Heart Attack
Dr. Hassan Chamsi Pasha Dr. Fawaz
Akhras
A heart attack is the most common serious illness of the developed
world today. Many patients make an excellent recovery, but leading a healthy
life can prevent heart attack from occurring in the first place.
What is a
heart attack?
The heart depends on its own blood supply to provide it with the oxygen
that is essential for it to function properly. The heart is supplied by two
coronary arteries. If there is a sudden blockage of a coronary vessel supplying
blood to the heart muscle, the portion of the heart affected will die.
How
serious is it, doctor?
The seriousness of the heart attack depends on where the blockage or
infarct occurs. If only a small part of the heart is affected, the person can
survive the heart attack even though a part of the heart does not work. If
however, the blockage halts the blood supply to a large area of the heart
muscle it may be fatal.
What
is the cause of a heart attack?
The main cause of a heart attack is a condition called
"atherosclerosis" in which fatty deposits, or atheroma, attach
themselves to inner lining of an artery. The arteries that were once smooth and
elastic become rough and inflexible. As they narrow, the volume of blood they
can transport is progressively reduced. As the mass of the atheroma grows it
may turn into a hard chalky plaque that further inhibits blood flow. If a crack
occurs in this plaque a blood clot may be formed at the crack shutting off the
blood flow entirely and causing a heart attack.
What
is the difference between angina and heart attack?
Because of the narrowing in coronary arteries, the heart muscle may not
receive sufficient blood supply. An inadequate blood supply is called
"ischaemia" (the term
"ischaemic heart disease" is synonyms with "coronary
heart disease" ). If the blood supply to the heart muscle is insufficient
because of increased demand such as during exercise, a transient ischaemia will
develop. This may cause chest pain called "Angina" which
characteristically disappears on rest. When the reduction in blood supply is so
severe as to cause death of the muscle cells beyond the obstruction, this is
known as "myocardial infarction" or "heart attack".
What are the
risk factors of coronary artery disease?
The most important risk factors are family history of coronary disease,
smoking, high blood cholesterol, hypertension and diabetes mellitus. Other risk
factors include age, male gender (men are more likely to suffer heart attack
than women), lack of exercise, obesity, unhealthy diet (eating a lot of fat)
and stress. The children of someone who has died of heart attack are more likely
than average to die from this cause.
How old do I
have to be before I'm at risk for a heart attack?
Unfortunately heart attacks are occurring in younger patients. They are
occasionally seen in patients in their twenties. By the late thirties and early
forties they are really quite common.
What are the
symptoms of a heart attack?
The main symptom of a heart attack is severe central chest pain that
might spread out to one or both arms and sometimes to the neck and jaw. The
victim may also be breathless,
apprehensive, have a cold clammy skin and feel nauseated or vomit.
If you do suffer from an attack of pain which you think might be a
heart attack you should seek medical advice immediately.
Could
I have had a minor heart attack without knowing it?
Yes. It is fairly common to see a clear evidence of a previous heart
attack on the electrocardiogram in patients who have never had any symptoms.
The so called "silent" heart attack is commonest in elderly.
How
is the diagnosis of heart attack confirmed?
Your doctor will perform an immediate electrocardiogram and take blood
for measurements of certain enzymes released into the blood from a damaged
heart muscle. These will show characteristic changes confirming that the pain
is due to a heart attack.
How is the
heart attack treated?
The first priority for any doctor treating a patient with a heart
attack is to relieve the pain. This is usually done with an injection of
morphine or a similar drug. It is extremely important that patients with suspected
heart attack are taken to the hospital as soon as possible and without delay.
There are now drugs such as streptokinase and TPA that can be used to unblock
the arteries by breaking up the thrombosis that is usually the cause of a heart
attack. If irreversible damage to the heart muscle is to be prevented these
drugs have to be administered by injection preferably within the first six
hours of onset of chest pain. The
patient is usually given one tablet (300 mg) of aspirin to chew once the
diagnosis of heart attack is established (provided patient is not known to have
peptic ulcer). Coronary angiography may be performed to identify the extent of
lesions in the coronary arteries and in certain cases, angioplasty (widening of
narrowed coronary arteries by balloon) may follow coronary angiography.
Coronary artery bypass surgery may have to be considered in other cases.
Why
to go to Coronary Care Unit?
The patient should be transferred without delay to a Coronary Care Unit
where he is also likely to be given other drugs such as nitroglycerin infusion,
beta blockers, ACE inhibitors or heparin.
An essential component of coronary care is the use of
electrocardiographic monitoring. This involves attaching two or three
electrodes to the chest wall. By these means, the rhythm of the heart is
continuously displayed on a monitoring screen.
In coronary care units nursing and medical staff are trained to
recognize and institute early treatment of arrhythmias (abnormal heart rhythm),
and many patients find the environment reassuring.
It is usual for a needle to be inserted into a vein on the back of the
hand or in the forearm and left in place for easy access to blood stream.
What
are the possible complications of a heart attack?
Damage to the heart muscle may be so severe that it leads immediately
to heart failure. Abnormal heart rhythm is common in patients with heart attack
and closed monitoring in the coronary care unit leads to immediate treatment of
such complications.
When can I
get up and when can I leave the Coronary Care Unit?
Mobilization following a heart attack depends on its
size, the presence or absence of complications and the speed of recovery. Most
patients can sit out of bed on the second or third day, and discharged from the
unit to the general ward around this time. If, however, the blood pressure has
been low or if there has been recurrent pain or breathlessness, or if there has
been a disturbance of the heart rhythm, both mobilization and transfer may be
delayed.
What
happens between transfer from the
Coronary Care Unit and discharge from hospital?
This time is spent in getting the patient rehabilitated and gradually
becoming fully mobile. A treadmill exercise test may be carried out about one
week after admission. If the patient is unable to perform well on the treadmill
or develop angina or major ECG changes, he may require coronary angiography. If
the patient does very well on the exercise test, this is very reassuring and
usually implies that the outlook is good.
When
am I going home?
Patients are usually discharged home on the seventh to tenth day but
this depends on the speed of recovery. By that time the patient is usually
walking comfortably.
What
medication do I need to take home?
Most patients will be given two or more drugs. The use of aspirin and
beta blockers is almost routine as they reduce the risk of having another heart
attack. Other drugs such as ACE inhibitors, diuretics or digoxin may be given
if there has been heart failure and according to patient's needs.
How
long does it take to recover from a heart attack?
Recovery from a heart attack can take 6-8 weeks, since the tissues of
the heart, like those of the nervous system, cannot regenerate; healing is by
process of scar formation, not muscle cell replacement.
When
can I go back to normal life?
Patients should gradually increase their activities day by day. They
should be warned not to take up strenuous exercise e.g. carrying heavy shopping
in the first few weeks.
By the end of the first week, patients may be able to take short walks
which can be increased gradually provided there is no chest pain or
breathlessness. By the end of the month, most patients should be able to walk a
mile at a normal pace.
By the end of the second month, most patients should aim to be fitter
and do more exercises than just prior to the heart attack.
When can I
have sex, after a heart attack, doctor?
Patients should be reassured that they can resume normal sexual
activities after 4 weeks as long as it does not provoke chest pain.
When
can I drive?
Patients with heart attack should not drive in the first 4-6 months.
They should also not drive if this provokes angina.
When
can I fly?
Patients with heart attack are advised not to fly during the first three
weeks after a heart attack.
When
can I return to work?
Most patients doing nonphysical jobs can go to work 4-6 weeks after
leaving hospital. Patients should be advised to take the first week or two at
work fairly gently.
How
can I prevent another heart attack?
Smokers should give up smoking and patients should undertake regular
exercise. Obese patients or those with elevated cholesterol in blood should
loose weight. This enhances a sense of well-being and decreases the work of the
heart.
Patients need to be
followed up in cardiology clinic for further assessment and advice.
From the Book : “ Patient Guidelines to Heart Disease : Questions and Answers “
By Dr. Hassan Chamsi Pasha & Dr. Fawaz Akhras
Dar Almanara – Jeddah in 1999