Perhaps nowhere in medicine is such attention and funding evident than in the diagnosis, treatment, and prevention of heart disease. It is perhaps because of that attention that I have chosen it as the subject of my first article.
The heart has always been a very special organ as recognized by the early Greek and Chinese doctors and it has always been attributed with special powers and some spiritual sense. Indeed it is a remarkable organ beating some 30 million times in an average western life. It is awesome to think of any mechanical equivalent that supports such technological brilliance and yet at a basic level it is a very simple 4 chambered muscular pump with 4 valves and an electric circuit that maintains its operation.
It is important to recognise that we have perhaps been seduced into believing that modern medicine and technology are absolutely necessary for us to survive heart disease and easy to forget that when I was a physician 30 years ago most people survived their heart attacks at home going on to live a healthy life afterwards. Sadly a few did not survive but the increase in salvage that has come in those years has not been as great as we perceive and it is important to recognise that. The fact that most Western European countries and America have a falling mortality from heart disease may be more to do with decreased tobacco consumption and better nutrition than in high technology.
Heart attack also called coronary (artery) thrombosis, or myocardial infarction is the most common, and indeed the most worrying, condition to affect the heart. It is in simple terms a sudden obstruction to the blood flow of an area of the muscular pump with death of the muscle and subsequent scarring. Most patients make a full recovery as the dead piece of muscle scars. Unless the affected area is huge or supports some of the heart’s vital circuitry death does not occur. Usually the process is very painful but often, especially as we get older, can be a painless experience or silent heart attack which is often picked up on later screening.
The sudden obstruction is caused by the build up of fatty deposits in the arteries suppling the heart, a process called atherosclerosis, more often deposits partially block arteries causing a cramping chest pain on excercise – called angina. It seems that this process may well be natural in western society – many young soldiers killed in Vietnam had coronary artery occlusions that were evident at post-mortem. Sometimes decreased blood flow to the heart solely produces the symptom of excercise intolerance.
There is a genetic form of high cholesterol (fat) levels that puts its family members at huge risk of coronary atherosclerosis and in these families heart attacks and deaths often occur in the third and fourth decades. All membersof such families should be screened and treated for high cholesterol levels. Some people and families handle cholesterol well and have no history of heart disease others less well. Smokers and those with high blood pressure are more at risk whilst diabetics have a ten fold increase in the risk of heart attack. Lowering cholesterol across a whole population will reduce the risk of heart attacks, but not to a large extent in those with no other risk factors whilst decreasing it in those with multiple risk factors and a genetic predisposition undoubtedly saves lives.
Heart attack is now treated with immediate aspirin to thin the blood and by a “clot-busting” drug – streptokinase, if the heart is unstable in anyway either electrically (giving an irregular rthymm or infrequent impulses) or is failing to beat well then a long tube is inserted into an artery in the leg and directed to the coronary arteries where the injection of dye can demonstrate the blockage and a small metal tube or stent is used to push the clot aside, some such stents even exude drugs to prevent further blockage. Usually this procedure allows the heart to resume better function and to heal well.
There is now irrefutable evidence that decreasing cholesterol in those who have heart disease or who have had a heart attack brings considerable benefits as does the use of aspirin and a drug to lower pulse rate.
The prevention of coronary artery disease and its diagnosis at treatable stages have now reached the art of perfection but not without some considerable intervention – some not without risk. Whilst prevention revolves around life-style issues of diet, excercise, no smoking and low blood pressure and for some at higher risk the consumption of lipid lowering drugs we are just becoming aware that exchanging a lipid containing diet for one high in refined carbohydrates increases obesity and the risks of diabetes which in turn heavily impacts on heart disease.
Diagnosis should always begin with a skilled physician taking a history and assessing risk factors and determining to what extent the individual wishes to undergo tests in the light of such risk. Resting cardiographs give little accurate information about blood flow to the heart but may indicate poor blood flow or past heart attacks, a cardiograph on a treadmill will give more accurate information an may indicate that further tests are required. Angiography mentioned above will give an accurate picture of the hearts blood supple and can be supplemented by the simultaneous insertion of stents where appropriate. It is however not without risk of heart attack itself and if a clot is dislodged it can also cause a stroke. More modern tests some of which are now available in Ukraine include CT imaging and the use of nuclear and echo stress tests all of which now provide accurate results in specialist centres and have no serious risks.
Coronary artery bypass surgery has to a great extent been superceded by the use of stents but after both procedures fatty clots have a tendency to reform over a ten year period so follow up diagnostics are important.
Whilst modern medicine has gone a long way to minimise the risks of heart disease and treat it effectively progress has posed new problems. Today’s dilemma demonstrating the fragility medicine is the patient who has maybe inadvertently had a diagnostic procedure in the absence of any risk factors or symptoms but yet is shown to have incomplete occlusion of his coronary arteries. Is this a natural process that will reverse as it probably would have done in the young Vietnam soldiers or should he have immediate intervention? 40 years ago it wouldn’t have been a question. Hopefully one day soon we will have the answer.
Dr. Richard Styles is a British Family Physician at American Medical Centers