While the country remains busy either battling infections such as AIDS and TB, or battling mosquito borne diseases such as dengue and malaria, there is a silent killer lurking in the background, and striking the middle aged people with striking impunity in their most productive years. The menace goes by the name of coronary artery disease (CAD) With India set to become the diabetes capital of the world, there is no doubt that this menace of coronary artery disease is here to stay.
Coronary artery disease (CAD) is the most common form of heart disease. In CAD deposits of a fatty substance called plaque block the coronary arteries, the vessels that bring oxygen-rich blood to the tissues of the heart. As plaque builds, the arteries become narrower and less oxygen and nutrients are transported to the heart. At resting state this decreased supply may be sufficient for heart however in conditions like stress physical or mental demands of the heart increases and during such times this supply is not sufficient leading to problems, such as angina (pain caused by not enough oxygen-carrying blood reaching the heart) and heart attack. In a heart attack, or myocardial infarction, there is such poor oxygen supply to the heart that part of the heart muscle dies. If a sufficiently large portion of the heart is affected, it may no longer be able to pump blood efficiently to the rest of the body, resulting in condition termed chronic heart failure i.e. longstanding inefficient functioning of the heart.
As simple as it sounds detection of heart attacks/ coronary artery disease can be really challenging at times. This is because the classical chest pain of heart attack isn’t that common anymore. These heart attacks/coronary artery diseases can present with variety of complaints, hence a doctor has to always bear in mind the possibility of CAD. At times the complaints can be misleading too, for e.g. a young guy in his twenties with complaints of left sided chest pain, very high possibility of these due to acidity; however complaints of acidity in an elderly person could be due to CAD. This is just to emphasize how variable the presentation could be.
So what are signs or clues that point towards CAD?
Typical angina (chest pain due to CAD) is not always an actual pain, but it’s a heaviness or tightness in the centre of chest which might radiate (move) to both shoulders, left shoulder, neck, jaws, upper back or even teeth. Patients often describe this pain as pressure like sensation, like ‘100 elephants are stamping on their chest’. One important point to mention is this pain is associated with exertion like while climbing stairs. Patients complain – earlier I used to walk for a mile without any discomfort but lately I feel some chest discomfort even after walking for half a mile.
Anybody who gets discomfort or heaviness in the centre of chest when he / she walks uphill, climbs staircase hurriedly, rushes in hurry to catch up with a train or bus or after walking post lunch or post dinner is an angina. Those who get this type of discomfort feel relieved when they rest for a while or take sorbitrate tablet. Sometimes rest and sorbitrate tablet might succeed in aborting these episodes signifying bad underlying coronary artery disease (BLOCKS).
Patients with such presentation warrant further evaluation in the form of tests such as ECG/ 2D ECHO/ Stress Test/ Stress ECHO/ Coronary Angiography, details of which are discussed in subsequent chapter.
Is Every Chest Pain “Angina?”
No, not all chest pain originates from the heart, and not all pains from the heart mean angina. For example, if the pain lasts for less than 30 seconds or if it goes away during a deep breath, after drinking a glass of water, or by changing position, it almost certainly is NOT angina and should not cause concern. But prolonged chest (retrosternal) pain, unrelieved by rest and accompanied by other symptoms (refer the table above) may signal a heart attack.
What is the difference between angina and heart attack?
If angina persists for more than 30 min with sweating, vomiting, shortness of breath, ECG changes, then it is said that angina has got culminated into a heart attack. Angina is fore-runner of Heart attack.What is common non cardiac pain causing panic situation or anxiety of heart attack?
Many cautious/over cautious people, but who are actually unaware of classic cardiac symptoms rush to see a cardiologist / physician for chest pain which is localized towards left side of chest. They can actually point a finger or two to left nipple side for the localized pain. Those pains which are localized to the left side of the chest, even though major part of the heart, is never cardiac pain.
And if you press at a particular point and patient winces with pain, then that is again a non cardiac pain. It is mostly because of muscle aches in response to some local insult which might go unnoticed.
When do heart attacks occur commonly?
Heart attack occur early in the morning commonly between 3.00 – 5.00 am and during day time when there is a peak of mental -physical stress.
What age is common for heart attack?
Heart attacks are common above 45 years of age in males and 55 years of age in females. But no age is immune for heart attack. Heart attacks can occur at any age.
Why do even fitness freak people or otherwise in general also people develop heart attack immediately after exercise?
Those who have underlying signs of high grade Coronary Artery Stenosis / block have decreased exercise performance. They limit their lifestyle in accordance to it and might not have angina / chest pain, despite this. But when these people are made to exercise under supervision on a Treadmill, the stress test comes positive giving the justification of underlying cause.
Those individuals who are athletes have no exertion-related angina, negative stress test and nil positive on clinical / biochemical analysis. They might still have non flow limiting / non obstructive plaques. Any percentage of blocks which is less than 50 – 70% might not cause symptoms of angina and the person might pass out all the test results and might be certified as fit physically. It depends on the plaque morphology. Those who have underlying co-morbid factors like smoking, abnormal lipid/fat levels, high blood pressure, strong family history etc. might have some instability (pulpiness) into that plaque (unstable plaque). These plaques rupture all of a sudden, even when they are minor, especially when there are wide fluctuations of blood pressure, pulse rate, physical dynamics and blood flow dynamics. This is similar to a very gentle push to a healthy person who is standing on a cliff of a mountain. Otherwise if a person is standing on a flat safe torrent gentle push will never cause catastrophe. So there has to be some or the other underlying cause for development of certain heart attacks in a person who is completely physically fit and who has completed physically challenging jobs / tasks without any symptoms.
Those individuals who suddenly halt after sudden severe physical activity can have wide fluctuations of heart rate and blood pressure. In addition to this, the metabolites of muscle metabolism come up suddenly in circulation causing Coronary Artery spasm or plaque rupture. This, in turn, causes an event called “Coronary Thrombosis”. Some individuals develop 100% block into the Coronary Artery because of this. Sometimes, some patients develop a condition called sudden onset / Acute Coronary Dissection causing similar cascade of events, leading to blood clot formation at that site. This is how heart attack develops. It is very difficult to diagnose or anticipate the person at risk of such an event by non invasive tests. Recently there is a study being carried out worldwide to pick up such risk individuals by a method or technology called as non invasive FFR (Fractional Flow Reserve). This method is shortly going to get introduced into the clinical practice in India. Currently we have invasive counterpart of this, but the problem with both invasive and non invasive part would be the cost involved in it. We have some other important but not very specific markers to pick up like Carotid Intima thickness (thickness of the Carotid Artery wall) to judge the risk of such an event.
What are plaques?
Fatty substance called as plaques which are responsible for narrowing of arteries resulting in BLOCKS in medical parlance termed as atherosclerosis. Atherosclerosis is a systemic process and affects the complete body. It is a continuous and insidious process which actually starts when we are born but its effects are not seen until wear and tear reaches a particular level to hamper the blood flow to vital organs. In the process of atherosclerosis lipids (fats) get deposited onto the surface of the internal linings of the blood vessels causing speed-breakers (blocks) due to the gradual heaping of fat. When fat deposits some portion of these speed breakers gets ruptured or denuded causing roughage where the circulating blood cells chiefly platelets and RBC, s settle down by forming clumps. Sudden formation of blood cell clot/clump impeding the circulation to a sector/s of heart pump is called as heart attack and if not treated this causes permanent damage to the heart. It’s always better to prevent this thing happening rather than facing emergency situation as an effect of this.
Atherosclerosis starts when we are born but it takes a leap during adulthood. It can affect arteries of heart (Coronaries), brain (Carotids, Cerebral and Vertebrals), kidneys (Renals), thoracic cage (Aorta), abdomen (Aorta), lower limbs (Femorals, Popliteals, Tibials etc). It can lead to Heart Attack, Stroke, Kidney Failure, Gangrenes of limbs.
Certain notions/ misconceptions regarding heart attacks: People feel that first heart attacks are usually mild, second more serious and third as the final call heart attack. Actually severity has no correlation with the number whether it’s a first, second or a third heart attack. First heart attack can be lethal life threatening. Every heart attack has a potential of threatening the life.
What is Heart Failure?
Heart failure is not complete stoppage of heart pumping, but it means significant drop in forward pumping of blood by heart into circulation. As an effect, blood/fluid gets pooled in lungs.
Breathlessness after a heart attack/heart failure can be due to filling of watery fluid into the lung spaces (alveoli-bronchioles).It may give whitish or sometimes pink frothy sputum when a patient coughs. Sudden froth at mouth or nostrils or chest pain followed by cold feel of the body may signify a massive heart attack.
It’s the greatest killer disease of present times. India ranks second in world at present and by 2020 we will rank first in heart attack incidence and so also in diabetes mellitus world over. Whenever a person develops heart attack the greatest challenge is reaching a proper facility in time. All of us should be aware of symptoms of heart attack by now.