As we all know heart attack is a big killer continues to be so despite advances in the treatment options and technology becoming more accessible and affordable. Public awareness about lifestyle modifications and seeking treatment on time can help reduce the mortality and morbidity associated with heart attacks. And this mortality and morbidity of heart attacks mainly affects young earning population and affects young families and society and nation as such. So it is important that we cardiologists try to educate public regarding heart attacks , its prevention and disease as such so that public can seek medical help timely and avert a potential catastrophe. That is the background of this article. Preventive measures had been discussed in this forum before and hence I am not going to elaborate on that here, instead I shall try to detail about the disease symptoms and available treatment options .
Who all can develop heart attack?
Potentially anyone!
But more commonly men than women, especially after 45 years.
Smokers ,sedentary people with less exercise , diabetic patients, people with high BP or cholesterol (despite all the social media controversy regarding cholesterol , it’s still a major risk factor),or with family history of heart attacks are more more prone to develop heart attacks .
Is heart attack different from “blocks’?
Heart attacks develop in patients with blocks in coronary arteries ( blood vessels supplying heart muscles ). But very rarely heart attacks can develop even without blocks , but that is very rare and we need not discuss that in detail as it’s very uncommon . And all blocks need not develop into heart attacks .
How does a block present ?
As we have seen all blocks may not cause heart attacks. A lot of them could be asymptomatic as they may be too small to produce a reduction in blood flow and hence symptoms . Sometimes patients may get used to a block developing over years and may be asymptomatic for long time till heart is significantly compromised.
Symptomatic blocks may present like
Effort related angina
Unstable angina ( minor heart attacks )
NSTEMI ( intermediate heart attacks )
STEMI ( major heart attacks)
Heart failure
Sudden cardiac death
What are the symptoms of blocks ?
Effort related angina mostly presents like central chest pain or heaviness occurring after a brisk walk or heavy exertion. Sometime it could be like a squeezing like sensation or burning in chest. Same symptoms may radiate to jaws , throat upper back or arms or sometimes appear alone in above mentioned areas. There could be another group , totally asymptomatic , or having shortness of breath on exertion which is taken as ‘normal’ for age. They can be diagnosed with a stress test . TMT is the commonly used stress test in our part of the world. But TMT can miss 25% of such blocks and report as negative (normal ) despite blocks . Angiogram is the test to diagnose such blocks , but we don’t do it on asymptomatic patients , that is the reason to emphasize on the importance of preventive lifestyle modifications .
Same symptoms occurring at rest is termed a heart attack. A discomfort lasting less than 30 minutes is defined as a minor or intermediate heart attack ( depending on changes in ECG or blood tests ). A major heart attack will have symptoms lasting more than 30 minutes. Occasionally patients may feel only extreme fatigue, profound unexplained sweating or shortness of breath alone without pain. All these symptoms warrant an emergency medical help.
When should one seek medical help ?
Patients with effort related symptoms can electively take an appointment and consult his doctor .
Anybody with symptoms occurring at rest (heart attack) should seek medical help urgently , and if available should go to hospital in an ambulance .
Who all need angioplasty or surgery ?
Patients with exertional symptoms ,(angina or shortness of breath due to heart failure ) or asymptomatic patients with positive TMT can undergo an elective coronary angiogram. If blocks are in the proximal part of major blood vessels ( towards the origin of blood vessels) they will have to undergo angioplasty or bypass surgery depending on the type and number of blocks. If blocks are in small branches or distal part ( towards the end) of a major blood vessel, blocks can be treated medically in such patients.
Patients with major heart attack needs to undergo angiography and subsequent angioplasty on an emergency basis , ideally within 90 minutes of reaching hospital. Major heart attack happens when a vessel is 100% blocked and every minute delay is killing heart muscle supplied by that blood vessel and causing permanent irreversible damage. A delay can cause heart pumping failure and can cause heart failure later on .
Patients with minor or intermediate heart attacks can wait for 24 to 48 hours before undergoing an angiogram and need subsequent angioplasty or bypass surgery depending on the nature , type and number of blocks.
Are the stents for life ?
New generation stents are have excellent long term patency , but still there can be around 2% stent failures. And patients with stents need to be on medications for life term to keep it open.
Do patients need medicines after angioplasty or surgery ?
Anybody developing a block has an inherent tendency , genetic and acquired, to develop blocks and they run a lifetime risk of developing blocks in same or other blood vessels and hence they will need lifetime medications to prevent further blocks and to maintain patency of stents and grafts .
What is new ?
FFR- It is test to assess the functional significance of a block. A positive FFR means a block is significant and needs angioplasty or a bypass grafting. It is commonly used in effort angina patients and asymptomatic patients with positive stress test . Heart attack patients don’t usually need this test.
IVUS/OCT – they are like a camera looking inside the blood vessels and help us study the nature and significance of a block and to know how well is stent ‘put’ inside a blocked vessel. It is important because a ‘well put’ stent has a better long term patency .
Concluding a concerted preventive lifestyle modification, prompt recognition of symptoms, and timely management using the optimal technology can help us reduce the burden of this new age scourge which is taking a big toll on humanity.
Dr. Joby K Thomas
MD, DM
Consultant Cardiologist
Carithas Hospital
Thellakom, Kottayam