A Family Doctor's Tale - CORONARY HEART DISEASE

DOC I HAVE A BLOCKED HEART ARTERY

Coronary Heart Disease is the second highest cause of death in Singapore after cancer. Many people do not realize that they have poor blood flow to the heart until it is too late. The lucky ones are those who realize the chest pain or discomfort may be related to heart trouble and see a doctor early. If their heart arteries are getting blocked a stent or ballooning of the artery can save their life. A Heart Bypass surgery is done only when 3 or 4 arteries are blocked.
 
Coronary Heart Disease occurs when the coronary arteries become blocked. The blood supply to the part of the heart cannot provide the oxygen and nutrients to the muscles of the heart. The cells in that part of the heart died off and that part of the heart is unable to function. This is called a heart attack.


Coronary Heart Disease can lead to sudden death.


Coronary Heart Disease occurs when
1.there is a blockage of an artery in the heart by a blood clot, piece of fat or air bubble traveling in the blood from another part of the body. This leads to lack of supply of oxygen and nutrients to the heart muscle. As a result the heart cells died leading to loss of function of the  part of the heart.


2. narrowing of the blood vessel due to fat deposit in the walls of the artery supplying blood to the heart. This reduce the blood supply of oxygen and nutrients to the heart muscles cells and reduce its function.


Causes of Coronary Heart Disease are:
1.High Blood pressure-
 Hypertension narrows the arteries of the heart  and causes blockage


2.High cholesterol-
Cholesterol deposit thickens the walls of the arteries, making them narrow and reducing blood flow.


3.Diabetes mellitus
The high blood sugar level thickens the arteries and make the blood thick so that less blood is able to flow through them.


4.Obesity
A BMI of 23.0kg/m² and above increases the risk of getting high blood pressure, diabetes and heart attack.


5.Smoking
Tobacco smoke narrows arteries and reduces oxygen supply to the heart.


6.Drinking of Alcohol
Alcohol can cause liver and kidney damage, increase blood pressure and affect diabetes


7.Stress
Repeated stress, if poorly controlled, can lead to high blood pressure.


Angina Pectoris

It is a early warning sign of a ischemic heart disease.
Angina occurs when the blood supply of the heart is partially blocked either by narrowing of the blood vessel.

1.It occurs during exertion when the supply of the blood to the heart is insufficient to keep up with the increase demands of the heart muscles.


2.It can also occurs when anger or fear can
ses the heart muscles to pump faster to supply the body with oxygen.


3.Stress can also causes spasm of the coronary arteries reducing oxygen to the heart tissues.
4.Smoking can also constrict the blood arteries to the heart.


 The symptoms of Angina Pectoris are:
1. Crushing heavy pain in the sternal area of the chest or chest discomfort lasting 2-10 mins


2.It occurs during exertion, anger or stress


3.It is relieved by rest or taking sublingual
 nitroglycerin.


4. The major sign is ST depression in the ECG (electrocardiogram) during the attack which becomes normal after the attack.


5.Threadmill examination can spark off an attack of angina because of the exertion involved in doing the threadmil.


The symptoms of Coronary Heart Disease are :
1.Crushing heavy (not sharp) chest pains in the mid sternal region of the chest which may radiate to the Left jaw, neck, shoulder and down the inside of the left arm and hand. This pain occurs when not enough oxygen is supplied to the heart muscles. The pain is usually not relived by rest.


2.Breathing difficulty is usually associated with the chest pain due to the lack of oxygen being pumped from the heart to the lungs. The patient finds difficulty in lying and needs to sit up or in a inclined position.


3. Cold sweats may also be associated with the chest pain


4.Paleness of the face due to poor flow of blood from the heart


5.Fatigue and tiredness


6.Confusion,dizziness,


7. Difficulty in movement and speaking




Diagnosis of coronary heart disease is usually confirmed by:
1.History of chest pain and physical examination
2.ECG(electrocardiogram)shows typical features of depression in Q wave, ST segment and raised RS segment. A 12 leads ECG may showed the presence of Coronary heart disease more clearly
3.Threadmil -Features of ECG is enhanced during exertion on the threadmill
4.CAT scan of the heart- anew technology where the complete scan of the heart with the movement of dye through the coronary ateries can show presence of narrowing or blockage of the arteries.
5.Angiogram( cardiac catheterisation)- a small catheter is entered into the artery at the groin.The catheter is guided through the blood vessel to the coronary arteries with the aid of a special x-ray machine. A radio-opaque dye is injected into the artery and its passage is recorded on a screen. Occlusion or narrowing of any of the coronary arteries can be seen.
6.intravascular ultrasound (IVUS) and fractional flow reserve (FFR), may be performed together with cardiac catheterization to obtain more detailed images of the walls of the blood vessels.
6. Blood cardiac enzymes and ESR may be raised.


Any heart attack is an EMERGENCY!
Immediate treatment is urgent!
While waiting for the ambulance, lie the patient in a slightly inclined position.
Give nitroglycerin under the tongue if available.
Admit to hospital as an emergency.
Severe cases are admitted to Cornary care unit(CCU) for constant monitoring of the heart, blood pressure and abnormal rhythm of heart rate.
Risk factors for Coronary heart disease like hypertension, high cholesterol, diabetes must be treated.
Medicine:
--------
Anticoagulants such as warfarin, aspirin, Plavix,should be given to
prevent blood clots .


Vasodilators like isorbide are give to help dilate the artery to the heart


Any abnormal rhythm of the heart must also be treated with medications or pacemaker if severe as damage to heart may affect the conduction of the electrical impulse of the heart to the cardiac muscles.


Because of the psychological effect of a heart attack on the patient, sometimes antidepressant or tranquilliser may be given.


Interventional Procedures:
--------------------------
Once stable the patient may be requred to have a ballooning of the narrowed artery or a stent inserted in the narrowed artery. This can be done during the cardiac catheterisation.
1.balloon angioplasty
balloon is inflated to compress fatty matter in the wall of narrowed artery and dilate the blood vessel
2.Stent:
balloon angioplasty is performed in combination with placement of a stent which is a small, metal mesh tube that provide support inside the coronary artery.
3.drug eluting stents (DES):
Drug-eluting stents contain a medication that is actively released at the stent implantation site to prevent recurrence of narrowing of the artery
4.rotablation
he Rotoblation special catheter, with an acorn-shaped, diamond-coated tip,  spins around at a high speed and grinds away the heavily calcified  plaque on the arterial walls.
5.cutting balloon 
The cutting balloon catheter has a balloon tip with small blades which are activated  when the ballon is inflated. The small blades remove the plaque and the balloon compresses the fatty matter into the arterial wall.


Surgery :
-------------
If the narrowing involved too many arteries, then a coronary artery bypass graft (CABG) surgery will have to be done.


Usually a heart attack patient stays in hospital for 2-4 weeks depending on the severity of his condition.
Mild exercise is started once his condition is stable. Exercise is good for the patient because it helps the blood circulation.
However strenous exercise including sexual inercourse should start until at leaset 4-6 weeks later.
Most patients should be able to drive or fly after 2 months.


Prevention of a heart attack is the same as prevention of a stroke as both involve the avoiding the blockage of a major artery to the brain or heart.


1.Control the Blood Pressure
Have your blood pressure checked at least once a year from the age of 40 years.
If there is high blood pressure, lifelong treatment with monthly checkups will keep it under control.


5.Control the Diabetes
Check for diabetes starting from the age of 40 years. If there are risk factors for diabetes, screening should start earlier.
If there is diabetes, take the medicine or injections regularly.
Monitor the sugar levels daily.
Control the diet.
Check with the doctor regularly.


2.Watch Your Diet
Reduce consumption of fat, high-cholesterol food, sugar and salt.
Take more fruit, vegetables and moderate servings of carbohydrates.
Eat more bean curd, dried peas, dried beans, fish and chicken instead of red meat.
Drink low-fat milk.
Avoid full cream milk.
Avoid alcohol.
Drink less coffee, tea and cola drinks.


3.Don't Smoke
Stop smoking immediately.
Don't start smoking if you are not a smoker.


4.Physical Activity
Regular exercise is good for you.
Do moderate intensity physical activity for 30 minutes such that you sweat and breathe deeply without getting breathless. Examples include brisk walking, swimming, cycling. 


6.Learn To Relax
Have adequate rest especially when you feel tense or tired.
Take up a hobby.
Do relaxation exercises such as yoga or deep breathing exercises.
Time management is important. 


The outlook following a coronary heart attack is generally good. About 80% of patients are alive after 3 years and 70% after 6 years.
The outlook varies depending on the age and severity of the heart attack.
However with new treatment and a healthy lifestyle, the prognosis has improved tremendously.
Medication such as Aspirin or warfarin may have to be taken permanently to prevent a recurrent attack.