How to recognise heart attack early ?

The symptom of heart attack vary from one person to another.Recognition of these symptoms are very important for early detection of heart attack The most common symptoms are

• Chest pain: Patients may experience tightness, heaviness or pain in the chestpain may be felt in arms, neck, jaw, back or stomach: for some people, the pain or tightness is very severe, while some people just feel uncomfortable
• Sweating
• Feeling of light-headedness
• Breathing difficulty
• Feeling nauseous or vomit
• Severe tiredness

If you experience the above symptoms donot hessitate , immediately seek medical help.Emergency ECG and Echo test is required to rule out the myocardial infarction

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What is sudden cardiac death and its management

Sudden cardiac death is defined as Natural death due to cardiac causes, heralded by abrupt loss of consciousness, within 1 hour of the onset of a/c symptoms. Preexisting heart disease may or may not have been known to be present, but the time and mode of death are unexpected. It is due to direct consequence of cardiac arrest

Risk factors of  sudden cardiac death

Age.elderly at risk.

Male Gender.

Familial factors.Positive family history may be present.

Structural and functional factors.

Heart attack and chest pain - 80%.

Cardiomyopathies - 10 to 15%.

Other causes - 5 to 10 %.

Management of sudden cardiac arrest

Confirm cardiac arrest.

Call for help.

Give Chest compression.

Maintain airway –with  head tilt , chin lift, clear passage.

Look, listen and feel   the breathing.

Hospitalize the patient as early as possible. 

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How will you care heart attack patient ?

Heart attack is a common problem in the community, but majority of the people don’t know what are the precautions we should take after a major heart attack. Understanding of which is very important because it will help us to avoid further attack, and improve the quality of life. Patients and their relatives should take special attention in understanding this aspect. Millions of people are living with heart disease,but it is not easy to live with heart attack.Following are the tip for caregivers and patients.

1.Healthy food - Patient should take a balanced food.Predominantly vegetarian food is preferred,food should be rich in antioxidants.

2.Exercise - Daily exercise will help to protect the heart,only safe exercise is advised.

3.Stop smoking and heavy alcohol intake.

4.Ensure adequate sleep.

5.Patient should not stop drugs without doctors advise.

6.Patients can  take part in cardiac rehabilitation program  after dicussing with the treating doctor.

7.Caregivers should understand the psychological ,cultural and spiritual aspect of health and disease.

8.Avoid mental and physical stress.

9.CPR - Cardio pulmonary resuscitation  is called as chain of survival,it is important that care givers should learn it for their loved one.

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Diet for Heart disease - A must read for every one

Coronary artery disease (Heart attack) is  a multi factorial disease. Here the strongest environmental factor is diet. Basic abnormality that lead to coronary artery disease is  is atherosclerosis. Major constituent of atherosclerosis is cholesterol esters,which  are carried by LDL (Law Density Lipoproteins ) in the blood. LDL cholesterol is affected by the type of  dietary fat.
Saturated fatty acid raise the blood cholesterol,while polyunsaturated fatty acid decreases the cholesterol. Cholesterol is found only in  animal food.

Following are the dietary recommendation in patients with coronary artery disease.

• Balanced diet is recommended.
• High fiber content (Complex carbohydrates) - Effect is determined by the type of dietary fiber. Soluble fibers such as pectin, guar and oat fibers can produce moderate reduction of cholesterol. Wheat fibers (wholemeal breads or bran) wont reduce the plasma cholesterol, but those who consume more wheat fibers and whole grain food the incidence of CAD  is decreased.
• Weight reduction to achieve optimal BMI (Body Mass Index) - Overweight, especially abdominal obesity is an independent risk factor for CAD. Weight reduction will reduce the cholesterol.
• More vegetables and fruits - Soya protein if included in the diet help to reduce the total and LDL cholesterol. Vegetables and fruits are law in fat and contain pectin other dietary fibers ,flavanoids and antioxidants. Five servings of different vegetables and fruit per day (400 g/day average weight)  is recommended.
• Avoid excessive caffeine intake - Coffee contains small amounts of diterpenes (lipids), cafestol and kahweol - not caffeine - it raise plasma total and LDL cholesterol. Since the diterpenes are removed  filtered or instant coffee does not raise the cholesterol.
• Avoid junk food.
• Avoid  foods with high fat content especially MUFA, excess salt ,cholesterol.
• Fish oil (omega 3 PUFA), garlic, plant sterols, antioxidants all help in reducing the cholesterol.
• Salt (NaCl)   should be restricted to 6 gram/day for the general population this is more important for CAD  patients.
• Fish  at least twice a week preferably fatty fish is recommended, it should not be fried in saturated fat. EPA (eicosapentanoic acid) help in reducing  CAD.
• Alcohol one or two drinks per day may be beneficial in middle aged people at risk for CAD, because of complications of over intake not recommended in general population.
• The following dietary components reduce the risk of coronary heart disease. Fruits and vegetables, cereal fiber,  PUFA, linolenic  acid, alcohol and fish, nuts, vitamin E, folate.

Glossary

1. BMI - Body mass index
2. CAD - Coronary artery disease
3. LDL - Law density lipoproteins
4. MUFA - Monounsaturated fatty acids, plant-based fats found in avocado, nuts and seeds, oils, olives, and dark chocolate
5. PUFA - Cutting off all vegetable oils except coconut oil, olive oil and palm oil. 

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Drugs used for treatment of heart attack patients.

Heart attack occurs when there is reduced blood supply to heart. It is an emergency situation and immediate medical care is required. Here in this article we will tell you some of the drugs and their aims. It is always good to have these in your mind

Following are the aims of treatment.

1.Immediate stabilization of patient.

2.longterm symptom control.

3.Cure of the condition if possible.

Drugs used for the treatment are given below.

1. Antiplatelet drugs –Aspirin and Clopidogrel, it is a group of powerful drugs that will prevent the blood clotting.

2. Nitrates will help to reduce the pain

3. Betablockers decrease the heart rate, blood pressure and improve the oxygen supply to heart.

4. Statin will reduce the blood cholesterol. Stabilize the plaque so prevent further attack.

5. ACE Inhibitors- role is to reduce the blood pressure, dilate the blood vessels and increases the blood supply.

6. Angiotensin II Receptor Blockers will increase the blood supply to heart.

7. Clot lysis with streptokinase give immediate improvement.

8. Diuretics remove excess salt and water from the body so help the heart to work properly.

9. Digoxin improve the function of heart.

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Statin a cholesterol lowering agent - Reduce cholesterol in 4 weeks

The problem of high cholesterol is increasing in the society. This will lead to atherosclerosis and increased risk for heart attack and stroke. Statin's will help to reduce the cholesterol level and thus will help to reduce heart attack and stroke in the community. Statin's are the most efficacious and best tolerated lipid lowering drug. They will reduce both primary and secondary hypercholesterolemia. Statin's can reduce the total cholesterol in 4 to 6 weeks. All the statin's are given at bedtime to get maximum effect.

Statins include the following

1. Atorvastatin­ dose 10 to 80 mg/day.

2. Lovastatin­ 10 to 40 mg/day,this is the first used statin.

3. Simvastatin ­5 to 20 mg/day.

4. Fluvastatin.

5. Pravastatin.

Adverse effects of statins

1. Headache.

2. Nausea and bowel upset.

3. Rash.

4. Sleep disturbance.

5. Muscle pain and rise in CPK level.

6. Increase in serum transaminase,but liver damage is not seen.

Uses of Statins

1.Reduce  cholesterol level.

2.Decrease heart attack rate

3.Decrease  stroke rate.

4.Help in plaque stabilization in atherosclerosis.

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Prevention of recurrent heart attack

Prevention of heart attack is very important because the chance of second attack is high in known heart patient. Repeated attacks are dangerous because it will increase the  risk of death in a given patient. The interesting factor is that the recurrent attack can be prevented with control of risk factors along with certain drugs. This will improve the long term survival.

Following are the measures to prevent recurrent heart attack

1.Drugs

2.Control blood pressure

3.Control blood glucose

4.Regular exercise

5.Balanced diet

6.Control blood cholesterol

7.Stop smoking

8.Avoid excessive alcohol intake

9.Reduce mental and physical stress.

Drugs that will reduce recurrent heart attack

Antiplatelets such as Aspirin and Clopidogrel will produce a 25%reduction in recurrent attack and increase the survival.

ACE inhibitors and ARBS (Angiotensin II receptor antagonists) are also useful in prevention.

Beta blockers will reduce the heart rate and help to  improve the long term survival.

Regular exercise will help to reduce weight ,cholesterol ,control of hypertension and diabetes.

Diet should be low in fat and rich in calories.

Quitting of smoking is very important as it will help to increase the Oxygen supply to heart and decrease the atherosclerosis.

Note : In diabetic patients apart from control of blood glucose control of blood pressure to 120/80 mm of mercury and LDL cholesterol to less than 70mg /dl is advised. 

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Tips to keep your heart young and healthy

Here are few tips that will help to keep your heart healthy and young

1. Avoid fried foods.
2. Avoid fatty foods such as beef, pork and mutton.
3. Eat small fish such as sardine that is good for your heart.
4. Take un cooked vegetables daily such as cucumber ,carrot, tomato and onion.
5. Reduce salt intake.
6. Take high fiber diet including green leafy vegetables and legumes such as . Soybeans, fava beans, peas ....
7. Avoid egg yolk which has high cholesterol content.
8. Avoid eating fried foods and salty foods such as chips and corn while reading and watching television.
9. Better avoid milk and dairy products.
10. Avoid hotel foods and if inevitable take only vegetarian food.
11. It is better to prevent diabetes and if already present strict control is necessary.
12. Strict control of blood pressure is advised.
13. If possible avoid using lift and climb the staircase.
14. Better to walk small distances rather than using a vehicle.
15. If your work demands sitting for long hours better to take rest and walk in between.
16. Walk for 40 minutes daily.
17. Avoid smoking and alcohol consumption.
18. Maintain body weight , weight should be in proportion to your height.
19. Better to go to bed early and wake up early in the morning.
21. Even if you have to do heavy work do it systematically and ensure adequate rest and enjoyment in between.
22. It is better to practice yoga and meditation.
23. For a happy family environment healthy sexual life is inevitable, avoid extramarital relationships which is a frequent source of mental stress and risk factor for heart disease.

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Medicinal effect of garlic in heart patients.

Medicinal effects of Garlic (Allium sativum) is known from the ancient days itself. It is used for treatment and prevention of many disease. Heart attack patients get several benefits with garlic intake. 

Active ingredient is Allicin which is an odorous sulfurous compound that has several medicinal effect. Following are the benefit of Garlic in heart attack patients. The main abnormality in blood vessels in heart attack patients is atherosclerosis. 

• It helps to reduce the blood clotting. It produce irreversible inhibition of platelet aggregation ,which is a blood component. Major action of drugs given in heart attack patients is to inhibit the platelet, which is responsible for blood clotting.
• Reduction of cholesterol and triglycerides levels which is responsible for formation of atherosclerosis and plaque in blood vessels leading to reduction in blood supply.Several studies showed 9 to 12% reduction in cholesterol and moderate reduction of triglycerides levels with its use.
• Help to reduce blood pressure which is also a risk factor for heart attack .There will be an average reduction of 11mm of Hg in systolic and 6.5 mm of Hg diastolic blood pressure.
• Garlic has anti atherosclerosis action,which help to reduce the formation of new atherosclerosis lesion and prevent the progression of older lesions.

Garlic is available as fresh cloves, powders, extract, tablets. At least one-half garlic clove per day  is required for medicinal effects.Although the tablets and powders are convenient, the amount of active ingredient is insufficient.

Some people may experience gut (gastrointestinal system ) symptoms such as flatulence(gas), chest pain and abdominal pain after garlic intake.

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Heart failure classification, risk factors and precipitating events

Heart failure:Clinical syndrome that occurs in patients due to any STRUCTURAL OR FUNCTIONAL CARDIAC DISORDER, so that patient develop a constellation of symptoms (DYSPNOEA and FATIGUE) and signs (OEDEMA and RALES) which lead to frequent hospitalizations, poor quality of life and a shortened life expectancy. It is the end result of various disease of heart. In cardiac failure heart fails to maintain an adequate blood supply to meet the metabolic demand of body. In mild to moderate disease heart maintain adequate cardiac output at rest but cant meet the increased demand such as exercise. Prevalence of heart failure increases with age. It carries a poor prognosis. Sudden death can occur due to malignant ventricular arrythmias or heart attack. Coronary artery disease is the leading cause of heart failure in western world.

Nyha classification.

Class I : Patients with cardiac disease but no limitation of physical activity; there are no symptoms from ordinary activities.

Class II : Slight limitation of physical activity; the patient is comfortable at rest.

Class III : Marked limitation of physical activity; the patient is comfortable only at rest.

Class IV : Any physical activity brings on discomfort and symptoms occur even at rest.

Following are the risk factors of heart failure

1. Coronary artery disease.
2. Hypertension.
3. Diabetes Mellitus.
4. Dilated and Hypertrophic cardiomyopathy.
5. Valvular heart disease.
6. Cigarette smoking.
7. Alcohol intake.
8. High output failure - Anaemia, thyrotoxicosis, arteriovenous fistulae,Paget’s disease
9. Pericardial disease - Constrictive pericarditis,Pericardial effusion
10. Primary right heart failure- Pulmonary hypertension

Preecipitating or aggrevating factor are those increases the oxygen demand of body.

Preecipitating factors

1. Myocardial ischemia or heart attack.
2. Infection.
3. Arrythmia.
4. Increased salt intake.
5. Non compliance with anti CHF medications.
6. Acute myocardial infarction.
7. Aggravation of Hypertension.
8. Administration of drugs with negative ionotropic properties(beta blockers) or fluid retaining properties(NSAIDS, steroids).
9. Pulmonary embolism.
10. Conditions associated with increased metabolic demand - Pregnancy, thyrotoxicosis, anemia.
11. Intravenous fluid overload – post operative iv infusion.
12. Rheumatic, Viral, and Other Forms of Myocarditis.
13. Infective Endocarditis.
14. Physical, Environmental, and Emotional Excesses.

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Significance of early diagnosis of heart attack

Chest pain is a Common complaint in  emergency department (ED). Approximately 5% of all ED visits or 5 million visits per year is due to chest pain .There is a wide range of etiologies Cardiac, Pulmonary, Gastrointestinal, Musculoskeletal. Distinguishing these causes matter because management vary  according to etiology.

When there is a block in coronary arteries that supply heart muscle it will produce heart attack .Most common manifestation is  cardiac pain which is called angina pectoris.

Key features of typical cardiac pain

From history 

Location : Pain can be central, left or right part of chest.

Timing : It can be gradual or sudden onset.

Provocation : By exertion.

Quality : Diffuse or constricting type of pain it can be an uncomfortable pressure, fullness, squeezing in the chest.

Radiation : Can radiate to back, neck and arm.

Severity : Severity vary from a scale of 1-10.

Associated symptoms : Breathlessness, sweating, nausea, fainting, feeling of impending doom, cold clammy skin may be present.

When the patient is asked to localize the sensation, he or she will typically press on the sternum, sometimes with a clenched fist, to indicate a squeezing, central, substernal discomfort (Levine's sign). 

                 Levine's sign 

Key Emergency Physical examination 

1. General appearance - Patients are usually anxious and restless.
2. Vital signs - Watch for hypotension or hypertension.
3. Heart - Examine the heart sounds is it muffled? regular? fast?
4. Neck dilated neck vein.
5. Abdominal distension.
6. Lowerlimb oedema and calf muscle tenderness.
7. All these features need not be present in every patients.

Whenever you have chest pain consider above mentioned points you should not ignore the chest pain if  at least one or two features are present  and attend the emergency department and do proper evaluation.Early diagnosis is important because if there is a delay in treatment  more than 6 hours, there will be irreversible damage to heart muscles.

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