What is heart attack?
Heart Attack or Myocardial Infarction (medically called MI or Coronary Thrombosis) is the consequence of the complete obstruction of Artery that supply blood to a part of the heart muscles. This occurs due to a 100% blockages in any of the coronary arteries or their branches. The heart muscles are completely deprived of their blood and oxygen supply which leads to the death. The severity of the heart attack would depend on how much area of the heart muscle is actually involved. It is mild, if only 5 to 10 % area is involved and most of the patients survive. But if the dead area is more than 30 to 40 % of the heart muscles, the attack is considered severe, and if not managed properly and immediately, can even lead to death.
High Blood Pressure
Another name for high blood pressure is hypertension. (High blood pressure means the pressure in your arteries is consistently above the normal range. Blood pressure is the force of blood pushing against blood vessel walls. It's written as two numbers, such as 122/78 mmHg. The top, systolic number is the pressure when the heart beats. The bottom, diastolic number is the pressure when the heart is at rest. High blood pressure is a consistently elevated pressure of 140 systolic or higher and/or 90 diastolic or higher. No one really knows exactly what causes most cases of high blood pressure. It usually can't be cured, but it can be controlled. Millions of Indians (1 in 4 adults) have it, and many don't even know they have it. Not treating high blood pressure is dangerous. You can live a healthier life if you treat and control it! High blood pressure usually doesn't have any signs-that's why it's so dangerous. Make sure you get it checked regularly and treat it the way your doctor advises. Who is at higher risk?
  • People with close blood relatives who have it
  • People over 35
  • Overweight people
  • People who use too much salt
  • People who use too much alcohol
  • Women who take birth control pills
  • People who aren't active
  • Pregnant women
How can I tell I have it?
  • You usually can't tell! Many people have it and don't know it.
  • The only way to know if your blood pressure is high is to get it checked regularly by your doctor.
What can untreated high blood pressure lead to?
  • Stroke
  • Heart attack
  • Heart failure
  • Kidney failure
What can I do about it?
  • Lose weight if you are overweight.
  • Eat a healthy diet that is low in salt and fat.
  • Be more active.
  • Take medicine the way your doctor tells you.
  • Know what your blood pressure should be and work to keep it at that level.
How can medicine help?
  • Some medicines help relax and open up your blood vessels so blood can flow through better.
  • A diuretic can help your body from holding too much water and salt.
How can I learn more?
  • Talk to your doctor, nurse or health care professional. Or call your SAAOL Heart Center Tel: 6235168, 6283098, 6211908.
  • If you have heart disease, members of your family also may be at higher risk. It's very important for them to make changes now to lower their risk.
Pet Scan
PET Scan is the latest non-invasive investigation to ascertain coronary artery disease progress or the reversal of blockages. Dr. Dean Ornish used this investigation to show that reversal in the blockages of the coronary arteries of his patients had occurred. This extremely expensive and sophisticated investigation is available in a few centres only of the world. The patient is made to lie down on a table which is introduced into the scanner and sectional pictures are taken of the heart. A coloured graphical representation of the blood flow throughout the heart can also be obtained giving an accurate idea of the blockages present. The PET Scan Machine costs around Rs.15 crores and is not as yet available in our country.
Acceptence of Heart Attack
If the above is the cause of heart attack, one can easily interpret that the sole cause of the heart attack was the growth of the fatty blockage in majority of the cases. If the growth of the blockages is not allowed, the covering membrane would never burst. What should ideally be done by any doctor, is an advice to modify the risk factors of heart disease, namely the low fat food, regular exercise, stress management, Yoga, weight reduction, control of high blood pressure and diabetes. Unfortunately, this is not coming from the cardiologists and big Heart Institutes. Most of these doctors have accepted the fact that one day or the other the heart attack has to come. So rather than prescribing the proper lifestyle they prefer prescribing only symptomatic medication. More often they have accepted this eventuality. I don't know whether this helps them in their practice or not, but it will never help the patients who have to suffer. Surprisingly, the patients also have accepted the fact that even after taking all these medicines and surgery they may still have a heart attack. There is a general tendency amongst the heart patients to ask their cardiologists for residence numbers or mobile phone numbers so that in case of heart attacks they can reach the doctors without delay. They do not know that they may not have a heart attack if they completely change their lifestyle.
Bypass Surgery
What Is Coronary Bypass Surgery? Coronary Artery Bypass Surgery is a major heart operation of by passing the blocked arteries in the heart by putting veins removed either from legs of patients or any other part of the body so that blood can flow through the new arteries to the heart the way it should. Almost half a million Coronary Bypass operations are performed each year, which are expensive costing between 1.5-2 lacs. This surgical procedure is only a temporary solution as half of the patients come back with reblockages within 3-5 years. How is it done?
  • Your doctor will take a blood vessel from your chest or from your leg.
  • One end is attached to your aorta (the large artery that comes out of the heart), and the other end is attached to the coronary artery below the point where it's clogged.
  • Blood can now flow through the new channel to the heart.
What is surgery like?
  • You will be asleep during the operation. It can take 3 to 6 hours.
  • After surgery, you go to an intensive care unit (ICU) for several days.
  • Your family can visit you briefly in ICU.
What about after surgery?
  • You'll wake up in ICU and may feel confused at first.
  • It's busy in ICU and the lights are always on. It's normal to lose track of time.
  • You'll have a tube in your mouth and throat to help you breathe. It's uncomfortable and you can't talk with it, but nurses will help you communicate.
  • The breathing tube will stay in until you can breathe on your own - in about 24 hours.
  • You'll be hooked up to many tubes and wires.
How can I learn more?
  • Talk to your doctor, nurse or health care professional. Or call SAAOL HEART CENTER, 6235168
  • If you have heart disease, members of your family also may be at higher risk. It's very important for them to make changes now to lower their risk.
Angina is the chest pain or discomfort that occurs when your heart doesn't get as much blood and oxygen as it needs. Over time, the coronary arteries that supply blood to your heart can become clogged from a buildup of cells, fats and cholesterol. This buildup is called plaque. If one or more arteries are partly clogged, not enough blood can flow through, and you can feel chest pain or discomfort. Angina may not cause long-term heart damage; it's a sign of heart disease. When a clogged artery keeps the heart from getting enough blood and oxygen, angina can occur. What does angina feels like? Angina usually lasts for just a few minutes. Here's how people say it feels:
  • Chest feels tight or heavy.
  • Hard to breathe.
  • Pressure, squeezing or burning in chest.
  • Discomfort may spread to arm, neck, jaw or back.
  • Numbness or tingling in shoulders, arms or wrists.
When will I get angina? You may get angina when you:
  • Climb stairs
  • Carry groceries
  • Feel angry or upset
  • Work in very hot or cold weather
  • Have sex
  • Have emotional Stress
  • Exercise
  • Combine any of these
What tests might I have?
  • Blood tests
  • Electrocardiogram (EKG or ECG)
  • Treadmill exercise test
  • CT Coronary Angiography or Scan - 128/64 slice
  • Cardiac catheterization, which shows where the artery is blocked
How is angina treated? Your doctor may give you nitroglycerin, a medicine to relieve the discomfort. Nitroglycerin:
  • Comes as tiny tablets you put under you tongue, and as spray, capsules, skin patches and ointment.
  • Is safe and not habit-forming.
Be sure to ask you doctor, nurse or pharmacist about:
  • What to do if you get angina
  • How to use your nitroglycerin the right way
What can I do about angina? Don't give into it! You can change your way of life and lower your chance of having angina attacks. A few simple steps can help you feel more comfortable every day. They are:
  • Stop smoking.
  • Eat healthy meals
  • Control high blood pressure and blood cholesterol level
  • Learn to relax and manage stress.
  • Avoid extreme temperatures.
  • Avoid strenuous activities.
  • Call your doctor if your angina changes. For example, if you get angina while resting or if it ever gets worse.
What can I do about angina?
  • Talk to your doctor, nurse or health care professional. Or call SAAOL Heart Center Tel: 6235168, 6211908, 6283098.
  • If you have heart disease, members of your family also may be at higher risk. It's very important for them to make changes now to lower their risk.
Heart Attack
Every 33 seconds, someone dies from heart and blood vessel diseases, India's number one killer. Since most of those deaths are from heart attack - it's important to learn all you can about heart attack. Don't ignore heart problems. It's a matter of life and death! For example, you should know the warning signs so you can get help right away, either for yourself or someone close to you. Acting quickly can save many, many lives! Get help fast if you feel any of these signs:
  • Uncomfortable heavy feeling, pressure, pain or squeezing in the center of your chest that lasts more than a few minutes.
  • Pain that goes to your shoulders, neck or arms
  • Discomfort in your chest along with a light head, fainting, sweating, nausea or shortness of breath
What causes heart attack? Another name for a heart attack is myocardial infarction) - "M.I." for short. It occurs when the blood flow to a part of the heart is blocked (often by a blood clot). This happens because coronary arteries that supply the heart with blood slowly become clogged from a buildup of cells, fat and cholesterol called plaque Blood that tries to flow through these clogged arteries can form a clot. If this clot cuts off the blood flow completely, the part of the heart muscle supplied by that artery begins to die. How can I recover?
  • Depending on the extent of your heart attack, you may only be in the hospital a few days. But your recovery is just beginning.
  • It's very important to start taking steps now to get your heart in good shape and to avoid another heart attack. Eat a healthful diet, exercise, and if you smoke, quit.
  • Talk with your doctor and nurses about how you can live as normal a life as possible. Ask how soon you can go back to work, drive a car, have sex, and what to do if you have chest discomfort. Your doctor or nurse can answer your questions about other matters, too.
How can I avoid a heart attack? Even if you have heart disease, there's a lot you can do to improve the health of your heart. Making changes can prevent a heart attack. Ask your doctor or nurse for help and information about how to change.
  • Don't smoke.
  • Treat high blood pressure if you have it.
  • Eat a diet that's low in fat, cholesterol and salt.
  • Eat lots of fresh fruits and vegetables.
  • Exercise.
  • Keep your weight in the normal range.
  • Follow your doctor's orders for taking medicine.
  • See your doctor for regular checkups.
  • Control your blood sugar if you have diabetes.
You can help prevent a heart attack! You must control your blood pressure, stop smoking, eat a healthful diet, exercise and know the warning signs! How can I learn more?
  • Talk to your doctor, nurse or health care professional. Or call your SAAOL Heart Center. Tel: 6235168, 6283098, 6211908.
  • If you have heart disease, members of your family also may be at higher risk. It's very important for them to make changes to lower their risk.
Interesting-Facts about the Heart
Investigation the rate of deposition of cholesterol in the lining of the blood vessels or the breakdown of the deposits (reversal of blockages) can be predicted. The normal values of these tests are given in the table below, but I would always recommend people not to keep their value at the upper end of the range but to keep them at the lower end. For example, if the range of Cholesterol is between 130 to 200 mg/dl - it is good to have a value which is near to 130 mg/dl. This becomes more important for those who already have blockages in the heart arteries or those who have other risk factors which they cannot control, due to circumstances. Normal Range
  • Cholesterol                         130 to 200 mg/dl
  • Triglycerides                       100 to 160 mg/dl
  • HDL (good) Cholesterol       30 to 60 mg/dl
  • LDL (bad) Cholesterol          50 to 120 mg/dl
  • VLDL Cholesterol                 12 to 35 mg/dl
Unfortunately enough, I have been seeing numerous heart patients being prescribed all sorts of blood tests in the cardiology hospitals other than this most important blood test. Even angiographies and bypass surgeries are being done on these patients without even looking at the lipid profile. It is a routine procedure to collect so many blood samples in the hospitals from heart patients and do tests like Australia Antigen, AIDS Sero Tests, Urea, Creatinine, Total and Differential blood Counts, Urine Tests.... and so on. Most of these tests are done in order to prepare the patients for procedures called Bypass surgery or Angioplasty. I have seen lipid profile reports still missing. Lipid Profile Report Since the heart disease is caused by fats, which is existing in different forms in the blood stream - heart patients are recommended to get a Lipid Profile Test. This is a blood test where the parameters usually tested are - Cholesterol, Triglycerides, HDL Cholesterol (good Cholesterol), LDL Cholest erol and VLDL Cholesterol. Blood has to be collected after 12 hours of fasting in this test.
Tmt or Stress Test
It is common to find heart patients who have normal ECG. One must remember that the ECGs are taken at rest when the heart is beating at its lowest rate. Even with 90% blocks the patients can have a normal ECG. In such cases the patient would also agree that at rest there is no pain in the chest, the angina symptoms would only come when they increase the heart rate, while doing some physical exertion like walking.
This is the condition where we need a TMT test. The patients are to gradually increase their heart rate, thus increasing the blood requirement of the heart muscles. Simultaneously ECG records are taken. If there is a blockage of approximately more than 70% ECG shows changes, suggestive of Angina.
Patients have to physically exert for this test which uses a computerized machine. The level of the exercise is gradually increased according to a standard protocol called the Bruce's Protocol. The continuous ECG monitoring during the exercise would reflect any blood and oxygen deficit in the muscles of the heart during exercise. The patient is asked to stop exercising as soon as ECG changes appear or any symptoms of chest pain or discomfort or breathlessness are felt.
TMT test is also called Exercise Stress Test, Computerized Stress Test or simply Stress test. This is the most easy, popular and common test performed on heart patients to determine the severity of the heart disease. Taken at an interval, this test can also show the improvement or deterioration of patient's angina.
A negative TMT or Stress Test is declared when the patient can reach a certain heart rate without showing any ECG changes. This rate is called a target heart rate and is calculated by a formula (Target Heart Rate = 220 - age of patient). If this rate is reached by the patient without producing any ECG changes, though the TMT can be called negative, but it would not mean that the blockage is zero. It will only mean that the person performing the test probably has a blockage less than 70%.
Cause of Attack
Almost all the heart attacks are sudden in onset and the cause is a rupture of the growing blockages. The blockages are usually covered by a thin membrane called Intimal membrane, which also keep the deposits intact. This elastic membrane gets more and more stretched as more and more fatty deposits occur. But if the fatty deposits continue below this permeable membrane, one day the time will come, when the membrane cannot stretch further and breaks off. This leads to the formation of a clot or thrombus inside the tube, closing the lumen completely. This completes the process of heart attack. The area of the myocardium (heart muscles) which gets the blood through the closed artery, dies - in the event of no blood supply.
Heart attack, often occurs after a heavy meal full of fat, after sudden anger or excessive sorrow or grief or excessive stress. Heart attacks occur more frequently in the early mornings. Heart attacks also occur during the process of Angiography and Angioplasty when the catheter or balloon is inflated and completely blocks the lumen of the coronary artery or breaks off the blockage by mechanical means.
Angiography:The Procedure
In Angiography, a long wire called catheter is inserted inside the artery of the leg, near the thigh crease. This catheter is then pushed against the blood flow towards the heart blindly. With a view of the tip of the catheter on the fluoroscopy monitor (which exposes the patient to very heavy radiation) this catheter is pushed onwards by trial and error method. If it gets stuck somewhere on the route, it is withdrawn a little and again pushed in. Not only it scratches the whole length of the arterial tubes of the body but it can also puncture any corner of the tubes. Once the tip reaches the heart area, further manipulation is done to push the tip in one of the coronary arteries. Once inside the coronary tube, after a lot of trial and error, a radioactive dye is injected through the hole in the catheter inside the coronary tubes and further fluoroscopy photographs are taken. The tip of the catheter is again withdrawn, negotiated inside another coronary tube and the same photos are taken. If the dye seems to fill up the coronary tubes completely, the blockages are probably not there. It the dye can not fill the tubes (as roughly seen in the photos taken) inside, it is taken as filling defect and indirectly interpreted as blockages. The viewer mostly puts a rough percentage. This report, being an eye estimation is given as 70%, 80% and so on. It varies from one viewer to another. It also depends on the timing of the photograph (best is before the dye is washed out), angle of the photograph etc. and is thus amenable to lot of different reports. It is not at all accurate and thus given in variations of 10%. One of my patients came to me the other day and told me that in the last two days he has already reversed his heart blockage by 10%. I asked "By what method"?. He said- "the second cardiologist told me that the blockage was 70%. Till now it was 80% according to the first cardiologist!" Accuracy of Angiography All the time you must have noticed the blocks are reported on 70%, 80%, 90% and so on. Why should they jump by 10% each time! This only shows how rough estimates are generalised and made a round figure. Ten to twenty percent variations are also there depending on the individual bias or variability of the cardiologist concerned. Angiographies are casually performed in India in most hospitals and are highly inaccurate. One day one patient told me "Sir, only yesterday I did 10% reversal of blockage. The cardiologist who I consulted last, said after seeing the film the blockage is not 80% but 70%"
  • Death
  • Myocardial Infarction
    • Factors predisposing
    • Unstable Angina
    • Angina at Rest
    • Recent Sub-endocardial MI
    • Insulin Dependent Diabetes Mellitus
  • Neurological
    • Transient
    • Persistent (Stroke)
    • A-V fistulae
    • Haematomas with Vascular and neural compression
    • Delayed Haemorrhage
  • Local, Brachial and Femoral Complications.
    • Brachial
      • Arterial Thrombosis
      • Median N. Injury
      • Late Arterial bleed
      • Bacterial arteritis
      • Local Cellulitis, Phlebitis
    • Femoral
      • Arterial or venous thrombosis
      • Distal Embolization
      • False aneurysm
  • Perforation of the Heart or Great vessels
  • Vaso-Vagal Reactions
  • Arrhythmias and Conduction Disturbances
  • Phlebitis, infection, fever
  • Pyrogen Reaction
  • Hypotension
  • Allergic
    • Shock
    • Hypotension/Anaphylaxis
  • Other Complications
    • Pulmonary edema
    • Pulmonary artery perforation & Pulmonary Hemorrhage
    • Coronary Artery Dissection
    • Cholesterol Embolization
    • Systemic or Pulmonary Embolization of Vegetations
    • Pulmonary Embolism
    • Catheter Entanglement
  • Drawbacks
    • High costs and risks involved
    • Invasive procedure
A simple ECG is the best way to confirm a heart attack. There are very clear cut changes in the ECG of heart patients having heart attacks. The ST segment becomes elevated, which confirms the attack. If there is a doubt about the ECG and the pain/symptoms continue, the patient should be asked to rest and the ECG can be repeated after an hour.
A single ECG curve has five main components - p, q, r, s, t. The space between s and t , called the ST segment can indicate angina, during the recording of the heart beating. ST segment lowering (medical term depression) is taken as a sure sign of angina. T wave inversion is also a sign of Angina.
One must realise a doctor has to get a training of more than five years to analyse the ECG, even then it may be difficult for him to know everything about ECG. It is advisable that a final decision should be taken only after the ECG is seen by a qualified doctor.
ECG is a simple and convenient investigation which can be done at the bed side to observe angina. Breathlessness is felt, if ECG changes appear early in the TMT, then the coronary heart disease is severe, and if the changes appear later they are not so severe.
Confirmation of Attack
During the heart attack the muscles of the heart die, as they are not getting any blood supply. As the Cholesterol Blockages cannot be removed (which form 70-80 %), the blood clot removal is the only source of relief for the patients - who are in the face of losing heart muscles.
Immediate injection of clot busters like Streptokinase, Urokinase (very expensive injections) or drip of Heparin is the only possible remedial measure. If they are able to break the clot ( which usually closes 20-30% of the lumen of the tube), the heart muscles would be able to get at least some blood immediately and will survive if administered within one hour of the attack these injections can nullify almost all the damages of the heart attack. It will still have some effect if given within next five hours. But many a time these injections fail to deliver results. These medicines also have their side-effects like internal bleedings, cerebral hemorrhage, peptic ulcer bleeding and can be dangerous sometimes.
The damaged area of the heart causes a strain on the other live areas of the heart muscles. And it is very essential to avoid further heart attacks. So, after a heart attack, the patients are advised to stay in the hospital for a period of about seven days, the first few days being in the ICCU (Intensive Coronary Care Unit). Here, it is possible to take care of any emergency.
Early mobilisation of the heart attack patient, starting from the fifth day, is the latest concept of treatment. Previously it was seen that heart patients were not allowed any movement for the next one month or so. Now the dictum has changed, as with early movement (walks, exercises) the recovery has been found to be better.