Examples of such situations would be :
Q. The patient in question is asymptomatic or minimally symptomatic. A routine coronary angiography shows multiple severe degree of blocks. How does one deal with this and is there no option but intervention or surgery ?
A. This is an unfortunate and erroneous impression given to the public. If interventional or surgical methods had no risks, or complications, and a sure short at good length recovery or cure, the choice would have become obvious. However we all know it is not so. The patient should be given a first choice and a second choice. Life is not necessarily doomed if he decided against intervention or surgery and opts for medical management. Many such patients live for years with medical management. The natural forces come to their rescue. The Invasive procedures do not provide a risk free life and there is no guaranteed immunity from a fresh heart attack in the near future. The advantages are in relative terms of lessening the chances. Even the claimed prolongation of life in some patients cannot be assessed in quantitative terms. It is still a game of the possibility and probability. Those patients who are willing to undergo surgery for a better life style, should first undergo tests for objective evidence and degree of ischemia. Ischemia can be assessed objectively in an asymptomatic or minimally symptomatic patients with the help of such tests such as Treadmill exercise test, MUGA test or Thallium testing.
Q. What benefits could be expected from modern revascularization procedures ?
A. By performing either angioplasty or By-pass surgery, the aim is to provide normal blood supply to the heart muscle by opening the blocked lumen of one, two , three or even four large or medium sized arteries. This is known as establishing Revascularization. This concept is very attractive and appears a solid strategy. The presumption made is that after either opening up the blockage or by passing it, there is no further impediment to blood flow in the smaller important pathways including the capillaries. The heart muscle size similar to all other body organ cells in the end receive their blood supply via the terminal capillary pathways. Now the problem may lie in the deranged health of the arteriolar and capillary vessels. These final pathways too, can get deranged in the process of myocardial ischemia and infarction, and hence although there may be flow down the large and medium sized arteries, it does not mean that it effectively is reaching the end organ, namely the heart muscle cell. Moreover, as pointed out earlier, grafts used in bypass surgery have a failure rate of 10% per year . Put simply at the end of five years there is 50% chance that graft will be closed with no flow, similarly at 9 years it is closed to 80%. After understanding the above it can be realized that the benefit of the " open artery hypothesis" does have limitations. No doubt, revascularization may help, but how much and for how long is still unanswered. Clinically revascularization can offer the following benefits and limitations. It is done with three expectations :
They are :
Q. Now a days we hear such terms such as " silent heart attack " and " silent angina ". We are preplexed and in the absence of symptoms should we go see our doctor ?
A. Let us first talk about the term " silent heart attack or silent myocardial infarction". Fortunately, the incidence is not as high as was initially reported from the Framingham study in the U.S. when the investigators requestioned the same patients, surprisingly a significant number of patients confessed to having some acute symptoms in the past which they attributed as being " wind" , "indigestion" , muscular " or "tiredness and fatigue". Since they did not suspect these symptoms as possibly being cardiac they conveniently forgot about these episodes. This often happens in practice. Such instances tend to exaggerate the number of patients with " silent heart attacks." Crudely speaking it is often a situation where either the physician is " deaf " or the patient is " dumb". The physicians "deafness" would improve if he were to spend more time taking a detailed history from the patient. Quite often the patient uses his own terminology or nomenclature. With a little extra ear and time along with using the art of medical history taking, the so called silent now becomes manifest. In a similar way some patients remain "dumb" either due to fear of facing heart disease, or in some instances due to denial. Patients should be made to talk by a thorough cross questioning examination. The analogy can be drawn of a clever lawyer who can extract information from an unwilling witness in the witness box. The clever cross examination by medical doctor like that of a good lawyer would again make some more patients revert to the "Symptomatic" heart attack group rather than the "silent" group. All the same, there do remain some patients with genuinely "silent" heart attacks. They are only few and far between about 2% to 3% in our experience. It generally is seen in very old patients who tend to forget recent events easily. A few diabetic patients develop diabetic neuropathy of the heart nerve fibres without giving chest pain.
"Silent Ischemia " is relatively a benign entity and need not be that much feared. It is detected during Treat mill exercise or Holter - Monitor testing without the patient having any chest pain or discomfort. Silent Ischemia if detected would mainly call for " Risk Factor Modification " . A few patients with a strong family history may need invasive testing of Coronary Angiography.
Q. Is it really necessary to undergo invasive testing with coronary angiography in all patients with angina, myocardial infarction or those with a positive treadmill exercise test. Would the other simple tests not suffice at least in some patients ?
A. In general, this test is recommended for those patients in whom interventional or surgical treatment is contemplated. It is needed if the patientís symptoms justify and his life style is demanding during his productive years. The more severe the anginal symptoms, the stronger the justification. IN this group, iterventional or surgical treatment may become the preferred approach but not the only approach. Let it once again be clarified that barring a few statistically fortunate patients ( 15% - 20% ), the invasive procedures do not, in spite of tall claims, prevent a future heart attack. (One simple crack in the inner arterial wall even though it had only minimal disease previously can trigger off the cycle of a blood clot leading to a fresh heart attack. Unfortunately this happens in two-thirds of the patients according to recent data.). These invasive approaches admittedly give symptoms free life for some years. One has, in the meanwhile, to take calculated risks for the involved procedural complications and accept future chances of possible relapses. In a few patients, anginal pain may be replaced by other heart symptoms such as cardiac failure. To emphasize once again, in a good majority of situations, it is an operation to bring about good relief of angina symptoms but not the real cure of the disease. The future course of the original disease cannot be modified by any of the known procedures today.
After basic understanding of the above, in our country there can be different demands, different expectations, and different patient scenarios. Simple rules of mathematics cannot be mechanically applied for each and every coronary system. We would outline just a few instances where the test of coronary angiography may not be ordered in each and every patient as asked in the original question.
The medical management would remain the same irrespective of the number of anatomical blocks. The number of blocks can not guide the physician to choose his medicines. Again, the map of coronary angiography ordinarily holds good for a limited time frame of about six months. Risk stratification can be done by so many other simple methods. To summarize them, the simple advice would be, not to take an arithmetic equation path for every patient. Our views are cut out for our Indian core of patients and may not be applicable to patients in U.S.A. or Europe. The doctors there more often practice defensive medicine in order to avoid medico-legal battles in the court.
Let us digress for a moment to be provocative enough for some fresh thoughts on modern medical regime. We would consider some of the figures obtained from the current day medical regime as published in our first grade medical journals. To quote only a few :
To all of the above, please add the beneficial value of reduction of body weight, regular age related exercises and modern cholesterol lowering drugs. Where do we stand then ? Can the above quoted statistical figures bring home some truths about the treatment for heart disease whether surgical, interventional or medical ? Are we going crazy or become laughable? It is rightly said that in life, the rare and the most difficult sense to possess is common sense or, is it as written in the interesting book by Stewart entitled " Does God play dice " applicable to the cardiology world !!
Q. I am staying on the second floor of an old building where there is no elevator. Can I climb upstairs after my heart attack ?
A. Yes, after about two months of a heart attack you can climb up provided there is no residual complication such as cardiac failure. One must climb slowly but certainly not like a sick man. Whenever you feel out of breath, wait for a while before you resume a further upward climb. You need to pause only for a short time, of about two minutes, whenever you get unduly breathless. To start with, climb up once every day. You can do the same twice a day or even thrice, if the situation demands. The only precautions required are not to rush up like a young man of twenty and not to climb up on a full stomach. Climbing up should be so timed that you are on an empty stomach. Climbing down the stairs causes no strain on the heart.
In case you suffer from angina while exerting, it would be better to use nitroglycerine or isosorbide tablet and continue sucking it while climbing up. Some elderly persons do suffer from a sudden fall in blood pressure after using this pill and may complain of a fainting sensation. Should this happen, it would be safer to avoid use of this pill while in the upright nature, particularly the standing posture. In such a situation, the elderly patient with angina would require to pause for a few minutes as soon as the angina pains come on.
IT IS NECESSARY TO REMEMBER THAT REPEATED USAGE OFNITROGLYCERINE IS NOT HABIT FORMING, NOR DOES IT LEAD TO TOLERANCE.
Q. Can I undertake the exertion of driving a car ?
A. Driving a car is no physical exertion. However, in congested cities with disorderly traffic, taxi-drivers and truck drivers, it can cause mental strain and exhaustion, which is not good for the heart. It would, therefore, be advisable to have somebody else driving you in the city, at least for six months. Highway driving can be done, provided you yourself do not belong to a class of reckless drivers.
Q. I stay in the suburbs and have to come to the city for my work on a suburban train, I shall have to negotiate climbing up railway bridges to reach the platform. What should I do ?
A. You can certainly climb up bridges, provided you follow the same principle outlined for climbing up to the second floor of a building. Take precautions not to undertake climbing for at least two hours after a meal. Do not carry a heavy briefcase or a bag while climbing, and do not rush and run to catch a train or a bus. Better to be late for work than to have a heart symptom.
Q. How long after the attack can one undertake an air journey ?
A. In an uncomplicated case, an air journey for domestic flights can be undertaken safely after four to six weeks. All planes, are pressurized to a level of five to six thousand feet about sea level, This is a safe height to fly for the heart. In a patient who has recovered with some complications, it is better to avoid air journeys for about two months. Prior to travel clearance should be obtained from your attending physician.
Q. Can you advise me regarding the Doís and Doníts of my diet? Why doníts you give a diet chart ?
A. The detailed explanation and the principles of diet have already been described in this book. Frankly, there is no diet chart. Reduce the quantum of food that you have been consuming daily. This will surely include chapati, bread, biscuits, dal, all other cereals and pulses, dry fruits, milk, ghee, butter, cheese, all other oils, sugars, soft drinks, and alcohol. Increase in the quantum of foods containing vegetables, clear soups and salads and some helping of fruits. If you feel hungry in between , a cup of tea prepared out of 30 ml. of milk and one teaspoon of sugar can help You can also use buttermilk, soup etc. Three to four teaspoons of sugar per day are in order and would help you control your hunger and prevent a sense of weakness. Even a diabetic patient can take half this amount of sugar provided he controls other items of food and controls his weight. Dieting is simple and nothing complicated to understand. However, a strong will and determination are required.
Q. What is this " exercise prescription " that we read about as a method of curing heart ailments ?
A. To begin with, exercise cannot cure a heart ailment. Exercise trains the heart of a patient to endure certain physical work load. This helps the patient realize that his heart is capable of withstanding physical exertion. By gradual training, the heart can be made capable of enduring more physical activity. However, so far there is nothing to suggest that it has a curative value in the sense that it can make your heart stronger than before or that it would open up new collateral coronary channels. At the same time, the beneficial value of exercise cannot be underrated. Exercise in moderation which makes you feel pleasantly tired, is certainly good . It tones muscles and make you feel younger and fitter. The energy-levels, stamina and self-confidence are enhanced. Nature has provided us with legs which are meant for walking They must be used as we use all the other parts of the body.
The question comes up as to how much to use them? The rational answer would be to use them enough without getting to tired or fatigued. At the same time, do not try to be an over enthusiastic "athlete". If you overdo any exercises you will land up, in fact, precipitating a fresh heart attack, cardiac failure etc. Similarly, in a patient who has already got cardiac failure, more than mild exercise will weaken the heart further.
Realizing the benefits of exercise, please settle down to strike a healthy balance. The level of exercise has to be gradually built up and the heart must be kept under a periodic check by your physician. The usual exercises that are allowed in a previously sedentary middle aged person are low level to mid level exercises. These include walking ( not necessarily brisk or to sweat) at your own pace, standing, running, use of a stationary bicycle, light drill, activities such as golf, swimming badminton, doubles etc.
These physical exercises are good for the body as a whole. The limit of the exercise should be based on your age, previous habits and your inclination for regularity. Having, gradually built up your physical exercise capacity, it is important to carry out this ritual on a regular basis for at least five days of the week. For a person who is not going, to be regular, simple walking would be the safest form of exercise.
The term "aerobic exercises " appears frequently and sounds impressive. The term means increased aeration or rate of breathing to get more oxygen from the air. It would also reflexly increase the pulse rate. When done gradually and progressively, there is minimum strain with good conditioning. In fact, all the exercises described above are "aerobics ". They can be non-aerobic with oxygen debt only if they are severe and sudden like prolonged fast running. Certain static exercises such as weight lifting are not aerobic.
To summarize then, an exercise prescription for a patient who has recovered from a heart attack is meant to adjust and train the heart for physical activity for its general benefit. It is not prescribed to make the heart stronger and also not for the wishful development of better coronary collateral. Sudden and severe exercise may in fact, do more harm than good to the heart.
Q. Can a heart patient eat eggs ?
A. Yes. One can eat the white of an egg everyday and the yellow of an egg twice in a week. The yellow of an egg is rather too rich in cholesterol.
Q. What are the general precautions to be taken ?
A. Avoid a heavy meal, avoid fast walking, walking after a meal, avoid sudden and severe exercise, avoid climbing uphill rapidly, avoid a crowded work schedule. Avoid specific situations which give you mental agitation, observe regular hours of sleep and rest, keep your body weight in check and practice moderation in all activities including working and walking.
Wherever you go, carry with you the first aid drugs of
Q. You advise a change in life style - How can this be done at my age ?
A. Nothing is impossible. It may be difficult but with strong determination a great amount can be achieved. Where there is a will there is a way. Remember that you are doing this for your health. There is nothing more valuable than good health. One must take a day at a time and be determined to do something positive for your health and every single day. Try to be action -oriented and not always result-oriented. This will give you work satisfaction without mental tension. Success always comes in its own good time. Have a faith in your work and in your actions.
Q. Can a patient who has developed left ventricular failure or congestive cardiac failure be helped by coronary bypass surgery or other forms of intervention ?
A. Perhaps not and very little if at all in our experience. The established case of cardiac failure cannot be helped much by this form of intervention. The heart muscle has already become weak and certain fibrotic changes have developed in the muscle which cannot be rejuvenated even though they look viable. A few patients who develop a ventricular aneurysm (bulge) which contributes to their heart failure. IN these patients the aneurysm can be surgically removed or plicated and this type of surgery can be of great help. This operation no doubt, carries significant risk by itself. However, it can be thought of in an intractable case of cardiac failure. The diagnosis of aneurysm can reasonably and safely be made by nuclear cardiac study and by two dimensional echocardiogrphic study.
Q. Is the narrowing or obstruction in the passage of coronary arteries brought about by the atheromatous deposits only or is there any other cause ?
A. Apart from atheroma, which is no doubt common, the role of a coronary artery spasm and certain blood clotting factors is being increasingly recognized. The arterial spasm can produce an obstruction independent of atheroma and give rise to angina and occasionally even an infarction. The presence and degree of spasm in a specific patient can only be diagnosed clinically and after a normal looking coronary angiographic study. The spasm may be provoked in susceptible patients using " Ergonovine " injection. However, this is a very risky procedure and is generally discouraged. "By-pass" surgery or stents cannot be of help to patients where the spasm is predominant factor. The factors which are responsible for producing spasm are thought to reside in the nerves of the heart, in blood platelets and in some yet unidentified chemical substances that are locally produced in the heart muscle.
Q. After a successful recovery from a heart attack, should all patients undergo non-invasive tests such as 24 hours Holter Monitoring, Radionuclide Cardiac Scan Study, Echocardiography, Tread Mill Exercise Test, etc. ?
A. The cost benefit ratio must be worked out for each patient by the doctor. While analyzing several patients, the authors have found no need for further testing in about 40% of patients. IN these patients, the tests do not help further in management strategies. IN general, the need for the tests may not may not be there. Each patient should be assessed independently by the clinician. If consideration is being given to surgical or intervention then one may start with a tread mill exercise test. If the test is negative then in all probability the disease is not much advanced so as to need the surgery or intervention. If the test is positive, then coronary angiography would be strongly indicated. In a few cases to document objective evidence of ischemia, prior to coronary angiography, other non-invasive tests such as thallium, MUGA exercise, echo studies maybe required. If ichemia is identified then, this should be followed by coronary angiography to assess possible modalities of invasive treatment.
Q. Can clot dissolving agents be used for acute unstable angina ?
A. Currently there is ongoing research regarding the role of so called "clot buster " in severe or unstable anginA. As of this writing they are not recommended for unstable anginA. These drugs are however beneficial in acute infarction, if administered within 6 hours of the onset of symptoms. "Clot busters " have some of the potential of some very serious and sometimes life threatening side effects, such as bleeding in the brain which may result in stroke. They should be used only in an infarct setting after a check-list has been gone through to make sure that there are no contra-indications.
Q. The patient in question has made an uneventful recovery following an acute heart attack. He does not have any symptoms suggestive of an active anginA. What is the justification of having an early coronary angiographic study within few days of an infarct in such a patient ?
A. Frankly speaking, there is rarely any need to go aggressively straight away. In U.S.A. and other countries, this procedure is done early because of financial reasons. The insurance company has to pay on an average of 800 to 1000 U.S. dollars per day for each patient only for occupying the hospital bed. They therefore pressurize the hospital management for early investigations so that the patient can be sent home soon.
As repeatedly emphasized by us that mere identification of the number and degree of blockages do not necessarily decide the immediate treatment option. The blocks that are seen on an angiogram are not more vulnerable for impending complications than those that are less seen or not seen at all. The left ventricular function, the degree of ischemic symptoms either subjective or objective, associated diseases, genetic history, age and attitude are equally important determining factors for choosing the future line of management. On the contrary, by focussing only on the blockages known as "occulostenotic reflex" , can create mental fixation and judgment blocks even for attending doctors and the panic scenarios with relatives and the patient. It is pity to witness such scenes.
In an uncomplicating patient, it is rational to go systematically to study left ventricular function from Echocardiogram. This can be followed for objective evidence for the degree of ischemia through Tread Mill, Muga and if possible with Thallium or Sestamibi tests. To stratify patients into "High Risk " and "Low Risk " on the basis of only an angio study is not justifiable in the majority of patients. The other non-invasive tests mentioned above can provide enough clue. The invasive investigation of angiography is not always first and the ultimate. As mentioned repeatedly, its map information is useful for a limited time frame of an average of six months.
In general, there is rarely any need for rushed up decision making. The future line on the type of treatment whether medical, stent angioplasty or Bypass can be planned safely in 4 to 8 weeks time following an event free infarct. The procedural risks become less after thing cool off in the coronary system. The natural defensive, reparative and adjustment forces are also at their best after 3 to 6 weeks of the acute event. Better judgment can be made then to plan for the required number of tests and for his proper line of treatment.
Q. Nowadays some cardiologist, when the patient is in the ICCU unit, advise us, at times, to go for emergency coronary angiography so that they can look at the anatomy of the block that is created by the blood clot and then, if necessary, go ahead with emergency angioplasty or even by-pass surgery. How much is such an aggressive approach justifiable within the first few hours of days of an acute heart attack ?
Can it always salvage the heart ?
A. This is now termed as " Acute Interventional Cardiology." The decision for acute intervention with invasive methods such as angiography, balloon or by-pass surgery may only at times have same justification and the risk-benefit and cost ratio has to be worked out in our Indian set up.
Unfortunately, at present, the "salvation army " knows all about the anatomy and very little of the physiology and pathology that is going around in that area of block and the distal small vessels. There are blood products, anti-clot natural mechanisms, artery spasm, platelet and vascular activity going on which is termed as "cascade of events. " The clot when fresh at times demands "respect" and may react adversely with "salvation armyís" methods of invasive angiography, balloon or by-pass surgery. The clot can get detached and block somewhere else, the blood vessel can be discussed, and the clot can reform with rebound and reocclude the vessel again in spite of aggressive counter measures. In this humdrum, when the situation is hot and unstable, the heart can even become further weaker or irregular.
To summarize then, this is a situation where decision making is very difficult. With the best of intentions of helping the heart, we may do more harm in a few patients. Hence, most of the centres the world over, adopt such an approach in a selected few patients with recurrent symptoms or those who manifest mechanical complications in a very early stage of the attack. Things are risky but may be worthwhile and beneficial in well organized centre with a sound infrastructure.