpandwhoaretooillforsurgery.

Stemcellsfromapatient’sownbonemarrowhelptorestorediseasedhearttissue.Researchershavealsofoundthatwhenstemcellsareinjectedintotheheartmusclesviaacatheter,patientscandevelopnewbloodvessels.Thesebloodvesselshelpreplacethoseblockedordamagedbyheartdisease.

07.GenesWhichAreInvolvedInCoronaryArteryDisease

Coronaryarterydiseaseisacomplexdisorderandmanygeneticandenvironmentalfactorscanaffectitsdevelopmentandprognosis.Whilethesearchofgenetickeysfordiagnosisandfightingcoronaryarterydiseaseisveryactivetoday,thereismuchthatremainstobediscovered.

First, it is important to understand that there are a number of different genes that can affect thedevelopmentofcoronarydisease.Also,foreachinvolvedgene,thereisavarietyofslightchangesinthechemicalstructureofagene.Someofthesechangescanincreaseone’sriskforcoronarydisease.

Someofthegenesareplacedonthefollowingchromosomesthatcanaffectcoronarydiseaserisk.

Name ChromosomalNumber

1.LDLR(LDL)receptor 192.APOA1(apo-lipoproteinA1) 113.CETP 164.APOE(apo-lipoproteinE) 195.apo(a) 66.PTGIS 207.ACE 20

The above are only a small portion of the genes involved in the coronary artery disease. Furtherstudieswill be needed to discover newgenes to better understand as to how the already-identifiedgenesinteracttopredisposeapersontocoronaryarterydiseaseortohelploweranindividual’srisktoit.

05.CardiacRehabilitationAndYourFutureCardiac

01.CardiacRehabilitation

Yourcardiacrehabilitationisdependentuponyourhealthsituation.

The rehabilitation programme should be tailor made specifically for an individual patient. Thiswouldhelpbothyourheartandgeneralhealth.

Thebasicphasesofcardiacrehabilitationareasfollows:

IntheHospital

Rehabilitationstarts,whileyouarestillinthehospital.

Motivateyourselfbyfocussingongoalswhichareimportanttoyoueg.returningtoyourwork,spendingtimewithyourfamily,enjoyingsports.

Thoughyouarethepersonwhohassufferedfromaheartattack,yourfamilyandclosefriendsarealsoaffected.Simplyhavingpeoplearoundyouandyouspeakingtothemcanhelpyouinrecovery. Communicate your feelings. Do not bottle them up inside. By discussing, variousemotionslikeanger,depressionandthefeelingofincompetencecanbeputtorest.Acceptyourconditionthatyouarestillatrisk.Youandyourfamilycanallmodifyriskfactorstoleadahealthierlife.Certainnon-strenuousactivities likesittingup inbedand takingcareofyourself likeshaving,shouldbestarted.Walkingandslowclimbingofstairsshouldalsobedoneinthehospital.

OnLeavingtheHospital

Recovery–EarlyPhase

Thisphasestartswhenyouleavethehospitalanditsdurationisgenerallybetween2-12weeks.Itdoesnotmatterifyouhadnotexercisedearlier.Exerciselikewalkingandgentlecalistheticswillimprovethecardiacfitness.Youshouldalsostartmodifyingyourhabitsandhaveahealthydiet.Whilecopingwithyourpresentconditionsexualactivitycanberesumed.

Recovery–LaterPhase

This is the maintenance programme of cardiac rehabilitation. It will go on life long. Your ownexerciseroutineshouldstartbuildingupyourconfidence.Recordyourprogresseveryday.Thiswillgiveyouasenseofachievement,whichwillboostyourconfidencetoleadanormallifeandslowlyprogressonit.Youcanalsojoinagymorfitnesscentre.Itwillbebetterifyoujoinarecreational

activitythatwillgiveyoupleasure.Changeyourlifestyleforthebetter.Makehealthierchoiceinfoodhabitsandmodifyyourrisks.Alsotakeyourmedicationregularly.Seeyourdoctorasadvised.

FiveStepsTowardsYourRehabilitation

It is a medically supervised programme to help heart patients recover faster. This helps in theimprovement of physical and mental functioning, and regaining your strength. To maintain ahealthier heart youwouldbe enrolled in a cardiac rehabilitationprogramnme.This programme isdesignedsuchastoreduceyourrisksforfurtherdevelopmentofatherosclerosisandcoronaryarterydisease.

1.Counselling

Thepatientinthissessionorsessionsismadetounderstandandmanagethediseaseprocess.

2.ModificationofRiskfactors

Thepatientishelpedtomodifyhisriskfactorslikebloodpressure,highbloodcholesterol,diabetes

andobesity.

LowerYourLipidProfile:Elevatedlipidcholesterolandtriglyceridesareimportantriskfactorsfordeveloping cardiac disease. The currently accepted safe limit for LDL-C (bad cholesterol) is 100mg/dl.Itisknownthatlevelsbelowitcanoffersignificantprotectionagainstheartdisease.Inpeoplehavingtwoormoreriskfactorstheacceptedsafelimitofcholesterolisunder70mg/dl.Youwillbeadvisedlipidloweringmedicationifyoucannotkeepthemundercontrolwithlifestylechanges.

ControlBloodPressure:Hypertensionorincreasedbloodpressuremakestheheartworkhardertogetthebloodcirculatingthroughyourbody.Shortnessofbreathonexertionneedstobereviewedbyyourdoctor.Keepyourbloodpressureundercontrolwithaproperdiet,exerciseandmedication.

StopSmoking:Yourchancesofhavingaheartattacktripleswithsmoking.Quitsmokingnow.

LoseWeight:Fataround themiddleespecially (appleshapedobesity) increasesyourchancesofaheartattackorstroke.Obesityalsoleadstodiabetes.Ahighfibredietwithwholegrains,vegetablesandmoderateexercise(30min/day)istheanswerforlosingexcessiveweight.

KeepYourBloodSugarunderControl:Highbloodsugar(diabetes) isamajorriskfactor in thedevelopment of cardiac disease. Burn off your sugarwith exercise. Have a proper, nutritious andbalanced diet. Avoid alcohol, juices, fruits high in sugar content and sweets. Stick to productscontainingslowreleasingsugarslikecomplexcarbohydrates.

Remember

1gmofproteinorcarbohydratecontains4calories.

1gmoffatcontains9calories.

Limit Salt Intake: The sodium in the salt helps your body to retain water. It increases the bloodvolume,inturn,raisingyourbloodpressure.

3.LifestyleEducation

Guidance for the patient for a nutritious and balanced diet but with adequate calorific valuerequired.Helpingthepatientavoidasedentarylifestyle.Tohelpinexerciseandavoidingunnecessarystress.

4.VocationalGuidance

Providingthepatientvocationalguidance,thusenablinghimorhertoreturntowork.Itisespeciallyimportantinpatientswhoarebelow60yearsofage.

5.PsychologicalSupport

Physicallimitationshavetobeexplainedtoeveryindividualpatient.Emotionalsupportorguidancewithapositiveoutlookmustbeprovided.

02.YourFuture

ToGetBacktotheMainstreamofLife

StayCommitted

Makingchangestobuildahealthylifestyleisnoteasy.Itisalong-termcommitment.

ProceedinSmallSteps

Planrealisticgoals,onesthatyoucanmeet.Tacklethemoneatatime.onotneglectyourgoals,evenifyouarebusy.

RewardYourself

Slowlymoveon,makingprogress.Rewardyourselfeveryonceinawhile.Treatyourselftoamovieordosomethingthatyouenjoy.Buynewclothesifyouhavelostweight.

Unwind

Talktopeoplewhohavehadasimilarproblem.Speaktoyourphysicianwhocanhelpclarifyyourdoubts.

TakeLifeinYourStride

Youwillimproveyourchancestoleadanormallifemuchmorequickly.

MaintainYourLifestyle

Donotslipuponwhatyouhaveachieved.

06.MythsAndFactFileMyth

HeartattackandhighBPonlyoccurinpeopleover50yearsofage.

Fact

Patients (developing high blood pressure and cardiac disease) in South Asia and the world arebecomingyounger.Heartattacksandhighbloodpressurearebeingdetectedinyoungsterswhoareintheir 20s and 30s due to an irrational and sedentary lifestyle, unhealthy food, drinking habits andobesity.

Myth

Apersonwithhighbloodpressurealwaysdevelopsaheadache.

Fact

Itisnottrue.Bloodpressureisknownasthe“silentkiller”.Youmaynotknowyourbloodpressureishigh and suffer from a heart attack or stroke. Blood pressure even if always normal, should becheckedtwiceayearoratleastannually.

Myth

Afterabypass Icangoback tosmoking,drinkingandeating(friesandsweets)asmyarteriesarenownotblocked.

Fact

Arepeatedunhealthylifestylewillagainblockyourarteries.Afterabypass,onemustleadahealthylifestylethroughproperdiet,relaxation,meditation,yogaandexercise.