Prevention of Heart Attack

Prevention of Heart Attack

Block (atheroma) formation in the coronary arteries is the biggest killer in the world. Coronary artery disease (angina and heart attack) remains the leading cause of death in men over 45 years and in women over 65 years through out the world now. The underlying atherosclerosis (block) develops insiduously, and is generally advanced and difficult to reverse once symptoms occur. Thus, treatments will generally be palliative rather curative. The development of heart attack is strongly related to lifestyle characteristics and associated risk factors, and there is now clear evidence that lifestyle modification and risk factor reduction can retard the development of angina or heart attack. Major advances in the diagnosis and treatment of coronary heart disease have not been paralleled by similar enthusiasm for measures aimed at its prevention.

Life style and characteristics associated with increased risk of future coronary artery disease (angina and heart attack) :

1. Life Style
a. Diet high in saturated fat, cholestreol and calories.
b. Tobacco smoking
c. Excess alcohol consumption.
d. Physical inactivity

2. Biochemical and Physiological Factors :
a. High blood cholesterol
b. Elevated blood pressure
c. Low plasma HDL
d. High blood triglyceride level
e. Diabetes
f. Obesity

3. Personal Characteristics :
a. Age
b. Sex
c. Family history of heart attack

Who are the Persons Require Attention (according to priority)
a. Priority-1 (very high risk). Patients with established angina or prior history of heart attack.
b. Priority-2 (high risk). No symptom but has diabetes or hypertension or high blood cholesterol. Smokers are also included in this group.
c. Priority-3 (moderate risk). Close relatives of patients with early-onset angina or heart attack.
d. Priority-4 (Low risk). Any adult patient not included above.

Preventive Approach :
Prevention of coronary artery disease is of two types primary prevention and secondary prevention. Primary prevention means, prevention before the disease manifests. So, they do not have angina and do not have any past history of heart disease. They are asymptomatic high risk persons. Secondary preventive approach is applied in those who are established to have coronary artery disease in the form of angina or heart attack. In this group preventive approaches are important to halt the further progression of disease or to reverse the process if at all possible. So, primary prevention is before the development of disease and secondary prevention is after the development of disease.

How to prevent heart attack ? (2)

Secondary prevention :

1. To Modify Lifestyle:
Avoidance of all tobacco

Modify food choices to reduce fat intake to 30 per cent or less of total energy and the intake of cholesterol to less than 300 mg/day. Vegetables, fruit and cereals intake should be emphasised. Calorie intake should be reduced in the overweight.

To improve physical fitness through regular leisure exercise.

2. To modify Risk Factors :
Again, lifestyle modification to control weight, high cholesterol and hypertension (high blood pressure) are appropriate. Drug therapy is needed for the control of high cholesterol and hypertension if lifestyle modifications fail to produce a satisfactory response.

Optimum control of blood sugar and meticulous attention to other risk factors along with diabetes.

Reduction in thrombotic tendency (solidification of blood) through avoidance of tobacco, changes in fat consumption as above and in women of fertile age avoidance of the oral contraceptive pills.

3. To Consider Preventive Medications :
Aspirin for most

Beta-blockers (tenotmin, tenoren, tenoloc, betaloc, betanol, cardipro, betasec etc) after heart attack to reduce the incidence of sudden death.

Angiotensin converting enzyme inhibitor medicines (zestril, acepril, neopril, capoten, vasopril, vasotec, lipril, topril, ramipril, Cardace, Inhibase, Coversyl etc) to prevent heart dysfunction after heart attack.

Primary Prevention:
The principle here remains the same. There is, as yet, no established place for universal preventive drug treatment with, for example, aspirin.

Smoking Kills the Heart:
Cigarette smoking is one of the major public health hazards in the developed and developing countries. It has been estimated that a 25 years old male who smokes twenty cigarettes per day will shorten his life by 8-10 years compared to his non-smoking counterpart. Others evils such as cancer and lung diseases aside, smoking is one of the most important risk factors of coronary artery disease (CAD). Epidemiological studies in USA showed that, overall age adjusted six-year risk of CAD death was 2. 3 time higher for cigarette smokers compared to non-smokers (3). As for the females, smoking and use of oral contraceptives carried a joint impact of a ten-fold increase in CAD compared to their counterparts.

The damage from smoking is "dose related". Pipe and cigar smokers were said to have less propensity to heart disease while use of efficient filters were thought to reduce the risk of smoking. But the only certain way to protect your heart is to quit smoking! Remember, when you quit smoking, you spare the "passive" (involuntary smokers who work in the same office with the smokers, spouses of smoker etc). Passive smokers are also prone to develop heart attack, lung cancer etc. The good news is that you could reverse many of the adverse effects of smoking by quitting now. Within 2 years of quitting smoking, the heart attack risk is reduced to half that in smokers. Within 10 years, the risk of heart disease is the same as that at non-smokers. Quitting smoking now greatly reduces serious risk to your health.

Kicking out the smoking habit do not come easy. Determination is the most important factor to success. Set an auspicious date to quit smoking and tell your close friends (particularly the smoking ones) and relatives about it to enlist social support. List the longterm health benefits of quitting smoking, and if this seems too remote think of the immediate rewards such as cleaner breath and improved stamina and money saving. Many people who succeeded in kicking smoking began to gain weight. They regained their appetite, and tended to snack when they craved for cigarettes. So keep a stock of low-calorie snacks on hand when you watch TV or read. Others turn to regular exercises to overcome the craving.

There are a variety of interventions to reduce smoking. On an average, about 5 percent of smokers will discontinue the habit for one year after receiving a physician's advice, although the rate of quitting will be higher in more highly motivated cohorts. Nicotine gum or transdermal patches may increase the one-year likelihood of smoking cessation by 30 to 100 per cent. Nicotine withdrawal can be managed by tapering cigarette smoking, gradually changing to lower nicotine cigarettes and substituting chewing of nicotine gum. Nicotine gum is prescribed as needed, up to 30 doses per day. The average patient uses 10 doses per day and the frequency of dosing declines over a 1 to 3 month period.

The association between heart disease and smoking is well known to lay public. Myocardial infarction (heart attack) or by pass surgery is a sufficient impetus for 20 to 60 per cent of patients to stop smoking.

Group counselling can increase rate of quitting. Public programmes also are effective, with television advertisements against smoking among the most cost effective.

Stop Smoking Right Now. Follow the Following Instructions to Quit Smoking :

  1. Get rid of all your cigarettes, discard matches and lighters.
  2. Take deep breaths, when ever you feel the urge to smoke. Hold your breath for 10 secs then release slowly.
  3. Exercise to relieve tension-walk instead of riding when ever possible.
  4. Think of negative image. You associate with smoking when you feel tempted. Select your worst memory connected to smoking. Think of breathlessness when running.
  5. Reward yourself, with apple slices instead of smoking.
  6. Eat three meals a day.
  7. Spend time with friends who do not smoke.
  8. Go publicly with plans to quit smoking.

Control Your Hypertension (high blood pressure) :
High blood pressure is an important risk factor for development of coronary heart disease or heart attack. Regular treatment of high blood pressure can reduce the incidence of heart attack. Even treatment of mild hypertension brings about 35 per cent to 40 per cent reduction in strokes and 20 per cent to 25 per cent reduction in heart attack (4, 5). If your blood pressure is not well controlled the chance of formation of block (atheroma) in your coronary artery increases. Persistent rise of blood pressure also increases the thickness of the muscle of heart which then demand more oxygen than normal. This increases in thickness of heart muscle is called left ventricular hypertrophy. This type of increase in thickness of heart muscle is found in upto 50 per cent of hypertensive patients and is associated with a fivefold increase in sudden death (6). Between 20 per cent and 30 per cent of the adult population in developed countries is found to have raised blood pressure; about two thirds have mild blood pressure (7). The separation between normotension (normal blood pressure) and hypertension (high blood pressure)is arbitrary. About 20 per cent of the adult population aged 18-74 has high blood pressure, defined as >/= 140/90 mm of Hg. Blood pressure rises with advancing age and affects approximately:

Classification of blood pressure for adult aged 18 years and older (8).

It is recommended that if blood pressure is persistently higher than 140/90 mm of Hg patient requires treatment. Single measurement of high blood pressure does not indicate that the patient is hypertensive, the decision should be based on the average of two or more readings taken at each of two or more visits after an initial screening. Optimal blood pressure in respect of cardiovascular risk is about 120 mm of Hg systolic and about 80 mm of Hg diastolic. It is rational to bring down blood pressure less than 140/90 by antihypertensive medicines.

We can bring down blood pressure by using many antihypertensive drugs. The important drugs are beta blockers, ACE inhibitors, calcium channel blockers, diuretics etc. Beta blockers are very popular in the treatment of blood pressure. Atenolol (tenormin, tenoren, betasec, tenoloc, atenol, betanol etc) in dose 25 mg to 100 mg daily, metoprolol (betaloc) 50 mg twice daily to 100 mg twice daily and propranolol (Indevar, inderal, propranol, adloc etc) 20 mg three times daily to 80 mg three times daily can effectively control blood pressure. But these drugs can not be used in patients with bronchial asthma, heart block and heart failure. ACE inhibitors such as lisinopril, captopril, ramipril, enalpril are also used in the treatment of hypertension. Lisinopril (Acepril, zestril, neopril, lipril) 5 mg to 40mg once daily, Captopril (capoten) 12. 5 mg to 50 mg three times daily or enalapril (Renetec, envas, vasotec, vasopril etc) in doses 5 mg to 40 mg once or in two divided doses or cilazapril (inhibase) 1 mg to 2.5 mg once a day can be used in the treatment of hypertension. Calcium channel blockers like nifedipine, diltiazem, verapamil, amlodipine etc are also excellent drugs in the control of blood pressure. Nifedipine (Adalat, calcigard, nefin, nedipine, ficard, neficap etc) in dose 10 mg three times daily to total maximum 120mg/day, diltiazem (Herbesser, cardizem, dilazem, metazem, Diltizem etc) 30 mg three times daily to maximum 360 mg/day, verapamil (isoptin, calan, angimil, vasodil etc) 40 mg three times daily to maximum 480 mg/day or amlodipine (norvasc, amdocal, amlocard, amlopin, sidopen) 5 mg once daily to 10 mg once daily may be used to control blood pressure. Diuretics like amizide, diazide, naturetic, natrilex etc are also effective in the treatment of high blood pressure. If single drug can not control blood pressure then combination of two or more drugs may be used.

If your heart muscle has already been thickened even then it can be reversed by some drugs. It has been proved that the medicines like ACE inhibitors (lisinopril, captopril, enalpril etc), diuretics like indapamide (natrilix) 2.5 mg once daily may reverse heart muscle thickening (9).

Control High Blood Sugar :
Diabetic patients are more prone to develop heart attack. They may develop heart attack without pain because pain perception may be impaired in many diabetics due to prior damage of pain carrying nerves. If you are diabetic you may have painless heart attack. So if any patient with diabetes suddenly develop shortness of breath or marked sweating or if blood pressure drops suddenly the possibility of myocardial infarction (heart attack) to be excluded by proper investigations.

Four Methods of Treatment are Available for Diabetic Patients :

Approximately 50 per cent of new cases of diabetes can be controlled adequately by diet alone, 20-30 per cent will need an oral hypoglycemic drugs like glibenclamide (daonil, dicon, dibenol etc), gliclazide (diamicron, dimerol, comprid, gored, diatrol etc), glipizide (diactin, minidiab), metformin (glucophage, metfen, daomin, comet, metfo, metforal etc) and 20-30 per cent will require insulin. Dietary measures are required in the treatment of all diabetic patients to achieve the overall goal. The body weight should be maintained at or slightly below the ideal for the patient's height. All the carbohydrate diet should be taken in the form of starches and other complex sugars. Simple sugars such as glucose and sucrose should be avoided because they cause a sudden rise in the blood sugar level. Fibre rich foods are better for diabetic patients. The total intake of fat should be reduced. Saturated fat (animal fat) to be reduced and unsaturated fat (vegetable fat) may be increased if possible. Low calorie and sugar free drinks are useful for patients on low calorie diets. Non-nutritive sweeteners (saccharin, aspartame, sucramate etc) are the most widely used non-nutritive sweeteners and provide means for reducing energy intake without loss of palatability.

Unmeasured Diabetic Diet

Breads of all kinds, biscuits, cereals, potatoes, peas, all fresh dried fruits, milk, fish, egg (excluding the yolk is preferable) etc.

Green vegetables, clear soups, fibre containing foods, tomato, lemon juice

Once upon a time it was thought that all the complications of diabetes can not be prevented even by good diabetic control. But this veiw has been changed in recent past. Now it is believed that all the complications of diabetes are essentially preventable by rigid blood sugar control. The Diabetes Control and Complication Trial (DCCT) has been published in New England Journal of Medicine in 1993 (10). The conclusions of this world famous study are clear and incontrovertible

You must try to maintain your blood sugar level according to the following recommendations :

1. HBA1C(Glycated haemoglobin) : </=9 per cent</li>
2. Blood sugar level :
a. Fasting to be maintained below 6.7 mmol/L (120mg per cent )
b. 2 hours after breakfast below 11.1 mmol/L (200mg per cent )

Impact of a single risk factor, multiple risk factors and clinically established coronary heart disease on absolute risk of a coronary event during 10 years based on the European Society of Cardiology (ESC), European Atherosclerosis Society (EAS) and European Society of Hypertension (11) is mentioned below

Submitted By
Professor Baren Chakraborty, Fcps, Fccp, Frcp

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