Heart Attack: Prevention and Treatment

Fall 2007 CSANews Issue 64  |  Posted date : Oct 17, 2007.Back to list

About one in four Canadians are affected by heart disease and about half of those will develop it after the age of 65. Because coronary artery disease (CAD), the major cause of heart disease, is still the number-one killer of seniors, the causes, current investigation, treatment protocols and especially the preventive measures are important for us to know.

In the 40 years since my graduation from medical school, there have been remarkable advances in all of these areas, resulting in a decreased incidence of heart attack and resulting complications.

At that time, there was not a lot of attention paid to the lifestyle modifications that are now well-known to be important in reducing risk. Additionally, angiography, angioplasty and bypass surgery were unknown, and most of those drugs so commonly used to prevent and treat coronary heart disease had not yet been discovered. In the 1990s, hormone replacement therapy, once hailed as beneficial to post-menopausal women’s health, was found to actually increase the risk of heart attack and stroke and is no longer recommended for a long-term basis.

The muscle wall of the heart, as all other areas of the body, requires a good blood supply. The coronary arteries are the small vessels that supply blood and oxygen to the pump’s wall and when one of these vessels blocks off as a result of the buildup of atherosclerotic “plaque,” that area of the muscle can be damaged. If the particular vessel is a major artery or one that supplies blood to a critical area of the heart, the heart attack (myocardial infarction) can be life-threatening. If the blockage is temporary or caused by spasm, the result may be angina, with symptoms similar to a heart attack, but usually coming on with exertion and relieved quickly with rest or a drug called nitroglycerine.

Symptoms
It is extremely important that we all recognize the symptoms of a heart attack, especially those who are at risk or have known coronary artery disease.  Symptoms can vary widely, but the most prevalent is a pain or tightness in the chest. It may feel like fullness or squeezing discomfort and may spread to the neck, jaw or shoulder and arm. Some persons feel the discomfort in their stomach area and mistakenly attribute it to “heartburn” or indigestion. Sweating, nausea and shortness of breath may occur. In women, these additional symptoms may not be accompanied by chest pain and in some cases, pain is felt in the back of the chest.

Such unexplained symptoms, even if mild, require emergency attention. This means a 911 call and urgent assessment and care at a hospital emergency department. Not only is this important because of the risk of dangerous early complications such as an abnormal rhythm or extension of the damage, but also because there are “clot-busting” drugs that are now effective in many cases in arresting or even reversing the blockage and subsequent damage. Do not procrastinate when unexplained symptoms such as these occur. If the symptoms are suspected to be cardiac and you are not advised against the use of aspirin, your doctor might advise you to take one adult aspirin at the onset of symptoms. This has been shown to significantly reduce death rates and will often be given by paramedics or hospital staff upon arrival. Snowbirds, in particular, when away from home seem reluctant in some cases to seek emergency evaluation, which can prove to be a fatal mistake. Spouses are advised to “take charge” when the patient seems to be reluctant. If the emergency room evaluation does not confirm the symptoms to be cardiac in origin, discharge is often on the same day. If the pain is cardiac but there is no damage, minimal inpatient investigation is usually followed up as an outpatient at home.

Treatment
A myocardial infarction is confirmed by a rise in the level of cardiac enzymes in the blood and/or typical changes on an electrocardiogram.  The accepted standard of care in this scenario, or if the pain is not relieved, is now an angiogram as soon as possible. An angiogram is a procedure in which a catheter is directed from a small incision in the groin into the femoral artery and the aorta, and a dye is injected into the area of the source of the coronary arteries to outline their architecture on X-ray. The offending artery(ies) can be identified and in some cases, an emergency dilatation of the vessel (angioplasty) will improve the blood supply. In addition, the insertion of a stent in each affected artery is commonly employed. A stent is a tiny metal mesh that opens up the artery to increase blood flow.

Post-operative Care
Following this procedure, the patient is sent to a coronary care unit for close monitoring and attention for a day or two, followed by a regular bed until discharge several days later for outpatient follow-up. Occasionally, the narrowed vessels are not amenable to angioplasty and bypass surgery is recommended. This may be an emergency situation in some cases, but most bypass surgery is done on a scheduled basis and snowbirds will have the opportunity of having the procedure done closer to home and family in a more stable condition, followed by a cardiac rehabilitation program.

Additional Risk Factors
We are now all well aware of the risk factors for coronary heart disease and the importance of preventive measures. We are unable to affect the genetic risk, but most other factors can be modified. Smoking and the inhalation of second-hand smoke is well documented as significantly increasing the risk of a heart attack. Cessation after several years can reduce this risk.

Elevated blood cholesterol has a direct effect on causing arteriosclerosis and all individuals over the age of 40 (or earlier, when associated with other risk factors) should have periodic blood cholesterol levels measured. Elevated levels usually result in the prescription for one of the “statin” drugs which can reduce the cholesterol level to normal. However, the occasional individual will have some success in reducing his or her level with non-prescription medication and strict dietary and/or weight control. Become knowledgeable about the cholesterol content of foods. Read food labels when uncertain and be conscientious about your cholesterol intake.

Lack of physical activity is another risk factor for coronary artery disease and heart attack – so keep physically active. For seniors, most are able to adhere to a daily walk, usually 30 minutes of a brisk but comfortable walk. Snowbirds have the opportunity to maintain this healthy lifestyle for 12 months of the year. Obesity not only increases your risk for CAD, but for many other conditions as well, including diabetes and joint problems. This further reduces your opportunities for exercise, and diabetes alone is associated with a much higher incidence of arteriosclerosis. In fact if you are diabetic, strict weight control, no smoking, a daily exercise program and drugs to strictly control cholesterol and blood pressure are essential.

Modify & Monitor
High blood pressure is a major risk factor for heart damage, especially the coronary arteries. Although there are hereditary factors, many patients must now be treated because of obesity, physical inactivity and excessive salt intake.  Modifying one’s lifestyle in these cases is essential. Prescription drugs should result in most blood pressures being below 140/90 and for diabetics, below 130/80. Be diligent in managing this aspect of your health. Buy an electronic home monitor, use pharmacy machines, record the levels and show them to your physician for advice.

Snowbird Solutions
For Canadians planning a winter vacation away from home, here are some added tips.
Plan your annual physical examination for each spring when you return. That way, if regular or particular investigations are indicated or your physician prescribes a new drug or new consultation, you will be more likely to be stable for the 90 days required by most insurance companies before your next trip south. Keep a written copy of your past history, current medical conditions, medication names and doses, and a copy of your most recent electrocardiogram (ECG). In the event of an emergency away from home, such immediate information is extremely important in assisting the evaluation of your condition by a new physician.

Travel Wisely
For travellers with known cardiac disease, there is further advice. Plan your holidays for locations at which there are reputable medical services close at hand. In the event of necessary repatriation to Canada, consider sites that have good airline services. Do not travel in high altitudes and carefully consider whether or not a cruise is a wise choice, recognizing the medical service limitations on board as well as the remoteness from tertiary health facilities. Make a courtesy visit to a chosen physician at your travel site upon your arrival, in order for you to have an established local medical resource. Although the costs of routine visits are not covered by emergency travel health insurance, having your heart condition monitored by a local physician is good advice. If you are on medications requiring regular testing such as warfarin or diabetic medications, be sure to make contact with a local laboratory.

Following a heart attack, cardiac rehabilitation programs are now considered the normal routine. This starts during the hospital stay and continues following discharge, often for months. Most programs focus on improving physical fitness and therefore cardiac fitness, stress management, weight management and monitoring of proper medications. Most individuals will be maintained indefinitely on a cholesterol-lowering drug, aspirin or a similar “blood thinning” medication, a “Beta-Blocker” which lowers your heart rate and blood pressure and in some cases, an ACE inhibitor drug which improves the heart’s pumping capability. Other medications may be necessary for concomitant conditions.

Strict adherence to these recommendations and regular assessment by your physicians will be important in secondary prevention.

Most of us are at risk for some degree of coronary artery narrowing. With proper attention to our weight, physical activity, cholesterol level, stress level and blood pressure along with smoking avoidance, we can do much to reduce the risk of angina and heart attack. Snowbirds in particular have more opportunities for this healthier lifestyle. We just need the will power!