HEART DISEASE Introduction to heart disease

The heart is like any other muscle, requiring oxygen and nutrient-rich blood for it to function. The coronary arteries that supply blood to the heart muscle spread across the surface of the heart, beginning at the base of the aorta and branching out to all areas of the heart muscle. The coronary arteries are at risk for narrowing as cholesterol deposits, called plaques, build up inside the artery. If the arteries narrow enough, blood supply to the heart muscle may be compromised (slowed down), and this slowing of blood flow to the heart causes pain, or angina. A heart attack or myocardial infarction occurs when a plaque ruptures, allowing a blood clot to form. This completely obstructs the artery, stopping all blood flow to part of the heart muscle, and that portion of muscle dies.

Heart disease facts

Coronary artery disease is the most common cause of death in the United States. Over a million people each year will have a heart attack and 25% will die before they get to the hospital while or in the Emergency Department. Prevention is the key to treatment of heart disease. Diagnosis of heart disease is often made by careful history taken by a health care practitioner. Some individuals may have atypical symptoms, including almost none at all. The testing strategy to confirm the diagnosis and plan appropriate treatment needs to be individualized for each patient diagnosed with heart disease. Treatment of heart disease depends upon the severity of disease, and is often directed by the symptoms experienced by the affected individual.

Risk factors for heart disease.

Risk factors for heart disease include:

Smoking High blood pressure (hypertension) High cholesterol Diabetes Family history Peripheral artery disease Obesity

Symptoms of heart disease?

The typical symptoms of coronary artery disease are chest pain associated with shortness of breath. Classically, the pain of angina is described as a pressure or heaviness behind the breast

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bone with radiation to the jaw and down the arm accompanied by shortness of breath and sweating. Unfortunately, angina has a variety of signs and symptoms, and there may not even be specific chest pain. Other locations of pain and other symptoms may include shoulder or back ache, upper abdominal pain, nausea, and indigestion. Women, the elderly, and people with diabetes may have different perceptions of pain or have no discomfort at all. Instead, they may complain of malaise or fatigue and generalized weakness and the inability to complete routine physical tasks such as walking or climbing stairs. Health care practitioners and patients may have difficulty understanding each other when symptoms of angina are described. Patients may experience pressure or tightness but may deny any complaints of pain. Health care practitioners may misinterpret these symptoms when patient answers "no" to the question whether "pain is present," even though the patient is experiencing other types of discomfort. People with coronary artery disease usually have gradual progression of their symptoms. As an artery narrows over time, the symptoms of decreased blood flow to part of the heart muscle may increase in frequency and/or severity. Health care practitioners may inquire about changes in exercise tolerance (How far can you walk before getting symptoms? Is it to the mailbox? Up a flight of stairs?), and whether there has been an acute change in the symptoms. Once again, patients may be asymptomatic until a heart attack occurs. Of course, some patients also may be in denial as to their symptoms and procrastinate in seeking care.

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How is heart disease diagnosed?

The diagnosis of heart disease begins with obtaining a history that the potential for coronary artery disease exists. Risk factors need to be assessed and risk stratification occurs. The type of testing that is recommended, if any, depends upon the potential that the patient's symptoms actually represent angina and are coming from the heart. Heart disease tests Not every patient with chest pain needs heart catheterization (the most invasive test). Instead, the healthcare provider will try to choose the testing modality that will best provide the diagnosis, and if coronary artery disease is present, decide what impairment, if any, is present.

Electrocardiogram (ECG or EKG)

The heart is an electrical pump, and the electrical impulses it generates can be detected on the surface of the skin. Normal muscle conducts electricity in a reproducible fashion. Muscle that has decreased blood supply conducts electricity poorly. Muscle that has lost its blood supply and has been replaced with scar tissue cannot conduct electricity. The electrocardiogram (EKG) is a noninvasive test used to reflect underlying heart conditions by measuring the electrical activity of the heart. Some people have "abnormal" EKGs at baseline but this may be normal for them. It is important that an electrocardiogram be compared to previous tracings if one is available. If a patient has a baseline abnormal EKG, they should consider carrying a copy with them for reference should they ever need another EKG.

Stress testing
If the baseline EKG is relatively normal, then monitoring the EKG tracing while the patient exercises may uncover electrical changes that may indicate the presence of coronary artery disease. There are a variety of testing protocols used to determine whether the exercise intensity is high enough to prove that the heart is normal. Some patients are unable to exercise on a treadmill, but they can still undergo cardiac stress testing by using intravenous medication that causes the heart to work harder. Stress testing is done under the supervision of medical personnel because of the potential of provoking angina, shortness of breath, abnormal heart rhythms, and heart attack.

Modifying risk factors for heart disease

While patients cannot choose their family and alter their genetic predisposition to coronary artery disease, the rest of the risk factors are under control of the patient. Keeping blood pressure, cholesterol and other lipid levels, and diabetes under control needs to become a life-long goal. Smoking cessation is highly encouraged.

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Medications
The purpose of medications for coronary artery disease is to allow more efficient heart muscle function to overcome any blockage that might exist. Aspirin is one of the cornerstones of coronary artery disease treatment. It prevents platelets from clumping together when blood becomes turbulent, like when it flows past a narrowing in an artery. Beta blockers prevent the action of adrenaline on the heart and allow the heart to beat a more efficiently by reducing the heart rate and causing the heart muscle to contract less aggressively. Examples of beta blockers include:

atenolol (Tenormin) metoprolol (Lopressor, Toprol XL) propranolol (Inderal, Inderal LA) carvedilol (Coreg) labetalol (Normodyne, Trandate)

Calcium channel blockers can also be used to control heart rate and allow the heart to beat more efficiently. Examples of calcium channel blockers include:

diltiazem (Cardizem, Dilacor, Tiazac) verapamil (Calan, Verelan, Verelan PM, Isoptin, Covera-HS)

Nitroglycerin dilates blood vessels and may be used sublingually, under the tongue, to treat angina. Some patients may be prescribed long-acting nitroglycerin to help control anginal symptoms.

Angioplasty and stenting

If the coronary angiogram (coronary=heart + angio=artery + gram=record) shows significant blockage in an artery, the cardiologist may attempt an angioplasty, in which a balloon is placed via a catheter (as with angiography) at the area of narrowing and when quickly inflated, compresses the offending plaque into the wall of the artery. Often a stent, or a metal cage, is placed at the site of angioplasty to keep the blood vessel from narrowing again. Should a stent be placed, patients are usually started on antiplatelet medication to prevent clot formation. Clopidogrel (Plavix) and prasugrel (Effient) are the two most common medications prescribed.

Surgery
For those patients with multiple coronary artery blockages, coronary artery bypass grafting may be a consideration.

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