FAQ - Heart Trouble

Heart Trouble

The heart, which is a muscular pump, starts beating and pumping blood even before one is born, and continues to do so throughout one’s lifetime. For pumping oxygenated blood containing oxygen to the entire body, the heart requires oxygen. The oxygen required by the heart is supplied by the oxygen-rich blood carried by the ‘coronary arteries’. If blood supply to the heart is reduced, one develops the ischemic heart disease (IHD). (There are other forms of heart-disease like rheumatic heart disease, congenital heartdisease and so on).

Ischemic heart disease (IHD).

Ischemic heart disease (IHD) is commonly known as ‘heart trouble’. Cholesterol and the fatty substances in the blood, get deposited on to the inner lining of the coronary arteries causing atherosclerosis. The coronary arteries become narrow and there is reduced blood supply to the heart, and, when one exerts, one feels pain & discomfort. The internal lining of arteries becomes irregular and rough. The special cells in the blood called platelets, which initiate clotting of blood, may get stuck to this irregular rough surface. This leads to the formation of a blood clot in the coronary artery blocking it completely. This block and the consequent death of a part of the heart-muscle is called ‘heart attack’. In medical language, it is known as myocardial infarction.

Why does heart attack occur ?

‘Heart trouble’ is primarily a disease of ageing. We know that an old water pipe gets rusted and lined with deposits inside. Similarly, with ageing, there is progressive deposition of cholesterol inside the lining of all arteries. Certain factors like heredity, diabetes, high blood pressure, obesity, smoking, stress, lack of physical exercise and so on hasten the process. The female hormone, oestrogen, reduces this tendency. So menstruating women are less affected. This disease was earlier seen in India in the age-group of fifty-plus. But, now, it is seen at a much younger age. This reflects the changes in life-style in India in the relatively well-to-do people. More over, there is scientific evidence that shows that South Asians probably have some genetic predisposition which makes them more susceptible to IHD (‘Syndrome X’)

How does one suspect ‘heart trouble’ ?

In its early stages, IHD shows no symptoms. Symptoms appear only after 70% of blockage. But as the disease progresses, the following symptoms occur; chest pain after quick walking or climbing up the staircase etc. This pain, called ‘angina’ is generally in the middle of the chest. The pain may spread to the inner side of the left hand, or the lower jaw, throat, or to the upper abdomen or right shoulder. This anginal pain generally felt does not occur at the site of the heart, i.e. left side of the chest, but is ‘referred’ to other sites because the nerve endings around the heart reach the skin at these other sites. Hence in any stress or damage to the heart, the pain is ‘referred’ to these sites. But the pain may be due to inflammation in organs in the area where pain is present. The pain in upper abdomen and in the middle of the chest may be due to hyperacidity or regurgitation of food into the food-pipe (oesophagus). This kind of pain may be relieved by taking an antacid. A muscular or joint pain would increase on pressure. In case of doubt, it is better to consult the doctor. Some patients may not feel any pain on exertion but they may feel discomfort, exhaustion or breathlessness. Pain caused by a heart attack is severe and continuous and cannot be relieved by tablets. There may be a lot of sweating, uneasiness, nausea, vomiting, or breathlessness. Very rarely does a heart attack occur without any pain or angina. This is likely in diabetics and old people.

Which tests are done to diagnose heart disease ?

Getting a thorough account of the symptoms is very important for the doctor. A preliminary diagnosis can be made on the basis of this detailed account. A primary diagnosis is made through physical examination and an electrocardiogram (ECG). ECG is the recording of the minute electrical impulses originating from the heart. ECG is taken to support the clinical diagnosis of IHD. ECG at rest is not a very sensitive test and the ECG may turn out to be normal despite the presence of IHD. Therefore, if the doctor has a suspicion of heart disease on account of other factors like the symptoms, diabetes, high level of blood cholesterol etc, he/she may advise a ‘stress-test’. In a ‘stress-test’ the patient is required to walk fast on a moving platform whose elevation and speed are gradually increased to put more workload on the heart, and simultaneously his/her ECG is taken continuously. If the blood supply to the heart gets reduced due to narrowing of the coronary arteries, this is far more likely to be revealed during a stresstest ECG than by an ECG at rest. Before a stress-test, less invasive though less definitive tests are advised - bloodsugar, cholesterol levels plus allied fats in the blood. Diabetes and raised levels of cholesterol increase the possibility of developing IHD. To test blood cholesterol, one has to fast overnight for at least 12 hours. Nothing except water is allowed during this fast. Fasting blood glucose is also examined at the same time. After drawing blood to detect fasting levels of glucose and cholesterol, the patient is given 75 gm. of glucose mixed in water, to drink. Blood is taken again, 2 hours after this glucose-drink (Only water is allowed during these two hours). The fasting and ‘post-glucose blood sugar’ test can detect diabetes. Total cholesterol ‘HDLcholesterol, and “LDL-cholesterol’ levels in the blood tell us about the chances of having coronary artery disease. In majority of patients, the above tests are sufficient, and the doctor can advise appropriate treatment. However, for some patients, after blood sugar and cholesterol test, the doctor may advise Stress-ECG test. Stress-ECG test is also not completely reliable; but if it is negative, one can say that the chances of a person having IHD is very low. One person out of 10,000 may precipitate a heart attack due to stress-ECG test. Therefore, this test is to be done only in a fully equipped medical centre under the direct supervision of an expert doctor. This test costs from Rs. 700/- to Rs. 1000/-. If Stress-ECG test is strongly positive, indicating considerable reduction in blood supply to the heart, a further invasive test called coronary angiography is needed to find out the precise location and the extent of narrowing of the coronary arteries. In this high-tech test, a catheter is passed through the artery in the thigh to reach the mouth of the coronary arteries. A ‘radio-opaque’ dye (one which is opaque to x-ray) is then injected into the coronary artery tree through the catheter. A number of x-rays of these arteries are taken. Before passing the catheter into the artery, the nearby part is anaesthetized by a small injection. Thus the procedure is not painful and the patient can comfortably see the process on the T. V. screen. This is a very reliable and accurate test. However, it costs more than Rs. 10,000 and carries more risk. The chances of developing complications due to this test, are as follows : Minor complications -1% , Serious complication - 1%, Death -0.25%. Moreover, if for financial or any other reason a patient is not prepared to undergo either angioplasty or coronary bypass surgery, there is no point in doing this angiography. One more test called Thallium scan’ is now available in India in many metropolitan towns. Unlike angiography, it is free of any additional risks. It shows to what extent blood is reaching the heart muscle. It is usually done after angiography and before bypass surgery. If angiography shows that a particular coronary artery is considerably narrowed, thallium scan shows whether that part of the heart being supplied by that artery is already dead or not. If that part is already dead, then there is no point in opening or replacing that artery . If the thallium scan shows that despite considerable narrowing of a coronary artery the part of the heart in question is adequately supplied with blood, then also bypass surgery is not advised. The thallium scan test is a stress test in which radioactive thallium is injected into the blood and the patient is asked to walk on the walking machine. Thallium reaches the heart and the series of ‘photographs’ of the heart show where it has reached. If a particular part of the heart is dead and hence does not receive any blood, this part looks different on the scan-photograph. This test costs around Rs. 5000/-. Thallium scan can sometimes be used to avoid angiography. If the cardiologist suspects that though the report of stress test is positive, the report is doubtful and the patient does not have IHD, he/she may advise a thallium scan instead of angiography. If a thallium scan shows normal blood supply to all parts of the heart muscle, the positive report of the stress test is discarded. If, however, the thallium scan shows reduced blood supply to a part of heart, the patient has IHD and angiography is needed to decide exactly which coronary artery has been significantly narrowed.

What to do in case of a suspected heart attack at home ?

The symptoms of a heart attack are given above. Once a person shows the above-mentioned symptoms, immediately make the patient lie down and do not allow him/her to move at all. If you are certain that the patient does not suffer from ulcer, give a tablet of aspirin. Aspirin helps to dissolve the blood clot clogging the coronary artery. Contact a doctor immediately who will guide you to an appropriate hospital with requisite facilities. Take all the medical papers (reports of various tests done earlier, drug prescriptions etc.) Do not waste time in calling a doctor home. Treatment of heart-attack cannot be done at home. Do not wait for the ambulance if the hospital is not far off. Use a rickshaw or a car. Do not allow the patient to walk upto the vehicle. Carry him/her on a chair etc. Do not panic, but also do not wait unnecessarily. Early hospitalization can be life saving and in case of a mild heart-attack, it can limit the damage to the heart.

What is the treatment given for a heart disease ?

Treatment depends upon the severity of the attack, the patient’s general health and habits. Effective and relatively safe drugs, which dilate the small blood vessels of the heart, are now available. They increase the blood supply to the heart and relieve pain. Besides drugs the following steps are vital as long-term measures - If overweight, reduce weight through dieting and exercise. If diabetes or high blood pressure, must be controlled. Tobacco in any form must be stopped immediately. Make effort to reduce psychological stress. Change in attitude, listening to music, meditation etc. can help a lot.

What are the dietary changes needed ?

Increased body fats due to a faulty diet is an important cause of IHD because this extra fat is an excess load on the heart. Moreover, excess fat leads to excessive cholesterol level in the blood. Therefore, if your weight is excessive, reduce it through dieting and exercise. If your blood cholesterol is high, there is even a greater need for dieting and exercise. It may/be noted that a high level of blood cholesterol may sometimes be found even in thin individuals. The basic principles for dieting in IHD are : reduce fats and sweets in your diet. Do not use more than 20 gms of fat daily (600 gms/month) in your kitchen. Stop fats of animal origin (ghee, butter and fat-containing non-vegetarian dishes) and dalda. Amongst non-vegetarian dishes, only fish is allowed. However, very little oil should be used in preparing the fish. The cholesterol content in mg in the various non-vegetarian foods per 100 gms of the foodstuff is as follows : brain -200, kidney - 375, liver - 300 , yellow of egg - 252, mutton - 60, one teaspoonful of butter - 35, ice-cream - 45 (Yes, milk products are non-vegetarian). Refrain from these items, if your blood cholesterol level is high. Use only vegetable oils 35 (except coconut oil) for cooking. What is more important is to consume less oil. Dietary restrictions can reduce the blood cholesterol by 40 to 55%. In some individuals, however dietary restrictions are ineffective and hence they have to take medicines under expert guidance. Since after the age of sixty, dietary restrictions on fat consumption do not reduce cholesterol levels, none are needed.

Should a heart patient climb stairs or not ?

Climbing means more and faster work for the heart. Some IHD patients get pain or other symptoms on climbing. But this problem can be overcome with proper medication, diet and appropriate exercise. Proper exercise helps to develop ‘collateral circulation’ (development of more small vessels which supply more blood to the affected area). If any exercise is avoided out of fear, the heart’s capacity to work is further reduced. Therefore, simple walking exercise should be started once the chest pain stops due to medication. Start slowly and take rest if there’s chest-pain or any other symptom’ of IHD mentioned earlier. Start with a 10 minute walk, increase it gradually to atleast 30-40 minutes, at a stretch, and gradually increase the speed also. You can then climb up the stairs as per your need. Even if you don’t need to climb up stairs, all patients of IHD have to do some exercise as per medical advice. Consult your doctor before starting the exercise to know the details. A test called ‘ stress-test’ will tell you how much exercise your heart can tolerate without developing problems.

What about sexual relations ?

Usual sexual relations are all right, if there is any chest pain etc, consult your doctor.

When should the doctor be consulted again after starting treatment ? How frequently should the tests be repeated ?

Once the chest pain stops due to medication, and medication is routinized, you may meet the doctor once in six-months and to repeat ECG once a year, if there are no other complications like diabetes. However, if there is no relief from chest pain, medicines have to be changed frequently till relief is obtained and hence you have to meet the doctor frequently . If there is inadequate relief despite full medical treatment, tests like angiography have to be done to find out if ‘angioplasty’ or a ‘bypass surgery’ is necessary. If the cholesterol level is high, it has to be checked every two to three months till it comes down adequately. If there is diabetes or high blood pressure, along with IHD, the doctor has to be consulted repeatedly and tests have to be done as per the severity of these problems and response to the treatment.

 

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