Heart Attack: Hear its silence

Friday, 4 July 2014

The heart is the major organ of human circulatory system and hardest working organ of human body. It continuously pumps blood enriched with oxygen and vital nutrients through a network of arteries to all body tissues. It is a powerful pump, which has got no match; during peak exercise it can pump about 50 liters of blood in a single minute. To perform this arduous task of pumping blood to rest of the body, heart muscle itself requires a good supply of oxygen rich blood. A network of coronary arteries supplies this. There are 3 main coronaries- left anterior descending (LAD), left circumflex (LCx) arising from left side and one right coronary artery (RCA) from right side. If blood flow to the heart muscle is interrupted or blocked the heart muscle suffers injury, which is called myocardial infarction and is commonly known as heart attack.

Coronary artery disease:
The heart attack is the severest form of coronary artery disease. Coronary artery disease is said to be present when plaque starts accumulating inside the walls of coronary arteries. Plaque is an atherosclerotic chunk of fatty deposits causing hardening and narrowing of coronary arteries. There is slow accumulation of fatty deposits causing gradual narrowing of coronary arteries and progressively starving heart muscle of oxygen and nutrients. When heart muscle is deprived of proper blood supply and oxygen, it becomes ischaemic and pain occurs. This pain is called angina. This initially occurs during increased demand of the body when heart has to pump more blood to body mainly during exertional activities. So angina occurs when coronary arteries are unable to supply adequate amount of blood to heart muscle as is required by it.
The plaque can also rupture under certain circumstances, which causes sudden occlusion of coronary artery by the formation of thrombus or blood clot. This sudden occlusion totally stops the blood supply to heart muscle and it leads to heart attack or myocardial infarction.

 Anginal syndromes:
Angina means chest pain; it is the primary symptom of heart disease and heart attack. It occurs when heart muscle doesn’t get as much blood (hence oxygen) as is required for a given level of work. It is usually referred to as one of the two states: stable and unstable. Anginal attacks can occur at any time during day, but a high proportion seems to take place in the early hours of the day. The unstable angina is often an intermediate stage between stable angina and a heart attack and its course is unpredictable and is a sign of more serious disease. It is usually diagnosed if one or more of following conditions occur.
  •   Pain awakens the patient or occurs at rest.
  •  A patient who has never experienced angina but is now having severe or moderate pain during mild exertion within last two months.
  • Stable angina has progressed in severity, frequency and duration or medications are less effective in relieving pain.
Stable angina:  It is extremely painful situation, more predictable course and less serious than unstable angina. It is usually relieved by rest and responds well to medical treatment especially nitrates which can be kept below the tongue. Any event that increases oxygen demand can cause an anginal attack. Some typical triggers include exercise, cold weather, emotional tension and heavy meals.
Unstable angina is usually described as part of a condition called acute coronary syndrome (ACS). It also includes patients with condition called NSTEMI (non ST-segment elevation myocardial infarction) also referred to non-Q - wave heart attack. In this ECG and blood tests suggest a developing heart attack. These conditions are less severe than heart attack but may develop into full-blown attacks without aggressive treatment. Full-blown heart attacks are usually called ST elevation myocardial infarction. 
Indicators of heart attack:
Anyone who believes he or she is having heart attack should not hesitate to contact emergency medical services. People with known heart disease, any unusual chest pain or other symptoms of heart attack which are not clearing up with routine medications are warning signals to go to the hospital. The severity of pain and specific symptoms before heart attack vary greatly among individuals and onset may be abrupt, gradual or intermittent.
Chest pain is the most common indicator and clinical expression of heart disease. People with risk factors for heart disease or having heart disease should be very particular about any chest pain. It is usually precipitated with exercise or stress and interrupts normal activities and does not clear up after taking rest and routine heart medicine. It may be experienced as crushing weight against chest with profuse sweating. Pain may radiate to left shoulder, arm, neck or jaw. Some may have sense of fullness, squeezing or pressure over the chest. People may also experience nausea, vomiting, cold sweats, indigestion, heart burn, abdominal pain, fainting and a great fear of impending doom i.e. angor animi. Nearly half of the patients may not have chest pain, they may present with shortness of breath and cardiac arrest.
Some people with severe coronary artery disease may not experience angina, this condition is called silent ischaemia. It may be due to abnormal processing of heart pain by the brain. It is a dangerous condition because patient has no warning signs of heart disease.

Symptoms that are less likely to indicate a heart attack:
Sharp pain brought on by respiration/coughing. Pain mainly in lower or middle abdomen. Pain is pin pointed with tip of one finger, pain reproduced by moving or pressing on chest wall/ arms. Very brief pain lasting few seconds.

What actions need to be taken at onset of symptoms?
  • Take nitroglycerin as spray or sublingual tablet and repeat after 5 minutes maximum upto 3 doses.
  • Immediately call or reach emergency services, do not deceive yourself.
  •  Chew a tablet of aspirin

  •                                                                         Dr TP Singh
                                                                 Chief Consultant Cardiologist,
                                                                           SGHS Hospital, Mohali
                                                               E-mail id:
                                                                      Mobile No : 09872421946


Tuesday, 27 May 2014

The usual indication of coronary artery disease / heart attack is chest pain, which is called angina pectoris. Angina is usually the pain felt right in the middle of the chest, behind breastbone, which can spread towards neck, jaw, left arm of wrist. It can feel like handcuffs or tightening of chest. The pain may be prolonged more then 30 minutes and if associated with profuse sweating, nausea, vomiting and palpitations is usually suggestive of heart attack.

The angina pectoris may come with exertion, walking up incline, after a heavy meal, after a strong emotion, fright, and nightmare or smoking a cigarette.

The angina pectoris may be a part of spectrum of acute coronary syndromes, which is heart attack or it may come after exertion, which is usually called chronic stable angina. The treatment options for both are different.

The evaluation for angina pectoris consists of various lab tests. The usually performed tests for evaluation of heart disease are ECG, Treadmill test (TMT), Echocardiography, Nuclear tests and Coronary angiography.

ECG: - This is the basic test for diagnosing heart disease. It is usually normal out side an angina episode or unless patient already had an old heart attack, enlargement of heart chambers or some conduction abnormality. It may signify a major heart attack or other minor forms of heart attack. A normal ECG does not rule out presence of heart disease.

STRESS TEST: - The patient is made to walk on a treadmill and continuous ECG recording is done. The active angina / heart attack should be ruled out before subjecting the patient to treadmill test. The results of this test may be normal or may give clues about presence of blockage in coronary arteries.

ECHOCARDIOGRAPHY: - This is basically ultrasonography of heart. This will tell us about functioning of heart, its contractility, ejection fraction, any valvular blockage or leakage, old or fresh heart attacks.
It may be abridged with a stress test, when it is called stress echocardiography. In this heart functioning is seen at peak exertion, for any areas which are not moving or working properly and signifying blockage in coronary arteries.

NUCLEAR SCINTIGRAPHY: - Nuclear test is done by injecting very small, harmless amount of radioactive substance in blood stream and taking images. Special gamma camera is used to take images of heart at rest and after a stress.

CT CORONARY ANGIOGRAPHY: - This is a newer modality for diagnosing blockage in coronary arteries. This is done by very high end CT scanners like 64 slices or 128 slices. The importance of this test lies in its high negative predictive value which means that if the test is negative showing normal coronary arteries, it is definite and quite reassuring to the patient. But if it is even slightest positive one should go for conventional angiography and diagnosis should be confirmed.

CONVENTIONAL CORONARY ANGIOGRAPHY: - This is the gold standard for diagnosing coronary artery disease. An introducing sheath is inserted through a groin artery or arm artery and a catheter is inserted and guided to coronary arteries, contrast dye is injected and X- Ray films are taken. These will show any blockage in the coronary arteries in form of filling defects, narrowing of lumen or irregularity of lumen.
The coronary angiography is done to decide whether patient needs a coronary angioplasty or coronary artery by-pass surgery or medical management only. The decision is taken only after reviewing the coronary angiography results.
These days it has also become relatively less invasive when it is done through arm i.e. Radial artery route. Radial angiography is devoid of any bleeding complications and is very comfortable for the patient. Patient can be discharged after a short hospital stay and cumbersome leg straightening for six hours is avoided.      

MANAGEMENT: - It is known that heart attack occurs when there is total blockage of coronary arteries with a thrombus or clot. The immediate treatment is addition to taking asprin tablet and other medicines is dissolution of thrombus and opening up of the coronary artery, which is causing heart attack so that damage to the heart muscle which is being deprived of blood and oxygen is avoided well within time. The clot can be tackled by immediate coronary angiography and removal by angioplasty procedure or dissolving the clot by clot busting drugs given intravenously which is called thrombolysis. The results of angiography and angioplasty, which is called primary angioplasty are more favorable if done well in time. The efficacy of clot busting drugs is maximum in first 3 hours. If the clot busting drugs have not worked in a given patient than one should plan for angioplasty procedure and opening of artery which is called rescue angioplasty.  
Actions needed to be taken on suspicion of heart attack : - Chew a tablet of aspirin. Take nitroglycerin as spray or sublingual tablet and repeat after 5 minutes maximum up to 3 doses. Try to call and reach emergency services as soon as possible, do not deceive yourself.
Dr TP Singh
Chief Consultant Cardiologist,
SGHS Hospital, Mohali
Mobile No : 09872421946


The basic mechanism for the development of heart disease or coronary artery disease is development of atheroma (fatty deposits) in arteries supplying the heart that is coronary arteries. These atheromas or plaques gradually reduce the internal diameter of arteries, and leads to obstruction. The question is why this plaque or atheroma starts accumulating in coronary arteries? This is because of genetic make up, internal lipid milieu and lifestyles of individuals. There are many risk factors, which accelerate the process of atheroma formation and lead to coronary artery disease. These risk factors are quite simply personal characteristics or features which make us more likely to suffer a cardiovascular accident some day.

The major risk factors are smoking, high blood pressure, high cholesterol, obesity and family history of premature heart disease. The minor risk factors can be high stress jobs, type-A personalities and sedentary lifestyles. Out of these some are modifiable risk factors, correction of those reduces the frequency of cardiovascular accidents. The risks, which can be modified by us alone, are smoking and sedentary lifestyle, modification of these risk factors significantly reduces the risk of heart disease.

Smoking: Cigarette consumption remains the single most important and modifiable risk factor for the development of heart disease. The risk of smoking is increasing in adolescents, young adults and women. A person who consumes 20 or more cigarettes daily is at 2-3 times higher risk for heart attack as compared to a non-smoker. Even the company of smoker is very harmful. It has been proven that passive smoking is as dangerous as active smoking. We should protect our selves and children from passive smoke.

Hypertension: Hypertension means increased blood pressure, is very aptly called a silent killer. One does not feel anything wrong and during a routine check up, it is diagnosed. It is quite simply the pressure of the blood in the main arteries of our body. This pressure allows the blood to flow from main arteries to the smallest vessels in all the organs of body. The blood pressure of an individual is quite variable. It may vary from one moment to next; it is usually lower at night and rises during exertion and emotion.

High blood pressure is major risk factor for heart disease. It is a preventable and treatable cause of heart disease and should be aggressively treated to target levels to prevent heart attacks. High blood pressure also increases the chances of stroke and heart failure.

Diabetes: The risk of heart disease is so great in diabetes that it is called coronary artery disease equivalent. It is just the prolonged excess of sugar in the blood that after certain time damages the arteries and nerves and causes various disease spectrums of diabetes. One may be diabetic without realizing it, that is why it is important to get the blood sugars checked regularly even in non-diabetic individuals.
                Patients with diabetes have 2-8 folds higher risk of heart disease and heart attacks as compared to age matched non-diabetic individuals. Heart disease is responsible for three fourth of deaths in diabetics. The main keys for the prevention of diabetes are physical exercise and weight reduction.

Obesity: The excessive fat in the body leads to obesity and causes significant health impairment. The obesity is simply measured by body mass index (BMI), which is weight in kilograms by square of height in meters. The normal values are 18-25, if it is more than 25 it is overweight and if more man 30 it is obesity. The Indians have typically central obesity, which means fat distribution is mainly around waist and it is called apple-shaped obesity. The risk if heart disease is more with apple shaped obesity as compared to pear shaped obesity, where fat is more around thigh and buttocks. The obesity is a health hazard and 31 % of urban Indians are either overweight or obese. The obesity or weight gain is controlled by lifestyle changes mainly in forms of diet modifications, physical activity and behavioral modifications.

Dyslipidemia: High cholesterols are another enemy for our heart. The bad cholesterols are increased due to dietary habits or genetic makeup. They start accumulating in arteries and progress to coronary artery disease. The more important thing is that average values may not be necessarily normal, which means it is not always number which matter, the quality of cholesterol matters more.

                There are some other risk factors for which we cannot do much like age, sex, and family history. These things cannot be changed, but development of heart disease can be halted by various life style modifications. The most important being healthy diets, regular exercise and no smoking. Regular health checkups and control of blood pressure and blood sugars are the need of hour to prevent heart attacks.

Preventing heart attack:

1.Improve cholesterol: People with at least 2 risk factors or a disease equivalent like diabetes should aim for LDL levels of less than 100 mg/dl.

2.BP control: People in normal health should aim for 130/80 or less. Patients with certain health problems, such as diabetes and kidney disease should aim lower.

3.Exercise, normal individuals should engage in at least moderate physical activity for a minimum of 30 minutes on most if not all days of week.

4.  Healthy Diet-Diet should contain healthy balance of fruits, vegetables, grains, fish, nuts, legumes, poultry and low fat diary items. One should avoid saturated fats and trans- fatty acids.

5. Quit smoking and avoid second hand smoke.

6.Maintain ideal body weight and aim for BMI of 18.5 to 24.9.

7. Aspirin: People whose risk for heart disease within 10 years is 10% risk or more (evaluation can be done by your doctor from Framingham charts) should take low dose aspirin every day, unless they have medical reasons to avoid it.

8.Control diabetes: People with diabetes should aim for fasting glucose of less than 100 mg/dl and HbA1C less than 7%.

Dr TP Singh
Chief Consultant Cardiologist,
SGHS Hospital, Mohali
Mobile No : 09872421946


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