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Protect Your Heart Now

Stay safe with this advice from a leading expert  

By Dr Ashok Seth  

India has the highest incidence of heart attacks and death from heart disease in the world. While it is the number one cause of death in both men and women, it does not spare the young. According to the National Interventional Council of India, in 2016 more individuals under 40 years went through coronary interventional procedures than ever before.

Coronary artery disease (CAD) catches up often with those who smoke, are obese and have a sedentary lifestyle. Other factors like diabetes, high blood pressure, raised cholesterol levels and a family history of heart disease can further add to the risk.

The first presentation of a heart condition could be angina, which is discomfort or pressure in the chest on exertion while walking or climbing stairs, caused by a blockage in arteries supplying blood to the heart. Angina symptoms may differ for women: shortness of breath with or without chest pain or pressure, dizziness, sweating, nausea and pain or discomfort in the jaw, neck, back, arms or the stomach.

 

When to see a doctor

Do not skip regular check-ups, if you have a family history of CAD. In case of angina-like symptoms, see a doctor who will use your medical history and electrocardiogram (ECG) to determine if the pain is musculoskeletal or cardiac in nature. Get help if you experience sudden severe, prolonged chest discomfort, similar to compression or indigestion, combined with sweating and pain radiating down the left arm to rule out a heart attack.

 

Tests for CAD

An ECG is the basic test. An echo Doppler examination [also known as an echocardiogram] of the heart is also advised. It demonstrates the efficacy of the heart muscle as well as the functioning of the valves. Both ECG and echo Doppler become abnormal in advanced heart disease or during heart attacks, hence a normal ECG and echo does not exclude CAD.

A treadmill test (TMT) or stress test is done for patients to confirm angina symptoms. Stress echo or exercise thallium scans are more accurate non-invasive tests and may be needed for a more definite diagnosis.

If tests point to risky blockages then a coronary angiogram is advised. This is performed in the cath lab under direct X-ray vision and involves puncturing an artery in the groin or wrist, under local anesthesia, and the insertion of a fine catheter into the arteries of the heart. Then, a dye is injected into the arteries of the heart and X-ray films are recorded to look at the extent and severity of the blockages. This involves hospitalization and is a relatively safe and painless investigation in expert hands. Those who have already had a heart attack usually undergo an echocardiogram and coronary angiography directly.

 

Treatment options

There are a variety of options if blockages are seen during an angiography. One of them is 'optimal medication' (blood thinners like aspirin, statins or cholesterol-lowering drugs, nitrates or drugs that dilate blood vessels and beta blockers or drugs slowing down heart rate, etc).

Other options include performing an angioplasty with medicated stents or a bypass surgery. These procedures are usually considered in patients who have troublesome symptoms of angina or recurrent unstable angina with a threat of a heart attack.

During an angioplasty, the blockage is opened up non-operatively with a 'balloon', and a nitinol/stainless steel spring-like medicated device (stent) is implanted to keep the artery open. This is performed like an angiography and done in the cath lab under local anesthesia. The patient is usually discharged the next day. In a bypass surgery, veins from the legs or other arteries from inside the chest wall (mammary arteries) are attached to the heart to create an alternative path (flyovers) so that the blood can get to the heart muscle beyond the blockages. This involves an operation with a week-long stay at the hospital.

Blockages are considered serious if their extent is more than 70 per cent and involve one or all or more of the three main arteries of the heart. If, however, they are less than 70 per cent or involve any of the smaller branches, the doctor could advise medication and aggressive lifestyle modifications under medical supervision and regular check-ups.

 

When surgery is necessary

While specific decisions may differ on a case-by-case basis, angioplasty is preferred if there are critical blockages of more than 70 per cent in the main segments of one or two arteries of the heart. Stents should not be implanted when the blockage is less than 70 per cent, unless tests indicate that it is the cause for troublesome angina or a heart attack.

A bypass surgery may be considered if the three main arteries are critically blocked. It is also a better bet if there are multiple or long blockages in a patient with conditions like diabetes.

Emergency angioplasty is the most beneficial and life-saving treatment for a heart attack if instituted within 12 hours, as it limits damage and prolongs life. For stable CAD treatment, if an angioplasty or bypass surgery is advised, but there is no threat of an immediate heart attack or the blockage is less than 90 per cent, then usually there is no need to have the procedure performed at the same sitting.

In some cases, angioplasty at the time of angiography adds to a patient's convenience and ease. It can help avoid repeat angiography procedures and may also reduce the cost. However, it does not give the patient or relatives enough time to consider all the options or get a second opinion.

 

Make an informed decision

Your doctor should always encourage a second opinion. You should take an informed decision, based on a knowledge-based discussion. It is alright to take a few hours or even days to seek opinions and arrive at a considered decision in non-emergency cases. On the other hand, it is also important to trust your doctor and understand that a situation could be truly critical and life-threatening. In such a case, a delay of a few days may be risky. It is then advisable to consult another doctor or make up your mind within a few hours.

Research and advances in lifestyle modification and medication have proved to be effective in preventing heart attacks and progression of blockages, for treating coronary artery disease. However, when a patient on medication continues to get worse, it is best to seek an opinion for moving on to angioplasty or a bypass surgery. The clear message is to not delay treatment and get timely advice for appropriate investigations and treatment, so that the life-threatening consequence of CAD can be avoided in time.    

 

Dr Ashok Seth is a leading interventional cardiologist and chairman of Fortis Escorts Heart Institute, New Delhi. He has been awarded the Padma Shri and Padma Bhushan for his contribution to medicine.

 

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