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WHEN THE HEART ATTACKS Do not ignore what lies beneath!
By: Dennis M. de Asis, M.D.
Fact: Diseases of the heart ranked number one as cause of death in the Philippines from 1985 to 2009 
Fact: The incidence of myocardial infarction worldwide is more than 3 million per year 
Fact: Coronary heart disease (CHD) is the number one cause of death in the Western world and as such constitutes an immense public health problem
Myocardial infarction(MI), more commonly known to lay people as “heart attack”, occurs when the heart muscles (myocardium) gets deprived of its oxygen supply because of a blockade of the coronary artery, the blood vessel that carries oxygenated blood to the myocardium. These arteries become obstructed because of the progressive accumulation of atherosclerotic plaques in the walls of the blood vessels. Risk factors have been identified in the development of this condition which include smoking (second-hand smoke not exempted!), hypertension, diabetes, obesity, hypercholesterolemia (elevated cholesterol levels), lack of physical exercise, alcohol, use of oral contraceptives, and stress – these are the modifiable risk factors, meaning they can be corrected or avoided. Other risk factors are called “unmodifiable”, which means they are inherent to the individual and therefore cannot be changed – these include age, sex, and genetics( strong family history). Men are at a higher risk than women, but because women live longer than men in general, higher deaths from ischemic heart disease are reported among women.
The typical presentation of myocardial infarction is a chest pain, described as chest heaviness, substernal in location, radiating to the left arm, shoulder, and neck; which may be precipitated by heavy physical activity, emotional stress, including sexual activity. The pain may last for several minutes, relieved by rest and intake of nitrates. When the pain occurs, a plaque in the coronary artery usually ruptures which occludes the blood flow to the myocardium. If the occlusion in the coronary artery lasts long enough, the myocardium is permanently destroyed through a process called necrosis, and the cells are eventually replaced by a scar. This may cause arrhythmia (irregular heart beat, usually ventricular fibrillation) and the formation of aneurysm that may rupture and cause fatal complications, such as sudden cardiac death (SCD). Levine’s sign, where the patient localizes the pain with a clenched fist over the chest was thought to be predictive of heart attack but studies have shown that is has a poor predictive value. Other symptoms which may be labeled “atypical” include shortness of breath/dyspnea, epigastric pain, back pain. Women and older patients present with atypical symptoms more frequently than their male and younger counterparts. A percentage of the population may not feel any pain or any symptom during an attack, and this is called a “silent MI” – this is seen in about 25% of cases, usually the elderly, diabetics and post heart transplant patients . Other reported symptoms include diaphoresis (excessive sweating), weakness, lightheadedness, nausea, vomiting and palpitations. These symptoms may be brought about by the body’s response to pain by releasing cathecolamines from the sympathetic nervous system. Loss of consciousness, and in the worst case scenario, sudden death may result from MI. Disease conditions that may mimic presentation of an MI include pulmonary embolism, aortic dissection, cardiac tamponade from pericardial effusion, tension pneumothorax, esophageal rupture and gastroesophageal reflux disease (GERD).
Several diagnostic tests are available to arrive at a diagnosis of MI which include electrocardiogram (ECG) and cardiac enzymes (troponin and CK-MB) determination. Using ECG as a guide, MI may be classified as either ST Elevation MI (STEMI) or non-ST Elevation MI (NSTEMI). The other way to classify it is dependent on the extent of myocardial wall involvement. A transmural infarct involves all layers of the myocardium and ST elevation and Q waves are seen on ECG. A subendocardial infarct, on the other hand, may involve only a small part of the subendocardium in the left ventricle, septum or papillary muscle. In contrast to transmural infarct, ST depression is seen on ECG with subendocardial infarcts. Another diagnostic tool is 2D-Echocardiography. It is just like an ultrasound that visualizes the heart real-time. Abnormal wall contractility, presence of mitral valve regurgitation may be suggestive of a coronary artery disease. Stress test is another diagnostic modality where a patient walks in a treadmill or asked to pedal a stationary bike with increasing levels of difficulty. While doing this, ECG, blood pressure and heart rate is being monitored in response to exertion. This determines adequacy of blood flow to the myocardium with increasing levels of activity. During a stress test, if you can’t exercise for as long as what is considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart, suggestive of a coronary artery disease. Coronary Angiography is an invasive procedure done by cardiologists, where the coronary arteries are visualized by injecting a dye and the site of obstruction is localized. The World Health Organization (WHO) formulated a criteria in 1979 for the diagnosis of MI. This was revised in 2000 and the latest guidelines state that a cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression, or coronary intervention is diagnostic of MI.
At the emergency room, once MI is suspected, oxygen therapy, aspirin and sublingual nitroglycerin is given immediately, followed by doing all the necessary work-ups. If ECG shows an ST Elevation MI, then a reperfusion therapy in the form of percutaneous coronary intervention (PCI) or thrombolysis may come into place. On the other hand, if it is a NSTEMI, patients may be managed with medication although PCI may be required if the patient’s risks warrants it. Coronary artery bypass graft surgery (CABG), or commonly known as bypass surgery to many, is indicated when there is multiple involvement of the coronary arteries or when PCI fails or is contraindicated. If without complications, a patient goes home after surgery in about 7 days. The use of stem cell therapy after an MI is still an ongoing investigation.
After hospitalization, whether patient is managed medically or surgically, they are sent home with maintenance medications including antiplatelets (aspirin, clopidogrel), beta blockers (metoprolol, carvedilol), ACE inhibitors, and statins. Strict compliance with these medications is advised, and modification of lifestyle (that is smoking, diet, exercise) is strongly encouraged.
Take Home Message:
1. When you feel any of the above-mentioned symptoms, consult your doctor immediately!
2. Better yet, make annual check-up a habit:)
3. Be considerate – remember, even second-hand smoking is a risk factor for MI, not only for lung cancer…so STOP SMOKING!
4. Life is short, relax, give yourself a break you most deserve…
5. The old adage never fails – Prevention is more than a pound of cure. Start now! One of the greatest enemies we can face in life is the illusion that there will be more time tomorrow than there is today.
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Welcome to the official website of the Philippine Association of Thoracic and Cardiovascular Surgeons, Incorporated, (PATACSI).
We are an organization of competent, ethical and socially responsive surgeons working to ensure quality of thoracic, cardiac and vascular surgery practice in the Philippines.
Our vision is to provide world class thoracic, cardiac and vascular surgical care responsive to the needs of the Filipino people.
Objectives of PATACSI
1) To ensure the highest standards of thoracic, cardiac and vascular surgery training programs.
2) To promote surgical research in thoracic, cardiac and vascular surgery.
3) To provide relevant continuing surgical education in thoracic, cardiac and vascular surgery.
4) To maintain the highest standards of ethical surgical practice
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May 23, 2012, 19:20