By Dr. Mahendra Carpen MBBS DM FACP, Medical Director/Consultant Cardiologist, Caribbean Heart Institute, Georgetown, Guyana
Introduction
Heart disease is the leading cause of death worldwide, accounting for almost half of all deaths. It is part of the spectrum of cardiovascular diseases that carries a high burden of death and physical dysfunction. The impact of heart disease is profound on the individual and has substantial implications for the national economy. Productivity lost due to sick days, inability to perform physical tasks and the psychosocial effects of heart disease are often overlooked but nevertheless have tangible consequences.
The most common type of heart disease in the western world is coronary artery disease, also known as ischemic heart disease. It is commonly referred to as “blockage.” This simply means that there is a narrowing of the lumen of the vessels (Arteries) responsible for transporting blood with oxygen to the heart muscles. When this happens there is reduced supply of oxygen to the heart muscle and the patient may experience chest pains or any of a number of other manifestations. When the heart muscle becomes damaged it cannot contract or relax normally and it can produce abnormal heart rhythms which may be fatal.
This article seeks to answer some of the more common questions related to a myocardial infarction, also known as a “heart attack.”
What is a heart attack?
The correct name for a heart attack is MYOCARDIAL INFARCTION. Health professionals often shorten this to MI. It refers to irreversible damage to a piece of heart muscle as a result of insufficient blood/oxygen supply. Heart muscle, like any living tissue, requires oxygen to perform its function and remain viable. This oxygen is carried by the red blood cells. In conditions where the blood/oxygen supply is severely reduced the heart muscles can become damaged beyond recovery. The reduced supply of blood/oxygen is as a direct result of plaque build-up on the inside of the arteries which take blood to the heart muscles. The plaque is usually made up of cholesterol and other materials and can lead to the formation of blood clots which stop all blood flow to the heart muscle. This sudden loss of blood/oxygen to the heart muscle results in death of that piece of tissue which depends on the blood/oxygen supply.
How is angina different from a heart attack?
Angina is chest pain caused by reduced blood/oxygen supply to the heart muscle (myocardium). This reduction in blood/oxygen flow is not sufficient to result in permanent damage/death of the tissue. However, it creates an imbalance between the supply and demand of oxygen. Angina can be stable or unstable. A patient with stable angina can usually predict what level of activity will precipitate their chest pain and will therefore adjust their lifestyle and activities accordingly. Stable angina can become unstable when the frequency and severity of chest pains increase or is brought on by significantly less effort.
Unstable angina may also occur at rest. The main difference between angina and a heart attack is the absence of permanent heart muscle damage in angina. Heart muscle damage is usually confirmed by serial blood tests which detect the leakage of chemicals from the damaged myocardium. Unstable angina and heart attacks can be referred to as Acute Coronary Syndrome.
What are the risk factors?
The risk factors for a myocardial infarction can be classified as modifiable or non-modifiable. Modifiable risk factors include Diabetes Mellitus, Hypertension, cigarette smoking, obesity, inactivity, stress and poor diet. The non-modifiable risk factors include a patient’s family history, male gender, age over 55 years for males and over 60 years for females, although some patients can develop heart attacks at much younger ages. This is particularly true for patients of South Asian decent. Less frequent risk factors include Lupus, Rheumatoid Arthritis and Sleep apnea.
Since 2007 about one in three deaths was due to heart attack in Guyana. The highest risk group were East Indian males over the age of 45.
What are the symptoms?
The classical complaint for a patient suffering a heart attack is crushing chest pain in the center of the chest with radiating pattern to the neck, jaw or left arm. More frequently patients experience a chest discomfort, heaviness or tightness. This can be associated with sweating, nausea, vomiting, palpitations and shortness of breath. Some patients with heart attacks may not experience chest symptoms, but rather, complain of pain in the upper part of the abdomen with associated symptoms of nausea or vomiting. Quite frequently, patients mistakenly attribute this feeling to “gas” or indigestion. Unfortunately this mistake leads to delay in appropriate care and increase in undesirable outcomes.
What should I do?
Anyone suspecting that they are having a heart attack should immediately chew one or two aspirins and head towards a hospital. If the Aspirin is regular strength 325 mg then one is sufficient, if it’s the “baby” aspirin at 81 mg then two will be sufficient. Inform someone else and if feasible do not drive yourself to hospital. Unfortunately, many persons are by themselves when having a heart attack and have no options but to go to seek medical attention by themselves.
Patients should try to not exert themselves during a suspected heart attack and accept help when present. Deep and controlled breathing can reduce the associated anxiety.
How is it treated?
The treatment of heart attacks can be invasive or non-invasive. Non-invasive treatment consists of medications and supportive measures. Standard medications in hospital include Aspirin and another anti-platelet medication like Clopidogrel. Heparin is also used to keep the blood thin and prevent expansion of blood clots in the arteries. High dose anti-cholesterol (statin) medications like Atorvastatin, Simvastatin or Rosuvastatin reduces the level of cholesterol but importantly also reduces the inflammation to the inner lining of the blood vessels.
Beta blockers like Metoprolol, Bisoprlol and Carvedilol reduces the oxygen requirement and the risk for fatal heart rhythm complications. Atenolol is a much older beta blocker with a much worse side effect profile but can still be used.
Angiotensin Converting Enzyme Inhibitors (ACE-I) and Angiotensin Receptor Blockers (ARB) reduce the blood pressure and prevents disorganized healing of the heart muscle. These drugs include Ramipril, Enalapril, Losartan and Valsartan.
The modern approach is more invasive once a heart attack is suspected. Many hospitals will proceed directly to perform a coronary angiogram and possible placement of stent(s) if suitable blockages/stenoses are found. This approach when used appropriately provides the best outcomes in terms of survival, reduction of symptoms and recovery time. A coronary angiogram is a simple procedure done through the wrist or the groin where a catheter is advanced to the heart and facilitates the identification of blockages responsible for heart attack.
What happens if it is not treated appropriately?
The worst outcome of a heart attack is death. Fortunately advances in medical treatment have reduced this significantly over the years. Heart attacks not treated early with the right interventions result in higher death rates and worse complication rates. Complications of a heart attack can include heart failure, abnormal heart rhythms, clots in the heart, leakage of heart valves and rupture of heart muscles. Patients who have had a heart attack are at higher risk for developing another heart attack in the future especially if not treated appropriately.
What medication should I be taking after a Heart Attack?
Almost everyone should be taking an Aspirin daily after a heart attack. A second drug with similar action is also used in combination with aspirin. The majority of patients should be on a cholesterol medication, a beta blocker and an ACE-I or ARB. Additional medications such as the Nitrates (GTN, Isosorbide Dinitrate, etc.) causes dilatation of the arteries and can reduce chest pains due to narrowed blood vessels. Other medications like Trimetazidine can also reduce chest pains and increase heart muscle relaxation.
What changes should I make?
The most important changes in lifestyle include the reduction and stoppage of cigarette smoking, exercise of at least 150 minutes per week and the embrace of a healthy diet. Cigarette smoking is possibly the worse habit one can develop with a myriad of proven adverse health outcomes. It can cause heart disease, stroke, kidney disease, vascular disease, stomach problems, erectile dysfunction and other health problems. Exercise of at least 30 minutes per day for five days per week is recommended. Brisk walking is considered among the best and cheapest method of recommended exercise. Diets rich in fruits, nuts, grains and vegetables are better for heart health. Persons who get adequate rest and sleep are generally healthier. Strict adherence to prescribed medical therapy is essential. Control of known medical conditions like diabetes, hypertension and abnormal cholesterol is critical in ensuring better longevity and quality of life.
Regular visits to your doctor after a heart attack will allow for closer monitoring and early interventions when necessary.
What is the follow up?
After a heart attack, it is important to have regular follow up visits with your doctor. Medical clinic visits follow a set pattern usually – history, physical examination, investigations and treatment plan. The history represents the part where patients tell the doctors how they are feeling and what complaints they have. Many physicians will guide the patient by asking relevant questions. It is very important to remember the emotional and psychological effects of a heart attack on patients and their families. The physical examination includes a check on the blood pressure, heart rate and general appearance. Complications of a heart attack are looked for – leg swelling, abnormal sounds in the heart and lungs and irregular heart beats. Blood sugar levels, cholesterol and kidney functions are evaluated by blood tests. An electrocardiogram (ECG) and an echocardiogram (ultrasound of the heart) are important in the follow-up evaluation. A patient’s tolerance can also be evaluated by means of an exercise test. Heart attack patients should see a cardiologist at least once every six months and see their general doctors in the interim.
What kind of costs are involved?
Adequate and appropriate care for a heart attack patient is very expensive and can be quite daunting to patients and their families. Many healthcare systems can provide some level of care “free” to patients in the acute stages.
However, the invasive aspect of heart attack management requires a different level of financial commitment. A coronary angiogram can range from US$1500 to US$5000. Placement of stents in the blocked arteries can range from US$5000 to US$30,000. Blood tests, ECG, echocardiograms, consultations, rehabilitations and medications are additional expenses. Strategies to reduce cost do exist and a few operational models have proved successful. Private and national health insurance coverage must be encouraged. Strategic partnerships between the public and private sectors offer promise in developing an efficient lower cost program.
The Caribbean Heart Institute (CHI) has been in existence in Guyana since 2006. We provide the most affordable high quality cardiac care in the Caribbean and is a great example of public-private partnership. Since its establishment, the CHI has done over 200 heart surgeries, 1000 coronary angiograms and 300 angioplasties with stent placement.
Conclusions
Heart attacks are among the leading causes of deaths and disability in the world. The consequences extend beyond the individual and have implications for families, communities and countries. Most of the risk factors are known and early warning signs may be present. Rapid actions and early interventions can save lives and improve quality of life. While a preventive strategy is best, heart attacks still occur with devastating outcomes. Some basic knowledge and appropriate actions can be very useful is ensuring better outcomes.
