Saturday, August 29, 2009

Angina and the 'Coronary Patient'


'Coronary Heart Disease' or better known as 'Ischaemic Heart Disease' is a major killer in Malaysia today.Most will present as 'Angina': described mostly as burning sensation in the centre of the chest following variable degree of physical activity or exertion like climbing staircase, during emotionally stressful situations or at about the climax of a sexual intercourse. For some the chest pain may just be a passing discomfort or mild heartburn lower down in the 'epigastrium' ie near the stomach region. Others may have a choking sensation up the throat or a 'dull' ache around the neck especially at the jaw.

This discomfort may or may not be related and accompanied by a 'numbness' feeling going down the forearm towards the arm, mostly the left but occasionally the right as well, and/or radiates to the back.To compound the problem for us doctors, some 20 per cent, especially in people who are diabetic, and to a much smaller extent those who lead very sedentary and inactive lifestyle, they may not have any symptom at all, to at least bring or push them to get some form of medical attention. Yet to compound the problem further,some 20 % of men would not know they have IHD until they have their first major heart attack.

I used to tell my friends and patients, for us men, as an imperative and incentive towards 'good adab and behaviour'[ sorry Friends , I cannot remove the 'ustaz' factor from the 'doctor' role of Nik Isahak, a very bad habit of mine],for the unfortunate 10 % of heart patients amongst men, they only know they have 'heart problem' when it was already "Maa rabbuka".

The damnning fact is : heart attacks, KILL, 30 per cent die during the first episode even before reaching hospital. Of the 70 % that reach the hospitals, another 5% do not make it. Since 20 % of men afflicted with IHD have no symptom, a significant proportion of them die without knowing what 'hits' them in the first place . This sudden death is due to ventricular fibrillation: The heart rythm just go 'berserk' at the point just after the Heart Attack mainly due to a big segment of the muscle not getting the blood supply suddenly. Normally the blockage is major and invovle the left main stem of the left coronary artery.

What then is the difference between Angina and a Heart Attack, one may ask?
When a major coronary artery supplying blood and nutrients and oxygen molecules to the heart muscle is significantly narrowed due to 'atheroma'[ we, cardiologists, call it 'plaque'] along the vessel which act as a supply chain, one gets angina. The more narrow the constriction, the less activity or exertion would be needed to bring out angina.

In a situation when a 'plaque' ruptures, there would be a 'cascade' of chemical reactions among the microelements in our blood[ platelets] which lead to further 'clogging up' of the already constricted section of that coronary vessel.Symptom wise, patients may now have pain or angina at rest or with just minimal activity[ acute coronary syndrome ]. When the 'clogging up' blocks the artery 100 %, you have a Heart Attack! The heart muscle supplied by the '100 % blocked' segment 'dies'[ become necrotic and blackish/purplish in colour instead of the healthy 'pink' ].

If you can imagine the 'coronary tree' like a ginseng root hanging down with the main trunk above and the smaller branches down, the severity of a heart attack depends on where the 100 % block occurs. If the block is in the main trunk[ we term this as Left Main Stem ], it is 100 % 'curtain' for you. If lower down,half a centimetre away, after the 'widow-makers junction', you have a 50 % mortality. Much lower down say 2 centimetres away, you join the 65 % statistics of those who survive to yet enjoy another 'breather'.... We are talking of centimetres here that make a difference between a fatal heart and a minor heart attack. Grim statistics..

Let us examine what we can do to delay or prevent IHD:

SMOKING : You can stop smoking. fullstop. My patients who had had their first 'coronary event' and having spent one or two days in the CCU almost normally never complain of 'gian' on stopping smoking. That is the 'odd' and curious way of how the element of fear works in motivation towards stopping smoking. It is the regular guys like you whom I see in the clinic that are 'recalcitrant' to any advice. For most, they have to experience the harrowing fear of 'near death' first before being motivated! Dont wait for an acute coronary syndrome before stopping smoking. By then it is a wee bit late, the 'coronary ginseng' by then is already full of plaques all along the way, if one were to take an' intracoronary excursion' using a coronary doppler wire.The coronary angiogram would just show narrowing here and there.

OBESITY : You can eat wisely, cut all those beers if you are not Muslim, join Celebrity Workout and live active lives. Not that simple though. Many 'quick fix' diet and 'herbal claims' in the market by people who wants to make a quick buck here and there. Cannot beat the' more burn and less calories' intake on a regular basis. Exercise ,exercise, exercise. factor exercise into your life. Take that staircase instead of the elevator. Go to work with KTM and walk that extra kilometre or two to your office. Park your car half a kilometre away fromTesco and walk to do your shopping. Choose a surau say one kilometre away from your house and go there daily for your 'Isyak' prayer. Burning calories does not mean you have to put on your 'shorts' and burn it in the gym. It means being active all the time. But of course if you have the time and inclination to do 'gym' work, do mix cardio and weights in the gym at least half an hour at a time ,three times a week. The more the better. Or take almost daily 'brisk walking or jogging in the evening or early morning.
As for the calories, eat whatever you like but EAT LESS. Reduce animal fats intake, less deep fry[ fats add calories doubly], more vegies and lots of fruit and plenty of water intake. Avoid adding calories to your drinks meaning drink just plain water or 'tea and coffee without sugar or milk. If I am sounding like I am asking yuo to be a hermit, well that is not the idea. Be a cournosier, not a gourmet. Think big: Picture the richest man on Earth, the Sultan of Brunei. Slim and steady at 60 plus. Yes you want to eat like him!

DIABETES : Very much related to obesity.My wife is a chronic diabetic and two of my children,sad to say, are 'grossly obese' and moving towards diabetese.They just eat too much and I do not mean to deprecate
them here. This is a common phenomena of the 80's,and we are going to have an epidermics of 'cardiovascular disease' this century and our work are all cut out for us for many years to come. This is the scrouge of this century all tied down to obesity, present sedentary lifestyle and poor eating habit.
If you are diabetic, DO NOT BE penny wise and pound foolish.Please get yourself a good doctor to 'lord' over you. 60 % of my heart patients are diabetic! And they are not a pleasure to work on when the 'plumbing' get clogged up: Their arteries are smaller, their disease are more diffuse. Even the surgeons do not like them. Higher mortality and morbidity risk as well.
Just remember this if you forget evrything you read on my blog today: Diabetes is a 'super major' cause of morbidity in this century. You have to be serious about it. Quite unrelated to the issue of 'heart health',both diabetes and obesity contribute to the problem of 'fatty liver' which form the basis in the long run for scarring[fibrosis] of your liver. Could progress to liver failure from liver cirrhosis.

HYPERTENSION : Should be no sweat here from the point of view of medication and control since unlike in the early 70's we have superb drugs now,but more than 70 % of people with high BP do not continue their medications or are not optimally controlled. Self medication is one of the problem, the other major cause of poor compliance Malaysian' tidakapathy'. We have Malaysians with 'double degree' who when asked 'what anti hypertensive they are on', were not able to tell the name. Again do not be penny wise and pound foolish, see your doctor regularly say once every three to four months when you are already stabilised on a 'regime' of medication. If to him ,140/90 is already acceptable, find another doctor. The aim is to be below 130/90 or lower.

Again,diet, medication and exercise. For the average 'men on the street', I would aim for a total cholesterol level to below 5 mmol, LDL[bad cholesterol] to below 3 mmol and HDL [ good cholesterol] of 1.2 or above. There is really no real' cut off' point at which level one would like to start medication such as the ' statins'[ simvastatin or Zocor, atorvastatin or Lipitor, Vytorin, and lastly the new kid on the block,Crestor]. This depend on the absence or presence of other risk factors. For the average 'man on the street' without any risk factor with a total cholesterol of below 6 mmol, I would advice him to diet and come back for review. I am more 'brutal' with diabetics and people who already have coronary problem: Would aim for their LDL to be below 2 mmol and HDL above 1.2 at least.
Exercise,if you are 'religious' about it, can push up the good choleterol significantly.

GENETICS : Well you cannot go to a supermarket and choose your parents but you can certainly live rightly. Take care of all the above risk factors. Exercise, keeping trim, watch you diet by by avoiding excessive animal fats, increasing fibre and fruit intake on a daily basis. Visit your family doctors annually to check for diabetes and hypertension and oyur lipids.If you have one of the above factors, be stringent with their control. Work out to acheive ideal body weight. My computation is easy: Ideal body weight is equal to your height in centimetres minus 100, plus minus 3 kg either way. Stick to it....By this computation, most of us, including myself, have a lot of work to do!

The bottomline is if you are diabetic,smoking and has hypertension and obese as well: That is not so good news!
The good news is ,it is not so bad if, provided if, you start from day one looking at your risk profile and enlist your doctor as a 'risk manager', the stickter the 'risk manager' the better. Achieving almost perfect 'glucose 'profile, trimming down all those excess fats, stopping smoking entirely and remaining true to your hypertensive drug regime even when you do not have untoward symptom requires a 'tough' and straight thinking 'sargent major' breathing down your neck! It require 'tons' of self discipline as well.

You may ask why?
Diabetes is high risk.Obesity confers a much higher degree of difficulty in your diabetic control even with all the new drugs and insulin. Difficult to have optimal control, at best very sub optimal. Your arteries in the brain,the heart and kidneys age that much faster.[ I am not mentioning the penis as well, but I am mentioning it now as ED is another common presentation of IHD patients . We will discuss this at some other time ].Added to this smoking and hypertension are another serious contenders of the 'makhluk perosak' to the basement membrane of your arteries. All 'makhluk perosak' hammering on a daily basis on that poor basement membrane in the arteries.....the bottomline is you get srtoke,heart attack, kidney failure and ED,one or two decades earlier than it should really be!

Oftentimes I wish I could be like Ms Chen, my Primary One teacher in Sultan Ismail Primary School in Kota Bharu, and able to ask some of my 'recalcitrant patients' to just stand on the chair outside my clinic or something. Their diabetic control is lousy, their weight remain static or even increase, they missed out on their hypertensive medications for weeks on end, and they continue to smoke, despite already having their 'first' coronary! But life as a doctor is not that simple...We can't, and oftentimes we end up blaming ourselves for not giving that 'proper education' to our patients.

I cannot 'sugar coat' that statement in any better way: We have to work harder on you!

The blind man is not equal to the seer;[19] Nor is darkness[tantamount to]light;[20] Nor is the shadow equal with the sun's full heat;[21] Nor are the living equal with the dead. Lo !Allah maketh whom He will to hear. Thou canst not reach those who are in the graves.[22]
[al Fatir , 35 : 19-22]

Glory be to Him who has control of all things. To Him you shall all be recalled.[Ya Sin, 36 : 83]

He it is Who createth you from dust, then from a drop [of seed] then from a clot, then bringeth you forth as a child, then [ordaineth]that you attain full strength and afterward that ye become old man-though some among you die before-and that ye reach an appointed term,that haply ye may understand.[67]He it is who quickeneth and give death. When he ordaineth a thing, He saith unto it only: Be ! and it is.[68].....[al Ghafir , 40 : 67-68]

Bethink you: If it is from Allah and ye reject it-Who is further astray than one who is in open feud with Allah?[52] We shall show them Our portents, on the horizons and within themselves until it will be manifest unto them that it is the Truth. Doth not thy Lord suffice, save He is witness over all things?[53] How? Are they still in doubt about the meeting with their Lord?
Lo ! Is not He surrounding all things?[54].....[al Fussilat , 41 : 52-54]

And we have commended unto man kindness towards parents. His mother beareth him with reluctance, and bringeth him forth with reluctance, and the bearing of him and the weaning of him is thirty months, till, when he attaineth full strength and reacheth forty years, he saith: My Lord! Arouse me that I may give thanks for the favour wherewith Thou has favoured me and my parents, and that I may do right acceptable unto Thee. And be gracious unto me in the matter of my seed. Lo! I have turned unto Thee repentant, and Lo! I am one of those who surrender unto Thee.[15]Those are they from whom We accept the best of what they do, and overlook their evil deeds. [They are]among the owners of the Garden. This is the true promise which they were promised[inthe world].[16]........[al Ahqaf , 46 : 15-16]

The life of this world is but a sport and a pastime. And if ye believe and work off evil. He will give you your wages, and will not ask of you your worldly wealth.[36] If He should ask it of you and importune you, ye would hoard it, and He would bring to light your secret hates.[37] Lo! Ye are those who are called to spend in the way of Allah, yet among you are some who hoard. And as for him who hoardeth, he hoardeth from his soul. And Allah is the Rich, and ye are poor. And if ye turn away He will exchange you for some other folk, and they will not be the likes of you.[38] ..............[Muhammad , 47 : 36-38]

Dr Nik Howk
[ related blog: Longevity 1, 2,3,4....under Health Section]
[ Exercise: Mixing the Sublime and the Profane.....Health Section ]


RahmatHarounHashim said...

Dear Dr Nik,
Dapat CME point tak?
A good refreshing course!
Can you write something about "Painless Heart Attack" and "Neurogenic Heart Attack".

Selamat Berpuasa dan Salam Ramadhan.

Pearls & Gem said...

Doc Rahmat,
I will talk to Ismail Merican about the CME thing the next time I see him...He he..

The 'painless heart attack' is pretty common.My late uncle had a'painless heart attack'.He was diabetic.When he say me in GHKL some 30 years back [I was running wild in GH,full of hormone then]for some other thing I noted his 'resting EKG already showed 'scarring', evidence of previous heart attack. He had no symptom at all.Just that as ayoung man of 40+, he was moving around like a man of late 50's. Diabetic, obese..He died suddenly a couple of years later from a 2nd attack.

Fairly common in Diabetic,obese individuals. Also known as 'silent heart attack' or 'asymtomatic heart attack'.Our heart has 3 arteries supplying blood to the heart muscle ie The Left Main on the left, that branches into Left Anterior Descending Artery, or LAD,[most dominant and I usually call this the 'Federal Highway']which supplies the most important front part of the heart mainly the left ventricle, the 'main piston' of the heart.Left Main give another branch called Circumflex Artery,which supplies the back portion of the left ventricle .[ Jalan 222,less important than the Federal Highway].

Then you have the Right Coronary Artery,RCA, supplying the right ventricle in the main.

'Painless Heart Attack' in diabetic usually involve the blockage of the Circumflex or the Right Coronary, or a segment of it.

Blockage of circumflrx branch though produce a full blown heart attack, does not lead to a fatal one because of the limited territory it covers.Similarly The RCA except in RCA in individuals with a dominant RCA blood vessel.In such situation fatality is due to ,usually the heart going into very slow rhytm called Heart Block,as a result of insult to the AV Node,'The Gong man ' of the heart,The focus in the mid portion of the heart that eminates electrical signal for the rest of the heart ventrcles to beat and contract accordingly to a normal fast rtyhm able to sustain a semblance of blood pressure able to push blood to the rest of the body.

Tolak campur tolak campur Doc Rachmat," LIFE IS FRAGILE".
If you guys have not notice it yet, that is why my blog is laced with all the 'ayats' here and there!
In Kelantanese parlance,"Kalau you pesakit jantung atau diabetes dan obese,pandai pandai lah,Jangan 'corner baring'".Has to work harder on you health.....

Anonymous said...

Most useful videos and your running commentary.Noted with thanks from hafiz

Anonymous said...

Thank you Doctor,

One of the best unofficial CME.. this should be officially endorsed by MMA!

Appreciate if we can have more article of this sort, for non-medic ppl like me.

Selamat Berpuasa dr Copenhagen.


Anonymous said...

Salam Doc,
Saya berusia 39 thn, semenjak 5 bln lalu saya sering mengalami sakit sama dgn semua tanda serangan jantung seperti yang doc terangkan. Setelah 5 kali melalui ujian ECG dgn 5 ord doc berlainan, keputusannya adalah negatif. Utk pengetahuan doc, saya mula merasa kesakitan setelah memakan aspirin yg diberi seorng doc swasta.Adakah ianya hanya reflux/gastrik dan tiada kaitan dgn jantung? Keluarga tiada sejarah sakit jantung. Sekian

Pearls & Gem said...

I am glad you find it useful.I thot the Longevity article, though longish is better.
Anon, your symptom sounds like aspirin related dyspepsia but when you say,ECG, do you mean stress ecg?If it is then , a normal stress Ecg in a situation of a aptient wuth chest pain make 'a cardiac' cause of the chest pain highly unlikely. I f it is not stress ecg ,go have one to be sure.