Physical Activity program for heart Patient.

What is graduated physical activity program?

A graduated program of physical and self care activities can begin upon transfer from the coronary care unit. In the coronary care unit (CCU), assisted range of motion exercises can be initiated in the first 24 to 48 hours for most patients. Self care activities such as shaving, oral hygiene and sponge bathing can be undertaken in the intensive care unit. Upright posture should be encouraged as much as tolerated. Patents should walk with assistance at least twice daily. White some inpatient programs suggest walking specific distance each day; ambulation can be based upon the patient’s tolerances. Most patients will tolerance a minimum of 5 minutes of walking the first day. Walking time can be increased until patients are walking for 30 minutes twice daily. At that point, the walking sessions should include stair climbing to ensure that patients can perform that task at home. Patients able to walk unassisted for 30 minutes and climb stairs have sufficient strength and endurance for most activities of daily living.

rehabilitation after bypass surgery

Rehabilitation After Bypass Surgery 

It is usually believed that heart operation is very taxing. But patient usually recover completely after the bypass operation. The patient may find himself tiring easily for a while but he must not be frustrated. Physical strength will return slowly and steadily over the coming months. Although by-pass operation is usually done for the relief of chest pain or to improve overall well being, the patient may not be fully aware of these benefits until several months after the surgery. A sensible balance of rest and activity is the keynote to a good and speedy recovery. Patient must abide by few instructions after the by pass operation:

1.     It is recommended that the patient must avoid heavy exercise within one month of operation. If you an activity tiring, stop and rest.

2.     Graded exercise program like walking is beneficial. It is better to walk at a comfortable pace, daily increasing the length of time according to physical condition.

3.     It is better to avoid walking in very cold or hot weather and to climb uphill. Exercise in extreme of weather is discouraged.

4.     Formal exercise programmes e.g. wall climbing exercise, riding a stationary bicycle, sit-ups are usually recommended. Riding a stationary bicycle is favourable. Patient can increase the daily time of exercise slowly. Other exercises are equally beneficial.

5.     Heart rate increases when you climb stairs, so climb stairs slowly.

6.     Patient can drive car after 2 months of discharge from the hospital.

7.     Sexual activity can be started once the patient is discharged from the hospital. This is up to you and your sexual partner, when you wish to incorporate intercourse into your activities. If you hesitant or fearful about resuming sexual activity, it is helpful to discuss the feeling with your partner. The stress and fatigue of your operation may initially lessen your interest in sex but as with any activity your desire will return with your increased strength and feeling of well being. Initially it is advisable to place as little pressure on the sternal area as possible. Change of intercourse position may be beneficial. If you feel shortness of breath or chest pain during sexual activity it is better to stop there and to start again when symptoms disappear.

Non-Cardiac Chest pain- Incisional probles

Incisional problems

It is important to know that most of the patients experience non-cardiac chest pain related either to the incision on the breast bone or to ribs on either side of the midline  This type of pain is usually different from the heart pain experienced by the patient in the past. It is important to distinguish between the two. Incisional pain is usually aggravated by coughing, sneezing or sudden changes in body position. Nitroglycerine tablet or spray under tongue will not relieve the pain. This pain is usually relieved by analgesic tablets like paracetamol, indomethacin etc. The patient must be informed that the incisional pain will diminish in time but may recur when there is an adverse change in the weather or when the patient overdose physically. This pain related to cut mark will become less frequent and bothersome as time goes by.

The long cut marks on legs are usually made to harvest sections of veins for using them as by pass channels during operation. There may be local pain and some swelling in the areas of these incisions. Patient may feel some sense of numbness of the skin on either side of the incisions. Patient may have some swelling around the ankle joint for time being. This will disappear in time and should not cause concern. If the patient develops swelling with redness along with discharge of watery substance or pus from the leg or chest wounds, doctor to be consulted immediately?

Coffee and heart disease

Coffee consumption and heart disease

Epidemiological studies have not yet clarified whether coffee consumption is a risk factor for coronary artery disease. Framingham study assessed the survey data on coffee consumption in relation to age, blood pressure and total cholesterol with regard to impact on coronary heart disease. The analysis did not show any association between coffee consumption and the presence of atherosclerosis. Moreover, there was no demonstrable relationship between coffee intake and subsequent coronary events in patients with coronary heart disease. The effects of coffee intake on cholesterol were gender dependent: an inverse correlation with total cholesterol and with LDL in men and a positive correlation with each of these cholesterol values in women.

Heart attacks management

 Important steps in the management of heart attack

1.     Oxygen inhalation

2.     Aspirin is an important medicine in the treatment of heart attack. Aspirin alone in dose 160 mg per day may reduce fatality by 21% and if aspirin and streptokinase are both used mortality can be reduced by 39%. Aspirin should be started as soon as the patient is admitted and given daily until discharged from the hospital, at which time it can be continued at a dose of 75 mg to 325 mg daily in absence of any specific contraindication.

3.     Nitroglycerine: either by mouth or through intravenous infusion.

4.     Morphine for relief of chest pain.

5.     Beta blockers for prevention of recurrent heart attack and sudden death.

6.     Angiotensin converting enzyme inhibitors for prevention of ventricular remodeling (heart dilatation).

Heart Transplant, TMR, Endarterectomy, Keyhole Surgery of bypass operations

New operative techniques  of Bypass Operations 

1.     Endarterectomy:

 During surgery removal of atheroma by opening the coronary artery is called endarterectomy. This procedure is sometimes utilized with CABG operation and may ensure good results.

2.     TMR: 

TMR represents a novel approach to treat coronary disease. In this procedure Laser is used to create or drill 15 to 30 channels approximately 1 mm in diameter in left ventricular wall. After TMR, an oxygen-starved area of heart gets direct contact with the oxygen rich blood in the chamber.

3.     Cardiac transplantation:

 The first human heart transplant was performed by a South African cardiac surgeon, Dr. Christian Bernard in South Africa in 1967. Cardiac transplantation is presently the optimum surgical treatment for severe end stage heart failure. Allograft transplantation results in 90% survival at one year and 50% survival at five years with return to a near normal quality of life.

4.     Cardiomyoplasty: 

In this technique severely failed heart is wrapped by chest muscle named Latissimus Dorsi. This muscle is then driven electrically which helps the heart in pumping. But this operation coats around 30% mortality in the first year.

5.     Reshaping the heart: 

Reduction of left ventricular volume by resecting a part may increase longevity. In this technique large part of the left ventricle is removed and size of the heart is reduced. Though this operation somehow improves the quality of life but this procedure carries 15% risk of death during operation.

6.     Artificial Heart: 

This is a new technique which showed promise in the surgical treatment of heart failure. The Jarvik 2000, is a pump, about the size of a thumb designed to sit within the apex of the heart and silently deliver non-pulsatile flow rates up to 10 liters per minute. In animal models it has shown excellent performance.

7.     Keyhole Surgery:

 This technique is one of the biggest achievements in the history of cardiac surgery. By using this technique surgeons can now perform bypass surgery through a simple three-inch incision. In a standard CABG operation, surgeons sever the patient’s breastbone with a saw; open the rib cage with a steel retractor  then stop the heartbeat while they reconfigure its supporting blood vessels. But in new technique surgeons make a small incision “Keyhole” between the ribs. This operation can be done when the heart is still beating and stopping the heart is optional. Patient may be discharged after three to five days and the patients are fit to play golf two weeks later. But this new technique will not eliminate open heart surgery. This procedure is intended mainly for single vessel bypass operations which are less common. So if the patient requires more than one bypass, may be possible through the keyhole operation.

8.     MIDCAB and OPCAB: 

These surgical strategies include surgery through small incisions or surgery without cardiopulmonary bypass or some combination of two. By pass on beating heart “off pump” bypass surgery through a small median sternotomy incision is the most widely used procedure now a day. “Off-pump” surgery through small incision is most commonly employed as a left internal mammary artery to the left anterior descending artery graft through a left anterior thoracotomy. Robotics technology, still in its infancy, offers the possibility of expanding access to coronary arteries “off-pump”.

9.     Hybrid operation: 

The concept of adjunctive coronary angioplasty combined with minimally invasive bypass surgery for revascularization of multivessel coronary artery disease has been developed in recent years. This minimally invasive bypass surgery has obviated the risks of median sternotomy and cardiopulmonary bypass procedure. Patients earlier considered high risk for a conventional CABG operation, are now candidates for surgical revascularization by the less invasive surgery. The hybrid operation is nothing but a combination of PTCA and CABG simultaneously on a same patient. This combined strategy of mini CABG and balloon angioplasty is extremely useful if used judiciously in appropriate high risk patients.  

Treatment Coronary Artery Disease

New techniques in the treatment of coronary artery blockage

1.     atherectomy2.     rotational ablation3.     laser balloon angioplasty

Atherectomy: This is the process of extraction of the cholesterol rich plague or blockage from the coronary artery. This is also introduced inside body through the groin and it also looks like a balloon catheter. The blockages are cut into pieces and are stored inside a small housing. The conventional balloon PTCA can not reduce the bulk of the blockage but only compress it. During atherectomy the bulk of the atheroma can be reduced, so it is a debulking procedure. There is cutting blade at the tip of the catheter and it spins at a rate 5000 rpm inside the coronary artery. Though this type of treatment can reduce the size of the blockage more effectively and produce lumen diameters better than PTCA but these new techniques have not reduced the rates of acute complications or restenosis after coronary angioplasty.

Rotational ablation: This is another approach for removing atheromatous plaque from the narrowed coronary arteries. It looks like a burr and the whole process can be compared with burring usually performed by the carpenters. This technique uses a diamond studded burr spinning at about 180000 rpm to excavate the obstruction. Though burring is associated with higher short-term success but the rates of restenosis is higher in burring patient compared to conventional PTCA.

Laser balloon angioplasty: the present technique involve the application of a continuous wave neodymium, yttrium laser irradiation transmitted through a fiberoptic system that heats up the culprit obstruction. Argon laser, Holmium laser are also used to reduce the blockage. This technique did not gain popularity as long term results are disappointing.

Coronary Stent

Coronary stent

The long-term benefit of conventional coronary angioplasty is limited by the possibility of restenosis (reocclusion) of the treated artery, which occurs in approximately 30 to 50% of patients. Preliminary evidence suggests that stents may reduce the chance of restenosis by decreasing the elastic recoil of the vessel and sealing internal flaps, thus providing a wider, smoother coronary lumen. The first human coronary stenting was done by Sigwart et al in 1987.

Angioplasty stent

Is stenting superior to conventional angioplasty?

Balloon expandable stents were introduced to prevent complications and sudden closure after ordinary angioplasty. The stent was first approved by Food and Drug Administration (FDA) in 1992 for the emergency management of abrupt vessel closure after angioplasty the so called bailout indication. But few trials have proved tant routine placement of stent (not bail out stenting) may reduce the restenosis rate of angioplysty, which is a great draw back of conventional PTCA. Some studies has document that stenting may reduce the incidence of restenosis after the procedure. In one study restenosis rate was 32% in conventional angioplasty and 22% in stentiion group and in another study restenosis rate was 43% in angioplasty patients and 30% in stented patients. So it is believed that coronary stenitng may be superior to ordinary balloon angioplasty and can reduce reocclusion rate significantly.

What is stent

What is a stent?

A coronary stent is a small, stotted, stainless steel tube mounted on a balloon catheter. It looks like a spring used in ordinary ball pen. It is introduced into the artery just after balloon angioplasty into the artery just after balloon angioplasty and is positioned at the site of the obstruction. The procedure is almost lie balloon angioplasty, so the patient can not understand the difference between ordinary stenting. The stent remains wrapped around the deflated balloon. When the balloon is inflated, the stent expands and is pressed against the inner walls of the coronary artery. After the balloon is deflated and removed, the stent remains in place, keeping patients artery. It helps to old the artery open, improves blood flow and relieves symptoms of chest pain.

During the first few days of stent implantation, the daily activities well are restricted. The patient must lie flat until the day following the procedure. The patient will stay in the hospital for up to 2 to 8 days before being discharged. If the patient experienced any chest discomfort, pain or bleeding of any kind after returning home, he/she should contact the doctor or hospital immediately. After 6 months the patients may be asked to return to hospital for a follow-up stress test/check coronary angiogram.

There are many types of stent at present in use. They are Gianturco-Roubin, Palmaz-Schatz, Wallstent, Medronic- Wiktor stents, Bard XT, AVE stent etc. All stents mentioned above are made of stainless steel except Wiktor stent which is made of Tantalum. All the stents are thrombogenic so it may re-occlude after placement. So it is extremely important to follow the medication exactly after implantation of a stent. These medicines keep the blood thin and prevent re-occlusion. Within about four weeks, the lining of the artery slowly grows over the stent, incorporating it into he arterial wall. During this time the patient must be treated with medications to thin the blood and to prevent blood clogging inside the metal surface of the stent. At earlier days combination of aspirin, warfarin and dipyridamole were used to prevent stent occlusion. But now the trend has changed. Now-a-days warfarin or coumadin are not used routinely. Combination of aspirin and ticlopidine has been proved more superior than aspirin and warfarim combination. Patient is advised to take ticlopidine 250 mg twice daily and aspirin combination for 4-8 weeks then only aspirin indefinitely. Any patient taking ticlopidine must check his blood count at an interval of 2 weeks to 1 month because white cell count may fall in 1-2% of patients taking this drug. Combination of aspirin and clopidogrel (plavix) 75 mg once a day may be used instead of combination of aspirin and ticlopidine.

Cardiac Stent

Advice to a stent patient

1.     You must follow your medications erectly.

2.     Do not stop taking any of the prescribed medicines unless you are instructed to do so by the doctor who implanted the doctor who implanted the stent.

3.     If you experience any side effects of the medications, such as headaches, nauseas, vomiting or skin rash, notify your doctor immediately.

4.     After stent implantation, if you develop chest pain or dyspnea immediately report to your doctor.

5.     Keep all appointments for follow-up care including blood testing.

6.     Do not go for a magnetic resonance imaging (MIR) scan within 8 weeks of stent implantation with out clearance from your cardiologist.

7.     Do not use antacids routinely unless prescribed by your doctor, as antacid decrease the absorption of aspirin.

Echocardiogram

Echo-cardiogram test

Echocardiogram is nothing but cardiac ultrasonography. In this sophisticated technique sound waves are used for direct visualization of heart. Doctors can see or scan the heart in a screen, which is almost like television screen. So echocardiogram is the technique of ultrasound imaging of the living heart using ultrasound waves to image various structures within the heart. It is a noninvasive procedure so patient does not feel any pain during echocardiography. Not only the doctor, but also the patient can see his heart movement in the television screen during the procedure. This technique provides detailed anatomical information on cardiac chambers, valves, holes in the heart, abnormal fluid collection around the heart and abnormal intracardiac masses such as tumors, blood clot and infective material. In this procedure a hand-held transducer housing the ultrasound crystal is applied to the patient’s anterior (front) chest wall. Through this, a beam of ultrasound waves is transmitted into the patient’s heart and the returning echoes are then converted into images which are displayed on a video monitor to be recorded on tape in real-time for easy play-back and hard-copy print-out. Doctor can take multiple two dimensional pictures of heart in different positions during the procedure. Doppler echocardiography is used along with the two dimensional echocardiography for detecting flow direction, for measuring blood flow velocity and pressure gradient. Now a day, through colour Doppler imaging, doctor can see the actual blood flow in and around the heart. Obstruction of the values and any trivial leaking can also be demonstrated by colour flow imaging. Heart can also be scanned by using transesophageal echocardiography. Here, the ultrasound crystal is mounted at the tip of an endoscope which is similar to that used by gastroenterologists for studying the stomach and intestines. This tube is introduced through the patient’s mouth in to the esophagus (food-pipe) which lies immediately behind the heart. This technique is usually used when conventional transthoracic (through external chest wall) images are technically suboptimal or inadequate for definitive interpretation.

In patients with coronary heart disease echocardiography usually detect left ventricular wall motion abnormality. In a patient with history of previous heart attack, echo can demonstrate that the wall affected previously either is not moving at all or contracting sub normally. So this procedure is an excellent diagnostic tool for assessing left ventricular function (heart pump function). But in patients with only angina pectoris with out any previous heart attack echo may not show any abnormality. So a normal echo study does not exclude the possibility of significant block in coronary circulation. But newer technique which is called tress echo can detect angina pectoris by stressing the heart and simultaneously real time imaging of heart function. Echocardiography can also document blood clot (solidified blood) inside heart. Now a day’s bed side echocardiography is used to diagnose heart attack at a very early stage when ECG interpretation gives equivocal result.

Stress testing

Stress testing

Many patents with coronary heart disease may have apparently normal rest ECG. So if you’re ECG is normal it does not completely exclude the possibility of pressure of significant block in your coronary arteries. If you have symptoms like exertional chest pain or breathlessness on mild to moderate exercise or suffering from easy fatiguibility, you should go for stress test to exclude the possibility of coronary heart disease. Any type of exercise results in an increase in myocardial (heart muscle) oxygen supply. This increase in oxygen need can only be met by coronary artery dilation or expansion. If you have significant block in any of your three coronary artery, the exercise induced increase in heart muscle oxygen consumption cannot be met due to presence of fixed block in coronary arteries. So during rest your ECG can remain normal and can indicate the abnormalities only during exercise, but in rest.

There are different ways to perform this test. But the Bruce treadmill test is the most popular one. During this test the patient is asked to walk fast or run on a treadmill and continuous ECG is recorded in a computer monitor. The test is continued as long as the ECG does not reveal any ischaemic change suggestive of block or target heart rate is achieved or the patient becomes fatigued.

Stress test is an excellent investigation for the diagnosis of coronary heart disease. This test is reported to have specificity of 77% for the detection of significant steno sis or block in any of your coronary arteries. If you are male and your stress test is positive for block then you can take it as 90% guarantee that you are having coronary artery disease. But in case of female this test is some times misleading and gives false positive result. If your stress test is positive, then doctor will advise you to undergo coronary angiogram. Stress test can tell you that probably you are having block but it can not tell you where are the blocks, how severe are the blocks and how many blocks you have. So stress test is the initial screening test but coronary angiogram is the final test for decision making.

Stress test is a noninvasive test and painless. Risk involved in this test is very little with a fatality of 1 in 10,000 patients. Preparation of the patient for this test is also simple. The patient is only advised not to take heavy meals 4 hours before testing. Patients undergoing diagnostic testing ideally should have beta blockers (e.g tenormin, tenoren, cardipro, betasec, betanol, tenoloc, inderal, indevar, adloc, carditab, propranol etc.) at least 24 hours before the test if possible. This test is also done after heart attack for further coronary risk stratification. If after heart attack this test becomes positive then it is a strong indication for coronary angiogram.

Smoking and Heart Disease

Smoking and Heart Disease

Smoking is one of the important remediable risk factor of heart attack. Tobacco products produce IHD in many ways:

1.    Smoking produces platelet aggregation (blood cell clogging) and helps in the formation of block inside the coronary arteries. It also helps in the formation of blood clot (solidification of blood).

2.    Blood clotting factor, fibrinogen level is higher in the smokers. In Framingham study, fibrinogen value was found significantly higher in the smokers.

3.    Cigarette smoking has been found to have adverse effect on the blood fat level. Compared with nonsmokers heavy smokers have lower levels of HDL (good cholesterol) and higher levels of LDL (bad cholesterol) and triglycerides.

4.    Acute inhalation of smoke is associated with increase in blood pressure which may have detrimental effects in patients with IHD.

5.    Approximately 50 to 150 microgram of nicotine is absorbed through the lung mucosa with each puff of tobacco. Nicotine is potent agonist for the adrenergic nervous system and it causes contraction of coronary and prevents normal blood flow in heart.

Diabetes and Heart Disease

Diabetes and heart disease

Diabetes is an independent risk factor for the development of coronary artery disease. The overall prevalence of coronary artery disease (IHD) is as high as 55% among adult patients with diabetes compared with 2-4% for general population without diabetes. Coronary heart disease is not only more prevalent, it is also clearly more extensive in diabetic than no diabetic patients.

Epidemiological data derived from the Framingham Heart Study demonstrated the increased incidence of heart attack in patients with diabetes and their poor outcome. The death rate from heart attack is more than double in men and more than quadruple in women who have diabetes, compared with the rate in their no diabetic counterparts. The relative risk of myocardial infarction (heart attack) is 50% greater in diabetic men and 150% greater in diabetic women. Similarly diabetic men succumb to sudden death 50% more often and diabetic women 300% more often than do their age-matched no diabetic counterparts. Diabetic women have poorer prognosis than do diabetic men and the cause is unknown. Acute myocardial infarction (heart attack) is said to account for as many as 30% of all deaths in diabetic patients.

Diabetes can predispose you to increased risk of heart attack for few reasons:

1.    Patients with diabetes have higher levels of VLDL (bad cholesterol) and triglycerides (fatty substance) and lower level of HDL (good cholesterol) than do patients without diabetes. Elevated fat level in blood induces coronary artery damage and cause thrombosis at any time.

2.    Blood cells, platelets aggregate spontaneously in patients with diabetes and form colt/thrombus inside coronary artery and cause heart attack.

3.    The blood of patients with diabetes appear much thicker (high viscosity) than normal and solidify easily causing coronary block.

4.    Autonomic neuropathy (nerve destruction by longstanding diabetes) may increase heart muscle oxygen demand and may reduce blood flow to heart muscle by causing increased vascular tone (contraction of the coronary artery).

Diabetic patients are at increased risk of complication associated with heart attack. Patients may fail to recognize the chest pain due to nerve damage. Diabetic patient may have heart attack without any chest pain and presentation may be atypical. Atypical symptoms like confusion, breathlessness, fatigue, vomiting may be the initial symptoms of heart attack. Patients may think that they are having these symptoms for their poor diabetic control like hypoglycaemia (low blood sugar) or due to hyperglycaemia (high blood sugar),  which may cause delay in initiation of treatment of heart attack. For these false beliefs 35% of diabetic patients with heart attack were admitted in general wards rather than to the coronary care unit. Atypical symptoms may alter the patient’s perception of the nature of their illness and interfere with their decision to seek medical care and may cause unfortunate fatality.

Type 2 diabetes increases the risk of coronary heart disease by a factor of two to four. The relative increase in the rate of coronary heart disease among patients with diabetes in most studies is greater for women than men.

Thallium Heart Test

Thallium scan of Heart

The concept of introducing a radioactive substance into the body for diagnostic purposes has been in practice for more than three decades. Radioactive iodine is being used for diagnosis and treatment of various thyroid gland diseases. The isotope scan is also used for assessing kidney function and for diagnosis of spread of different cancers in body. The isotope emits radioactive energy scintillates (lights up) in a gamma camera. Radioactive particles like thallium and MIBI (methyl isonitryl butyl isonitryl) scan are frequently used for the diagnosis of coronary artery disease. Thallium scan and MIBI scan are almost like a conventional stress test. The test is also carried out like a conventional exercise test. The patient is exercised (walking fast or running of a treadmill) until near fatigue or development of chest pain. The isotope is then injected through intravenous route in one hand vein. Then the test is terminated. The patient then lies down while a gamma camera is focused on the heart. This camera then takes multiples picture of the heart at different angles. Thallium and MIBI is preferentially taken up by viable myocardial (heart muscle) cells in the presence of normal coronary flow with out any block. Areas of the heart which are supplied by stenos ed or blocked coronary artery can not take thallium or MIBI normally and shows impaired uptake of the isotope. This defect documented by gamma camera is called perfusion defect. In this test perfusion at rest and at peak exercise are also compared to document reversibility of blood flow. Thallium scan is superior to exercise ECG test in the diagnosis of coronary artery disease. The accuracy of isotope scan has been shown to be around 95% in the detection of significant blockage in coronary artery as opposed to 75-85% in the case of the conventional exercise ECG test. Exercise ECG can detect coronary artery block but can not accurately detect the territory of muscle involved and how much muscle is in threat. The added advantage of isotope scan over a conventional exercise ECG test is the ability to localize the blocked coronary arteries. The pump function of the heart can also be assessed by isotope scanning. This heart function test is called MUGA scan. Coronary angiogram is a invasive test which carries definite risk so difficult to perform repeatedly for the evaluation of continued patency of coronary arteries after balloon angioplasty and by-pass operation. But isotope scan can be done repeatedly on the same patient in evaluating continued patency of coronary arteries after balloon angioplasty and by-pass surgery. That’s why nuclear cardiology has established itself as a most useful non-invasive diagnostic modality. These procedures do not require any special preparation on the part of the patient. It is a safe procedure and the isotopes used exhibit very low radioactivity.

High cholesterol and Heart Attack

High blood cholesterol and heart attack

Cholesterol is a complex fatty substance produced by liver for various functions in the body. The amount of cholesterol in our food also contributes to the cholesterol level in blood. If we take excess amount of cholesterol rich food it well predisposes us to increased risk of heart attack. Any excess of cholesterol results in the deposition of cholesterol in the arteries resulting in narrowing and hardening of the arteries (atherosclerosis). When the narrowing of the artery becomes severe enough to result in insufficient blood supply to the heart, chest pain (angina) occurs. The chest pain usually occurs on exertion and is usually relieved by rest. When the artery is completely blocked, the portion of the heart muscle supplied by the artery will be damaged, resulting in heart attack.

Basic research and evidence from observational studies and clinical trials have shown a consistent positive relation between the blood cholesterol level and the risk of heart attack. Recent overviews have indicated that a I percent reduction in a person’s total blood cholesterol level yields a 2 to 3 percent reduction in the risk of coronary heart disease. The seven countries study found that coronary artery disease was less common in Japan and Mediterranean countries (where the average diet is low in cholesterol and saturated fat) than in the United States. Finland and Netherlands (where the cholesterol and saturated fat content of average diet is higher). In the United States, the Framingham Heart Study and more recently the Multiple Risk Factor Intervention Trial (MRFIT) have shown that the incidence of coronary artery disease is positively associated with blood cholesterol levels in a continuous, graded and progressive manner. By reducing the blood cholesterol level to normal the risk of heart attack can be decreased by 23%. In the Oslo study the smoking cessation and cholesterol lowering resulted in 47% reduction of heart attack and sudden death compared to control.
Cholesterol in blood is carried in two main forms, low density lipoprotein (LDL) and high density Lipoprotein (HDL). LDL is called bad cholesterol and HDL is called good cholesterol. High LDL cholesterol is associated with atherosclerosis (blockage of coronary artery). HDL cholesterol or good cholesterol removes excess bad cholesterol from the arteries. It is good for the HDL cholesterol to be high and the LDL cholesterol to be low. The role of another blood lipid, triglyceride in producing heart disease independently is questionable. But a recently published study, Helsinki Heart Study documented an inverse relation between elevated triglycerides and low level of HDL that may be reversed with treatment by Gemfibrozil.
The public health effect of the National Cholesterol Education Program’s guidelines is great. Their aim is to lower mean blood cholesterol levels to less than 200 mg% (5.2 mmol per liter), primarily by decreasing the total fat content of the diet to below 30% of total calories and saturated fat to below 10%. The HDL level is to be kept above 55 mg%. A mean 11% increase in the level of HDL cholesterol (good cholesterol) corresponded to a 34% decrease in the incidence of coronary heart disease.

Aspirin for Heart attack

Can low dose aspirin prevent heart attack?

Attention has recently focused on the possible role of prophylactic low-dose aspirin in reducing the risk of heart disease. The hypothesis that platelet inhibition with low-dose aspirin reduces the risk of heart attack n apparently people have been tested in two trials of primary prevention in men. The U.S physicians Health Study of 22,071 men 40 to 84 years of age observed a statistically significant 44% reduction in the risk of first heart attack whereas the British Doctor’s Trial of 5139 men 50 to 79 years of age observed no significant reduction. However an overview of both trials of primary prevention demonstrated a 33% reduction in the risk of fatal heart attack. Although no randomized trial has been completed specifically in women, the Nurses Health Study recently reported that women who took one to six aspirin weekly were 32% less likely to have an acute myocardial infarction.

At present the data on the role of aspirin in the primary prevention of stroke and heart attack are inconclusive. But some authorities recommend routine use of aspirin in asymptomatic men and women older than 50 years to prevent first myocardial infarction. It is important to view the clear benefits of aspirin in the primary prevention of heart attack in the context of what is already known about the modification of other coronary risk factors. It would be unfortunate if a middle aged smoker took aspirin instead of quitting smoking, because the benefits from quitting far exceed any protective defect of aspirin of heart attack. Any decision to use aspirin prophylaxis should be made on an individual basis, and in general, should be considered only for those whose absolute risk of a first heart attack is sufficiently high to warrant accepting the potential adverse effects of long-term aspirin use.

Antioxidants

Antioxidants with coronary artery disease

Epidemiological studies have suggested that high intake of antioxidants may modify coronary artery disease risk. The relative impact of vitamin E, vitamin C, beta carotene and flavonoids still remains unclear. Nurses Health Study and the Health Professional’s Follow-up Study showed 34% and 36% reduction in coronary events, respectively among women and men who take vitamin E supplement regularly. Oxidized LDL (bad cholesterol particles are believed to play a key role in the atherogenesis (blockage formation). So, theoretically any oxidant is likely to prevent coronary artery narrowing by preventing oxidation of LDL. In the European Community Multicenter Study on Antioxidants, Myocardial Infarction and breast cancer trial high beta carotene intake was protective only among smokers; vitamin C intake showed no relationship with coronary artery disease.

Results from most of the observational and experimental studies consistently support an effect of vitamin E supplemental on reducing the risk of heart attack. It is suggested that supplemental intake of vitamin E at or above 100 IU/day will reduce incidence of coronary artery disease. Long-term intake of vitamin E may reduce the progression of blockage in coronary arteries.

Carnivores and Herbivores

We are Carnivores or herbivores?

Human beings basically are not carnivores. We are basically herbivores (vegetarian) but we always behave like carnivores (flesh eaters). If several characteristics of carnivores are compared, human beings clearly have more characteristics of herbivores than carnivores. The teeth of carnivores are sharp; those of herbivores, mainly flat (for grinding). The intestinal tract of carnivores is short; that of herbivores is long (the small intestine of humans is 26 feet long!). Carnivores cool their bodies by panting; herbivores by sweating (as human beings). Carnivores make their own vitamin C (like animals); herbivores obtain their vitamin C from their diet. Most human beings believe themselves to be carnivores (we eat flesh) but fundamentally our characteristics more closely resemble the herbivores. Foods intended for Homo sapiens (man) probably are only three: starches (rice, corn, potatoes, beans etc), vegetables, and fruits.