Coronary atherosclerosis develops over many decades and can culminate in obstructive coronary artery disease or plaque rupture. Cardiovascular disease is a leading cause of death worldwide.
Heart failure is a complex medical condition associated with poor survival. There are over 26 million people worldwide living with heart failure. Hypertension and diabetes are implicated as the major causes of cardiovascular diseases. Here is an update on the latest management for cardiovascular diseases.
INTRODUCTION
Coronary artery disease occurs when atherosclerotic plaque builds up inside the coronary arteries and restricts the flow of blood and therefore the delivery of oxygen to the heart . Coronary arteries are tubes which supply blood to the heart. Plaques are fatty deposits that build up within the artery walls. The artery becomes narrow. This is called atherosclerosis.
Heart attacks otherwise known as acute coronary syndrome are caused due to rupture of a cholesterol plaque in a coronary artery. Rupture causes blood clots or thrombus and can cause decreased blood flow. The degree of arterial blockage by the thrombus determines the extent of heart muscle damage.
PATIENT COMPLAINTS OR SYMPTOMS
– Squeezing or pressing type of pain associated with or without burning sensation that radiates to the neck, shoulder, jaw, back, upper abdomen or either arm.
– Exertional dyspnea or laboured breathing that radiates with pain or rest
– Vomiting sensation
– Reduced tolerance to physical activity
– Variant angina is chest pain which mainly occurs at rest due to tobacco consumption
– Palpitations
– Diaphoresis or sweating
EPIDEMIOLOGY AND STATISTICS OF HEART DISEASE
Despite relatively recent declines in age-adjusted death rates in 2005, cardiovascular disease was the primary cause in 864,480 [35.3%of total] and the secondary cause in another 507.520 deaths in the United States.
Many countries where coronary heart disease is on the rise have instituted counselling and educational methods to encourage people to reduce their risks for developing heart disease. Heart disease is the number one killer disease worldwide and 12 million deaths occur annually.
Indians are more susceptible than any other ethnic group and get heart disease at a much younger age, 5 to 10 years earlier than other countries. The disease in Indians follows a more severe course and there are 3 times higher rates of heart attack and two times higher mortality than whites.
Despite this high prevalence, evidence increasingly suggests that the atherosclerotic process can be greatly slowed and its consequences markedly reduced by preventive measures. Primary prevention deals with delaying or preventing the onset of cardiovascular diseases. Intervention results in small reductions in risk factors including blood pressure, cholesterol, and smoking.
Secondary prevention relies on early detection of disease process and application of interventions to prevent progression of the disease.
RISK ASSESSMENT AND PRIMARY PREVENTIONS
| CATEGORY | RISK FACTORS |
| NONMODIFIABLE | AGE, SEX, FAMILY HISTORY, GENETICS |
| MODIFIABLE | SMOKING, ATHEROGENIC DIET OR HIGH FAT DIET, PHYSICAL ACTIVITY, DYSLIPIDEMIAS or HIGH CHOLESTEROL, HYPERTENSION, OBESITY, DIABETES |
| EMERGING | C-REACTIVE PROTEIN [CRP] FIBRINOGEN, CORONARY ARTERY CALCIFICATION |
THE ILL EFFECTS OF SMOKING
- Tobacco dependence is a chronic disease and increases blood pressure
- Decreases HDL [Good cholesterol]
- Damages arteries and blood cells
- Increases heart attacks.
- Cigarette smoke contains more than 4,000 chemicals and 200 of these are poisonous.
- Risk of heart attacks decreased 50% at 1 year after smoking cessation
- Smell and taste improve within days and within three months of quitting, the smoker’s cough disappears.
OBESITY
Obesity is defined as people who are overweight [10-30% more than their normal weight].Body mass index is calculated as weight in kilogram divided by height in square metres. Obesity increases the likelihood of developing other CVD risk factors including hypertension, dyslipidemia, and Type 2 Diabetes.
Grade 1 obesity-BMI 25-30 KG/M2
Grade 2 obesity-BMI 30-40KG/M2
Grade 3 obesity-BMI >40 KG/M2.
HYPERTENSION
- Well established risk factor for adverse heart disease outcomes.
- Systolic blood pressure is a powerful coronary risk factor as diastolic blood pressure.
- The goal is BP <140/90 mmHg or <130/80 mmHg if the patient has diabetes or kidney disease. For all patients, initiate or maintain lifestyle modification, weight control, sodium reduction and increased consumption of fresh fruits, vegetables, and low-fat dairy products.
HEALTHY DIET
- Reduce daily salt intake to less than 2300 mg.
- Consume less than 300 mg/day of dietary cholesterol.
- Reduce intake of calories especially from solid fats and added sugars.
- Increase vegetables and fruit intake, eat a variety of vegetables especially green and red and orange vegetables and beans and peas.
HEART HEALTHY COOKING OILS
- Saturated fats like Vanaspati ghee increase cholesterol and should be avoided.
- Monosaturated fats [MUFA] like olive oil, groundnut oil are heart-healthy.
- Polyunsaturated Fats [PUFA] like sunflower oil, soyabean oil are heart-healthy.
- Omega -3 fatty acids and Fish oil are heart-healthy.
PHYSICAL ACTIVITY
- Sedentary individuals are at higher risk of Coronary heart disease.
- Exercise serves to reduce weight, total cholesterol and blood pressure and increases HDL cholesterol. Most exercise programs recommend at least three sessions of aerobic exercise such as brisk walking, jogging, and swimming of 30 minutes per week.
- Children should engage in 60 minutes or more of physical activity daily.
ACUTE CORONARY SYNDROME [ACS-HEART ATTACKS]
ACS is a clinical condition due to unstable angina, ST-elevation myocardial infarction, and non-ST elevation myocardial infarction. ACS is due to rupture of atherosclerotic plaque in the coronary artery. The degree of blockage caused by the blood clot determines the extent of damage to the heart.
TREATMENT AND MANAGEMENT
- Diagnosis is by symptoms and blood tests and ECG will help in management.
- Bed rest and oxygen are advised after admission.
- Pain relief and blood clot dissolving medications are given. Aspirin has been shown to improve outcomes in heart attack patients.
CARDIAC CATHETERIZATION
A plastic tube is inserted into an artery or vein and doctor injects a dye. This can determine where the blockages are located. This is also a good method to determine the amount of blood and oxygen the heart is receiving.
CABG-CORONARY ARTERY BYPASS SURGERY
This is most frequently performed major surgery. Surgery reroutes and bypasses blood around clogged arteries
ANGIOPLASTY [PTCA]
It involves creating a space in the blocked artery by inserting a small balloon and then inflating it. Now includes the placement of a mesh stent to improve effectiveness
WHO IS AT HIGH RISK
DIABETICS
- At any given cholesterol level, diabetic persons have 3 fold higher risk of heart attack or stroke.
- A diabetic is more likely to die of a heart attack than a non-diabetic.
- 80% of Diabetics die from heart disease.
- The risk of sudden death from a heart attack is the same as that of someone who has already had a heart attack.
- All adults should have their blood sugar checked regularly as there are no early symptoms of diabetes.
Article by Dr. B. Nagamony
Senior Consultant – Interventional Cardiologist
Kauvery Hospital, Chennai